Treatment of Uterine Fibroids
Diagnosis and Imaging
- The American College of Radiology recommends MRI for accurately identifying and mapping fibroids, potentially altering management in up to 28% of patients, with transvaginal ultrasound combined with transabdominal ultrasound as the initial imaging modality of choice, having a reported sensitivity of 90-99% for detecting uterine fibroids 1
- Color Doppler helps differentiate fibroids from other conditions, with a peripheral vascular flow pattern characteristic of fibroids, and resistive index <0.7 and pulsatility index <1.2 helping to differentiate fibroids from adenomyosis with 93.4% sensitivity and 95.6% specificity 1
Treatment Options
- For patients with intramural fibroids, the American College of Radiology recommends laparoscopic or open myomectomy as the most appropriate treatment option when symptoms are present and fertility preservation is desired, while uterine artery embolization (UAE) is preferred for those not desiring future fertility 2
- Medical management options include:
- The following table summarizes the treatment options and their outcomes:
| Treatment | Description | Symptom Improvement |
|---|---|---|
| Medical Management | NSAIDs, hormonal contraceptives, tranexamic acid | Temporary relief |
| Myomectomy | Laparoscopic or open surgery to remove fibroids | Permanent resolution |
| UAE | Uterine artery embolization to reduce blood flow to fibroids | 85-94% |
| MRgFUS | High-intensity ultrasound waves to thermally ablate fibroids | 18% decrease in fibroid diameter |
| Hysterectomy | Surgical removal of the uterus | Permanent resolution |
Potential Complications and Considerations
- Uterine rupture during future pregnancies is a potential complication of myomectomy, with a higher risk if the uterine cavity is entered during surgery, and the recurrence rate of fibroids is 27% at 10 years, higher in patients with multiple fibroids 4
- Correction of anemia before surgery is recommended to minimize blood loss during myomectomy, according to the American College of Radiology 4
- Storage of autologous blood to avoid homologous transfusion is a suggested strategy to reduce the risk of blood transfusion-related complications 4
- Appropriate imaging (ultrasound/MRI) to determine fibroid location and vascularity is essential for planning the surgical approach 4
- Treatment selection should consider symptom severity, patient's age and fertility desires, uterine size, and economic considerations, with regular monitoring of hemoglobin levels and lesion size with imaging (ultrasound) before and after treatment, as recommended by the American College of Radiology 2
- Intramural fibroids significantly reduce pregnancy and implantation rates (16.4% vs 30.1% in controls), according to the American College of Radiology 4
- Subserosal fibroids do not significantly impact pregnancy rates (34.1% vs 30.1% in controls), as observed in a study published in Environmental Health Perspectives 4
- Myomectomy for women desiring fertility preservation, with improved quality of life for up to 10 years, but less than half of patients achieve pregnancy after myomectomy at up to 3 years of follow-up 2
- Confine incisions to the anterior uterine surface when possible to minimize adhesion formation, and use adhesion prevention barriers such as oxidized regenerated cellulose, polytetrafluoroethylene, or hyaluronic acid with carboxymethylcellulose 4
- Minimize surgical trauma to reduce adhesion formation, as this can help improve outcomes and reduce the risk of complications 4