What is the recommended treatment for a 1.8 x 2.0 x 1.6 cm anterior fundal fibroid, classified as FIGO (International Federation of Gynecology and Obstetrics) 4?

Treatment of Anterior Fundal Fibroid-FIGO 4 (1.8 x 2.0 x 1.6 cm)

For a small (1.8 x 2.0 x 1.6 cm) anterior fundal fibroid classified as FIGO 4, hysteroscopic myomectomy is the treatment of choice if the patient is symptomatic, as it provides the best outcomes with minimal invasiveness. 1

Understanding FIGO 4 Fibroids

FIGO 4 classification refers to an intramural fibroid that extends to the endometrium without involvement of the endometrial cavity. Key considerations for this type:

• Location: Anterior fundal region
• Size: Small (1.8 x 2.0 x 1.6 cm)
• Classification: Intramural with extension to endometrium

Treatment Algorithm

For Asymptomatic Patients:

• Expectant management is recommended as most fibroids decrease in size during menopause 2
• Regular monitoring with ultrasound (transvaginal and transabdominal) is sufficient 1

For Symptomatic Patients:

1. First-line treatment options:

   • Hysteroscopic myomectomy - Preferred for this size and location 1
   • Benefits: Shorter hospitalization, faster recovery, and equivalent symptom improvement compared to more invasive approaches 1

2. Medical management options (can be used as primary treatment or pre-surgical):

   • First-line medications:

     • NSAIDs and estrogen-progestin oral contraceptives for bleeding symptoms 1
     • Tranexamic acid for heavy menstrual bleeding 1

   • Second-line medications:

     • GnRH agonists (leuprolide acetate) or antagonists (elagolix, linzagolix, relugolix) 1
     • Can reduce fibroid volume by 30-70% and control bleeding 1
     • Useful for short-term treatment before surgery 1
     • Limitation: Hypoestrogenic side effects and rapid recurrence after discontinuation 1

   • Selective progesterone receptor modulators (SPRMs):

     • Ulipristal acetate shows promise for intermittent use 1
     • Can be used for 1-2 courses for symptom control 1
     • Limitation: Potential hepatotoxicity has limited FDA approval in the US 1

3. Alternative interventional options:

   • Uterine artery embolization (UAE):

     • Effective for symptom control in 80% of patients 1
     • Reduces uterine volume by 40-50% 1
     • Higher reintervention rates (36%) compared to myomectomy (5%) 1
     • Not recommended as first-line for women desiring future fertility 3

   • MR-guided focused ultrasound (MRgFUS):

     • Limited evidence for FIGO 4 fibroids 1
     • Can achieve 66% decrease in perfused fibroid volume 1

Special Considerations

For Women Desiring Fertility:

• Hysteroscopic myomectomy is recommended even for asymptomatic fibroids if fertility is desired 4
• UAE should be avoided due to concerns about decreased ovarian reserve and increased risks of pregnancy complications 3

For Perimenopausal Women:

• Consider pulsatile courses of SPRMs to help transition to menopause while avoiding surgery 1
• If family is complete and symptoms are significant, hysterectomy provides permanent cure 5

Monitoring and Follow-up

• Post-treatment surveillance with ultrasound at 3 months and 12 months is common practice 1
• Parameters to assess: uterine volume, fibroid volume, percent infarcted volume 1

Common Pitfalls to Avoid

1. Underestimating the impact of small fibroids - even small fibroids in certain locations can cause significant symptoms
2. Overlooking rapid growth - sarcomatous change, while rare, should be suspected with rapid growth 5
3. Inappropriate use of morcellation - not recommended due to risk of spreading possible occult malignancy 1
4. Prolonged use of GnRH agonists - can lead to trabecular bone loss 1

The treatment approach should prioritize the least invasive option that effectively addresses symptoms while considering the patient's fertility desires and proximity to menopause.