A 37-year-old G0 African-American female with progressive, worsening heavy menstrual bleeding leading to anemia over the past few years. Her past medical, gynecologic, and surgical histories are otherwise unremarkable. She desires future fertility. Office ultrasound and hysteroscopy revealed an anterior fundal fibroid impinging on the endometrial cavity. She was referred by her Reproductive Endocrinologist to see Dr. Miller.

There are several management options to consider when one approaches a fibroid uterus: expectant, medical, radiologic, and surgical. Multiple factors are important to consider when determining which option is best for each patient. Each decision should be based upon the size, number, location, and symptoms of the fibroids. Furthermore, the patient’s age and desire for fertility should be taken into account. Thus, the management options can be further subdivided into fertility sparing versus conception contraindicated. The plan for the case above was a dragnostic hysteroscopy and laparoscopic myomectomy. The different management options are discussed in detail below.

The prevalence of fibroids in the general female population is difficult to determine. Pathologists report finding fibroids in 77% of women status post hysterectomy, but severity depends upon race [1]. Only 25% of the Caucasian population develops clinically significant disease with a higher incidence, approaching the prevalence, in the African-American population [1]. Thus, there is an unknown percentage of fibroids that are asymptomatic. If watchful waiting was considered in the case above, then preconception counseling is important. Fibroids may enlarge during pregnancy or potentially degenerate and subsequently cause pain. A CBC to assess for anemia should be performed and subsequent hematologic workup undertaken. Microcytic hypochromic red blood cells, increased transferrin, and decreased ferritin confirm iron deficiency anemia due to blood loss. Hemoglobin should be optimized with iron replacement as necessary. Ultrasound evaluation, ideally transvaginal, is important to confirm the location of the fibroids. If necessary, further workup may require sonohysterogram or MRI with or without contrast.

Counseling regarding submucosal fibroids’ impingement on the uterine cavity and the potential for infertility, spontaneous abortion, or preterm birth should be discussed. Pritts et al. performed a metamanalysis of randomized trials and concluded that submucosal and intramural fibroid cause problems with fertility, and their removal has been shown to confer a benefit. However, no significant difference in preterm delivery was observed [2]. Anatomic changes due to fibroids can result in malpresentation, dysfunctional labor, or placental abruption. Thus, Cesarean delivery has been reported to increase by over 30% in those affected by fibroids [3]. The same anatomic abnormalities can in theory predispose to an increased risk of postpartum hemorrhage, although reports are conflicting [3]. Thus, several experts recommend that in a patient desiring pregnancy, hysteroscopically resectable fibroids should be removed [3, 4].

Further counseling about infertility is especially important in patients of advanced maternal age. Someone contemplating a future pregnancy with a preexisting potential infertility factor, such as fibroids, should be counseled about oocyte cryopreservation.

Currently, in the United States, there is no long-term medical treatment for fibroids. Symptoms caused by fibroids do not begin to resolve naturally until menopause alters the hormonal state. Thus, relatively young patients remote from menopause should be counseled that greater than 50% of women using medical treatment undergo surgery within 2 years [5].

GnRH agonists are the most effective medical therapy currently available in the United States. The use of GnRH agonists can shrink a fibroid by 30–40%, stop bleeding, and improve anemia [6]. However, the mechanism of action, feedback inhibition, ultimately results in a hypogonadotropic hypogonadal state. This causes a pseudo-menopausal hypoestrogenic state with side effects such as amenorrhea, hot flashes, bone loss, and sleep and mood disruptions. If used for an extended period of time (greater than 6 months), one must provide add back therapy with progesterone alone or in combo with estrogen to prevent bone loss and vasomotor problems. Ultimately, once GnRH agonist therapy concludes there is a rapid return of the fibroid to pretreatment size. These drugs are not approved by the FDA to decrease fibroid size; the only FDA approved use of GnRH agonists in the treatment of fibroids is to treat anemia. A typical regimen is 3.75 mg leuprolide acetate^® every month for 3 months with iron supplementation. A statistically significant elevation in post-op hemoglobin has been seen in GnRH agonist-treated groups; however, there was no difference in transfusion requirements [7]. Further, preoperative treatment with GnRH agonists causes degenerative changes of the fibroids capsule. These changes result in a more difficult surgical resection, which translates to increased operative times [8, 9]. One use of GnRH agonists at this time is to shrink a large fibroid while optimizing hemoglobin in an attempt to convert an open procedure to a minimally invasive approach.

