What is the optimal treatment for a 45-year-old perimenopausal woman with a single 5.7 x 5.4 cm intramural fibroid (Leiomyoma) in the anterior myometrium, presenting with severe abdominal pain?

From the Guidelines

For a 45-year-old perimenopausal woman with a single 5.7 x 5.4 cm intramural fibroid in the anterior myometrium causing severe abdominal pain, I recommend minimally invasive options like uterine artery embolization (UAE) or focused ultrasound surgery (FUS) as the best initial treatments. These procedures preserve the uterus while effectively addressing symptoms. UAE involves injecting small particles into the uterine arteries to block blood flow to the fibroid, causing it to shrink, while FUS uses high-frequency ultrasound waves to destroy fibroid tissue.

Key Considerations

• Hormonal medications such as GnRH agonists (like leuprolide 3.75 mg monthly injections for 3-6 months) can provide temporary symptom relief and reduce fibroid size, making them useful as bridge therapy before definitive treatment 1.
• For immediate pain management, NSAIDs like ibuprofen 600 mg every 6 hours or naproxen 500 mg twice daily can help 1.
• If these conservative approaches fail or if symptoms are severely impacting quality of life, surgical options including myomectomy (fibroid removal) or hysterectomy should be considered, with the least invasive route for hysterectomy being preferred if this option is chosen 1.
• Given the patient's perimenopausal status, expectant management with symptomatic treatment might also be reasonable, as fibroids often shrink naturally after menopause due to declining estrogen levels.

Treatment Choice Factors

• The final treatment choice should be based on the patient's desire for future fertility, symptom severity, and personal preferences.
• Medical management should be trialed prior to pursuing more invasive therapies, as recommended by the most recent guidelines 1.
• The use of progesterone receptor modulators like ulipristal acetate may also be considered for reducing both bleeding and bulk symptoms, although its approval for use in the United States is pending due to reports of hepatotoxicity 1.

From the Research

Treatment Options for Uterine Fibroids

The optimal treatment for a 45-year-old perimenopausal woman with a single 5.7 x 5.4 cm intramural fibroid in the anterior myometrium, presenting with severe abdominal pain, depends on various factors, including the patient's age, fertility desires, and the size and location of the fibroid.

• Surgical Interventions: Hysterectomy and myomectomy are common surgical interventions for uterine fibroids 2, 3. Myomectomy is considered for women who wish to retain their uterus, while hysterectomy is the standard treatment for women with symptomatic fibroids who have not improved with medical treatment.
• Medical Treatment: Medical treatment options, such as progestogens, combined oral contraceptives, and gonadotropin-releasing hormone agonists and antagonists, are generally used for short-term treatment of fibroid-induced bleeding 3. Preoperative medical therapy, such as GnRHa, can reduce uterine and fibroid volume, increase preoperative haemoglobin levels, and reduce blood loss and operation time during hysterectomy 4.
• Minimally Invasive Techniques: Minimally invasive techniques, such as uterine artery embolization, myolysis, magnetic resonance-guided focused ultrasound surgery, and radiofrequency ablation of fibroids, are also available 3. Magnetic resonance-guided focused ultrasound surgery (MRgFUS) can be a feasible treatment option for intramural fibroids, especially for women who are not candidates for surgery or prefer a non-invasive approach 5.
• Referral: Referral to a specialist is recommended for women with fibroids >3 cm in diameter, uterus palpable abdominally or >12 cm in size on scan, persistent intermenstrual bleeding, or age >45 where treatment has failed or been ineffective 2.

Considerations for Treatment

When considering treatment options, the following factors should be taken into account:

• Fibroid size and location: The size and location of the fibroid can affect the choice of treatment. For example, larger fibroids may require more extensive surgery, while smaller fibroids may be treated with medical therapy or minimally invasive techniques.
• Patient's age and fertility desires: The patient's age and fertility desires can also influence the choice of treatment. For example, women who wish to retain their fertility may opt for myomectomy, while women who have completed their family may prefer hysterectomy.
• Symptom severity: The severity of symptoms, such as abdominal pain and bleeding, can also impact the choice of treatment. Women with severe symptoms may require more aggressive treatment, such as surgery, while women with mild symptoms may be managed with medical therapy or observation.