Intramural Leiomyoma of the Uterus – Diagnosis, Impact & Modern Treatment Options

 A leiomyoma—also commonly known as a uterine fibroid—is a non‑cancerous growth that develops from the smooth muscle cells of the uterus. When such a growth is located within the muscular wall of the uterus (the myometrium) itself, it is referred to as an intramural leiomyoma. Although benign, intramural leiomyomas can exert significant effects depending on their size, number, and location—and their management must take into account both symptoms and future fertility goals.

What is an Intramural Leiomyoma?

In simple terms, an intramural leiomyoma grows within the wall of the uterus. Unlike submucosal fibroids (which bulge into the uterine cavity) or subserosal fibroids (which protrude toward the outer surface of the uterus), intramural fibroids are embedded in the myometrium. Their position means they can enlarge the uterine wall, distort uterine shape, or press on adjacent structures while remaining within the muscle wall.

Because they grow within the uterine wall, they may not be immediately obvious but can still cause symptoms—especially if they become large, multiply, or press on nearby organs.

How Common Are They & Who Gets Them?

Uterine fibroids are among the most common benign gynecological tumors in women of reproductive age. Studies suggest that a large proportion of women have fibroids by the time they reach their 40s or 50s. Many of these are intramural in location. Certain factors increase the risk: reproductive‑age women, hormonal factors (especially higher exposures to oestrogen/progesterone), family history, obesity, and earlier start of menstruation. Many intramural leiomyomas remain undetected because they cause no or minimal symptoms.

Symptoms & Potential Impact

Many intramural leiomyomas cause no symptoms, and are discovered incidentally during imaging or pelvic examination. However, when symptomatic, the effects can include:

• Heavy or prolonged menstrual bleeding, often because the fibroid distorts the muscle of the uterus and interferes with normal contraction and shedding.

• Pelvic pressure or pain, sometimes described as fullness, pelvic heaviness or lower‑back ache.

• Bladder or bowel pressure when a large fibroid presses on adjacent organs.

• Fertility or pregnancy issues, when the fibroid distorts the uterine cavity, interferes with implantation, or affects uterine muscle function. Some evidence suggests intramural fibroids may reduce fertility chances or increase miscarriage risk when large or located unfavorably.

• Anemia, due to heavy bleeding over time, which can cause tiredness and other systemic effects.

It’s important to note that symptom severity is not always proportional to fibroid size: even relatively modest intramural leiomyomas can cause significant bleeding or pain depending on location.

How Are They Diagnosed?

Diagnosis of intramural leiomyomas is typically done through a combination of clinical evaluation and imaging:

• A pelvic exam may reveal an enlarged or irregular uterus.

• Ultrasound, often transvaginal, is usually the first imaging tool; it can show fibroids, their approximate size and location.

• MRI may be used for more detailed characterisation—especially if multiple fibroids exist, fertility preservation is planned, or the anatomy is complex.

• Blood tests (for example if heavy bleeding has caused anemia).

• In cases of infertility work‑up, other assessments may include assessment of uterine anatomy, cavity distortion, and fallopian tube patency.

Once the presence of an intramural leiomyoma is confirmed, the next step is assessing whether it is causing symptoms or threatening future fertility—this drives treatment decisions.

Treatment Options

The strategy for managing an intramural leiomyoma depends on three major factors: symptoms, desire for future fertility, and size/location of the fibroid(s). The typical options include:

1. Observation (“Watch and Wait”)

If the fibroid is small, not increasing, and not causing significant symptoms, then observation may be entirely appropriate. Many fibroids shrink after menopause when hormone levels decline. No treatment may be required unless symptoms develop.

2. Medical Management

• Hormonal therapies (e.g., birth‑control pills, progestin‑releasing IUDs) may help control heavy bleeding, though they do not necessarily shrink fibroids substantially.

• Gonadotropin‑releasing hormone (GnRH) agonists or antagonists may shrink fibroids by reducing estrogen/progesterone effect; these are often used short‑term, sometimes prior to surgery.

• Non‑hormonal treatments (e.g., tranexamic acid) may help reduce heavy bleeding.
  Medical therapies can ameliorate symptoms but often are not sufficient when the fibroid is large, causing pressure effects, or fertility is compromised.

3. Minimally Invasive & Uterus‑Sparing Procedures

• Uterine artery embolization (UAE): An interventional radiology procedure that blocks the blood supply to fibroids, causing them to shrink. It preserves the uterus but its effect on future fertility is still something to discuss in depth.

• MRI‑guided focused ultrasound (or other energy‑based ablation techniques): These use heat or ultrasound energy to destroy fibroid tissue without major surgery. Recovery time can be shorter.
  These options are appealing when preserving the uterus is important; however they may suit only selected cases depending on fibroid size, number and location.

4. Surgical Options

• Myomectomy: Surgical removal of one or more fibroids while preserving the uterus. It can be done by hysteroscopy (for fibroids close to the uterine cavity), laparoscopy/robotic, or open surgery depending on size and location. This is often the choice when future fertility is desired.

• Hysterectomy: Removal of the uterus. This is definitive (no risk of recurrence of fibroids in the uterus) and suited for women who have completed child‑bearing and have significant symptoms.
  The choice between these depends on multiple factors: fibroid burden, symptom severity, fertility plans, patient’s general health and preferences.

Making the Right Decision – What to Discuss With Your Doctor

When facing an intramural leiomyoma diagnosis, good questions to explore with your gynaecologist include:

• Are my symptoms likely caused by the fibroid(s)?

• How large and how many are they? Is the size increasing?

• Is my fertility or pregnancy plan affected by these fibroids?

• What are the pros & cons of each treatment in my situation?

• What are the risks (e.g., recurrence after myomectomy, effects on future pregnancy, recovery time)?

• What lifestyle or supportive measures (diet, weight, exercise) might help?
  Understanding the full picture ensures the plan fits your goals—whether relief of symptoms, preserving fertility, or both.

Prognosis & Outlook

In most cases, intramural leiomyomas are benign and manageable. Many women live with them without needing major intervention. Outcomes depend on the treatment chosen:

• After myomectomy or minimally invasive procedures, many women experience relief from heavy bleeding or pressure symptoms and can go on to have successful pregnancies (though monitoring is critical).

• If a hysterectomy is done, fibroid symptoms resolve but fertility is no longer possible.

• Recurrence is possible after surgery (new fibroids can develop).

• After menopause, fibroids often shrink due to the decline in oestrogen, so symptom improvement is common.
  With timely diagnosis and a tailored plan, quality of life is very good.

Summary

An Intramural leiomyoma of uterus embedded within the uterine muscle wall. While harmless in many, when symptomatic—causing heavy bleeding, pelvic pressure or affecting fertility—it warrants evaluation and discussion of treatment options. The pathway ranges from observation to medical therapies, minimally invasive procedures, and surgical interventions—with fertility goals and symptom severity guiding choices. In collaboration with a specialist, most women can achieve both symptom relief and an outcome aligned with their reproductive plans.