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Uterine Fibroid

Uterine Leiomyoma

Uterine fibroids are common benign tumors of myometrial origin. Symptomatic fibroids cause abnormal uterine bleeding.


Presentation

One of the main complaints of women with symptomatic fibroids is abnormal uterine bleeding, which is characterized by heavy blood loss. Also, these patients may experience acute or chronic pelvic pressure as the tumors enlarge, degenerate or twist. Furthermore, symptoms such as urinary frequency and urgency, and constipation may be observed. These are attributed to compression of bladder and intestines, respectively. In fact, large fibroids can reflect in abdominal fullness distorting the abdomen. Very large leiomyomata can project an outward appearance resembling that of pregnancy [18]. 

The size, number, and location of fibroid(s) contribute to the likelihood of a symptomatic clinical picture. That being said, many are actually small and symptomatic. Also, they can shrink or enlarge.

Pleural Effusion
  • A 51-year-old woman presented with dyspnoea due to pleural effusion, which repeatedly reaccumulated rapidly after tapping. A pelvic mass was present and she was considered to have disseminated ovarian malignant tumour.[ncbi.nlm.nih.gov]
Anemia
  • These all […] Learn more Can Fibroids Cause Anemia? Anemia occurs when the amount of blood the body loses is greater than its ability to replace lost blood cells.[fibroids.com]
  • The most frequent symptoms are pelvic pain and heavy menstrual bleeding resulting in anemia. The role of fibroids in infertility remains debated but probably mostly related to submucosal location due to implantation impairment.[ncbi.nlm.nih.gov]
  • Tips for preventing anemia Anemia occurs when your body cannot produce blood as fast as it is being lost. As a result, you have fewer red blood cells in the blood. A test called a complete blood count (CBC) can tell you whether you have anemia.[cigna.com]
  • Treat underlying anemia with iron supplements and monitor for improvement. Malignancy Uterine leiomyomas are typically benign. They rarely undergo malignant transformation and develop into sarcomas.[symptoma.com]
Inguinal Hernia
  • A bulging 5 x 5 cm tender mass appearing intermittently in the left groin in association with vigorous physical activity between 20 and 24 weeks' gestation was thought clinically and ultrasonographically to represent an inguinal hernia.[ncbi.nlm.nih.gov]
Constipation
  • A 48-year-old nulliparous presented with a two-day history of abdominal pain, bloating, constipation, and menorrhagia. Within eight hours, her distress level increased.[ncbi.nlm.nih.gov]
  • This can include questions about urinary issues, constipation, fertility issues, abdominal pressure or pain, painful menses, and pain during intercourse.[medbroadcast.com]
  • When the colon is compressed, this can cause constipation. Both constipation and bloating can cause pain and discomfort. Other Symptoms While many women with uterine fibroids are asymptomatic, others experience serious complications.[alatehealth.com]
  • Symptoms include: heavier than usual menstrual bleeding bleeding between periods abdominal swelling feeling of pelvic pressure or heaviness urge to pass urine (as fibroid presses on bladder) feeling of constipation (as fibroid presses on bowel) difficulty[gain.org.au]
Pelvic Mass
  • A pelvic mass was present and she was considered to have disseminated ovarian malignant tumour. Total hysterectomy with bilateral salpingo-oophorectomy was performed, and the tumour was shown to be a necrotic uterine fibromyoma.[ncbi.nlm.nih.gov]
  • A pelvic mass was felt, and computed tomography demonstrated a 13-cm hypodense multilocular cystic mass adjacent to the uterus. The anterior wall of the cyst was thinned and discontinued, suggesting rupture of the cyst.[ncbi.nlm.nih.gov]
  • Clinical presentations include abnormal bleeding, pelvic masses, pelvic pain, infertility, bulk symptoms and obstetric complications.Almost a third of women with leiomyomas will request treatment due to symptoms.[ncbi.nlm.nih.gov]
  • Figure 5 Pelvic computerized tomography revealed a lobulated pelvic mass, a low attenuation-filling continued defect within right internal iliac vein . RIIV: right internal iliac vein.[cardiovascularultrasound.biomedcentral.com]
  • This, along with an abdominal examination, may indicate a firm, irregular pelvic mass to the physician.[stanfordchildrens.org]
Lower Abdominal Pain
  • We present a case of a 37-year-old white nullipara who presented in the emergency room with acute, lower-abdominal pain which reportedly started after riding over a bump on a motorcycle.[ncbi.nlm.nih.gov]
  • abdominal pain; increase in size around the waist and change in abdominal contour...[emedicinehealth.com]
Abdominal Mass
  • A 35-year-old woman presented with an abdominal mass found incidentally on an ultrasound scan. On examination, the uterus was mobile and 14 weeks in size.[ncbi.nlm.nih.gov]
Low Back Pain
  • The patient was a 44-year-old woman who presented with low back pain and left leg pain. Examination suggested lumbar radiculopathy but lumbar magnetic resonance imaging was negative with the exception of a large mass in the pelvis.[ncbi.nlm.nih.gov]
  • We report the case of a 55-yr-old woman with a history of chronic low back pain who presented with progressive right buttock and posterolateral right lower limb pain associated with right foot numbness and tingling.[ncbi.nlm.nih.gov]
  • A feeling of fullness in the lower abdomen Frequent urination resulting from a fibroid that compresses the bladder Pain during sexual intercourse Low back pain Constipation Chronic vaginal discharge Inability to urinate Severe menstrual cramps Infertility[my.clevelandclinic.org]
  • But because estrogen levels can rise during the early menopausal years, previously asymptomatic fibroids may grow in the years just before the cessation of menses, resulting in symptoms such as feeling of heaviness in the belly, low back pain, pain with[womenlivingnaturally.com]
Radiculopathy
  • In a female patient with suspected radiculopathy, in whom lumbar imaging is negative, or who does not respond as expected to treatment, UF should be considered.[ncbi.nlm.nih.gov]
  • The patient was initially treated for a probable right lumbosacral radiculopathy, without improvement.[ncbi.nlm.nih.gov]
Pelvic Pain
  • Although most fibroids are asymptomatic, about 25% are associated with symptoms that can have a significant impact on patient's quality of life, including prolonged or excessive menstrual bleeding, pelvic pain or bulkiness, dyspareunia, increased urinary[ncbi.nlm.nih.gov]
  • UFs are usually asymptomatic but at times can produce symptoms such as excessive menstrual bleeding, intermenstrual bleeding, dysmenorrhea, pelvic pain, pelvic pressure, bloating, dyspareunia, urinary and bowel disturbance, subfertility, and pregnancy-related[ncbi.nlm.nih.gov]
  • The most frequent symptoms are pelvic pain and heavy menstrual bleeding resulting in anemia. The role of fibroids in infertility remains debated but probably mostly related to submucosal location due to implantation impairment.[ncbi.nlm.nih.gov]
  • After UFE, patients can reasonably expect resolution of symptoms such as menorrhagia, pelvic pressure, and pelvic pain.[ncbi.nlm.nih.gov]
  • Post-embolization pelvic pain (according with VAS score) was on average 2.2 at discharge (24 h).[ncbi.nlm.nih.gov]
Vaginal Bleeding
  • One-month after the procedure she developed massive vaginal bleeding and required an emergency hysterectomy. Pathologic evaluation of the uterus revealed ulceration of the endometrium overlying the necrotic fibroid.[ncbi.nlm.nih.gov]
