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OBJECTIVE: To review the available English literature that examines the biology of leiomyoma uteri in African-American women and other ethnic groups. Factors that influence the growth and development of leiomyomas are examined to understand the basis for larger myomas in African-American women. DESIGN: Literature review of 176 articles regarding the pathobiology of leiomyoma in various ethnic groups. RESULTS: The initiating factor(s) associated with the transformation of a normal myometrial cell into a leiomyoma cell remain(s) to be determined. Epidemiological studies have confirmed that different ethnic groups develop leiomyomas. However, African-American ethnicity is a risk factor for the development of leiomyomas. Studies have examined diet, genetics, hormonal, growth, enzymatic and molecular determinants of myoma biology, with critical advances in some of these areas. The best radiological tools to identify and monitor leiomyomas are ultrasonography and/or magnetic resonance imaging. Evidence supports progesterone and growth factors (e.g., transforming growth factor-B), have significant impact on the development of leiomyomas. CONCLUSIONS: Early monitoring and intervention should become standard for African-American women who are at greater risk for developing leiomyomas. There are plausible biological mechanisms that explain the predisposition for developing larger leiomyomas in African-American women as compared with other ethnic groups.