What are the treatment options for a myometrial mass?

Treatment Options for Myometrial Masses

The primary treatment for myometrial masses depends on the specific type of mass, with surgical intervention being the standard approach for symptomatic uterine leiomyomas (fibroids), which are the most common myometrial masses. 1

Diagnostic Evaluation

Before determining treatment, proper diagnosis is essential:

• Imaging studies: Transvaginal ultrasound is the first-line imaging modality for evaluating myometrial masses 2, 3
• MRI: Provides better characterization of myometrial masses, especially to differentiate between fibroids, adenomyosis, and potential malignancies 4, 5
• Biopsy: May be necessary if malignancy is suspected based on rapid growth, irregular appearance, or postmenopausal presentation 6

Treatment Options by Mass Type

1. Uterine Leiomyomas (Fibroids)

Medical Management

• First-line medications for symptomatic fibroids:

  • NSAIDs for pain and bleeding reduction
  • Hormonal contraceptives for bleeding control
  • Tranexamic acid for heavy bleeding
  • Progestin-containing IUDs 2

• Second-line medications:

  • GnRH agonists (leuprolide acetate) - can reduce fibroid size by 40-50%
  • GnRH antagonists (elagolix, relugolix) 2
  • Note: These medications provide temporary relief and fibroids typically regrow after discontinuation 1

Surgical Options

• Myomectomy: Surgical removal of fibroids while preserving the uterus

  • Approaches: Abdominal, laparoscopic, or hysteroscopic (for submucosal fibroids)
  • Recurrence rates range from 23-33% 1
  • Preferred for women desiring future fertility 1

• Hysterectomy: Complete removal of the uterus

  • Definitive treatment that eliminates recurrence risk
  • Simple hysterectomy is often chosen as a curative procedure 1
  • Approaches: Abdominal, vaginal, or laparoscopically assisted 1

Minimally Invasive Procedures

• Uterine Artery Embolization (UAE):

  • Non-surgical procedure that blocks blood flow to fibroids
  • Shorter hospital stay and recovery time compared to surgery
  • Higher reintervention rates (36%) compared to myomectomy (5%) 1

• Hysteroscopic myomectomy:

  • Most cost-effective method for completely intracavitary fibroids
  • Suitable for submucosal fibroids with significant protrusion into the endometrial cavity 1

• Other techniques:

  • Laparoscopic uterine artery occlusion (LUAO)
  • High-intensity focused ultrasound (HIFU) 1

2. Endometrial Carcinoma with Myometrial Invasion

• Standard treatment: Total hysterectomy with bilateral salpingo-oophorectomy 1
• Adjuvant therapy based on depth of myometrial invasion:
  • For <50% myometrial invasion: Vaginal brachytherapy may be sufficient
  • For >50% invasion: External radiotherapy with brachytherapy boost 1

3. Gestational Trophoblastic Neoplasia

• Initial treatment: Suction dilation and curettage under ultrasound guidance
• Follow-up: Regular hCG monitoring until normalization and beyond 1

Treatment Selection Factors

1. Patient factors:

   • Age
   • Desire for future fertility
   • Symptom severity
   • Comorbidities

2. Mass characteristics:

   • Size and location
   • Number of masses
   • Growth rate
   • Histological type

3. Symptoms:

   • Heavy menstrual bleeding
   • Pelvic pressure or pain
   • Urinary or bowel symptoms

Important Considerations

• Fertility preservation: Myomectomy is preferred over UAE for women desiring pregnancy, as UAE has been associated with higher rates of pregnancy complications 1

• Malignancy risk: Although rare (0.5% of presumed fibroids), rapid growth or irregular appearance should prompt evaluation for leiomyosarcoma 4, 6

• Morcellation caution: Morcellation during minimally invasive procedures is not recommended due to risk of spreading occult malignancy 1

• Expectant management: Small asymptomatic fibroids (e.g., 7mm) rarely warrant intervention and can be monitored with periodic ultrasound 2