• Uterine fibroids are also known as leiomyomas/myomas, protrude as noncancerous growths that develop in the muscular wall of the uterus.
• They are the most common type of benign tumors found in women of reproductive age. Uterine fibroids vary in size, ranging from small, undetectable growths to large masses that can distort the shape and size of the uterus.
• Certain factors are known to contribute to their development. These factors include hormonal imbalances, exceptionally high levels of estrogen and progesterone, as well as genetic predisposition. Estrogen, in particular, appears to play a significant role in the growth and maintenance of fibroids.

• Uterine fibroids affect women of reproductive age. It is estimated that up to 80% of women will develop fibroids by age 50. However, not all fibroids cause symptoms or require treatment. Fibroids predominantly occur during the reproductive years, with the highest incidence observed between 30 and 50. They are more prevalent among African American women than women of other racial or ethnic backgrounds. African American women tend to have more extensive and numerous fibroids and may experience more severe symptoms.

• Uterine fibroids predominantly affect women during their reproductive years, typically between 30 and 50.
• The prevalence of uterine fibroids varies widely, ranging from 20% to 80% of women by age 50, depending on the population studied and the diagnostic criteria used.
• Women of African descent have a higher risk of developing fibroids than women of other racial and ethnic backgrounds. They also tend to develop fibroids earlier and have more extensive and symptomatic fibroids.
• Family history of fibroids is a known risk factor, suggesting a genetic predisposition for the condition.
• Reproductive factors such as early onset of menstruation, nulliparity (never giving birth), and late menopause have been associated with an increased risk of uterine fibroids.
• Obesity is a risk factor for uterine fibroids, possibly due to the higher estrogen levels associated with excess adipose tissue.
• There are geographic variations in the prevalence of uterine fibroids, but the reasons for these differences are not yet fully understood.

The etiology, or cause, of uterine fibroids, includes several factors identified as potential contributors to their development. These factors include:
• Hormonal Influences: Hormonal imbalances, exceptionally high levels of estrogen and progesterone, play a significant role in the growth and maintenance of uterine fibroids. Estrogen, in particular, promotes the growth of fibroids. Fibroids tend to grow during reproductive years when hormone levels are at their highest and often regress after menopause when hormone levels decline.
• Genetic Predisposition: There appears to be a genetic component in the development of uterine fibroids. Women with a family history of fibroids are at a higher risk of developing them. Specific genes and genetic mutations are being investigated for their association with fibroid development, but further research is needed to understand the genetic factors involved fully.
• Growth Factors and Cytokines: Various growth factors and cytokines, such as insulin-like growth factor (IGF), vascular endothelial growth factor (VEGF), and transforming growth factor-beta (TGF-β), have been implicated in the growth and progression of fibroids. These molecules regulate cell proliferation, angiogenesis (formation of new blood vessels), and extracellular matrix remodeling, which can contribute to fibroid growth.
• Extracellular Matrix (ECM) Abnormalities: Fibroids are characterized by an overgrowth of smooth muscle cells within the uterine wall. Abnormalities in the extracellular matrix, which provides structural support to tissues, have been observed in fibroids. Changes in the composition and organization of ECM components, such as collagen, proteoglycans, and fibronectin, may contribute to the development and growth of fibroids.
• Other Factors: Other factors that may influence the development of uterine fibroids include obesity, race/ethnicity (as mentioned earlier, women of African descent have a higher risk), and specific environmental exposures (although the evidence is limited and further research is needed).

Prognostic factors in the context of uterine fibroids refer to factors that can influence the outcome and progression of the condition. These factors can help healthcare providers assess the likelihood of complications, response to treatment, and long-term prognosis for women with uterine fibroids. Here are some critical prognostic factors:
• Size and Number of Fibroids: The size and number of fibroids can influence the severity of symptoms and the risk of complications. Larger fibroids or a greater number of fibroids are more likely to cause significant symptoms such as heavy menstrual bleeding, pelvic pain, and pressure symptoms.
• Location of Fibroids: The location of fibroids within the uterus can affect symptomatology and treatment options. Submucosal fibroids protruding into the uterine cavity are more likely to cause heavy menstrual bleeding and reproductive issues such as infertility or miscarriages. Subserosal fibroids, on the other hand, may cause pressure symptoms and impact nearby organs.
• Symptom Severity: The severity of symptoms experienced by a woman with uterine fibroids can impact her quality of life and treatment decisions. Women with severe symptoms, such as heavy menstrual bleeding leading to anemia or significant pain, may require more aggressive treatment approaches.
• Age: Age can be a prognostic factor for uterine fibroids. Fibroids tend to shrink and become less symptomatic after menopause when estrogen levels decline naturally. For women approaching menopause, less invasive management strategies may be recommended if symptoms are not severe.
• Desire for Fertility: The desire for future fertility can influence treatment decisions. In cases where a woman wishes to preserve fertility, treatment options that spare the uterus, such as myomectomy (removal of fibroids while preserving the uterus), may be considered.
• Response to Treatment: The response to various treatment modalities can impact the prognosis. Some women may experience complete resolution of symptoms with conservative management, while others may require more invasive interventions. The effectiveness of specific treatments, such as medication therapy, minimally invasive procedures (e.g., uterine artery embolization), or surgical interventions (e.g., hysterectomy), can vary among individuals.
• Recurrence: Uterine fibroids have the potential to recur even after treatment. The risk of fibroid recurrence depends on several factors, including the type of treatment received, the presence of residual fibroids, and the patient’s hormonal profile.

