Uterine fibroids

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 10 Aug 2025

Last updated: 21 Jun 2024

Uterine fibroids are the most common benign uterine tumor and most common pelvic tumor in women.

Most are asymptomatic; however, can present with excessive uterine bleeding, symptoms secondary to pressure on bladder and rectum, and, less often, distortion of the uterine cavity, leading to miscarriage or infertility.

An enlarged irregular uterus may be found on examination and the woman may be anemic because of heavy menstrual bleeding.

Pelvic ultrasound usually shows well-circumscribed uterine tumors.

No treatment required if asymptomatic, but follow-up should be scheduled annually.

If symptomatic, definitive treatment is surgical, including hysterectomy if fertility is not desired or myomectomy to preserve fertility.

Nonsurgical treatments include uterine artery embolization, gonadotropin-releasing hormone agonists, hormones (birth control oral contraceptives pills or other delivery forms of hormones i.e.such as a transdermal patch, or implant), gonadotropin-releasing hormone antagonists plus hormonal add-back therapy, or symptomatic management with nonsteroidal anti-inflammatory drugs.

Definition

Uterine fibroids (leiomyomata) are benign tumors of the uterus primarily composed of smooth muscle and fibrous connective tissue.[1][2] They range in size from seedlings to large uterine tumors. Grossly, these tumors are round, firm, and well-circumscribed nodules located just under the uterine serosa (subserosal), within the myometrium (intramural) or just below the endometrium (submucosal). There are often multiple tumors in a single uterine specimen.[1] Microscopically, these nodules are made up of spindle-shaped cells with no mitotic activity or remarkable nuclear atypia.[3]

History and exam

Key diagnostic factors

asymptomatic
heavy menstrual bleeding
irregular firm central pelvic mass

Full details

Other diagnostic factors

pelvic pain
pelvic pressure
dysmenorrhea
bloating
fatigue and loss of productivity in working
infertility
urinary complaints
constipation
enlarged uterus (regular contour)
dyspareunia

Full details

Risk factors

increased patient weight
age in the 40s
black ethnicity
hypovitaminosis of vitamin D
hypertension
early menarche (under 10 years)
use of oral contraceptives (if started before age 16 years)
nulliparity
younger age at first birth
poor vitamin A intake
dietary intake high in beef and other red meat
sex hormone exposure
menstrual history
smoking
alcohol consumption

Full details

Diagnostic investigations

1st investigations to order

ultrasound
endometrial biopsy

Full details

Investigations to consider

sonohysterography
hysteroscopy
MRI
laparoscopy

Full details

Emerging tests

sonoelastography
MR elastography

Treatment algorithm

ONGOING

fertility desired

fertility not desired

Contributors

Authors

Ayman Al-Hendy, MD PhD FRCSC FACOG CCRP

Professor (visiting) and Director

Translational Research

Department of Obstetrics and Gynecology

University of Illinois

Chicago

Disclosures

AAH serves on the external advisory board of Bayer, AbbVie, Myovant, Pfizer, ObsEva and Allergan, and has received research funding from the National Institutes of Health. AAH is an author of references cited in this topic.

Obianuju Sandra Madueke-Laveaux, MD MPH

Assistant Professor of Obstetrics and Gynecology

Department of Obstetrics and Gynecology

University of Illinois

Chicago

Disclosures

OSML declares that she has no competing interests. OSML is an author of references cited in this topic.

Vuslat Lale Bakir, MD

Assistant Professor of Obstetrics and Gynecology

Department of Obstetrics and Gynecology

Haseki Training and Research Hospital

Health Sciences University

Istanbul

Turkey

Disclosures

VLB declares that she has no competing interests.

Acknowledgements

Dr Al-Hendy, Dr Madueke-Laveaux, and Dr Bakir would like to gratefully acknowledge Dr Mohamed Mitwally, Dr Intisar Elnahhas, and Dr Robert J. Fischer, the previous contributors to this topic.

Disclosures

MM, IE, and RJF declare that they have no competing interests.

Peer reviewers

Everett Magann, MD

Chairman

Department of Obstetrics and Gynecology

Naval Medical Center

Portsmouth

Disclosures

EM declares that he has no competing interests.

Amy Niederhauser, MD

Doctor

Department of Obstetrics and Gynecology

Naval Medical Center

Portsmouth

Disclosures

AN declares that she has no competing interests.

Adam Magos, BSc, MB, BS, MD, FRCOG

Consultant Gynaecologist

University Department of Obstetrics and Gynaecology

Royal Free Hospital

London

Disclosures

AM declares that he has no competing interests.

Peer reviewer acknowledgements

BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.

Disclosures

Peer reviewer affiliations and disclosures pertain to the time of the review.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Stewart EA, Cookson CL, Gandolfo RA, et al. Epidemiology of uterine fibroids: a systematic review. BJOG. 2017 Sep;124(10):1501-12.Full text Abstract

Marshall LM, Spiegelman D, Barbieri RL, et al. Variation in the incidence of uterine leiomyoma among premenopausal women by age and race. Obstet Gynecol. 1997 Dec;90(6):967-73. Abstract

American College of Obstetricians and Gynecologists. ACOG practice bulletin no. 228: management of symptomatic uterine leiomyomas. Jun 2021 [internet publication].Full text

Wise LA, Laughlin-Tommaso SK. Epidemiology of uterine fibroids: from menarche to menopause. Clin Obstet Gynecol. 2016 Mar;59(1):2-24.Full text Abstract

American College of Radiology. ACR Appropriateness Criteria®. Fibroids. 2022 [internet publication].Full text

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials
- Adenomyosis
- Endometrial polyp
- Endometrial hyperplasia
More Differentials
Guidelines
- ACR appropriateness criteria: clinically suspected adnexal mass
- ACR appropriateness criteria: fibroids
More Guidelines
Patient information
Fibroids
Fibroids: questions to ask your doctor
More Patient information
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Uterine fibroids

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Emerging tests

Treatment algorithm

fertility desired

fertility not desired

Contributors

Authors

Ayman Al-Hendy, MD PhD FRCSC FACOG CCRP

Disclosures

Obianuju Sandra Madueke-Laveaux, MD MPH

Disclosures

Vuslat Lale Bakir, MD

Disclosures

Acknowledgements

Disclosures

Peer reviewers

Everett Magann, MD

Disclosures

Amy Niederhauser, MD

Disclosures

Adam Magos, BSc, MB, BS, MD, FRCOG

Disclosures

Peer reviewer acknowledgements

Disclosures

References

Key articles

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials

Guidelines

Patient information

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice