A woman’s individual circumstance, including fibroid-related symptoms and their effect on quality of life, desire (or not) to preserve fertility, and her wishes regarding treatment options should be considered when discussing possible treatments. Multiple treatment options usually exist and the following points might be considered.
For an asymptomatic woman diagnosed with fibroids who desires fertility in the near future, evaluation of the uterine cavity with saline infusion sonography, hysteroscopy, or MRI provides useful information regarding the presence of submucous fibroids and their potential impact on fertility. If the cavity is not deformed, fibroids need not be treated and conception may be attempted. If the cavity is deformed, myomectomy (hysteroscopic or abdominal) can be considered. An experienced laparoscopic surgeon may offer laparoscopic myomectomy, with a multilayered myometrial closure.
For an asymptomatic woman who does not desire future fertility, observation (watchful waiting) should be considered. A periodic review of the patient’s symptoms and a pelvic examination to evaluate uterine size should be accomplished. In the presence of very large fibroids, renal ultrasound or computed tomography urogram can be considered to rule out significant hydronephrosis.
For a symptomatic woman who desires future fertility and her primary symptom is abnormal bleeding, baseline hemoglobin measurement should be considered because accommodation to anemia can occur. If indicated, further evaluation of the endometrium with endometrial biopsy can be performed. Evaluation of the uterine cavity with saline-infusion sonography, hysteroscopy, or MRI can help determine the appropriate treatment options.
If the cavity is deformed, myomectomy (hysteroscopic or abdominal) should be considered.
An experienced laparoscopic surgeon may offer laparoscopic myomectomy. If the symptoms of pain or pressure (bulk symptoms) are present, and if the uterine cavity is not deformed, myomectomy (abdominal or laparoscopic) can be considered.
For a symptomatic woman who does not desire future fertility, observation (watchful waiting) can be considered if no treatment is desired at that time. A symptomatic perimenopausal woman may desire observation until she enters menopause, when symptoms often diminish. Baseline hemoglobin measurements should be obtained and if a significant anemia exists, then treatment should be considered. If metrorrhagia is present, evaluation of the endometrium with sonography or endometrial biopsy should be considered. If the endometrium is normal, a levonorgestrel-IUS or endometrial ablation may be appropriate treatment. Myomectomy (hysteroscopic, abdominal, or laparoscopic), hysterectomy (vaginal, laparoscopic, or abdominal), or uterine artery embolization can be considered.
For a woman with primarily fibroid-related pain or pressure symptoms (bulk symptoms), myomectomy, hysterectomy, and uterine artery embolization or focused ultrasound (presently limited by size and number of fibroids) may be considered.
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