What are the implications of a uterus with multiple large transmural leiomyomas (fibroids), significant endometrial distortion, and an intrauterine device (IUD) in place, with associated ovarian cysts and normal cervical anatomy?

From the Guidelines

The patient's ultrasound findings indicate the presence of multiple large transmural fibroids, which are significantly distorting the endometrium and may be impacting fertility, and therefore, consideration of surgical or medical treatment should be prioritized to improve fertility outcomes. The ultrasound findings show an enlarged uterus measuring 11.7 x 6.5 x 9.5 cm in an anteverted position (tilted forward). Multiple large transmural fibroids (leiomyomas) are present throughout the uterus. The largest fibroids include a 3.5 x 2.9 x 3.2 cm one in the right upper uterus, a 5.7 x 3.4 x 4.3 cm one in the posterior lower region, and a 3.1 x 3.4 x 4.0 cm one in the left upper uterus. These fibroids are significantly distorting the endometrium (uterine lining), which measures 3.1 mm in thickness. An intrauterine device (IUD) is properly positioned in the endometrial canal of the upper uterus. The cervix appears normal. The right ovary measures 4.1 x 4.2 x 3.8 cm with a normal blood flow pattern (resistive index of 0.59) and contains a 3.3 cm simple cyst classified as ORADS 2, indicating it is likely benign. The left ovary was not visualized during the examination, which could be due to positioning, bowel gas, or other technical factors.

Key Findings and Recommendations

• The presence of multiple large transmural fibroids is likely to be impacting fertility, as evidenced by studies such as 1, which found that pregnancy and implantation rates were significantly lower in patients with intramural fibroids.
• The significant distortion of the endometrium caused by the fibroids may also be contributing to fertility issues, as noted in 1, which highlights the importance of considering the impact of fibroids on fertility.
• Given the potential impact on fertility, surgical or medical treatment of the fibroids should be considered, as recommended in 1, which outlines the importance of understanding the role of treatment options in various clinical scenarios.
• The patient's treatment plan should be individualized, taking into account their specific symptoms, medical history, and preferences, as well as the potential risks and benefits of each treatment option, as discussed in 1 and 1.

Treatment Options

• Surgical options, such as myomectomy, may be considered to remove the fibroids and improve fertility outcomes, as noted in 1 and 1.
• Medical treatment options, such as GnRH agonists or levonorgestrel-releasing intrauterine devices, may also be considered to manage symptoms and improve fertility, as discussed in 1 and 1.
• The patient should be presented with the outcomes and complications of each treatment option, as recommended in 1, to make an informed decision about their care.

From the Research

Uterus Findings

• The uterus measures 11.7 x 6.5 x 9.5 cm and is in an anteverted position.
• Numerous large transmural leiomyomas are present, with the following measurements:
  • Dominant right upper uterine transmural leiomyoma: 3.5 x 2.9 x 3.2 cm
  • Posterior lower transmural leiomyoma: 5.7 x 3.4 x 4.3 cm
  • Left upper uterine transmural leiomyoma: 3.1 x 3.4 x 4.0 cm
• There is significant distortion of the endometrium, with a measured thickness of 3.1 mm.
• An IUD is positioned in the endometrial canal of the upper uterus.

Ovarian Findings

• The right ovary measures 4.1 x 4.2 x 3.8 cm, with a resistive index of 0.59 and a normal arterial waveform.
• A 3.3 cm anechoic cyst is present on the right ovary, classified as ORADS 2.
• The left ovary is not visible.

Relevant Studies

• According to 2, GnRH agonists are effective in reducing leiomyoma volume and symptoms, but their use is limited due to side effects and health risks.
• 3 discusses the role of medical management for uterine leiomyomas, including hormonal and non-hormonal therapies, and highlights the effectiveness of GnRH agonists and selective progesterone receptor modulators in reducing leiomyoma volume and symptoms.
• 4 reports on the use of oral GnRH antagonist combination therapy for preoperative management of refractory leiomyoma-related heavy menstrual bleeding, demonstrating its clinical utility in this setting.
• 5 reviews the effects of GnRH-agonists and GnRH-antagonists in the preoperative therapy of uterine fibroids, highlighting the advantages of GnRH-antagonists in rapidly suppressing gonadotropin release without an initial flare-up.
• 6 provides updated evidence-based recommendations for the medical, procedural, and surgical management of symptomatic leiomyomas, emphasizing the importance of individualized treatment approaches.