Intramural Fibroid — Symptoms, Diagnosis, and Treatment Options

Uterine fibroids (medically called leiomyomas or myomas) are benign (non-cancerous) tumours that grow in or on the uterus. They are made of smooth muscle and connective tissue.

Types of uterine fibroids (based on location): • Intramural fibroids: Grow within the muscular wall of the uterus (myometrium) — the most common type • Submucosal fibroids: Grow just beneath the inner lining of the uterus (endometrium) — most likely to cause heavy bleeding • Subserosal fibroids: Grow on the outer surface of the uterus, projecting outward • Pedunculated fibroids: Attached to the uterus by a stalk (can be inside or outside) • Cervical fibroids: Located in the cervix

Intramural fibroids specifically: • Located within the myometrium (the thick muscle layer of the uterus) • Most common of all fibroid types • Can remain small and asymptomatic (causing no symptoms) or grow large enough to distort the uterine cavity • A single uterus may have multiple intramural fibroids • Mostly affect women aged 30–50; shrink after menopause (oestrogen-dependent growth) • More common in Black women than in women of other ethnicities

Many intramural fibroids cause no symptoms and are discovered incidentally during a routine ultrasound. When symptoms do occur, they include:

1. Heavy Menstrual Bleeding (Menorrhagia): • Most common symptom • Periods may be heavier, longer, or more frequent than usual • Can lead to anaemia (iron deficiency) due to blood loss • Passing large blood clots during menstruation

2. Pelvic Pain or Pressure: • A feeling of fullness, heaviness, or pressure in the pelvic area • Pelvic pain or discomfort, especially during menstruation (dysmenorrhoea) • Lower back pain or pain in the legs

3. Frequent Urination: • A large fibroid can press on the bladder, causing the need to urinate frequently • May also cause difficulty fully emptying the bladder

4. Constipation: • Fibroids pressing on the rectum can cause constipation or difficulty with bowel movements

5. Abdominal Bloating or Enlargement: • Large fibroids can cause visible abdominal swelling or a 'pot belly' appearance

6. Reproductive Issues: • Intramural fibroids that distort the uterine cavity may affect fertility or increase risk of miscarriage • However, many women with intramural fibroids conceive and carry pregnancies normally

7. Pain during Intercourse (Dyspareunia): • Some women experience discomfort or pain during sex

The exact cause of uterine fibroids is not fully understood, but the following factors are associated with their development:

Hormonal influence: • Fibroids are oestrogen and progesterone sensitive — they grow during the reproductive years when hormone levels are high • They typically shrink after menopause when oestrogen levels fall • Pregnancy (high oestrogen) can accelerate fibroid growth

Genetic factors: • Fibroids tend to run in families • A woman whose mother or sister had fibroids has a higher risk

Race and ethnicity: • Fibroids are significantly more common and often more severe in Black women compared to women of other ethnicities • Black women are also more likely to develop fibroids at a younger age

Other risk factors: • Obesity (higher body weight associated with more oestrogen) • Early onset of menstruation (menarche before age 10) • Diet high in red meat and low in green vegetables • Vitamin D deficiency • No prior pregnancies

Fibroids are NOT cancer and very rarely (less than 1 in 1,000) become cancerous (a condition called leiomyosarcoma).

Diagnosis of Intramural Fibroids:

1. Ultrasound (Sonography): • Most common first-line diagnostic tool • Transvaginal ultrasound (probe inserted into the vagina) gives a clearer picture of the uterus and fibroids • Transabdominal ultrasound also used • Can determine size, number, and location of fibroids

2. MRI (Magnetic Resonance Imaging): • Provides detailed images of fibroid size and location • Used when ultrasound is inconclusive or before surgery to plan treatment

3. Hysteroscopy: • A thin camera (hysteroscope) is inserted through the cervix into the uterus • Can directly visualise submucosal fibroids and the interior of the uterus

4. Hysterosalpingography (HSG): • X-ray using contrast dye to visualise the uterine cavity and fallopian tubes • Used particularly when evaluating fertility

Treatment Options:

1. Watchful Waiting: • If fibroids are small and cause no symptoms, monitoring is recommended • Fibroids naturally shrink after menopause

2. Medications: • GnRH agonists (e.g., leuprolide): Temporarily shrink fibroids by reducing oestrogen • Hormonal contraceptives (pills, IUD): Help control heavy bleeding but do not shrink fibroids • Tranexamic acid: Reduces heavy bleeding during periods • Iron supplements: To treat anaemia caused by heavy bleeding

3. Surgical Treatments: • Myomectomy: Surgical removal of fibroids while preserving the uterus — preferred for women who want to become pregnant • Hysterectomy: Complete removal of the uterus — permanent cure; no recurrence of fibroids; only for women who do not want future pregnancies

4. Minimally Invasive Procedures: • Uterine Fibroid Embolisation (UFE): Blocks blood supply to fibroids, causing them to shrink • Endometrial Ablation: Destroys the lining of the uterus — treats heavy bleeding but not suitable if pregnancy is desired • Focused Ultrasound Surgery (MRI-guided): Uses sound waves to destroy fibroid tissue without surgery