Non-specific signs & symptoms
• Pelvic discomfort
• Back Pain
• Abdominal bloating
• Urinary symptoms
• Constipation
• Painful intercourse
Systemic signs & symptoms
• Fatigue
• Anemia
• Abdominal distension
• Impact on fertility

• Abdominal Examination: The healthcare provider may palpate (feel) the abdomen to assess the uterus’s size, shape, and consistency. Enlargement of the uterus may indicate the presence of fibroids. The provider may also check for any abdominal tenderness or masses.
• Pelvic Examination: A pelvic examination involves the healthcare provider visually inspecting and manually examining the pelvic organs. The provider may use a speculum to visualize the cervix and perform a bimanual examination by inserting one or two gloved fingers into the vagina while placing the other hand on the lower abdomen. During the bimanual examination, the provider can assess the size, shape, and position of the uterus and check for any palpable fibroids.
• Cervical Examination: The healthcare provider may inspect the cervix for any abnormalities or signs of cervical involvement by the fibroids.
• Rectal Examination: In some cases, a rectal examination may be performed to assess the presence and extent of fibroids close to the rectum. The provider will insert a gloved finger into the rectum to feel for any masses or abnormalities.
• Other Assessments: Depending on the specific situation, additional assessments may be performed, such as an evaluation of the lower back or a neurologic examination if symptoms suggest nerve compression or involvement.

• The acuity of presentation refers to the speed or severity with which the symptoms of uterine fibroids manifest. Uterine fibroids can have varying degrees of acuity, ranging from an asymptomatic or mild presentation to a more acute and severe presentation. They include: asymptomatic presentation, gradual onset of symptoms, acute or sudden symptom exacerbation

• Anemia
• Infertility
• Pregnancy complications
• Urinary symptoms
• Bowel symptoms
• Impact on quality of life

• The treatment paradigm for uterine fibroids depends on several factors, including the severity of symptoms, the size and location of the fibroids, the woman’s desire for future fertility, and her overall health. Treatment aims to alleviate symptoms, improve quality of life, and address reproductive concerns.

Psychiatry/Mental Health

• Diet: Maintaining a healthy and balanced diet is essential for overall well-being. Although no specific diet has been proven to prevent or cure fibroids, a diet rich in fruits, vegetables, whole grains, and lean proteins can promote a healthy weight and hormonal balance. Additionally, reducing the consumption of processed foods, high-fat foods, and red meat may be beneficial.
• Physical Activity: Regular exercise is essential for overall health and can help manage fibroids. Engaging in moderate-intensity aerobic activities like brisk walking, swimming, or cycling can help maintain a healthy weight and promote hormone regulation.
• Stress Management: Chronic stress may impact hormonal balance, potentially influencing fibroid growth. Implementing stress-management techniques, such as meditation, yoga, deep breathing exercises, or engaging in hobbies, can help reduce stress levels.
• Hormone Disrupting Substances: Certain substances, known as endocrine disruptors, can interfere with hormone regulation in the body. Limiting exposure to these substances in certain plastics, cosmetics, and personal care products may be beneficial. Choosing “phthalate-free” or “paraben-free” products can help reduce exposure to these potential hormone disruptors.
• Weight Management: Obesity has been associated with an increased risk of fibroids and may contribute to their growth. Maintaining a healthy weight through proper nutrition and regular physical activity can be beneficial.

Surgery, General

• Hysteroscopic removal of submucosal fibroids
  Hysteroscopic removal, also known as hysteroscopic resection or hysteroscopic myomectomy, is a minimally invasive surgical procedure used to remove submucosal fibroids. This technique involves accessing the uterus through the vagina and cervix using a hysteroscope, a thin, lighted instrument with a camera attached.
• Hysteroscopic removal of submucosal fibroids is generally considered a safe and effective procedure with a high success rate. It offers several advantages over traditional open surgery, including shorter recovery time, less pain, and a lower risk of complications.
  s

OB/GYN and Women\'s Health

Medical therapy using contraceptives can be an option for managing uterine fibroids, mainly when the primary goal is alleviating symptoms such as heavy menstrual bleeding and pain. Contraceptives that contain synthetic hormones, such as combined oral contraceptives and progestin-only contraceptives, can help regulate menstrual cycles and reduce fibroid-related symptoms.
• Tranexamic acid:
Tranexamic acid is a medication that is sometimes used to manage heavy menstrual bleeding associated with uterine fibroids. It works by preventing the breakdown of blood clots and reducing bleeding.
When used for uterine fibroids, tranexamic acid is typically prescribed to be taken during menstruation. It can help reduce excessive bleeding and normalize the duration and intensity of menstrual flow. Controlling heavy bleeding can alleviate symptoms such as anemia, pain, and discomfort.
• Linzagolix:
Linzagolix works by suppressing the production of certain hormones, such as estrogen and progesterone, thereby reducing the size of fibroids and alleviating associated symptoms. It is typically taken orally once daily.