Aromatase inhibitors work to suppress estrogen but, unlike GnRH agonists, avoid the initial flare. Due to a paucity of research on aromatase inhibitors, the treatment of fibroids with these medications is currently an off-label use [10]. However, there are case reports that show efficacy in the treatment of fibroids [11]. Further data is needed before the routine use of aromatase inhibitors to treat symptomatic fibroids is recommended.

There is a plethora of other medications that have been used to treat fibroids and its symptoms. In a patient attempting pregnancy, several of these are contraindicated. Progesterone receptor modulators , such as ulipristal acetate and mifepristone, have shown efficacy in shrinking fibroids and reducing symptoms [12, 13]. However, unwanted side effects are seen such as amenorrhea, endometrial hyperplasia, and transient elevations of transaminases. These side effects severely limit its usefulness. Levonorgestrel intrauterine device can also decrease vaginal bleeding, but intracavitary fibroids are a relative contraindication due to a higher rate of expulsion [5]. Oral estrogen-progesterone contraceptive pills (OCPs ) have several known non-contraceptive benefits: a decrease in the risk of ovarian and endometrial cancer and treatment of acne, menorrhagia, and dysmenorrhea. Long-term longitudinal studies show that women who used OCPs for 10 years had a 31% reduction in fibroid risk [14]. Clinically, they have been used to successfully improve anemia in patients with menorrhagia. However, evidence of efficacy in treating women with symptomatic fibroids is scarce and of low quality [15]. A trial of OCPs can be attempted in women who do not currently desire pregnancy.

Several radiologic treatment modalities that combine radiologic imaging with a minimally invasive approach are in various stages of development.

UAE is the nonsurgical systematic occlusion of blood flow to the uterus performed by interventional radiologists. This procedure has been shown to cause a 30–40% decrease in fibroid size [16]. The upper limit of fibroid or uterine size safely treated with UAE has not been established. Pedunculated fibroids or a large fibroid burden (dominant fibroid >10 cm and/or uterine volume of >700 cm³) is a relative contraindication due to early case reports of ischemic uterine artery injury which manifests as severe pain and infection [17]. Thirty percent of fibroids recur, and between 15 and 32% require surgery within 2 years of UAE [16, 18].

A retrospective cohort by Goldberg et al. compared pregnancy following UAE to pregnancies following laparoscopic myomectomy. They concluded that surgical treatment is superior since most patients end up needing surgery after treatment. They also found that pregnancies post UAE were at increased risk of preterm delivery and malpresentation [18]. Due to a lack of research in women desiring fertility after UAE, pregnancy post UAE is relatively contraindicated per ACOG [19]. However, there are case reports of patients becoming pregnant after UAE and carrying to term without complications [20]. At this time, UAE should be reserved for patients who no longer desire fertility and wish to avoid surgery.

One of the newer modalities used by interventional radiology is the use of thermoablative ultrasound energy to destroy fibroids. MRgFUS was FDA approved in 2004 and uses MRI mapping to deliver a focused ultrasound beam to fibroid tissue. The advantages of same day outpatient therapy with no incisions are appealing. However, several aspects of this time-consuming and costly procedure are yet to be elucidated. Preliminary case reports show that post-procedure pregnancy is possible, but the risk of rupture during pregnancy is unknown [21]. Another question that remains to be answered is the upper limit of fibroid size that can be ablated by this procedure. Contraindications to an MRI or Gadolinium use exclude patients from MRgFUS treatment. Side effects such as skin burns and bowel injury are possible. This is another example of a treatment modality in its infancy. Further data is needed before recommendations can be made.

Myolysis refers to the use of thermal, radiofrequency, or cryoablative energy to destroy fibroids. Laparoscopic radiofrequency volumetric thermal ablation (RFVTA) is now FDA approved for such use. The current technique involves 5–10 mm laparoscopic incisions; one to insert a laparoscopic ultrasound probe and another to introduce a handpiece that will deliver the energy. The fibroids are mapped with the ultrasound, and then the energy source is applied to the fibroid under ultrasound guidance. The technique has improved with the recent FDA approval of a guidance system. One prospective, single-center study concluded that RFVTA decreased intraoperative blood loss, decreased length of stay, and treated more fibroids, when compared to laparoscopic myomectomy [22]. The landmark 3-year prospective, multicenter, international trial of 135 premenopausal women demonstrated a repeat intervention rate of 11% [23]. There is also a concern for increased risk of adhesion formation. Case reports of viable term pregnancies after myolysis do exist [24]. However, some studies suggest an increased risk of uterine rupture during pregnancy [25]. Further data is needed before universally recommending myolysis as a first-line treatment.