The following treatment options are presented to her at this time (from least invasive to most invasive):

Lifestyle and dietary modifications : There have been numerous studies looking at the epidemiology of uterine fibroids, and different lifestyle modifications to help treat the symptoms of uterine fibroids. These include decreasing exposure to plastics and chemicals, preservatives, pesticides, foods with additives such as hormones, soybeans, dairy, caffeine, and alcohol [1–4]. All of these options are discussed with the patient as an initial step to try to help with some symptom control and as a path towards a healthier lifestyle, especially given her desire to pursue pregnancy.

Medication (nonhormonal ): Following a discussion of lifestyle modification, medications are discussed with this patient. She has already tried nonsteroidal analgesics that had been recommended to her by her family physician; however, she has not really found any change in her symptomatology. Her flow did not decrease with the NSAID, and she was not experiencing much cramping with her menses to begin with. One older randomized controlled trial in the literature has demonstrated that while Naprosyn might help with idiopathic heavy menses, it does not necessarily have an effect on fibroid-induced menses [5]. A more recent Cochrane database review of nonsteroidal anti-inflammatory drugs for heavy menses also demonstrated that while it is more effective than placebo, other medications, such as tranexamic acid and hormonal medications, might be more efficacious [6].

Tranexamic acid is also a widely used nonhormonal medication for treatment of symptomatic uterine fibroids in the setting of heavy menses [7–9]. By inhibiting fibrinolysis, it can be a useful treatment for women who do not wish to take a daily medication and who still want to get pregnant. It is safe and generally well tolerated [9]. This medication is one which the patient is amenable to trying, particularly because she is not keen on taking daily medication.

Medication (hormonal): Hormonal medications are also discussed with the patient, and these include combined oral contraceptives , oral and injectable progestins, progesterone-releasing intrauterine devices, selective progesterone receptor modulators (SPRMs) , and gonadotropin releasing hormone (GnRH) agonists. Several studies have shown significant reduction in bleeding with these hormonal agents, and that GnRH agonists are likely to be the most effective with respect to both bleeding and reduction in fibroid size [10–12]. Europe and Canada have also seen some effect with SPRMs for management of bleeding secondary to fibroids and for reduction in fibroid volume, particularly for smaller uterine fibroids [13–15]. In this patient’s case, however, none of these medications would allow her the option to attempt pregnancy, except for perhaps the gonadotropin releasing hormone agonists combined with concomitant in vitro fertilization. This regimen, however, is something that the patient is not prepared to undertake at this point in time. She expresses her desire to consider further non-medicinal options.

Radiologic procedures : Uterine artery embolization (UAE) is discussed with the patient. This procedure has been shown to be an effective minimally invasive nonsurgical treatment option for women with uterine fibroids, treating both abnormal uterine bleeding, and fibroid volume or “bulk” symptoms by shrinking fibroids by up to 50% [16–18]. The placement of her cervical fibroid is not expected to adversely affect the success of the procedure, and interventional radiology feels that she would be a good candidate for the procedure, based on her initial ultrasound results. Risks of serious complications such as postembolization syndrome, premature ovarian failure, vaginal discharge/expulsion of infarcted fibroid, infection, and sepsis are felt to be quite low in her case as per radiology. The patient wonders, however, what the long-term implications on her fertility following UAE would be. Several recent studies have looked at the impact of uterine artery embolization on ovarian reserve in the young reproductive-aged woman, such as this patient [19–23]. The results of these studies are mixed. While one of the established risks of UAE is premature ovarian failure, there is no consistent evidence that there is clinical or subclinical reduction in ovarian function in women below the age of 40. Traditionally, however, UAE has been a treatment choice for women who do not desire surgery and are also not anxious for pregnancy. MRI guided high intensity focused ultrasound (HiFU) treatment of the fibroid is also discussed with the patient. However, after discussion with the interventional radiologists, they feel that the fibroid is too large to consider this option. Furthermore, they are concerned that treatment of this large cervical fibroid with HiFU might damage the adjacent bowel. UAE, as far as they are concerned, is the better of the two options for this patient.