OB/GYN and Women\'s Health

Uterine artery embolization (UAE), or uterine fibroid embolization (UFE), is a minimally invasive procedure for treating uterine fibroids. It involves blocking the blood supply to the fibroids, causing them to shrink and alleviating associated symptoms. Uterine artery embolization is generally effective in reducing symptoms associated with fibroids, such as heavy menstrual bleeding, pelvic pain, and pressure symptoms. It is a uterus-sparing procedure, which means it preserves the uterus and may be a suitable option for women who wish to retain their fertility.

OB/GYN and Women\'s Health

• Ultrasound surgery, or high-intensity focused ultrasound (HIFU) or focused ultrasound ablation, is a non-invasive procedure for treating various conditions, including uterine fibroids.
  Ultrasound surgery offers several advantages as a non-invasive treatment option for uterine fibroids. In some cases, it does not involve incisions or the need for general anesthesia.
• Hysterectomy:
  Hysterectomy is a surgical procedure that involves the removal of the uterus. It is considered a definitive treatment for uterine fibroids, as it eliminates the possibility of fibroid recurrence and can provide long-term relief from fibroid-related symptoms.

OB/GYN and Women\'s Health

• Gonadotropin-releasing hormone (GnRH) Agonists: GnRH agonists, such as leuprolide acetate and goserelin, are medications that temporarily suppress the production of estrogen and progesterone, inducing a state similar to menopause. They can be administered via injection or nasal spray. GnRH agonists are often used as short-term preoperative therapy to reduce fibroid size and control symptoms before surgery. However, they are not typically used as long-term maintenance therapy due to the side effects associated with estrogen deficiency.
• Progestin-Only Therapy: Progestin medications, such as medroxyprogesterone acetate or norethindrone, can help regulate the menstrual cycle and reduce heavy menstrual bleeding associated with fibroids. Progestins work by thinning the endometrial lining and reducing the growth of fibroids. They are available in oral form and may be prescribed for short-term or long-term use depending on the individual’s needs.
• Selective Progesterone Receptor Modulators (SPRMs): SPRMs, such as ulipristal acetate, are medications that specifically target the progesterone receptor in fibroid cells. SPRMs are typically used for a limited duration due to their potential impact on the endometrium and the need for regular monitoring.
• Nonsteroidal Anti-inflammatory Drugs (NSAIDs): NSAIDs, such as ibuprofen or naproxen, can manage pain associated with fibroids and reduce inflammation. They are over-the-counter and may be taken as needed or scheduled to provide symptomatic relief.
• Tranexamic Acid: Tranexamic acid is a medication that can manage heavy menstrual bleeding associated with fibroids. It works by helping to reduce blood loss during menstruation. Tranexamic acid is typically taken orally during the menstrual period.

OB/GYN and Women\'s Health

• Uterine Artery Embolization (UAE): UAE involves blocking the blood supply to the fibroids by injecting tiny particles into the uterine arteries. The fibroids shrink by cutting off the blood flow, and symptoms are relieved. An interventional radiologist performs this procedure, which can be an effective alternative to surgery.
• Magnetic Resonance-guided Focused Ultrasound Surgery (MRgFUS): MRgFUS uses high-intensity focused ultrasound waves to heat and destroy the fibroids. This non-invasive procedure is guided by MRI imaging, allowing for precise targeting and treatment. A radiologist performs MRgFUS and can provide symptom relief without incisions or hospitalization.
• Radiofrequency Ablation (RFA): RFA uses heat energy delivered through a needle-like probe to destroy the fibroid tissue. The probe is inserted into the fibroid, and radiofrequency energy is applied to heat and destroy the cells. RFA is typically performed under ultrasound guidance and can be an option for women who desire uterine preservation.
• Myolysis: Myolysis involves destroying or shrinking fibroids using various energy sources, such as laser or electric current. The energy is delivered directly to the fibroids, causing coagulation and necrosis. Myolysis can be performed laparoscopically or hysteroscopically.
• Hysteroscopic Myomectomy: Hysteroscopic myomectomy involves removing submucosal fibroids using a hysteroscope, a thin instrument inserted through the vagina and cervix. The fibroids are excised or resected, and the uterine cavity is restored.
• Laparoscopic or Robotic-assisted Myomectomy: These minimally invasive surgical procedures involve removing fibroids through small incisions in the abdomen using specialized instruments and a camera. Laparoscopic or robotic-assisted myomectomy allows for the precise removal of fibroids while preserving the uterus.

OB/GYN and Women\'s Health

• Assessment and diagnosis
• Symptom management
• Conservative management
• Medical therapy
• Minimally invasive procedure
• Surgical intervention
• Follow-up and maintenance