Uterine fibroids: diagnosis, treatment, and when to refer in AU general practice

Uterine fibroids (leiomyomata) are the commonest pelvic tumour in women — benign, oestrogen- and progesterone-dependent smooth-muscle growths of the myometrium. Cumulative incidence by age 50 reaches approximately 70% in white women and 80% in women of African ancestry (Baird, AJOG 2003), with African ancestry conferring roughly three times the risk and earlier onset. Around 30% are ever clinically symptomatic. The rest are incidental findings on imaging or at autopsy.

The fundamental principle of fibroid management is to treat the symptom, not the image. An asymptomatic fibroid — even a sizeable one — does not require treatment unless it is causing hydronephrosis or has subfertility implications.

A. Core clinical — the AU general-practice framework

Classification under FIGO PALM-COEIN

Fibroids are classified under the FIGO PALM-COEIN system (Munro, IJGO 2011) as the “L” arm, with types L0–L7 describing location from pedunculated intracavitary submucosal (L0) through intramural (L4) to pedunculated subserosal (L7). This classification directly informs treatment choice:

• Submucosal fibroids (L0–L2): most likely to cause heavy menstrual bleeding and subfertility; best addressed by hysteroscopic resection
• Intramural fibroids (L3–L4): cause bulk symptoms and dysmenorrhoea; usually managed medically or with myomectomy
• Subserosal fibroids (L5–L7): produce pressure symptoms (urinary frequency, constipation); less associated with bleeding

History to take

• Bleeding pattern: heavy menstrual bleeding (flooding, clots, soaking more than one pad per hour, needing double protection), cycle duration and frequency, intermenstrual or post-coital bleeding (consider concurrent polyp or cervical pathology)
• Bulk symptoms: pelvic pressure or heaviness, increased abdominal girth, urinary frequency and nocturia from anterior fibroid pressure, constipation from posterior fibroids
• Pain: dysmenorrhoea, dyspareunia, acute pain suggesting degeneration or torsion of a pedunculated fibroid
• Fertility plans: current and future pregnancy intentions, previous gynaecological or obstetric history, recurrent miscarriage
• Systemic: fatigue, dyspnoea on exertion, pallor — signs of iron-deficiency anaemia from chronic blood loss

A screening question often reveals that women have normalised severe symptoms for years before presenting.

Examination

• General: pallor, BMI
• Abdominal: palpable suprapubic mass (uterus larger than 12-week gestational size is usually abdominally palpable); rapidly enlarging or fixed mass is a red flag
• Bimanual pelvic: uterine size, lobulated contour, mobility, adnexal mass
• Speculum: assess cervix, confirm cervical screening status

Investigations

First-line in general practice:

• Transvaginal ultrasound (TVUSS) — documents fibroid number, size, FIGO L-type, cavity distortion, and endometrial thickness. Sensitivity approximately 95% for fibroids ≥3 cm
• FBC and ferritin — iron-deficiency anaemia is common and may be clinically silent
• Beta-hCG — exclude pregnancy before starting hormonal therapy
• TSH — thyroid dysfunction contributes to heavy menstrual bleeding and can coexist

Second-line / specialist-directed:

• Saline-infusion sonohysterography — distinguishes submucosal fibroid from endometrial polyp; maps cavity for hysteroscopic planning
• Pelvic MRI — gold standard before UAE, MRgFUS, or complex myomectomy; also the best modality for distinguishing fibroid from adenomyoma
• Endometrial sampling — indicated in heavy menstrual bleeding age ≥45, anovulatory pattern, persistent intermenstrual bleeding, BMI ≥30, tamoxifen use, or any postmenopausal bleeding

Red flag: rapidly enlarging mass in a postmenopausal woman should prompt urgent MRI — this pattern raises the possibility of leiomyosarcoma, which occurs in approximately 0.1% of women operated on for presumed fibroids (Pritts, AJOG 2015) but carries a five-year survival of 40–60%.

B. Medical management — the AU guideline hierarchy

Per RANZCOG C-Gyn 16 (2024 update) and eTG Reproductive health:

First-line for heavy menstrual bleeding and dysmenorrhoea

Tranexamic acid 1 g four times daily on days of heavy flow (up to five days per cycle) — antifibrinolytic; reduces menstrual blood loss by 30–50%; non-hormonal; avoid in VTE history; PBS general schedule.