  • Menstrual bleeding soaking through more than 3 pads per hour Severe or prolonged pelvic or abdominal pain Dizziness , lightheadedness, shortness of breath, or chest pain associated with vaginal bleeding Vaginal bleeding associated with pregnancy or possible[emedicinehealth.com]
  • However, some become symptomatic and may lead to: Excessive uterine bleeding Painful and prolonged menstrual periods Vaginal bleeding after menopause Difficulty with urination and constipation Pressure in the pelvic area Fullness or pressure in the belly[bostonscientific.com]
  • Around 30% of the women face complications in pregnancy such as abdominal pains along with vaginal bleeding. Unless your bleeding is substantial, your baby will be rarely affected.[momjunction.com]
Enlarged Uterus
  • Pelvic magnetic resonance imaging revealed a markedly enlarged uterus with multiple fibroids. The patient had laparoscopic hysterectomy with postoperative resolution of patient's symptoms and improved uroflow studies.[ncbi.nlm.nih.gov]
  • A magnetic resonance image of the pelvis revealed a markedly enlarged uterus, with a large pedunculated myoma impinging on the right sciatic foramen.[ncbi.nlm.nih.gov]
  • Two of the most common uterine symptoms of premenopause syndrome are an enlarged uterus and uterine fibroids.[womenlivingnaturally.com]
  • Enlarged uterus may be as big as term pregnancy.[slideshare.net]
Dysmenorrhea
  • UFs are usually asymptomatic but at times can produce symptoms such as excessive menstrual bleeding, intermenstrual bleeding, dysmenorrhea, pelvic pain, pelvic pressure, bloating, dyspareunia, urinary and bowel disturbance, subfertility, and pregnancy-related[ncbi.nlm.nih.gov]
  • Fibroids inside the uterus wall however may cause heavy bleeding (menorrhagia), painful periods ( dysmenorrhea ) as well as irregular or prolonged menstrual cycles ( oligomenorrhea ).[womens-health-advice.com]
  • Women with PMS often experience painful periods (dysmenorrhea) which are most often caused when the industrial lining of the uterus extends into the muscular wall of the uterus (adenomyosis).[womenlivingnaturally.com]
  • The most common symptoms are heavy cyclical menstrual bleeding (menorrhagia) accompanied by menstrual pain (dysmenorrhea).[newyorkfertilityservices.com]
  • The mass of the fibroids can also cause other painful symptoms including: Pelvic pain Abdominal pain Sudden or severe abdominal pain Fever Pain with intercourse ( dyspareunia ) Pain during menstruation (dysmenorrhea) Lower back and thigh pain Pain that[nezhat.org]
Dyspareunia
  • Although most fibroids are asymptomatic, about 25% are associated with symptoms that can have a significant impact on patient's quality of life, including prolonged or excessive menstrual bleeding, pelvic pain or bulkiness, dyspareunia, increased urinary[ncbi.nlm.nih.gov]
  • UFs are usually asymptomatic but at times can produce symptoms such as excessive menstrual bleeding, intermenstrual bleeding, dysmenorrhea, pelvic pain, pelvic pressure, bloating, dyspareunia, urinary and bowel disturbance, subfertility, and pregnancy-related[ncbi.nlm.nih.gov]
  • Additionally, women with uterine fibroids may suffer more often from dyspareunia and non-cyclic pelvic pain [ 27 ].[bmcwomenshealth.biomedcentral.com]
  • […] menomettrorhagia).Sustained non-menstrual pelvic pain may point to tortion of a pedunculated fibroid that is attached to the inner or outer wall of the uterus, or to degeneration, Other possible symptoms include pain with deep penetration during intercourse (deep dyspareunia[newyorkfertilityservices.com]
  • Fibroids can cause abnormal uterine bleeding, pelvic pressure, bowel dysfunction, urinary frequency and urgency, urinary retention, low back pain, constipation, and dyspareunia. Ultrasonography is the preferred initial imaging modality.[aafp.org]

