At what size is a uterine fibroid typically removed?

When to Remove Uterine Fibroids: Size and Symptom Guidelines

The decision to remove uterine fibroids should be based primarily on symptom severity rather than size alone, with surgical intervention generally recommended for fibroids >3 cm causing significant symptoms that have not responded to medical management. 1

Decision Algorithm for Fibroid Removal

Size-Based Considerations:

• Symptomatic fibroids >3 cm in diameter should be considered for surgical intervention when causing significant symptoms 1, 2
• Uterus palpable abdominally or >12 cm in size on scan warrants referral for surgical evaluation 2
• Fibroids >5 cm have higher reintervention rates after UAE and may be better suited for surgical approaches 1
• Pedunculated submucosal fibroids <5 cm are ideal candidates for hysteroscopic myomectomy 1

Symptom-Based Considerations:

1. Abnormal uterine bleeding/heavy menstrual bleeding

   • First try: Medical management (NSAIDs, hormonal contraceptives, tranexamic acid)
   • If persistent: Consider procedural intervention 3, 1

2. Pressure symptoms (urinary frequency, constipation, pelvic fullness)

   • Usually correlate with larger fibroids
   • Often require procedural intervention when severe 3, 4

3. Pain

   • Acute pain (e.g., from fibroid torsion) may require urgent intervention
   • Chronic pain affecting quality of life warrants intervention 4

4. Reproductive concerns

   • Submucous and intramural fibroids impacting fertility may require removal
   • Location more important than size for fertility impact 1

Treatment Selection Based on Fibroid Characteristics

For Small Fibroids (<3 cm) with Mild Symptoms:

• Medical management is first-line:
  • NSAIDs for pain and bleeding reduction (20-40%)
  • Hormonal contraceptives for bleeding control
  • Tranexamic acid for heavy menstrual bleeding 3, 1

For Medium Fibroids (3-5 cm) with Moderate Symptoms:

• Consider minimally invasive options:
  • Hysteroscopic myomectomy for submucosal fibroids
  • UAE for intramural fibroids (85-94% symptom improvement) 3, 1

For Large Fibroids (>5 cm) or Multiple Fibroids with Severe Symptoms:

• Surgical options often needed:
  • Laparoscopic or open myomectomy for women desiring fertility preservation
  • Hysterectomy for definitive treatment when fertility preservation not desired 3, 1

Special Considerations

Fertility Preservation:

• Myomectomy is preferred over UAE for women desiring future fertility
• Pregnancy rates after myomectomy are suboptimal (<50% conception rate, <50% live birth rate among those who conceive) 3

Rapid Growth:

• Rapidly growing fibroids, especially in postmenopausal women, should be urgently referred due to risk of sarcomatous change 2

Adenomyosis:

• Presence of concurrent adenomyosis may lead to treatment failure with endometrial ablation 3
• Hysterectomy may be more appropriate for combined fibroid/adenomyosis 3

Pitfalls and Caveats

1. Avoiding unnecessary interventions

   • Asymptomatic fibroids (approximately 66% of cases) do not require treatment regardless of size 2, 4

2. Reintervention risks

   • Myomectomy has 23-33% recurrence rate
   • UAE has reintervention rates of 28% at 5 years and 35% at 10 years 3, 1

3. Morcellation risks

   • Avoid morcellation during minimally invasive procedures due to risk of spreading occult malignancy 1

4. Hysterectomy considerations

   • Despite being definitive, hysterectomy carries risks including cardiovascular disease, mood disorders, and increased mortality when performed at young age 3
   • Should be considered only after less invasive options have failed 1

In summary, the decision to remove uterine fibroids should be guided by symptom severity, fibroid characteristics, and patient's fertility desires rather than size alone. However, fibroids >3 cm causing significant symptoms generally warrant consideration for procedural intervention, with the specific approach tailored to the patient's clinical presentation and goals.