Uterine fibroids are the most common female pelvic tumour, with a prevalence as high as 40% during the reproductive years and as high as 70 to 80% by age 50. Fibroids, which are almost always benign monoclonal tumours, arise from disordered smooth-muscle cells in the uterine myometrium. A variety of somatic mutations, especially of the MED12 gene on the X chromosome, have been described. Fibroids depend on oestrogen and progesterone and usually shrink after menopause. In early pregnancy and the postpartum period, however, they can grow rapidly.
The majority of fibroids are asymptomatic, but they can cause pelvic pressure, pain, and heavy uterine bleeding. Diagnosis is typically made by physical examination and confirmed by ultrasound. Although fibroids are not premalignant tumours, a uterine sarcoma can have similar symptoms at presentation.
Noninvasive, hormonally based anti-progesterone therapies such as oral ulipristal acetate (5 or 10 mg per day for 13 weeks) can reduce the size of fibroids, decrease dysfunctional uterine bleeding and pain, and improve overall quality of life. For persistent symptoms, surgical removal of the fibroid or of the uterus itself can be performed during laparotomy or by laparoscopic surgery. Power morcellation, a process by which the uterus is divided into smaller fragments that can be removed in stages laparoscopically, is no longer routinely recommended because of the small but finite risk of disseminating pieces of potentially malignant tissue found in a small percentage of fibroid uteruses. 16 Robotically assisted and laparoscopic hysterectomy have similar morbidity profiles, but the use of robotic technology results in substantially higher costs. Other strategies for the treatment of symptomatic uterine fibroids include uterine artery embolization, transvaginal temporary uterine artery occlusion, and MRI-guided focused ultrasound.