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usmle step 2 ck

Uterine Fibroids

Benign monoclonal smooth muscle tumors of the uterus causing heavy menstrual bleeding, bulk symptoms, infertility, pregnancy complications, or asymptomatic uterine enlargement

Review date
reviewed 2026-05-04
Reading time
8 min read
Author
Dr Kola Tytler MBBS CertHE MBA MSt MRCGP
Obstetrics & Gynecologycommonlong-term-condition
On this page
Condition details
Obstetrics & Gynecology
common
8 min read
reviewed 2026-05-04
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About This Page

This is a clinician-written, evidence-based summary aligned to the USMLE Step 2 CK Content Outline. It is intended for medical students preparing for USMLE Step 2 CK. Management reflects current ACC/AHA, USPSTF, and APA guidelines. Always cross-reference with UpToDate, institutional protocols, and clinical judgment.

Key points

  • Fibroids are benign estrogen/progesterone-responsive uterine smooth muscle tumors
  • Symptoms: heavy menstrual bleeding, pelvic pressure, bulk symptoms, infertility, recurrent pregnancy loss, pain from degeneration
  • Submucosal fibroids are most associated with bleeding and infertility
  • Pelvic ultrasound is first-line imaging
  • Definitive treatment is hysterectomy; fertility-sparing treatment includes myomectomy

Overview

Fibroids are leiomyomas arising from myometrium. Location matters: submucosal lesions cause bleeding/infertility, subserosal lesions cause bulk symptoms. Step 2 CK tests enlarged irregular uterus and management by fertility goals.

Epidemiology

Fibroids are extremely common and more prevalent/severe in Black patients. They often grow during reproductive years and shrink after menopause. Pregnancy complications include red degeneration, malpresentation, preterm labor, cesarean, and postpartum hemorrhage.

Clinical Features

Symptoms
Heavy menstrual bleeding or prolonged menses
Pelvic pressure, constipation, urinary frequency/retention
Infertility or recurrent pregnancy loss
Acute pain from degeneration or pedunculated torsion
Postmenopausal bleeding or rapidly enlarging mass
Signs
Enlarged irregular mobile uterus
Pallor/tachycardia from anemia
Pelvic mass arising from uterus
Uterine tenderness during degeneration
Fixed mass, ascites, systemic symptoms suggest alternative diagnosis

Investigations

First-line
Pregnancy testExclude pregnancy in AUB or pelvic mass
CBC and ferritinAssess iron deficiency anemia
Transvaginal ultrasoundFirst-line imaging for number, size, location, endometrium/adnexa
Second-line
Saline infusion sonohysterographyBetter for submucosal/intracavitary lesions
MRI pelvisBest mapping for preprocedural planning or uncertain diagnosis
Endometrial biopsyAUB age >=45 or younger with risk factors/persistent bleeding
Specialist
HysteroscopyDiagnostic/therapeutic for submucosal fibroids
Reproductive endocrinology consultationInfertility or fertility-preserving surgery

Management

ACOG Practice Bulletin: Management of Symptomatic Uterine Leiomyomas
1
Observation/medical therapy
  • Asymptomatic fibroids can be observed
  • NSAIDs reduce dysmenorrhea but limited volume effect
  • Tranexamic acid reduces heavy menses
  • Combined hormonal contraception/progestins reduce bleeding
  • LNG-IUD reduces bleeding if cavity not distorted
  • GnRH agonists/antagonists shrink fibroids temporarily as bridge therapy
2
Fertility-sparing procedures
  • Myomectomy for symptomatic patients desiring fertility/uterine preservation
  • Hysteroscopic myomectomy for submucosal fibroids
  • Laparoscopic/open myomectomy depending on size, number, location
3
Procedural/definitive treatment
  • Uterine artery embolization reduces bleeding/bulk but not first-line for strong future pregnancy desire
  • Radiofrequency ablation or focused ultrasound selected cases
  • Hysterectomy definitive and eliminates recurrence
4
Pregnancy considerations
  • Most fibroids need no pregnancy intervention
  • Red degeneration treated conservatively with analgesia
  • Prior extensive myomectomy entering cavity may require planned cesarean

Complications

  • Iron deficiency anemia: Chronic heavy bleeding
  • Infertility/pregnancy loss: Especially submucosal or cavity-distorting fibroids
  • Pregnancy complications: Malpresentation, preterm labor, cesarean, PPH
  • Red degeneration: Painful hemorrhagic infarction in pregnancy
  • Recurrence: Common after myomectomy
USMLE Step 2 CK Exam Tips
  • 1Heavy menstrual bleeding + enlarged irregular uterus = fibroids
  • 2First-line imaging = transvaginal ultrasound
  • 3Submucosal fibroids cause most bleeding/infertility
  • 4Definitive treatment = hysterectomy
  • 5Desires future fertility = myomectomy
  • 6Fibroid pain in pregnancy = red degeneration; supportive care
  • 7Postmenopausal bleeding still requires endometrial evaluation

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Verified Sources & References

ACOG Practice Bulletin — Management of Symptomatic Uterine Leiomyomas
ACOG Patient FAQ — Uterine Fibroids
ACOG Clinical Guidance
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