How to Clerk a Fibroid Case
When clerking a patient with suspected or known uterine fibroids, systematically document symptom patterns, reproductive history, and risk factors to guide imaging and treatment decisions, with particular attention to age-related malignancy risk requiring endometrial sampling in women ≥40 years.
Patient Demographics and Risk Stratification
Document age precisely, as this determines malignancy risk and treatment approach—women <40 have different recurrence patterns than perimenopausal women, and age >45 mandates different evaluation protocols 1, 2, 3
Record race/ethnicity, particularly noting African or Afro-Caribbean descent, as these women have 3-fold higher fibroid incidence (exceeding 80% by age 50) and develop clinically significant disease at earlier ages 4, 3
Assess parity status, as nulliparity is a significant risk factor for fibroid development 3
Obtain family history of fibroids, as this represents an independent risk factor 3
Document BMI and obesity status, as this increases fibroid risk 3
Symptom Characterization
Bleeding Patterns
Quantify menorrhagia severity by asking about pad/tampon changes per hour, clots, flooding, and duration of heavy flow—menorrhagia is the most frequent fibroid symptom and commonly causes iron deficiency anemia 4, 5, 6
Document dysmenorrhea (painful menstruation), including severity, timing relative to menses, and impact on daily activities 4, 7
Record any intermenstrual bleeding, as persistent intermenstrual bleeding warrants referral regardless of fibroid size 3
Bulk and Pressure Symptoms
Ask specifically about pelvic pressure, pain, or sensation of fullness/bloatedness, which are cardinal manifestations of fibroids 4, 7
Document urinary symptoms including frequency, urgency, and any history of urinary retention from bladder compression by anterior fibroids 4, 7
Record bowel symptoms including constipation from posterior fibroid pressure on the rectum 4, 7
Assess for increasing abdominal girth that the patient has noticed 3
Acute Pain Presentations
Characterize any acute severe pain, which may indicate fibroid degeneration (infarction or hemorrhage), torsion of pedunculated fibroids, or prolapse of submucosal fibroids through the cervix—these require urgent imaging 4, 7, 3
In pregnant patients, ask about acute pain suggesting red degeneration 3
Reproductive Impact
Document fertility history, including any history of infertility, difficulty conceiving, or pregnancy losses, as fibroids can impair fertility depending on size and location 1, 4
Record obstetric complications in previous pregnancies 4
Clarify future fertility desires, as this fundamentally determines treatment options 5, 6, 8
Menstrual and Reproductive History
Record last menstrual period and menstrual cycle regularity 5
Document menopausal status, as fibroid symptoms peak in perimenopausal years and typically decline after menopause due to decreased estrogen—postmenopausal women with persistent symptoms require heightened suspicion for malignancy 2, 4, 7
Note any postmenopausal bleeding, which mandates endometrial biopsy before any intervention 2
Previous Surgical and Medical History
Document any previous myomectomy, as this affects current management options and recurrence risk 1
Record history of other uterine procedures including endometrial ablation, uterine artery embolization, or other fibroid treatments 1
Ask about previous imaging showing fibroids, including size, number, and location if known 1
Screen for coexisting adenomyosis, which frequently coexists with fibroids and presents with heavy menstrual bleeding, dysmenorrhea, and dyspareunia—this complicates pain patterns and increases treatment failure rates 4, 7
Physical Examination Findings to Document
Perform abdominal examination noting any palpable uterine mass, as uterus palpable abdominally or >12 cm on scan warrants referral 3
Conduct speculum examination to identify any prolapsed submucosal fibroids through the cervix 7, 3
Perform bimanual pelvic examination documenting uterine size (in weeks if enlarged), contour (irregular vs smooth), mobility, and tenderness 5, 9
Critical Age-Specific Considerations
Women ≥40 Years with Abnormal Bleeding
Mandatory endometrial biopsy is required before any treatment to rule out endometrial cancer or hyperplasia, as malignancy risk increases dramatically with age (2.94 per 1,000 overall, but 10.1 per 1,000 in women aged 75-79) 2
Document that fibroids and uterine sarcoma can present similarly on imaging, and the presence of fibroids never excludes concurrent endometrial pathology 2
Perimenopausal Women
Note that asymptomatic multifibroid uterus should be managed expectantly, as fibroids naturally shrink after menopause and intervention carries unnecessary risks 2
Document that symptoms peak in perimenopausal years and typically resolve with menopause 4, 7
Postmenopausal Women
Fibroids become the second most common cause of acute pelvic pain in this age group, accounting for more cases than in younger women 4, 7
Maintain high suspicion for malignancy if fibroids persist or grow after menopause, or if symptoms continue 2, 7
Red Flags Requiring Urgent Referral
Rapid fibroid growth, as sarcomatous change is rare but associated with rapid enlargement—refer urgently 3
Submucous fibroid with abnormal bleeding warrants referral 3
Fibroids >3 cm in diameter causing significant symptoms, pain, or pressure require specialist evaluation 3
Persistent intermenstrual bleeding in women >45 where treatment has failed 3
Acute severe pain requires urgent imaging (contrast-enhanced CT preferred, showing 86% sensitivity for contrast enhancement and 100% sensitivity for ascites in fibroid complications) to exclude torsion, prolapse, or infarction/hemorrhage 4, 7
Documentation of Treatment Goals
Record patient's desire for uterine preservation independent of fertility goals, as this determines whether hysterectomy vs uterine-sparing procedures are appropriate 6, 8
Document whether patient's family is complete, as this influences recommendation for definitive vs conservative treatment 3
Note proximity to menopause, as women approaching menopause may benefit from temporizing medical management until natural fibroid regression occurs 5