In young patients with symptomatic fibroids who desire fertility preservation, myomectomy is currently the only appropriate intervention. Preoperative evaluation and work-up should be focused on identifying the appropriate route(s) of myomectomy and on mitigating and planning for potential complications. In the patient described above, two main preoperative issues stand out.

Initially the patient’s fibroid burden is significant. Not only are her fibroids quite large. They are also deeply intramural and numerous. Each of these factors is a risk factor for bleeding and complications during myomectomy. A recent review of risk factors associated with complications at the time of laparoscopic myomectomy highlight uterine size, fibroid size, and fibroid number as independent risks factors for bleeding and transfusion [1].

In this patient’s case, her large type 1-2 submucosal fibroid makes hysteroscopic myomectomy unreasonable. Given the complicating factors already identified, an open approach to myomectomy is reasonable in this case and is likely the most appropriate approach in the hands of all but the most experienced laparoscopic or robotic surgeons. Factors which make laparoscopy reasonable in the right hands include (1) uterine mobility and access to the lower uterine segment, (2) two large fibroids which once removed will make access to the uterus much easier, and (3) a discrete number of fibroids on MRI which will be identifiable at the time of laparoscopic surgery.

The second main preoperative issue in this patient is her significant iron deficiency anemia. In patients who report heavy menstrual bleeding and signs of anemia, assessment of a complete blood count and iron studies should occur following the initial visit. This allows time for preoperative treatment and decreases the operative risks of bleeding, transfusion, and associated postoperative complications.

Preoperative strategies to optimize blood count prior to surgery include starting the patient on a continuous progestational agent or initiation of GnRH therapy to stop preoperative menses for a period of time. Optimizing blood count and iron stores with preoperative intravenous iron infusions is a very effective approach to rapidly increase hemoglobin levels [2]. Of course preoperative blood transfusion is always an option in the most severe and refractory cases. We routinely attempt to stop menses preoperatively with continuous oral contraceptives and are quick to recommend iron infusions with a hematology group in all patients with a preoperative hemoglobin less than 10 g/dL. In patients with a religious objection to blood transfusion 6–8 weeks of GnRH agonist therapy in addition to iron infusions is often warranted.

This patient underwent infusions of feraheme spaced over a period of 9 days and was placed on continuous oral contraceptives. Her preoperative labs improved dramatically: