Are Fibroids Causing Your Symptoms?

What Are Uterine Fibroids?

Uterine fibroids are noncancerous smooth-muscle tumors that grow in or around the wall of the uterus. They range from the size of a sesame seed to larger than a grapefruit, and a single uterus can harbor multiple fibroids simultaneously. Malignant transformation to leiomyosarcoma is rare, estimated at fewer than 1 in 1,000 cases, so a fibroid diagnosis does not mean cancer. [1]

Fibroids are classified by location. Submucosal fibroids grow inside the uterine cavity and are the most likely to cause abnormal bleeding. Intramural fibroids sit within the muscular wall and are the most common type overall. Subserosal fibroids project outward from the outer uterine surface and more often create pressure or bulk symptoms than bleeding. Pedunculated fibroids attach to the uterus via a stalk and can occasionally twist, causing acute pain.

The growth of fibroids depends heavily on estrogen and progesterone. They typically appear during the reproductive years, often accelerate during pregnancy when hormone levels peak, and tend to shrink after menopause as circulating estrogen falls. This hormonal dependency is the basis for every medical treatment currently in use. [2]

Epidemiologically, Black women carry a disproportionate burden. A landmark analysis published in the American Journal of Obstetrics and Gynecology found that Black women are diagnosed 2 to 3 times more often than white women, develop fibroids at younger ages, and experience more severe symptoms. Genetic, environmental, and socioeconomic factors all appear to contribute to this disparity. [3]

The Most Common Symptoms of Fibroids

Heavy menstrual bleeding is the symptom most consistently linked to fibroids, and it is the one most likely to bring someone to a clinician's office. Submucosal and large intramural fibroids distort the uterine cavity and interfere with normal endometrial shedding, producing periods that soak through a pad or tampon every hour for several consecutive hours. Over time, that blood loss causes iron-deficiency anemia. A 2018 systematic review in the British Journal of Obstetrics and Gynaecology found that heavy menstrual bleeding occurred in approximately 30% of women with fibroids, compared with roughly 10% of women without them. [4]

Pelvic pressure and a sense of fullness are the next most reported complaints. Large subserosal or multiple intramural fibroids physically displace adjacent structures. Patients often describe feeling as though something is pushing downward, or as though their abdomen is constantly slightly bloated even between periods. Pain specifically tied to fibroids is less universal, though dysmenorrhea (painful periods) and dyspareunia (painful intercourse) are well-documented. [5]

Bladder and bowel symptoms deserve attention because they are frequently dismissed or attributed to other causes. A fibroid pressing on the bladder causes urinary frequency, urgency, or incomplete emptying. One sitting on the rectum or sigmoid colon produces constipation or a feeling of rectal pressure. These symptoms do not have to accompany heavy bleeding. A patient can have minimal bleeding and still carry a fibroid that is large enough to compress the bladder.

Fatigue and anemia come indirectly from chronic blood loss rather than from the fibroid tissue itself. Serum ferritin below 15 ng/mL in a woman with heavy periods should prompt investigation for a structural uterine cause, and fibroids top that list. [6]

How Doctors Diagnose Fibroids

Transvaginal ultrasound is the first-line diagnostic tool and correctly identifies fibroids in 95% to 100% of cases when performed by an experienced sonographer. It is fast, radiation-free, and widely available. Abdominal ultrasound adds value when fibroids are very large or when the uterus is significantly enlarged, since the transvaginal probe has a limited field of view. [7]

MRI of the pelvis provides far more anatomic detail than ultrasound. It can map the exact number, size, and location of every fibroid, differentiate fibroids from adenomyosis (a separate condition that mimics fibroid symptoms), and help a surgeon plan a myomectomy. The American College of Obstetricians and Gynecologists (ACOG) recommends MRI when ultrasound findings are inconclusive or when surgical planning requires precise mapping. ACOG Practice Bulletin No. 228 states: "MRI is the most accurate imaging modality for determining the number, size, and location of leiomyomas." [8]

Hysteroscopy visualizes the uterine cavity directly and is particularly useful for diagnosing submucosal fibroids. Saline infusion sonohysterography (SIS) provides a middle ground between standard ultrasound and full hysteroscopy, using saline instilled into the cavity to outline the endometrial contour. Both techniques are more sensitive than standard ultrasound for intracavitary lesions. [9]

Blood tests do not diagnose fibroids but are essential for assessing downstream effects. A complete blood count can quantify anemia. Serum ferritin, iron saturation, and thyroid-stimulating hormone should be checked in anyone presenting with heavy menstrual bleeding to exclude coexisting causes. [6]

Which Symptoms Point Strongly Toward Fibroids Versus Other Conditions?

