Uterine fibroids (leiomyomas): FIGO classification, assessment and medical management

A 41-year-old sits in your clinic with flooding periods, a palpable mass and an iron count that has crept down for two years. She has been told "it's just fibroids" and handed the pill. Your job is not to confirm the label — it is to map the FIGO type, decide whether the fibroid is even the driver of her bleeding, exclude pregnancy and malignancy, and build a goal-directed plan she can defend at her next visit. This topic is the assessment and medical management; the surgical and radiological options live in the dedicated surgical-management topic.^[3][4]

Overview and definition

A uterine leiomyoma (fibroid) is a benign, monoclonal neoplasm of myometrial smooth muscle, each surrounded by a fibrous extracellular matrix and a compressive pseudocapsule (compressed muscle, not a true anatomical capsule). They are the commonest benign solid neoplasm of women and the leading indication for hysterectomy worldwide.^[1][3]

Most are asymptomatic. When they declare themselves, the symptom is dictated almost entirely by location — which is why the FIGO subclassification is the first thing you reach for, not the size in centimetres.^[3][4]

References16ShowHide

1. [1]Stewart EA, Cookson CL, Gandolfo RA, Schulze-Rath R. Epidemiology of uterine fibroids: a systematic review BJOG, 2017.PMID 28296146
2. [2]Baird DD, Dunson DB, Hill MC, Cousins D, Schectman JM. High cumulative incidence of uterine leiomyoma in black and white women: ultrasound evidence Am J Obstet Gynecol, 2003.PMID 12548202
3. [3]American College of Obstetricians and Gynecologists (ACOG) Management of Symptomatic Uterine Leiomyomas: ACOG Practice Bulletin, Number 228 Obstet Gynecol, 2021.PMID 34011888
4. [4]Bajaj S, Gopal N, Clingan MJ, Bhatt S. A pictorial review of ultrasonography of the FIGO classification for uterine leiomyomas Abdom Radiol (NY), 2022.PMID 34581926
5. [5]Puri K, Famuyide AO, Erwin PJ, Stewart EA, Laughlin-Tommaso SK. Submucosal fibroids and the relation to heavy menstrual bleeding and anemia Am J Obstet Gynecol, 2014.PMID 24080304
6. [6]Donnez J, Tatarchuk TF, Bouchard P, et al. Ulipristal acetate versus placebo for fibroid treatment before surgery N Engl J Med, 2012.PMID 22296075
7. [7]Donnez J, Tomaszewski J, Vázquez F, et al. Ulipristal acetate versus leuprolide acetate for uterine fibroids N Engl J Med, 2012.PMID 22296076
8. [8]Al-Hendy A, Lukes AS, Poindexter AN 3rd, et al. Treatment of Uterine Fibroid Symptoms with Relugolix Combination Therapy N Engl J Med, 2021.PMID 33596357
9. [9]Al-Hendy A, Lukes AS, Poindexter AN 3rd, Venturella R, Villarroel C, McKain L, et al. Long-term Relugolix Combination Therapy for Symptomatic Uterine Leiomyomas Obstet Gynecol, 2022.PMID 36357960
10. [10]Yoon EL, Yuk JS. Use of Ulipristal Acetate and Risk of Liver Disease: A Nationwide Cohort Study J Clin Endocrinol Metab, 2021.PMID 33567071
11. [11]Dinis-Oliveira RJ, Vieira DN. Acute liver failure requiring transplantation: A possible link to ulipristal acetate treatment? Basic Clin Pharmacol Toxicol, 2021.PMID 34187080
12. [12]Gatti M, Poluzzi E, De Ponti F, Raschi E. Liver Injury with Ulipristal Acetate: Exploring the Underlying Pharmacological Basis Drug Saf, 2020.PMID 32748236
13. [13]Islam MS, Protic O, Giannubilo SR, et al. Uterine leiomyoma: available medical treatments and new possible therapeutic options J Clin Endocrinol Metab, 2013.PMID 23393173
14. [14]Gupta JK, Daniels JP, Middleton LJ, et al. A randomised controlled trial of the clinical effectiveness and cost-effectiveness of the levonorgestrel-releasing intrauterine system in primary care against standard treatment for menorrhagia: the ECLIPSE trial Health Technol Assess, 2015.PMID 26507206
15. [15]Edwards RD, Moss JG, Lumsden MA, et al. Uterine-artery embolization versus surgery for symptomatic uterine fibroids N Engl J Med, 2007.PMID 17251532
16. [16]Donnez J, Dolmans MM. Uterine fibroid management: from the present to the future Hum Reprod Update, 2016.PMID 27466209