Uterine fibroids
Guidelines
1. Screening and diagnosis
Clinical presentation
- As per ASRM 2017 guidelines:Insufficient evidence to conclude that uterine fibroids reduce the likelihood of achieving pregnancy with or without fertility treatment.Insufficient evidence to determine that a specific fibroid size, number, or location (excluding submucosal fibroids or intramural fibroids impacting the endometrial cavity contour) is associated with a reduced likelihood of achieving pregnancy or an increased risk of early pregnancy loss.
- As per AAGL 2012 guidelines, recognize that:submucous fibroids contribute to infertility, and, although their removal improves pregnancy rates, the fertility rate remains lower than in females with normal uterussubmucous fibroids increase the risk of recurrent early pregnancy losssubmucous fibroids increase the incidence of abnormal uterine bleeding, most commonly heavy menstrual bleeding, but the mechanisms by which the bleeding increases are unclearthe direct source of abnormal uterine bleeding in patients with submucous fibroids is usually the endometrium itself, a circumstance that allows for the selection of medical therapies aimed at the endometrium or for endometrial destruction, provided fertility is not an issuethe incidence of sarcoma in submucous fibroids is extremely low in patients < 50 years old; make clinical decisions in such patients with the understanding that submucous lesions are very rarely malignant.
2. Diagnostic investigations
Diagnostic imaging
- As per ACR 2022 guidelines, obtain pelvic/transvaginal ultrasound and duplex ultrasound as initial imaging of clinically suspected fibroids. Obtain pelvic/transvaginal ultrasound, duplex ultrasound, and MRI for treatment planning of known fibroids.
- As per AAGL 2012 guidelines, recognize the following outcomes of imaging modalities in diagnosis of submucous fibroids:infusion sonohysterography (saline solution, gel) and MRI are highly sensitive and specifichysterosalpingography is less sensitive and much less specific than infusion sonohysterography and MRItransvaginal ultrasound is less sensitive and less specific than infusion sonohysterography.
3. Diagnostic procedures
Hysteroscopy
recognize that hysteroscopy is highly sensitive and specific for the diagnosis of submucous leiomyomas, and is more sensitive and specific than hysterosalpingography and transvaginal ultrasound, but is inferior to MRI in characterizing the relationship of submucous fibroids to the myometrium and perimetrium.
4. Medical management
General principles
individualize the treatment of patients with uterine fibroids based on symptoms, size and location of fibroids, age, need and desire of the patient to preserve fertility or the uterus, the availability of therapy, and the experience of the clinician.
Expectant management
consider watching expectantly asymptomatic patients with submucous fibroids if fertility enhancement is not a goal..
Hormone therapy
consider offering hormonal treatment with progestin-containing agents such as combination of oral contraceptives, levonorgestrel-releasing intrauterine device, or depot medroxyprogesterone acetate for the treatment of abnormal uterine bleeding and reducing the growth rate of submucous fibroids.
Selective progesterone receptor modulators
- Consider administering prolonged intermittent selective progesterone receptor modulators for the treatment of fibroid-related symptoms in patients with uterine fibroids.
- Screen patients for the risk of liver impairment before commencing therapy with ulipristal acetate. Obtain liver enzyme monitoring monthly during treatment and 2-4 weeks following completion of the course of therapy with ulipristal acetate. Recognize the signs and symptoms of liver failure, and inform patients about the symptoms of liver failure.
5. Therapeutic procedures
Uterine artery embolization
- As per SOGC 2015 guidelines, consider offering uterine artery occlusion by embolization or surgical methods for selected symptomatic patients with uterine fibroids wishing to preserve their uterus. Counsel patients choosing uterine artery occlusion for the treatment of uterine fibroids regarding possible risks, including the likelihood that fecundity and pregnancy may be impacted.
- As per AAGL 2012 guidelines, do not perform embolic therapies (uterine artery embolization and occlusion) in patients with submucous fibroids having current infertility or wishing to conceive in the future.
Endometrial ablation
consider performing endometrial ablation in selected patients with type 2 fibroids and heavy menstrual bleeding not wishing pregnancy in the future.
6. Perioperative care
Management of preoperative anemia
- Attempt to correct anemia with menstrual suppression and/or iron therapy before elective gynecologic surgery, as preoperative anemia (Hgb < 120 g/dL) has been associated with adverse outcomes.