Workup

Any woman with increased uterine bleeding warrants a comprehensive history including detailed information about menstrual and bleeding pattern and quantity. Also, they should be assessed for anemia through history and exam findings. In addition, a bimanual exam is very important. A clinician may notice an enlarged uterus and/or palpate actual fibroids (if located on the outer uterus).

In patients with heavy bleeding (acute or chronic) and/or symptomatic anemia, obtain complete blood count to assess hemoglobin and hematocrit. Other laboratory work may be indicated as well.

Imaging is a key component of the workup. Vaginal and abdominal ultrasonography is the imaging of choice. Other modalities include sonohysterography, hysteroscopy, and MRI. Sonohysterography and hysteroscopy may be useful to visualize submucosal fibroids but they are invasive [19]. MRI can be beneficial in surgery planning since it provides precise mapping although images of the fibroids may be limited since they share attenuation features as the myometrium. Calcifications are also usually seen on CT.

Erythrocytosis
  • Both hyperprolactinemia and erythrocytosis unexpectedly regressed completely after the patient underwent hysterectomy for a uterine fibroid 9 months after the erythrocytosis was first disclosed.[ncbi.nlm.nih.gov]
  • Cerebral vein thrombosis is a potential complication of uterine fibroids with erythrocytosis.[ncbi.nlm.nih.gov]
Ovarian Mass
  • The subserosal fibroid can develop a stalk or stem-like base, making it difficult to distinguish from an ovarian mass. These are called pedunculated. The correct diagnosis can be made with either an ultrasound or magnetic resonance (MR) exam.[thegvi.com]
  • Hysterectomy with removal of the Fallopian tubes and ovaries (called a salpingo- oophorectomy ) may be indicated if there is suspicion of cancer or if ovarian masses are present.[emedicinehealth.com]
Pleural Effusion
  • A 51-year-old woman presented with dyspnoea due to pleural effusion, which repeatedly reaccumulated rapidly after tapping. A pelvic mass was present and she was considered to have disseminated ovarian malignant tumour.[ncbi.nlm.nih.gov]

Treatment

There are numerous treatment options for women with symptomatic fibroids. These include both surgical and nonsurgical interventions. When planning management with the patient, a clinician should consider the severity of symptoms, whether the patient wants to seek treatment and which intervention she prefers. The clinician should determine whether the patient has completed childbearing, if she is seeking fibroid treatment for fertility purposes, whether she has had previous surgeries, and if the patient has any contraindications to surgery or medical therapy. Many patients will have comorbidities such as hypertension, diabetes mellitus or obesity which can influence the decision making. All of these factors will help clarify the best treatment plan for the patient.

Surgical interventions

Hysterectomy is typically the treatment for women who do not want to preserve childbearing. If the uterus is removed, the patient avoids recurrent fibroids [20]. This can be performed laparoscopically or abdominally. The former is minimally invasive.

There are uterine sparing interventions that are available for women whether they seek to protect their fertility or not [21]. Black women are found to favor this option [22]. Myomectomy involves resection of fibroids, which can debulk the uterus and improve bleeding. However, there is a risk of recurrence. In fact, 10 to 25% will needed additional fibroid surgery. Endometrial ablation an intra-uterine procedure that removes the uterus lining. While this does not remove or minimize the fibroid(s), it may reduce or stop bleeding altogether. Women who undergo ablation should not have future pregnancies.

Drug treatments

There are various drug options available for those who are poor surgical candidates or opt for medications. Nonsteroidal anti-inflammatory drugs (NSAIDs) are beneficial for alleviating cramps and heavy flow. In addition, gonadotropin-releasing hormone analogue (GnRH) therapy may be an alternative to surgery since it mimics a menopausal state and helps shrink the fibroids. Treat underlying anemia with iron supplements and monitor for improvement. 

Prognosis

Malignancy

Uterine leiomyomas are typically benign. They rarely undergo malignant transformation and develop into sarcomas. In fact, the exact number that do is not clear since fibroids are very common unlike sarcomas, which may emerge de novo. Estimated incidence is as low as 0.2%.

