What is the recommended management for a 2.5 cm myometrial mass, presumably a fibroid, with symptoms of heavy menstrual bleeding and pelvic pressure?

Management of a 2.5 cm Myometrial Mass (Presumed Fibroid)

For a 2.5 cm posterior fundal myometrial mass with symptoms of heavy menstrual bleeding and pelvic pressure, hysteroscopic myomectomy is the recommended first-line treatment as it provides effective symptom relief with minimal invasiveness compared to other surgical approaches. 1

Initial Assessment and Treatment Options

Medical Management

For patients with symptomatic fibroids who prefer non-surgical management initially:

• First-line medications:

  • NSAIDs and estrogen-progestin oral contraceptives to reduce bleeding symptoms 1
  • Tranexamic acid as a nonhormonal alternative for reducing bleeding 1

• Second-line medications:

  • GnRH agonists (leuprolide acetate) or antagonists (elagolix, linzagolix, relugolix) which reduce bleeding and significantly decrease fibroid volume 1
  • These agents can be used as short-term therapy or in preparation for surgery 1
  • Combination with low-dose estrogen and progestin can mitigate hypoestrogenic side effects 1

Surgical Management

The 2.5 cm posterior fundal location of the fibroid makes it likely to be accessible via hysteroscopy, which is particularly important given the symptoms of heavy menstrual bleeding:

1. Hysteroscopic Myomectomy:

   • Procedure of choice for submucosal fibroids <5 cm 1
   • Associated with shorter hospitalization and faster recovery than laparoscopic or open procedures 1
   • Provides symptom improvement equivalent to more invasive approaches 1, 2

2. Uterine Artery Embolization (UAE):

   • Effective uterus-preserving option for patients who fail conservative measures 1
   • Can lead to fibroid expulsion in submucosal fibroids (50% rate of complete expulsion reported) 1
   • Improves quality of life and symptom scores for up to 7 years 1

3. MR-Guided High-Frequency Focused Ultrasound (MRgFUS):

   • Limited evidence for submucosal fibroids, but studies show significant improvement in symptom scores 1
   • One study demonstrated 66% decrease in perfused fibroid volume with 89% of women reporting improvement in bulk symptoms 1

4. Hysterectomy:

   • Provides definitive resolution of all fibroid-related symptoms 1
   • Accounts for three-quarters of fibroid treatments in the United States 1
   • Should be considered when less invasive approaches have failed or are not appropriate 3

Treatment Algorithm Based on Patient Factors

1. If fertility preservation is desired:

   • Hysteroscopic myomectomy is preferred for submucosal fibroids 1, 2
   • Medical management may be used temporarily but fertility is suppressed during treatment 1

2. If symptoms are primarily heavy bleeding:

   • Hysteroscopic myomectomy for direct removal 1, 2
   • Medical management as a temporary measure 1

3. If bulk symptoms predominate:

   • Myomectomy (hysteroscopic if accessible) 1
   • UAE or MRgFUS as alternatives 1

4. If definitive treatment is desired (family complete):

   • Hysterectomy provides permanent cure 1, 3

Important Considerations and Pitfalls

• Diagnostic accuracy: Ensure the mass is indeed a fibroid and not adenomyosis or malignancy, especially if there is rapid growth 3

• Fibroid location: The posterior fundal location described in the ultrasound may affect the technical approach during hysteroscopic myomectomy

• Concurrent conditions: The thickened endometrium (11 mm) should be evaluated, potentially with endometrial biopsy, before proceeding with treatment 1

• Treatment limitations: Medical management will only provide temporary relief; symptoms typically recur when treatment is stopped 1, 4

• Follow-up imaging: Important after conservative management to ensure stability of the fibroid 3

The management approach should prioritize the least invasive option that effectively addresses symptoms. For this 2.5 cm posterior fundal fibroid with symptoms of heavy bleeding and pelvic pressure, hysteroscopic myomectomy offers the best balance of effectiveness and minimal invasiveness.