Guideline sources The following summarized guidelines for the evaluation and management of uterine fibroids are prepared by our editorial team based on guidelines from the Society of Obstetricians and Gynaecologists of Canada (SOGC 2023; 2019; 2015), the American College of Radiology (ACR 2022), the American Society for Reproductive Medicine (ASRM 2017), and the American Association of Gynecologic Laparoscopists (AAGL 2012). 1 2 3 4 5 6 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. I https://web.pathway.md/diseases/recdhSk6zCjcze2br 1/6 6/29/23, 3:49 AM Uterine fibroids Pathway 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. I 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 uterus A submucous fibroids increase the risk of recurrent early pregnancy loss B submucous fibroids increase the incidence of abnormal uterine bleeding, most commonly heavy menstrual bleeding, but the mechanisms by which the bleeding increases are unclear B the 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 issue B the 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. A 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. B 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 specific hysterosalpingography is less sensitive and much less specific than infusion sonohysterography and MRI transvaginal ultrasound is less sensitive and less specific than infusion sonohysterography. A Show 2 more 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. A 4. Medical management https://web.pathway.md/diseases/recdhSk6zCjcze2br 2/6 6/29/23, 3:49 AM Uterine fibroids Pathway 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. B Expectant management: consider watching expectantly asymptomatic patients with submucous fibroids if fertility enhancement is not a goal. C 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. C Selective progesterone receptor modulators: Consider administering prolonged intermittent selective progesterone receptor modulators for the treatment of fibroid-related symptoms in patients with uterine fibroids. B 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. B 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. B 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. D Endometrial ablation: consider performing endometrial ablation in selected patients with type 2 fibroids and heavy menstrual bleeding not wishing pregnancy in the future. B Show 3 more 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. B Correct anemia before proceeding with elective surgery. B Consider using selective progesterone receptor modulators and GnRH analogues preoperatively to correct anemia. B https://web.pathway.md/diseases/recdhSk6zCjcze2br 3/6 6/29/23, 3:49 AM Uterine fibroids Pathway As per AAGL 2012 guidelines, use preoperative GnRH agonists to facilitate the process of treating anemia in patients planning surgery for submucous fibroids. A 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. B 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. I 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. C Management of postoperative bleeding: use either intracervical prostaglandin F2a (carboprost) or tamponade with an inflated balloon catheter for the management of postoperative bleeding. B 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. C Show 2 more 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. B Insufficient evidence to conclude that: removal of subserosal fibroids improves fertility myomectomy (laparoscopic or open) reduces miscarriage rates hysteroscopic myomectomy reduces the likelihood of early pregnancy loss in patients with infertility and a submucous fibroid. I As per SOGC 2015 guidelines, consider performing hysteroscopic myomectomy as first-line conservative surgical therapy for the management of symptomatic patients with intracavitary fibroids. B Show 3 more 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 https://web.pathway.md/diseases/recdhSk6zCjcze2br 4/6 6/29/23, 3:49 AM Uterine fibroids Pathway other circumstances where hysteroscopic myomectomy might be anticipated to damage a large portion of the endometrial surface. C Show 2 more 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. B 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 preoperatively intracervical injection of a low dose of dilute vasopressin solution intraoperatively. A Show 6 more 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. C Show 2 more 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. B 10. Preventative measures Levonorgestrel-releasing intrauterine device: consider using a levonorgestrel-releasing intrauterine device to reduce the incidence of submucous fibroids. C 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. B 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. C https://web.pathway.md/diseases/recdhSk6zCjcze2br 5/6 6/29/23, 3:49 AM Uterine fibroids Pathway Consider performing second-look hysteroscopy in patients with postoperative intrauterine adhesions and thereby reducing the long-term risk of adhesion formation. C References 1. George A Vilos, Catherine Allaire, Philippe-Yves Laberge et al. The Management of Uterine Leiomyomas. J Obstet Gynaecol Can. 2015 Feb;37 2 157 178. Open 2. Philippe-Yves Laberge, Ally Murji, George A Vilos et al. Guideline No. 389 Medical Management of Symptomatic Uterine Leiomyomas An Addendum. Obstet Gynaecol Can. 2019 Oct;41 10 1521 1524. Open 3. American Association of Gynecologic Laparoscopists AAGL Advancing Minimally Invasive Gynecology Worldwide. AAGL practice report: practice guidelines for the diagnosis and management of submucous leiomyomas. J Minim Invasive Gynecol. Mar-Apr 2012;19 2 152 71. Open 4. Expert Panel on GYN and OB Imaging, Susan M Ascher, Ashish P Wasnik et al. ACR Appropriateness Criteria Fibroids. J Am Coll Radiol. 2022 Nov;19 11S S319 S328. Open 5. Practice Committee of the American Society for Reproductive Medicine. Removal of myomas in asymptomatic patients to improve fertility and/or reduce miscarriage rate: a guideline. Fertil Steril. 2017 Sep;108 3 416 425. Open 6. Tarek Motan, Roland Antaki, Jinglan Han et al. Guideline No. 435 Minimally Invasive Surgery in Fertility Therapy. J Obstet Gynaecol Can. 2023 Apr;45 4 273 282.e2. Open https://web.pathway.md/diseases/recdhSk6zCjcze2br 6/6