Fertility

While most women with fibroids do not experience fertility issues, the location of these tumors can affect reproduction. For example, fibroids in the uterine cavity can compromise the ability to conceive. In fact, they may cause miscarriages. Surgical resection of this type can result in successful fertility. Leiomyomata on the outer wall of the uterus mildly reduce fertility. However, surgical removal does not necessarily improve fertility. Fibroids do not usually result in pregnancy complications, but large fibroids greater than 5cm may.  

Etiology

While the cause of fibroids has not been fully elucidated, it seems that they arise from a unicellular origin [1]. Furthermore, monoclonal proliferation of smooth muscle cells is seen histologically. The composition of these benign tumors are smooth muscle and fibrous tissue.

Some women may have predisposing genes [2] [3]. There may be a genetic component in tumor development as mutations in uterine muscle have been suggested [4]. But there is a multifactorial component promoting the growth of leiomyomata.

Reproductive and environmental factors are linked to the risk of developing fibroids. For example, higher parity [5] [6] and the use of progestin only injectable contraceptives are factors associated with a reduced risk [5] [6] [7]. Conversely, early menarche and the initiation of oral contraceptives prior to 16 years of age are correlated with a greater risk of forming fibroids [5] [6] [7].

Dietary risk factors also exist. A decreased risk is found in patients who incorporate a diet rich with fruits, vegetables, and low fat dairy [8]. A high body mass index (BMI) elevates risk [9] and has been observed in patient with fibroids.

Epidemiology

Fibroids are the most common tumors in the female reproductive tract. Approximately 70% of women will have uterine fibroid(s) by the age of 45 years. 

Race

Increased incidence of fibroids in black women has been demonstrated [10]. Furthermore, black women exhibit bigger and more symptomatic fibroids than white women [11] [12] [13] [14] [15]. 50% of black women and 25% of white women experience symptoms.

Risk factors

Women with hypertension [16] and high BMI are observed to be at greater risk of fibroid formation.

Protective factors

Parturition and cigarette smoking are associated with decreased risk.

Sex distribution
Age distribution

Pathophysiology

These benign tumors emerge during reproductive age as evidenced by a complex interplay between estrogen and progesterone on the influence of fibroids. They develop and grow during fertility years but regress during menopause. Comparison of estrogen and progesterone receptors on fibroid cells and uterine cells showed that cells of the former exhibit more hormone receptors, hence they have a capability to increase in size [17]. In addition to these two hormones, insulin like growth factor (IGF-1) [4] and growth hormone also contribute to the development of leiomyomata.

Fibroids are categorized according to their location in the uterus. In order of decreasing frequency, they are called: subserosal, intramural, and submucosal fibroids. Subserosal fibroids may be pedunculated. In addition, this type is found on extrauterine sites. Generally, any type can undergo changes such as degeneration, atrophy, hemorrhage, calcification, or fibrosis.

There are varying sizes that range from very small to extremely large. Sometimes, fibroids develop in other parts of the reproductive tract such as the broad ligaments, fallopian tubes, or even cervix.

Prevention

Dietary modifications may help reduce the risk of developing leiomyomata. One study showed that intake of pork and beef is associated with these tumors whereas vegetables provided protection [8]. Furthermore, food with a high glycemic index (GI) such as white rice, white breads, donuts and others elevate serum glucose level. This leads to the increase in IGF-1. Note from earlier discussion that this can stimulate fibroid growth.

One study showed that vitamin D plays a role in inhibiting growth, thus insufficient amounts of this vitamin may raise the risk of developing the benign tumors [23]. Another study explored the fibroid risk with intake of fruits, vegetables, and carotenoids. The results showed a lower risk in women with higher intake of fruit and retinol [8]. Furthermore, lower dairy consumption may be associated with higher risk [24]. 

Modifying diet by consuming vegetables, fruits, and dairy products can reduce the risk of fibroid formation but additional benefits include potential weight loss and improvement in hypertension, thus addressing other risk factors. 

