First principle: benign, hormone‑dependent myometrial tumours
Monoclonal, estrogen‑ and progesterone‑dependent smooth‑muscle tumours; grow in the reproductive years, regress after menopause.
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The governing principle
Presentation
Most are asymptomatic. When symptomatic: heavy menstrual bleeding (± iron‑deficiency anaemia), bulk/pressure (urinary frequency, constipation), and subfertility/obstetric complications.
Red flags & special cases 🚩
- Red (carneous) degeneration in pregnancy — acute focal pain ± low‑grade fever/vomiting from ischaemic infarction. Pregnant + painful fibroid → red degeneration.
- Rapid growth, especially postmenopausal → consider (rare) leiomyosarcoma.
Management logic
- Asymptomatic: observe.
- Symptomatic (bleeding): medical (tranexamic acid, hormonal, GnRH analogues to shrink pre‑op); procedural (hysteroscopic resection for submucosal; uterine artery embolisation).
- Fertility desired: myomectomy (preserve uterus).
- Family complete + severe symptoms: hysterectomy (definitive).
- Individualise on age, number, size, location, symptoms and wishes — never on age alone.
Pitfalls
- Attributing infertility to a subserosal fibroid; it is submucosal/cavity‑distorting fibroids that impair fertility.
Pearls
- 🎯 Submucosal → bleeding/fertility; subserosal → bulk. Pregnancy + pain → red degeneration.
- 🩺 GnRH‑agonist pre‑treatment shrinks fibroids and corrects anaemia before surgery (time‑limited; causes hypoestrogenism).
Next → At the far end of reproductive life, the ovary fails (Concept 21).