Transvaginal ultrasound performed in the emergency room had revealed an anteverted uterus with a single well-circumscribed 4 cm leiomyoma that appears to be bulging into the uterine cavity, as well as normal adnexa bilaterally (Fig. 7.1).

Vaginoscopic office hysteroscopy is performed with a 3 mm rigid hysteroscope, normal saline, no tenaculum, and no anesthesia (oral or local) for diagnostic workup of abnormal uterine bleeding [1]. Hysteroscopy reveals normal endometrium and a submucous leiomyoma that appears to be 40% within the cavity; otherwise, no polyps or lesions are noted. Bilateral tubal ostia are visualized, and she has a normal endocervical canal (Fig. 7.2).

This woman has been diagnosed with a 4 cm Type II submucous leiomyoma which has resulted in abnormal heavy uterine bleeding as well as associated iron deficiency anemia. Strategies for management should be individualized based upon the location, number, and size of leiomyoma while taking into account the severity of symptoms, age, fertility status, and proximity to menopause.

The differential to consider is leiomyoma, adenomyoma, focal adenomyosis, and leiomyosarcoma. To distinguish between these, we did an evaluation including a bimanual exam, transvaginal ultrasound, and office hysteroscopy. Had the patient been 45 years of age or older, we would have included an endometrial biopsy [2].

Our exam revealed an enlarged, nontender uterus consistent with fibroids and not adenomyosis. We reviewed the ultrasound images from the ED and noted a homogeneous mass with very distinct borders. In the myometrium not affected by the mass, the thickness is similar along the anterior and posterior wall. This would not be expected in patients with adenomyosis. Uteri affected by adenomyosis tend to be globally enlarged and classically have an asymmetric appearance with the posterior uterine wall approximately two times thicker than the anterior uterine wall. Furthermore, uteri affected by adenomyosis tend to be flexed backward in a “hockey stick” position, with the fundus retroflexed toward the posterior cul-de-sac [3].

In comparison, an adenomyoma is a nodular aggregate with an ill-defined border, appears heterogenous in echotexture, and classically contains cystic lakes of endometrial glands and stroma that may retain pockets of old blood. This patient has a mass with a distinct border that suggests a clear pseudocapsule. This pseudocapsule is not seen in adenomyomata.

Uterine leiomyomas are common and malignancy is very rare. For resectoscopic surgery, the incidence of malignancy has been reported as low as 0.13% [4]. This patient’s risk may be even lower given her young age.

Classification of the submucous leiomyoma into three subtypes can be useful for guidance and counseling of the patient [5]. The International Federation of Obstetrics and Gynecology (FIGO) put forth one of the most commonly used fibroid classification systems for the extent of myometrial involvement. FIGO describes Type 0 lesions as completely within the endometrial cavity, Type I lesions as those that extend <50% into the myometrium, Type II lesions as those in which ≥50% are within the myometrium, and Type III lesions are 100% intramural and abut the endometrium but do not distort the endometrial cavity. Removal of 100% of a Type I or II myoma can be safely achieved as long as one stays within the pseudocapsule and does not cut myometrium because a fibroid will displace myometrium and not invade it (as opposed to an adenomyoma). Patients with Type III myomas should only have hysteroscopic resection by very experienced hysteroscopic surgeons.

The management of uterine fibroids can generally be approached by a variety of options including medications, surgery, or minimally invasive embolization or ablative techniques [6]. Medical treatment alone is temporary and only effective while on the medication. Fibroid symptoms will recur if medical therapy is discontinued. Likewise, patients with submucous myomas more often experience irregular bleeding on suppressive hormonal therapy. Furthermore, many patients present with heavy bleeding despite already being on combined oral contraceptive pills or levonorgestrel IUD, which should prompt the provider to explore further the etiology of the abnormal uterine bleeding.

Nonsurgical treatment options such as uterine artery embolization (UAE) function by restricting the blood supply of the fibroid and inducing ischemic necrosis within the myoma. Patients should be counseled regarding the risk of reoperation, which is approximately 20% after a successful percutaneous embolization and up to 50% in situations of incomplete infarction [7]. A relative contraindication for UAE is submucous location of the myoma as well as desire for a future pregnancy, as there exists a lack of data ensuring favorable pregnancy outcomes after UAE [8]. One randomized control trial suggests myomectomy is favorable over UAE in regard to rates of successful pregnancy resulting in delivery [9].

A nonsurgical and minimally invasive option that utilizes high-frequency ultrasound is also available for therapeutic treatment of uterine fibroids. The high-intensity focused ultrasound beams is magnetic resonance-guided focused ultrasound (known as MRgFUS ) and utilizes thermal ablation to induce myoma shrinkage via tissue necrosis. However, concerns about detrimental impact on future fertility remain with this approach [10], as well as risk of needing a subsequent fibroid surgery within 2 years of having the procedure performed [11]. Of note, these methods also do not allow for histological evaluation of the pathology.

Another minimally invasive treatment option exists that utilizes laparoscopic ultrasound-guided radiofrequency volumetric thermal ablation (RFTVA) and has received FDA approval in the United States (Acessa; Halt Medical, Inc., Brentwood, CA, USA) as well as in Europe. The role of RFTVA is still being evaluated, as patient outcomes including quality of life as well as pregnancy outcomes are currently being followed longitudinally. A recently published 24-month interim analysis data suggest safety as well as efficacy when compared to laparoscopic myomectomy [12].