NSAIDs (mefenamic acid 500 mg three times daily, naproxen 500 mg twice daily) during menstruation — reduce prostaglandin-driven bleeding and dysmenorrhoea by approximately 30%; useful for concomitant pain.

LNG-IUS (Mirena) — PBS Authority Streamlined for heavy menstrual bleeding with contraception; reduces menstrual blood loss by up to 90% through endometrial atrophy. Critical caveat: may be displaced or fail to seat when the cavity is significantly distorted by submucosal fibroids (L0–L2) — confirm cavity shape with TVUSS or saline-infusion sonohysterography before insertion.

Combined oral contraceptive pill (COCP), progestogen-only pill, or depot medroxyprogesterone — moderate bleeding reduction; use WHO Medical Eligibility Criteria; avoid COCP if age >35 plus smoking, migraine with aura, or VTE history.

Fibroid-specific medical therapy (specialist-initiated; GP can continue)

Relugolix–estradiol–norethisterone (Ryeqo) 40/1/0.5 mg daily — oral GnRH receptor antagonist with integrated hormone add-back. The LIBERTY 1 and 2 RCTs (Al-Hendy, NEJM 2021) demonstrated that 73% of women achieved ≥50% reduction in menstrual blood loss at 24 weeks versus 19% with placebo, with bone density preserved. PBS Authority Streamlined since June 2024 for heavy menstrual bleeding associated with uterine fibroids; maximum 24-month total exposure; check VTE history and hepatic function before prescribing.

GnRH agonist (leuprorelin depot, goserelin SC depot) — PBS Authority Required for three-to-six months pre-operatively to shrink fibroids and correct anaemia; HRT add-back mandatory beyond six months to prevent bone loss per RCOG Green-top (2015) and AMH.

Note: Ulipristal acetate (Esmya) is no longer first-line following the TGA hepatotoxicity advisory (2020) — access only via specialist exemption.

C. Procedural options

Uterine-artery embolisation (UAE): Interventional radiology procedure; occludes both uterine arteries with microspheres, causing fibroid infarction. The REST RCT (Edwards, NEJM 2007) and EMMY trial demonstrated approximately 80% symptom control with shorter recovery than surgery, but approximately 20% reintervention by five years. Endorsed by RANZCOG (2024) for women not planning future pregnancy. Fertility outcomes after UAE are less favourable than after myomectomy — a fertility specialist’s input is important when conception is planned.

MR-guided focused ultrasound (MRgFUS): Non-invasive thermal ablation; available in limited Australian centres. Best suited to single, accessible fibroids.

Hysteroscopic myomectomy: Gold standard for submucosal L0–L2 fibroids; preserves fertility; best results when fibroid diameter is under 5 cm with at least 5 mm myometrial rim.

Laparoscopic or open myomectomy: Fertility-preserving for intramural and subserosal disease. Approximately 15% recurrence at five years; 25% require further surgery at ten years per RCOG (2015). Caesarean section is recommended for subsequent pregnancies if the uterine cavity was breached.

Hysterectomy: The only intervention that guarantees no recurrence. Consider when family is complete, symptoms are severe, or conservative measures have failed. Discuss opportunistic bilateral salpingectomy at the time (reduces future ovarian cancer risk) per RANZCOG guidance.

Uterine power morcellation: TGA-restricted since 2014 because of the risk of disseminating an occult leiomyosarcoma. If morcellation is required, a containment system is mandatory and the patient requires explicit counselling.

D. Australian operations

MBS items relevant to fibroid management:

• Transvaginal ultrasound (items 55065/55070), saline-infusion sonohysterography (55066), pelvic MRI (63461)
• FBC (65070), ferritin (66596), TSH (66716), endometrial biopsy (35727), diagnostic hysteroscopy (35691)
• IUD insertion/removal (items 35503/35506)
• GPCCMP item 965 / review 967 — fibroids with chronic anaemia, chronic pelvic pain, or perimenopausal comorbidity qualify
• Mental Health Care Plan item 2715 / review 2717 — QoL impact of heavy bleeding and bulk symptoms
• Telehealth (item 91790 and equivalents) — review consultations; in-person required for examination, IUD insertion, and procedures

PBS highlights: tranexamic acid (general schedule); NSAIDs (general / OTC); Mirena (Authority Streamlined for HMB + contraception); leuprorelin/goserelin (Authority Required pre-operative); Ryeqo (Authority Streamlined since June 2024); ferric carboxymaltose (Authority Required for iron infusion); oral HRT add-back for women on GnRH agonists (general schedule).

E. Special populations

Women planning pregnancy: Fertility is best preserved with hysteroscopic myomectomy (L0–L2) or laparoscopic/open myomectomy rather than UAE. Submucosal fibroids (L0–L2) are the subset with evidence of impaired implantation and recurrent miscarriage — these warrant specialist referral even if asymptomatic when pregnancy is planned.

Pregnancy with known fibroids: Most fibroids are managed conservatively in pregnancy. Red degeneration — central infarction causing acute severe pain, usually at 12–22 weeks — is treated with analgesia and observation. Fibroids are associated with higher rates of caesarean section, malpresentation, placenta praevia, and preterm labour; obstetric-led shared care is appropriate for significant fibroids.

Postmenopausal women: Fibroids typically regress after menopause as oestrogen falls. HRT generally does not cause significant fibroid growth, but postmenopausal bleeding in a woman with known fibroids requires endometrial sampling — fibroids do not explain postmenopausal bleeding. Rapid postmenopausal fibroid growth on imaging is a red flag for sarcoma.

Women of African ancestry: Present on average a decade earlier than white women, with larger and more numerous fibroids, greater symptom burden, higher rates of iron-deficiency anaemia, and higher rates of hysterectomy. Proactive screening for iron deficiency and early specialist discussion of fertility-preserving options are warranted.

When to escalate

Refer urgently to the emergency department or same-day specialist contact for:

• Haemodynamic instability from acute haemorrhage
• Suspected acute torsion of a pedunculated fibroid (acute severe pain)
• Suspected leiomyosarcoma (rapidly enlarging mass, especially postmenopausal)
• New postmenopausal bleeding with a known fibroid — endometrial sampling is required

Refer routinely to gynaecology for:

• Symptomatic fibroids not controlled by first-line medical therapy
• Submucosal L0–L2 fibroids with subfertility or significant heavy menstrual bleeding
• Large bulk symptoms with urological or bowel compression
• Heavy menstrual bleeding age ≥45 with risk factors for endometrial pathology (endometrial sampling before any procedural intervention)

What this article is and is not

This is general health information drawn from current Australian guidelines — RANZCOG C-Gyn 16 (2024), eTG, AMH, RACGP, and international sources including NICE NG88 and RCOG Green-top. It is not personal medical advice and does not create a doctor–patient relationship. Decisions about specific treatment, including procedural options and fertility planning, are made with your own GP and treating specialists.

For Australian consumer-friendly resources: Jean Hailes — Fibroids, HealthDirect — Fibroids, and Better Health Channel — Uterine fibroids.

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Sources cited

1. RANZCOG — Uterine fibroids C-Gyn 16 (2024 update)
2. Therapeutic Guidelines (eTG) — Reproductive health
3. Australian Medicines Handbook (AMH)
4. RACGP — Women’s health resources
5. NICE NG88 — Heavy menstrual bleeding (2018, updated 2021)
6. RCOG Green-top — Management of uterine fibroids (2015)
7. Al-Hendy A et al. — LIBERTY 1 and 2 (relugolix combination), NEJM 2021
8. Edwards RD et al. — REST trial (UAE vs hysterectomy), NEJM 2007
9. Munro MG et al. — FIGO PALM-COEIN classification, IJGO 2011
10. Baird DD et al. — Cumulative incidence of fibroids, AJOG 2003
11. Pritts EA et al. — Prevalence of occult leiomyosarcoma, AJOG 2015
12. TGA — Power morcellator advisory (2014, updated 2020)
13. Jean Hailes — Fibroids
14. HealthDirect — Fibroids
15. Better Health Channel — Uterine fibroids