Management of Uterine Fibroids

Diagnosis and Assessment

The American College of Radiology recommends hysteroscopic myomectomy as the procedure of choice for submucosal fibroids, providing effective symptom relief with minimal invasiveness, for patients with a uterine fibroid in the lower uterine segment and minimal fluid in the endometrial cavity 1
Ultrasound reveals a heterogeneous lesion with calcification in the lower uterine segment, consistent with a fibroid, with dimensions of 1.6 x 1.4 x 1.6 cm 1
The uterus measures 4.4 x 2 x 2.8 cm and is anteverted with heterogeneous parenchyma 1

The American College of Obstetricians and Gynecologists recommends hysteroscopic myomectomy as the first-line treatment for submucosal fibroids less than 5 cm in size, due to its effectiveness in providing symptom relief and shorter hospitalization compared to more invasive approaches 1, 2
Medical management, including ulipristal acetate (UPA) and GnRH agonists, can be considered as an alternative or bridge to surgery, with UPA reducing bleeding and shrinking fibroids, and GnRH agonists reducing fibroid volume by approximately 30% 2
Endometrial biopsy should be performed to rule out endometrial pathology, especially with the presence of fluid in the endometrial cavity 3

Hysteroscopic myomectomy is associated with shorter hospitalization and faster recovery compared to more invasive approaches, and provides effective symptom relief equivalent to more invasive approaches 1
Uterine artery embolization (UAE) and MR-guided focused ultrasound are less appropriate for this case, with UAE potentially resulting in fibroid expulsion and limited evidence for MR-guided focused ultrasound 4
Hysterectomy is overly invasive for a single small fibroid when less invasive options are available 3

Re-evaluation with imaging 3-6 months after intervention is recommended to confirm complete removal of the fibroid 6
If symptoms persist after treatment, additional workup should be considered to ensure no missed pathology 2
If the cavity is normal after treatment and fertility is desired, natural or assisted conception can be attempted without further intervention 2