Surgery : The discussion then turns to surgery. The patient is interested in uterine preserving surgery and makes it clear that she absolutely does not want a hysterectomy. Her main surgical option at this point is either laparoscopic or abdominal myomectomy . The patient would prefer a laparoscopic approach as opposed to the abdominal approach, as a shorter length of stay in the hospital and a quicker postoperative recovery are appealing to her. She understands, however, that there is always the possibility that it would need to be converted to a laparotomy. Furthermore, risks of power morcellation are discussed with the patient. The risk of a leiomyosarcoma (LMS) is discussed and while it is unlikely, the chance of upstaging, spreading concern, and worsening prognosis not only with power morcellation but also with any form of myomectomy are clearly and openly discussed. If she is truly worried about a LMS, then the only procedure that could be safely offered would be an abdominal hysterectomy.

The patient decides she would like to have a laparoscopic myomectomy . Her surgery is scheduled for 4 months later. In the interim, medications to help control her bleeding and raise her preoperative hemoglobin prior to surgery are again discussed, with the goal being short term preoperative use only. These medications include tranexamic acid, ulipristal acetate, levonorgestrel-releasing IUD, and GnRH agonists. The benefit of GnRH agonists on decreasing risk of even intraoperative bleeding and fibroid volume [24] is specifically emphasized. The patient decides to try only tranexamic acid during her menses for symptom control. As her hemoglobin is 140 g/L, it is felt that this decision is reasonable.

During her surgery, after induction of the general anesthetic, the patient is given an examination under anesthesia. This examination confirms that her uterus extends to her umbilicus, and bimanual examination confirms that there is a mass filling her pelvis, but that the entire uterus is quite mobile. After this examination, port placement is decided. The camera is placed through Palmer’s point, and all ports are moved up so that all laparoscopic instruments can work “down” on the uterus. One port is placed on the patient’s left, and two ports are placed on the patient’s right side. This is to facilitate the laparoscopic suturing anticipated with the laparoscopic myomectomy. The posterior cervical fibroid is noted to distort her entire pelvis. Vasopressin is then injected into serosa and myometrium overlying the fibroid to help decrease blood loss. A solution of 20 U in 20 mL of normal saline is used, and a total of 7 mL is used for the entire case. Vasopressin injection has been shown in several studies to help decrease blood loss during myomectomy [25–27]. Newer therapies such as transient occlusion of the uterine arteries with clips or suture have also been shown to be effective for decreasing intraoperative blood loss [28, 29]. Unfortunately the cervical fibroid resulted in too great of a distortion of the uterine arteries to make this feasible.

A horizontal incision is made overlying the fibroid. Surgeon preference often dictates the direction of the incision, although other concerns such as extension into the uterine arteries and other surrounding structures such as major vessels and ureters can influence this decision. Horizontal incisions, however, are more in keeping with the direction of the uterine smooth muscle fibers, possibly decreasing risk of uterine rupture concerns postoperatively, rather than performing a large vertical uterine incision. A recent analysis of arterial vessels around uterine fibroids suggests that with respect to blood loss, direction of the incision does not impact damage to arterial vessels, which travel diagonally on the surface of uterine fibroids [30]. After examining this patient’s pelvis and fibroid, the decision is made to continue with a horizontal incision. The ureters, major vessels, and uterine arteries are deemed to be far enough away from the site of the incision.

Monopolar energy with the laparoscopic Metzenbaum scissors on a cutting current (30–35 W) is used to make the incision. This makes the incision rapidly and with the least amount of smoke, as compared to a LASER, which often generates plume which can interfere with visualization. Minimal cautery of the incision is performed, as the most effective method to ultimately stop the bleeding is to quickly enucleate the fibroid and commence suturing of the defect. As well, minimal bipolar cautery is used, so that there is minimal thermal damage to the tissue around the incision. This will aid in postoperative healing of the uterus. The incision is quickly continued down to the level of the fibroid. It is often helpful to actually incise the fibroid to ensure that the correct depth is achieved and that the layer between the myometrium and the fibroid has been reached. This layer can often be deceptive if one is not careful, and dissecting the fibroid when this layer is not reached, even if the surgeon is a few cell layers too superficial, can result in more bleeding.

Once this layer is identified, the key to fibroid enucleation is adequate traction and countertraction. Often, a 10 mm single or double toothed tenaculum is used to grasp the fibroid, and traction is applied. The other two 5 mm ports are used to give counter traction, and slowly, the fibroid is enucleated. Care is taken to ensure that laparoscopic graspers do not dig into tissue without good visualization so as to avoid accidentally piercing into the uterine cavity. Care is also taken not to apply so much traction with the tenaculum on the fibroid so that the fibroid is not “ripped” away from the myometrium resulting in inadvertent damage to the endometrium, particularly during the dissection at the base of the uterine fibroid.