The incidence of uterine fibroid tumors increases as women grow older, and they may occur in more than 30 percent of women 40 to 60 years of age. Risk factors include nulliparity, obesity, family history, black race, and hypertension. Many tumors are asymptomatic and may be diagnosed incidentally. Although a causal relationship has not been established, fibroid tumors are associated with menorrhagia, pelvic pain, pelvic or urinary obstructive symptoms, infertility, and pregnancy loss. Transvaginal ultrasonography, magnetic resonance imaging, sonohysterography, and hysteroscopy are available to evaluate the size and position of tumors. Ultrasonography should be used initially because it is the least invasive and most cost-effective investigation. Treatment options include hysterectomy, myomec- tomy, uterine artery embolization, myolysis, and medical therapy. Treatment must be individualized based on such considerations as the presence and severity of symptoms, the patient"s desire for definitive treatment, the desire to preserve childbearing capacity, the importance of uterine preservation, infertility related to uterine cavity distortions, and previous pregnancy complications related to fibroid tumors. (Am Fam Physician 2007;75:1503-8. Copyright © 2007 American Academy of Family Physicians.)
Many women develop uterine fibroid tumors (i.e., leiomyomas) as they grow older. In one study, the prevalence of ultrasound-identified tumors ranged from 4 percent in women 20 to 30 years of age to 11 to 18 percent in women 30 to 40 years of age and 33 percent in women 40 to 60 years of age.1 Studies report that 5.4 to 77 per- cent of women have uterine fibroid tumors, depending on the population studied and the diagnostic method used.1,2 Women often consult family physicians because of symptoms related to fibroid tumors or after the lesions have been diagnosed incidentally during physical or radiologic examinations. This article reviews the epidemiology and etiology of uterine fibroid tumors, common clinical presentations, diagnostic strategies, and treatment options.
Epidemiology and Etiology
Leiomyomas are the most common female reproductive tract tumors. They are probably of unicellular origin,3 and their growth rate is influenced by estrogen, growth hormone, and progesterone. Although studies have not clarified the exact process, uterine fibroid tumors arise during the reproductive years and tend to enlarge during pregnancy and regress after menopause. The use of estro- gen agonists is associated with an increased incidence of fibroid tumors, 4 and growth hormone appears to act synergistically with estradiol in affecting the growth of fibroid tumors. Conversely, progesterone appears to inhibit their growth.
Several studies have documented an increased incidence of uterine fibroid tumors in black women.5 Some evidence also indicates that black women are more likely than white women to have larger and more symptomatic tumors at the time of treatment.6-10 Table 15-10 lists factors associated with the development of fibroid tumors. Recent evidence suggests that women with hypertension have a higher risk of fibroid tumors, possibly through smooth muscle injury or cytokine release.11
Clinical Features
Because of the high prevalence of uterine fibroid tumors and the fact that many are asymptomatic, attributing symptoms specifically to the tumors is problematic. Although evidence is largely drawn from uncontrolled studies, uterine fibroid tumors are commonly identified in women who have menorrhagia, pelvic pain, obstructive symptoms, infertility, or pregnancy loss.
Menstrual abnormalities, including menorrhagia, are the most common symptoms associated with uterine fibroid tumors. Submucosal tumors are often cited as a cause of menorrhagia, but there is no evidence that the endometrium over submucosal tumors differs from that overlying other areas of the uterus.12 Fibroid tumors may produce a dysregulation of local growth factors, causing vascular abnormalities that contribute to menorrhagia13 and are unrelated to their location in the uterus. One study attributed 11 percent of cases of symptomatic menorrhagia to uterine fibroid tumors.14 Conversely, a population-based study did not find any evidence relating general abnormalities in menstrual cycle length or heaviness to the presence of fibroid tumors.15
Pelvic pain and pressure are less commonly attributed to uterine fibroid tumors. Individual case reports have described very large tumors that result in pelvic discomfort, respiratory failure, urinary symptoms, and constipation.16-18 During pregnancy, the combination of large fibroid tumors and uterine enlargement can result in symptoms of urinary tract obstruction,19 abdominal pain (attributed to the degeneration of fibroid tumors), and, possibly, an increased risk of placental abruption if the tumor is located retroplacentally.20
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