Synopsis
Distinguish fibroids, endometrial polyps and adenomyosis by compartment and symptom pattern, select ultrasound or hysteroscopy, and match medical, hysteroscopic, radiological or surgical treatment to anatomy and fertility priorities.
- Fibroids are benign myometrial smooth-muscle tumours; submucosal lesions distort the cavity and commonly drive bleeding, intramural lesions enlarge the wall and subserosal lesions more often cause pressure.
- Endometrial polyps are focal cavity overgrowths that commonly cause intermenstrual, postcoital or irregular bleeding and require histology when removed.
- Adenomyosis is endometrial-type tissue within myometrium, typically producing heavy painful periods, chronic pelvic pain and a diffusely bulky tender uterus.
- Use transvaginal ultrasound to map fibroids and adenomyosis when acceptable; report fibroid size, number, site and cavity distortion rather than diameter alone.
- Use outpatient hysteroscopy when a polyp or submucosal fibroid is suspected because direct cavity inspection permits targeted biopsy and see-and-treat removal.
- NICE recommends an LNG-IUS as preferred treatment for HMB with no pathology, fibroids under 3 cm that do not distort the cavity, or suspected or diagnosed adenomyosis when acceptable.
- NICE advises specialist referral for fibroids 3 cm or larger to discuss medicines, uterine artery embolisation, myomectomy and hysterectomy according to location, severity and reproductive goals.
- Hysteroscopic removal is the directed treatment for submucosal fibroids and symptomatic cavity polyps; intramural or subserosal lesions require different approaches.
- Myomectomy preserves the uterus but fibroids can recur and pregnancy risks depend on incision; uterine artery embolisation can affect fertility, while hysterectomy is definitive and ends uterine pregnancy.
- Adenomyosis diagnosis does not require hysterectomy histology before treatment; medical suppression and symptom response are reasonable, with surgery considered for refractory completed-family disease.
Key red flags
Postmenopausal bleeding or a newly enlarging postmenopausal uterine or endometrial lesion requires urgent malignancy assessment rather than presumptive benign disease.
Persistent intermenstrual bleeding, tamoxifen use, an irregular focal cavity lesion or endometrial risk may require hysteroscopy and histology even when a polyp seems likely.
Severe anaemia, syncope or continuous flooding from a cavity-distorting lesion requires acute haemostasis and expedited definitive treatment.
Sudden severe pain, vomiting, fever or peritonism is atypical for stable adenomyosis or fibroid symptoms and raises degeneration, torsion, infection or adnexal disease.
Hydronephrosis, urinary retention, bowel obstruction or major venous compression from a large mass requires urgent organ-function and specialist review.
New growth, bleeding, pain or suspicious imaging after menopause requires urgent specialist assessment because a presumed fibroid diagnosis is not sufficient.
Investigation priorities
Exclude pregnancy-related bleeding and measure anaemia while structural assessment proceeds.
Management branches
Intermenstrual bleeding, imaging or HMB suggests a focal endometrial-cavity lesion.
- Offer outpatient hysteroscopy, explain analgesia and anaesthetic alternatives and obtain consent for biopsy or see-and-treat removal if appropriate.
- Remove a symptomatic polyp or suitable submucosal fibroid hysteroscopically and send all tissue for histological examination.
- Review bleeding and histology and plan staged resection or another technique when size, depth or pain prevents complete treatment.