Presentation

Symptoms of Uterine Leiomyomas

Key Points


  • The vast majority of leiomyomas are asymptomatic.
  • Symptoms such as abnormal uterine bleeding, infertility, and chronic pelvic pain are frequently unrelated to the leiomyomas seen.
  • Abnormal uterine bleeding  is frequently associated with leiomyomas (AUB-L); but when leiomyomas actually cause AUB the symptom is generally heavy menstrual bleeding, with a cycle length of 24 - 38 days, reflecting the underlying presence of ovulation.
  • When leiomyoma grow to a size that results in pressure on surrounding structures including organs such as the bladder or rectum, "bulk" or pressure symptoms can be said to exist - these include abdominal distention, urinary frequency, and tenesmus.
  • Women with sub mucous leiomyomas often experience infertility, frequently in association with the symptom of HMB.


While most leiomyomas don't cause symptoms, and frequently the symptoms experienced by the patient are not caused by the tumors themselves, it is clear that there are symptoms directly caused by fibroids. While it is obvious that large or numerous fibroids will cause pressure symptoms, the mechanisms whereby these tumors cause abnormal uterine bleeding, infertility, or recurrent pregnancy loss are less clear. Nevertheless, we do have a number of reasonable theories that can assist the clinician in determining when a tumor is the likely cause of the patient's symptoms.

Abnormal Uterine Bleeding (AUB)

When fibroids cause or contribute to AUB it is generally the symptom of heavy menstrual bleeding (HMB) which is classically associated with excessive  menstrual loss  while retaining the cyclical predictability of timing associated with ovulation.  Heavy menstrual bleeding is present when the patient says so. The National Institute of Health Care Excellence (NICE) defines HMB as " Excessive menstrual blood loss which interferes with the woman's physical, emotional, social, and material quality of life..." (NICE 2007)

The exact mechanisms whereby leiomyomas cause or contribute to infertility are not totally clear but they are thought to be related to abnormal molecular expressions from leiomyomas that are in contact with the endometrium - the submucous leiomyoma. It is also possible that some fibroids alter myometrial contractility in a fashion that alters sperm transport, or adversely impacts the ability of the embryo to implant if it reaches the endometrial cavity.

Recurrent Pregnancy Loss (RPL)

Although leiomyomas have been associated with recurrent pregnancy loss, the evidence supporting this notion is even less robust than those associated with AUB. This may be because the recurrent losses are conflated with decreased endometrial receptivity and associated "infertility". Nonetheless, there may be circumstances where leiomyomas are associated with RPL; we just need more evidence.

Pressure Symptoms

Large or numerous leiomyomas may cause symptoms should the aggregate mass be sufficient to distend the abdomen, or when any single or group of leiomyomas place pressure on a surrounding structure such as the urinary bladder, rectosigmoid, or vagina where sexual intercourse may be adversely affected.

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