Urinary Symptoms Fibroids may cause urinary symptoms, although few studies examined this association. Following uterine artery embolization with a 35% reduction in mean uterine volume, frequency and urgency were greatly or moderately improved in 68% of women, slightly improved in 18%, and unchanged or worse in only 14% (52). This finding suggests that increased uterine volume associated with fibroids is related to urinary symptoms.
Fourteen women with large fibroids and urinary symptoms were given six monthly injections of GnRH agonist (GnRH-a) with a resulting 55% decrease in uterine volume (53). Following therapy, urinary frequency, nocturia, and urgency decreased. There were no changes in urge or stress incontinence as measured by symptoms or urodynamic studies. It is not clear whether these findings are related to a decrease in uterine volume or to other effects of GnRH treatment.
Natural History of Fibroids
Most fibroids grow slowly. A prospective, longitudinal study of 72 premenopausal women (38 black, 34 white) using computer analysis of serial MRI found that the median growth rate was 9% over 12 months (17). However, multiple fibroids in the same individual were found to have highly variable growth rates, suggesting that growth results from factors other than hormone levels. After age 35, growth rates declined with age for white women but not for black women, which likely explains the increased fibroid-related symptoms noted in black women. Seven percent of fibroids regressed over the study period. Continued follow-up of these women is planned and should provide a better understanding of this important issue.
Rapid Fibroid Growth In premenopausal women, “rapid uterine growth” almost never indicates presence of uterine sarcoma. One study found only 1 sarcoma among 371 (0.26%) women operated on for rapid growth of presumed fibroids (54). No sarcomas were found in the 198 women who had a 6-week increase in uterine size over 1 year, which is the definition of rapid growth that was used in the past.
Uterine Sarcoma Women found to have uterine sarcoma are often clinically suspected of having a pelvic malignancy (54,55). Women with pain and bleeding and who are closer to menopause or postmenopausal may have a rare sarcoma. Of nine women found to have uterine sarcomas, all were postmenopausal and eight were admitted with abdominal pain and vaginal bleeding (55). All eight had presumed gynecologic malignancies: uterine sarcoma in four, endometrial carcinoma in three, and ovarian cancer in one. One additional woman had surgery for prolapse and a sarcoma was found incidentally (55). Between 1989 and 1999, the Surveillance, Epidemiology, and End Results (SEER) database reported 2,098 women with uterine sarcomas with an average age of 63 years, whereas a literature review found a mean age of 36 years in women subjected to myomectomy (54,56).
Pelvic Examination Clinically significant subserosal and intramural fibroids can usually be diagnosed by pelvic examination based on findings of an enlarged, irregularly shaped, firm and non-tender uterus (57). Uterine size assessed by bimanual examination, even for most women with BMI greater than 30, correlates well with uterine size and weight at pathological examination (58). Routine sonographic examination is not necessary when the diagnosis is almost certain. However, a definite diagnosis of submucous fibroids often requires saline-infusion sonography, hysteroscopy, or magnetic resonance imaging (MRI) (59).
Fibroid Location The FIGO fibroid classification system categorizes submucous, intramural, subserosal, and transmural fibroids.
Type 0 -intracavitary (e.g., a pedunculated submucosal fibroid entirely within the