Symptom overlap between fibroids, endometriosis, adenomyosis, and polyps is real and clinically challenging. Heavy bleeding plus pelvic pressure without cyclical pain elsewhere in the pelvis leans toward fibroids. Cyclical pain radiating to the legs or shoulders, or pain that begins days before the period, more often suggests endometriosis. A diffusely enlarged, boggy uterus on exam with dysmenorrhea starting after a prior pregnancy or uterine procedure raises suspicion for adenomyosis. Polyps tend to cause intermenstrual spotting or postcoital bleeding rather than the gushing flow typical of submucosal fibroids.

Age and reproductive history matter too. Fibroids are uncommon before age 20 and peak in the late 30s to late 40s. Any woman in this age window with new heavy bleeding and a palpably enlarged uterus on bimanual exam should have pelvic ultrasound ordered that same visit, not after a waiting period. [10]

A practical 3-question screening framework for use at initial presentation:

1. Are you soaking through a pad or tampon in under an hour on your heaviest day?
2. Do you feel pelvic pressure or fullness between periods?
3. Has your lower abdomen grown noticeably larger without a change in weight?

Two or more yes answers in a woman aged 25 to 52 carry a positive predictive value high enough to justify same-visit imaging referral rather than watchful waiting.

The Role of Hormones in Fibroid Growth

Fibroids express higher concentrations of estrogen receptors and progesterone receptors than the surrounding myometrium. This is why pregnancy, exogenous estrogen, and obesity (which drives peripheral aromatization of androgens to estrogen in adipose tissue) all promote fibroid growth, while menopause and GnRH-based therapies shrink fibroid volume.

Research published in Fertility and Sterility demonstrated that insulin-like growth factor-1 (IGF-1) and transforming growth factor-beta (TGF-beta) work alongside sex steroids to stimulate fibroid cell proliferation and excessive extracellular matrix deposition, which is why fibroids become increasingly fibrous over time. [11]

Vitamin D deficiency has drawn interest as a modifiable risk factor. A study of 1,610 premenopausal women published in Epidemiology found that women with serum 25-hydroxyvitamin D levels below 20 ng/mL had a 32% higher odds of fibroid diagnosis compared with women with sufficient levels. [12] Whether correcting a deficiency slows growth remains under investigation, but measuring vitamin D in a fibroid workup costs very little and may inform adjunctive management.

Medical Treatment Options for Fibroid Symptoms

Not every fibroid requires intervention. Asymptomatic fibroids discovered incidentally can be monitored with annual ultrasound. Treatment is indicated when symptoms impair quality of life, cause significant anemia, or affect fertility or adjacent organ function.

Levonorgestrel-releasing intrauterine system (LNG-IUS, Mirena 52 mg). This is the most evidence-supported non-surgical option for heavy menstrual bleeding from fibroids. A Cochrane review of four randomized controlled trials found that LNG-IUS reduced menstrual blood loss by 74% to 97% at 12 months compared with baseline, though it is less effective when a submucosal fibroid significantly distorts the cavity. [13]

Combined oral contraceptives (COCs). COCs reduce menstrual flow and provide cycle control but do not reliably shrink fibroid volume. They are a reasonable first choice for women seeking contraception alongside symptom management. [8]

Tranexamic acid 1 to 300 mg orally three times daily for up to 5 days per cycle. This antifibrinolytic reduces blood loss by inhibiting plasminogen activation. The ECLIPSE trial found that tranexamic acid reduced heavy menstrual bleeding by 40.4% versus placebo over 3 cycles. [14] It does not affect fibroid size or growth.

GnRH agonists (leuprolide acetate 3.75 mg IM monthly or 11.25 mg IM every 3 months). These agents suppress ovarian hormone production, reliably shrinking fibroid volume by 30% to 50% within 3 to 6 months. The trade-off is menopausal side effects and bone loss with prolonged use, which limits this class to short-term preoperative preparation or bridge therapy. Add-back regimens using low-dose estrogen-progestin can mitigate bone effects. [15]

Relugolix combination tablet (Myfembree: relugolix 40 mg / estradiol 1 mg / norethindrone acetate 0.5 mg). This FDA-approved oral GnRH antagonist combination reduces heavy menstrual bleeding caused by fibroids without the delayed onset of GnRH agonists. The LIBERTY 1 and LIBERTY 2 phase 3 trials (combined N=770) showed that 73.4% of women taking Myfembree achieved the primary responder endpoint (menstrual blood loss volume below 80 mL per cycle plus at least a 50% reduction) at 24 weeks versus 18.9% on placebo. [16] FDA approval extends use for up to 24 months.

Elagolix (Oriahnn: elagolix 300 mg with add-back hormones). An alternative GnRH antagonist combination approved specifically for heavy menstrual bleeding due to uterine fibroids in premenopausal women, also limited to 24 months of use. The ELARIS UF-I trial (N=571) found 68.5% of women in the elagolix arm met the primary endpoint versus 8.7% of placebo. [17]

NSAIDs. Ibuprofen 400 to 600 mg every 6 to 8 hours during menstruation reduces prostaglandin-mediated cramping and can modestly lower blood loss, though effect size is smaller than tranexamic acid. Still useful for dysmenorrhea management while awaiting specialist review.

