Transvaginal ultrasonography is non-invasive in nature and cost-efficiency. It is considered the best initial test for fibroids to be followed by further tests if necessary.

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In most women symptoms are mild, and no treatment or pharmacological therapy will be required. However, some women experience symptoms that would be described as moderate or severe. Those women typically require pharmaceutical therapy.

Beyond their physical morbidity, uterine fibroids are a frequent cause of significant impairment of quality of life (QoL). In particular, abnormal uterine bleeding is one of the most frequently disabling symptoms of uterine fibroids, and this has associated physical, social and financial implications (including lower employment rates, more frequent absence from work, and loss of earnings in women). It is thought approximately 30% of symptomatic women suffer from abnormal bleeding which can negatively impact them due to feelings of self-consciousness and a reduction in their quality of life. Severe bleeding can also lead to severe iron deficiency, otherwise known as anaemia, which in its own right can cause fatigue, feelings of weakness and shortness of breath following exertion.

The main symptoms common with uterine fibroids are:

* The Uterine Fibroid Symptom and Quality of Life (UFSQOL) questionnaire^3,4.

Uterine fibroids, and in particular those which distort uterine anatomy and interfere with normal uterine physiology, can have adverse effect on reproductive function, leading to sub-fertility, later pregnancy complications, and miscarriage¹⁶. The incidence of fibroids in infertile women without any other obvious cause of infertility is estimated to be between 1% and 2.4%, however, there is a lack of prospective studies available to clearly determine the burden of fibroids in terms of their impact on fertility¹⁷.

A number of factors may influence fertility and pregnancy outcomes, including the size, location, and number of fibroids. Available evidence suggests that submucosal, intramural, and subserosal fibroids interfere with fertility in decreasing order of importance. Indeed, submucosal fibroids are linked to a 70% reduction in delivery rate¹⁷. There is some data suggesting an impact of the number and dimension of the lesions on fertility; in particular, fibroids over 5 cm in diameter, and located close to the cervix, are more likely to pose a problem¹⁶.

Uterine fibroids are traditionally classified according to their anatomical location as intramural, submucosal or subserosal. In addition, fibroids may be pedunculated (attached to the uterus by a stalk). Some larger fibroids may have characteristics of each type. Fibroids are not always isolated as there are often several coexistent lesions; in cases of multiple fibroids, a detailed ‘mapping’ of each lesion is valuable from a surgical point of view, although this may not always define a precise clinical situation¹⁴.

Fibroids can vary in size from millimetres to over 10 centimetres, and this can have a considerable clinical impact on the patient^, with larger fibroids tending to respond less to pharmaceutical interventions, requiring more invasive surgical treatment options¹⁵.

Classification of Uterine Fibroids^{14, 16}

• Intramural fibroids: are fibroids which normally do not distort the uterine cavity and have <50% protruding into the serosal surface of the uterus and are the most common type. They typically develop within the wall of the uterus, beginning as small nodules in the muscular wall of the uterus. With time, intramural fibroids may expand inwards, causing distortion and elongation of the uterine cavity. They typically give the uterus a globular feeling on examination (like early pregnancy). They increase overall blood flow to the uterus and if large can distort and enlarge the internal cavity, even if they do not encroach onto it.
• Subserosal fibroids: are those were >50% of the fibroid protrudes out of the serosal surface of the uterus. A subserosal fibroid may be sessile or pedunculated. They can grow quite large, but do not typically affect the size of the uterine cavity. They are more likely to produce pressure symptoms than heavy menstrual bleeding or infertility.
• Submucosal fibroids: are defined as fibroids, which distort the uterine cavity according to the classification by the European Society of Hysteroscopy. The classification of these fibroids is then further divided into three subtypes: pedunculated fibroids without intramural extension (type 0), sessile (fixed in one location) with intramural extension of fibroid <50% (type I), and sessile with an intramural extension of >50% (type II). The degree of intramural extension can be assessed by ultrasonography or by hysteroscopy by observing the angle between the fibroid and the endometrium at the attachment to the uterine wall.

Submucosal fibroids are the fibroid type most likely to interfere with fertility¹⁴.

Other types of less frequent fibroids are:

• Cervical fibroids: are found in the ‘neck’ (cervix) of the uterus and are difficult to remove without damaging the surrounding area.
• Intraligamentous fibroids: are fibroids which may grow from a subserosal location into the peritoneal folds of the broad ligaments.

The pathophysiology of uterine fibroids (also called leiomyoma, fibroma, fibromyoma, myoma or leiomyofibroma) is not well understood. There is, however, some epidemiological evidence to suggest a genetic predisposition for non-syndromic uterine fibroids, although no specific gene has yet been identified.

Oestrogen and progesterone are recognized as promoters of tumor growth, and the potential role of environmental oestrogens has only recently been explored. Growth factors with mitogenic activity, such as TGF-β3, bFGF, EGF, and IGF-I, are elevated in fibroids and may be the effectors of oestrogen and progesterone promotion¹².

Several predisposing factors have been identified as being associated with uterine fibroids, including black race, heredity, nulliparity (the condition of never having given birth), obesity, polycystic ovary syndrome (PCOS), diabetes, and hypertension, and there is emerging evidence that familial predisposition to uterine fibroids is associated with a distinct pattern of clinical and molecular features compared with uterine fibroids in families without this prevalence¹³.