Signs and Symptoms of Uterine Fibroids

• Heavy menstrual bleeding (menorrhagia) - the most common symptom, especially with submucosal or intramural fibroids that distort the endometrial cavity
• Prolonged periods (bleeding lasting more than 7 days)
• Bleeding between periods (intermenstrual spotting)
• Chronic heavy bleeding can lead to iron-deficiency anemia, causing fatigue, weakness, dizziness, or shortness of breath

• A constant dull ache or sensation of pelvic pressure/fullness
• Dysmenorrhea (painful periods)
• Dyspareunia (pain during intercourse)
• Acute, sharp pain can occur if a fibroid outgrows its blood supply and undergoes degeneration ("red degeneration"), which can be sudden and severe
• Low back pain, particularly with large or posterior fibroids

• Frequent urination or urinary urgency (bladder compression)
• Difficulty fully emptying the bladder, or urinary retention in some cases
• Constipation or dyschezia (painful defecation) from rectal compression
• A palpable pelvic/abdominal mass or noticeable enlargement of the lower abdomen ("growing stomach area") in large fibroids

• Infertility or subfertility (particularly submucosal fibroids distorting the cavity)
• Recurrent miscarriage
• Obstetric complications: malpresentation, increased likelihood of cesarean section, preterm labor

• Pelvic exam may reveal an enlarged, irregularly shaped, firm, mobile uterus
• A fixed or retroverted uterus with associated dyspareunia and low back pain can suggest a differential diagnosis worth distinguishing (e.g., endometriosis)

Abnormal Uterine Bleeding (AUB)

Normal menstrual parameters (for reference)

FIGO PALM-COEIN Classification

• P - Polyp: endometrial or endocervical polyps
• A - Adenomyosis: endometrial glands/stroma within the myometrium; increasingly diagnosed pre-hysterectomy via ultrasound/MRI criteria
• L - Leiomyoma: uterine fibroids - the most common genital tract tumor (occurs in up to half of women over 35). Submucosal fibroids are most likely to cause bleeding; number/size doesn't strongly predict bleeding
• M - Malignancy and hyperplasia: unopposed estrogen exposure drives a spectrum from cystic/adenomatous hyperplasia to atypia to invasive carcinoma. Abnormal bleeding is the most frequent symptom of invasive cervical cancer - any visible cervical lesion needs biopsy rather than waiting on cytology results

• C - Coagulopathy: systemic bleeding disorders (e.g. von Willebrand disease)
• O - Ovulatory dysfunction: chronic anovulation (e.g. PCOS) causes unopposed estrogen and irregular endometrial buildup, leading to long cycles with heavy, prolonged, unpredictable bleeding
• E - Endometrial: primary disorders of endometrial hemostasis/local mechanisms causing heavy bleeding despite regular ovulatory cycles
• I - Iatrogenic: hormonal contraception (breakthrough bleeding), IUDs, anticoagulants
• N - Not yet classified: rare/poorly defined causes (e.g. arteriovenous malformations, cesarean scar defects)

Clinical approach

1. Exclude pregnancy first - AUB terminology does not apply to gestational bleeding
2. Structured history (bleeding pattern, associated symptoms) plus pelvic exam
3. Pelvic ultrasound is the initial imaging of choice; MRI or hysteroscopy for further characterization of structural lesions
4. Consider AUB-M workup (endometrial biopsy) in higher-risk patients: age over 45, obesity, diabetes, hypertension, PCOS, nulliparity, late menopause, unopposed estrogen exposure, tamoxifen use, or Lynch syndrome/family history of breast, colon, or endometrial cancer
5. Check CBC (anemia is common, especially with submucosal leiomyoma or proliferative endometrial causes) and coagulation studies if indicated
6. Direct management at the identified etiology