Summary

Uterine leiomyomas (or uterine fibroids) are the most common tumors in the female genital tract. They are benign and rarely become malignant sarcomas. Fibroids are composed primarily of smooth muscle as well as fibrous tissue. In fact, they basically grow from the uterine muscle.

While genetic mutations have been associated with development of this benign tumor, the cause is likely multifactorial. There are established risk factors such as black race, obesity, hypertension, nulliparity, and family history.

Fibroids are under the influence of estrogen and progesterone and hence occur during reproductive years. While many leiomyomata are small and asymptomatic, an increase in size and number of the benign tumors tends to cause symptoms. The clinical presentation consists of abnormal uterine bleeding, pelvic pressure, urinary and/or abdominal symptoms.

There are surgical and drug therapies available to treat symptomatic women. The management is tailored for each patient since medical and personal factors play in role in the decision making.

Patient Information

Uterine fibroids, also called uterine leiomyomas, are benign tumors that arise from the muscle of the uterus. They usually do not become malignant. Most women will have these tumors as they are very common in women of reproductive age. In fact, they are found in about 70% of women by age of 45. There are risk factors that increase the possibility of developing fibroids such as obesity, black race, never had children, positive family history, and having high blood pressure.

Many fibroids are small and do not produce symptoms. Patients with large and/or many fibroids have a higher chance of having symptoms. The biggest complaints include heavy bleeding, increased urinary frequency and/or urgency, constipation, abdominal fullness, and pelvic pressure or pain.

Diagnosis is done through an ultrasound that is performed vaginally and abdominally. Also, your doctor may be able to feel the fibroid(s) and diagnose this during a pelvic exam. 

There are a number of ways to treat fibroids that cause symptoms. In women who have completed child bearing, they can opt for a hysterectomy, which is a surgery in which the uterus is removed. The surgery could be done with minimal invasiveness. Women who want to keep their uterus and/or preserve fertility can have other procedures such as a myomectomy, which is removal of the fibroid. 

For those are not good candidates for surgery or just do not want it altogether, there may be drug therapies that can help shrink the fibroids. The patient and her doctor will discuss all appropriate options and together decide what the best plan is. 