Surgical and Procedural Treatment Options

Surgery becomes relevant when medical therapy fails, when fertility is desired alongside fibroid removal, when the diagnosis is uncertain, or when fibroids are very large (typically over 10 to 12 cm) and compressing vital structures.

Myomectomy. Surgical removal of fibroids while preserving the uterus. It can be performed hysteroscopically for submucosal fibroids, laparoscopically or robotically for intramural and subserosal fibroids, or via open laparotomy for very large or numerous fibroids. Recurrence rates are real: approximately 27% of women require a repeat procedure within 10 years. [18] For women who want future pregnancies, myomectomy remains the standard surgical approach.

Hysterectomy. Removal of the uterus is the only definitive cure and eliminates recurrence entirely. It accounts for roughly 200,000 procedures per year in the United States where fibroids are the primary indication. It is appropriate for women who have completed childbearing and prefer a permanent solution after exhausting or declining other options. [19]

Uterine fibroid embolization (UFE). An interventional radiology procedure that occludes the uterine arteries feeding fibroids via catheter-delivered embolic particles, causing infarction and shrinkage. A long-term follow-up study published in Radiology found that 73% of women reported symptom improvement at 5 years post-UFE, with approximately 20% requiring additional intervention. [20] UFE preserves the uterus but is generally not recommended for women actively trying to conceive, as data on subsequent pregnancy outcomes remain limited.

Endometrial ablation. Destroys the endometrial lining to reduce or eliminate bleeding. Effective for heavy periods without fibroids or with only small submucosal fibroids, but not appropriate when fibroids are the primary bulk-symptom driver or when fertility is desired. [8]

MRI-guided focused ultrasound (MRgFUS). A noninvasive technique that uses high-intensity focused ultrasound beams to thermally ablate fibroid tissue while MRI provides real-time guidance. The FDA cleared this technology for symptomatic fibroids; 12-month data show meaningful reductions in symptom severity scores, though long-term recurrence data are still accumulating. [21]

Fibroids and Fertility

Fibroids affect fertility through multiple mechanisms: distorting the uterine cavity, obstructing the fallopian tubes, impairing implantation, and altering uterine contractility. A meta-analysis in Human Reproduction covering 23 studies found that submucosal fibroids significantly reduced clinical pregnancy rates (relative risk 0.32) and live birth rates (relative risk 0.28) compared with infertile women without fibroids. Subserosal fibroids showed no significant effect on these outcomes. Intramural fibroids not distorting the cavity showed a modest negative effect (relative risk approximately 0.7 for live birth), though the evidence remains debated. [22]

ASRM guidelines state that hysteroscopic myomectomy is the standard of care for submucosal fibroids in women seeking fertility and that the procedure improves reproductive outcomes compared with expectant management. [23]

Fibroid size and number matter. A single 2 cm submucosal fibroid in the cavity is more consequential for fertility than five 1 cm subserosal fibroids on the outer surface. Precise mapping with MRI or saline sonohysterography before any fertility treatment is not optional, it is a prerequisite.

When to See a Doctor Without Delay

Some presentations should prompt a visit within days rather than weeks. Sudden severe pelvic pain may signal torsion of a pedunculated fibroid or degeneration of a rapidly growing fibroid. Fever plus pelvic pain after a uterine procedure raises concern for infection. Rapidly progressive abdominal enlargement over weeks, not months, combined with abnormal bleeding warrants expedited evaluation to exclude the rare but serious leiomyosarcoma, which can mimic benign fibroid growth on clinical exam. [1]

Anemia causing symptoms such as palpitations, dyspnea on exertion, or resting heart rate above 100 beats per minute is a medical indication for prompt hemoglobin check and likely intravenous iron or transfusion before any elective surgical intervention.

What Black and Brown Women Should Know

The racial disparity in fibroid burden is not a minor statistical footnote. Research published in the American Journal of Epidemiology found cumulative incidence of fibroids by age 50 reaches 80% in Black women compared with approximately 70% in white women, with Black women experiencing onset a full decade earlier and symptoms that are significantly more severe at time of diagnosis. [3] This gap persists after adjusting for socioeconomic status, pointing to biological contributors including differences in vitamin D metabolism, stress hormone exposure, and genetic variants in fibroid-related pathways.

Access to care disparities compound this. Black women are more likely to undergo hysterectomy for fibroids than white women with equivalent disease burden, even when uterine-preserving options are available and desired. Advocating clearly for minimally invasive options, requesting MRI before surgery, and seeking a gynecologist with subspecialty training in minimally invasive gynecologic surgery (MIGS) can each materially alter the surgical path offered. [24]