- Correct anemia before proceeding with elective surgery.
- Consider using selective progesterone receptor modulators and GnRH analogues preoperatively to correct anemia.
- As per AAGL 2012 guidelines, use preoperative GnRH agonists to facilitate the process of treating anemia in patients planning surgery for submucous fibroids.
Gonadotropin-releasing hormone agonists
- As per SOGC 2019 guidelines, consider administering GnRH agonists to decrease fibroid size, improve anemia, and reduce the probability of perioperative blood transfusions.
- As per AAGL 2012 guidelines:Insufficient evidence to determine the role of GnRH agonists administered for the purpose of reducing operating time, the amount of systemic absorption of distention media, and the risk of incomplete resection of submucous fibroids.Consider offering suppressive therapy with GnRH agonists, or other medical therapies, which may be used continuously or continued intermittently until menopause in patients with submucous fibroids and abnormal uterine bleeding who are in the late reproductive years.
Management of postoperative bleeding
use either intracervical prostaglandin F2a (carboprost) or tamponade with an inflated balloon catheter for the management of postoperative bleeding.
7. Surgical interventions
Myomectomy
- As per SOGC 2023 guidelines, consider performing myomectomy in patients with FIGO type 0-2 (submucosal) fibroids and unexplained infertility, particularly if the patient is undergoing fertility treatments.
- As per ASRM 2017 guidelines:Recognize that there is fair evidence that:
- myomectomy does not impair reproductive outcomes (clinical pregnancy rates, live-birth rates) following assisted reproductive therapy
- hysteroscopic myomectomy for submucosal fibroids improves clinical pregnancy rates.
- Insufficient evidence to conclude that:removal of subserosal fibroids improves fertilitymyomectomy (laparoscopic or open) reduces miscarriage rateshysteroscopic myomectomy reduces the likelihood of early pregnancy loss in patients with infertility and a submucous fibroid.
- As per SOGC 2015 guidelines, consider performing hysteroscopic myomectomy as first-line conservative surgical therapy for the management of symptomatic patients with intracavitary fibroids.
- As per AAGL 2012 guidelines, consider performing abdominal myomectomy in patients desiring future fertility or currently having infertility if there are ≥ 3 submucous fibroids or in other circumstances where hysteroscopic myomectomy might be anticipated to damage a large portion of the endometrial surface.
Hysterectomy
consider performing hysterectomy by the least invasive approach possible as the definitive treatment for symptomatic patients with uterine fibroids not wishing to preserve fertility and/or their uterus and who have been counseled regarding the alternatives and risks.
Technical considerations for surgery
- Use any of the following cervical preparation techniques to reduce the requirement for dilation, and, likely, the incidence of uterine trauma associated with hysteroscopic surgery, including hysteroscopic myomectomy for submucous fibroids:laminaria or prostaglandins preoperativelyintracervical injection of a low dose of dilute vasopressin solution intraoperatively.
8. Specific circumstances
Patients with acute uterine bleeding
consider offering conservative management with estrogens, selective progesterone receptor modulators, antifibrinolytics, Foley catheter tamponade, and/or operative hysteroscopic intervention in patients presenting with acute uterine bleeding associated with uterine fibroids.
9. Patient education
General counseling
reassure asymptomatic patients with uterine fibroids that there is no evidence to substantiate major concern about malignancy and that hysterectomy is not indicated.
10. Preventative measures
Levonorgestrel-releasing intrauterine device
consider using a levonorgestrel-releasing intrauterine device to reduce the incidence of submucous fibroids.
11. Follow-up and surveillance
Post-treatment surveillance (imaging)
obtain pelvic/transvaginal ultrasound, duplex ultrasound, and pelvic MRI for surveillance or post-treatment imaging of known fibroids.
Post-treatment surveillance (hysteroscopy)
- Consider performing second-look hysteroscopy and appropriate adhesiolysis when fertility is an issue in patients with post-myomectomy intrauterine synechiae, which are more common after multiple submucous myomectomies.
- Consider performing second-look hysteroscopy in patients with postoperative intrauterine adhesions and thereby reducing the long-term risk of adhesion formation.