References

Article

  1. Hashimoto K, Azuma C, Kamiura S, Kimura T, Nobunaga T, Kanai T, et al. Clonal determination of uterine leiomyomas by analyzing differential inactivation of the X-chromosome-linked phosphoglycerokinase gene. Gynecologic and Obstetrical Investigation. 1995;40(3):204–8.
  2. Mäkinen N, Mehine M, Tolvanen J, et al. MED12, the mediator complex subunit 12 gene, is mutated at high frequency in uterine leiomyomas. Science. 2011;334(6053):252-255.
  3. Eggert SL, Huyck KL, Somasundaram P, et al. Genome-wide linkage and association analyses implicate FASN in predisposition to uterine leiomyomata. American Journal of  Human Genetics. 2012;91(4):621-628.
  4. Vollenhoven BJ, Herington AC, Healy DL. Messenger ribonucleic acid expression of the insulin-like growth factors and their binding proteins in uterine fibroids and myometrium. J Clin Endocrinol Metab. 1993 May;76(5):1106-10. 
  5. Marshall LM, Spiegelman D, Goldman MB, et al. A prospective study of reproductive factors and oral contraceptive use in relation to the risk of uterine leiomyomata. Fertility and Sterility. 1998;70(3):432-439.
  6. Wise LA, Palmer JR, Harlow BL, et al. Reproductive factors, hormonal contraception, and risk of uterine leiomyomata in African-American women: a prospective study. American Journal of Epidemiology. 2004;159(2):113-123.
  7. Hodge JC, T Cuenco K, Huyck KL, et al. Uterine leiomyomata and decreased height: a common HMGA2 predisposition allele. Hum Genetics. 2009;125(3):257-263.
  8. Wise LA, Radin RG, Palmer JR, Kumanyika SK, Boggs DA, Rosenberg L. Intake of fruit, vegetables, and carotenoids in relation to risk of uterine leiomyomata. American Journal of Clinical Nutrition. 2011;94(6):1620-1631.
  9. Wise LA, Palmer JR, Spiegelman D, et al. Influence of body size and body fat distribution on risk of uterine leiomyomata in U.S. black women. Epidemiology. 2005;16(3):346-354.
  10. Wise LA, Palmer JR, Stewart EA, Rosenberg L. Age-specific incidence rates for self-reported uterine leiomyomata in the Black Women's Health Study. Obstetrics and Gynecology. 2005;105(3):563–8.
  11. Kjerulff KH, Langenberg P, Seidman JD, Stolley PD, Guzinski GM. Uterine leiomyomas. Racial differences in severity, symptoms and age of diagnosis. Journal of Reproductive Medicine. 1996;41(7):483–90.
  12. Ross RK, Pike MC, Vessey MP, Bull D, Yeates D, Casagrande JT. Risk factors for uterine fibroids: reduced risk associated with oral contraceptives. British Medical Journal (Clinical research ed). 1986;293(6543):359-362.
  13. Ligon AH, Morton CC. Leiomyomata: heritability and cytogenetic studies. Human Reproduction Update. 2001;7(1):8–14.
  14. Chiaffarino F, Parazzini F, La Vecchia C, Marsico S, Surace M, Ricci E. Use of oral contraceptives and uterine fibroids: results from a case-control study. British Journal of Obstetrics and Gynaecology. 1999;106(8):857–60.
  15. Lumbiganon P, Rugpao S, Phandhu-fung S, Laopaiboon M, Vudhika-mraksa N, Werawatakul Y. Protective effect of depot-medroxyprogesterone acetate on surgically treated uterine leiomyomas: a multicentre case-control study. British Journal of Obstetrics and Gynaecology. 1996;103(9):909–14.
  16. Boynton-Jarrett R, Rich-Edwards J, Malspeis S, Missmer SA, Wright R. A prospective study of hypertension and risk of uterine leiomyomata. American Journal of Epidemiology. 2005;161(7):628–38.
  17. Andersen J, Barbieri RL. Abnormal gene expression in uterine leiomyomas. Journal for the Society of Gynecologic Investigation. 1995;2(5):663-672.
  18. Uterine fibroids. Cedars-Sinai website. http://www.cedars-sinai.edu/Patients/Health-Conditions/Uterine-Fibroids.aspx.
  19. Griffin KW, Ellis MR, Wilder L, DeArmond L. Clinical inquiries. What is the appropriate diagnostic evaluation of fibroids? Journal of Family Practice. 2005;54(5):458,460,462.
  20. Marret H, Fritel X, Ouldamer L, et al. Therapeutic management of uterine fibroid tumors: updated French guidelines. European Journal of Obstetrics, Gynecology, and Reproductive Biology. 2012;165(2):156-164.
  21. American College of Obstetricians and Gynecologists. ACOG practice bulletin: alternatives to hysterectomy in the management of leiomyomas. Obstetrics and Gynecology. 2008; 112(2 part 1):387-400.
  22. Stewart EA, Nicholson WK, Bradley L, Borah BJ. The burden of uterine fibroids for African-American women: results of a national survey. Journal of Women's Health (Larchmt). 2013(10);22:807-816.
  23. Sharan C, Halder SK, Thota C, Jaleel T, Nair S, Al-Hendy A. Vitamin D inhibits proliferation of human uterine leiomyoma cells via catechol-O-methyltransferase. Fertililty and Sterility. 2011;95(1):247-253.
  24. Wise LA, Radin RG, Palmer JR, Kumanyika SK, Rosenberg L. A prospective study of dairy intake and risk of uterine leiomyomata. American Journal of Epidemiology. 2010;171(2):221-232.

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Last updated: 2018-06-22 08:58