What are the treatment options for a patient with an intramural fibroid?

Treatment Options for Intramural Fibroids

For patients with intramural fibroids, laparoscopic or open myomectomy is the most appropriate treatment option when symptoms are present and fertility preservation is desired, while uterine artery embolization (UAE) is preferred for those not desiring future fertility. 1

Diagnosis and Evaluation

• MRI is superior to ultrasound for accurately identifying and mapping fibroids, potentially altering management in up to 28% of patients 1
• Transvaginal ultrasound combined with transabdominal ultrasound is the initial imaging modality of choice with reported sensitivity of 90-99% for detecting uterine fibroids 1
• Color Doppler helps differentiate fibroids from other conditions:
  • Peripheral vascular flow pattern is characteristic of fibroids
  • Resistive index <0.7 and pulsatility index <1.2 help differentiate fibroids from adenomyosis (93.4% sensitivity, 95.6% specificity) 1

Treatment Algorithm Based on Symptoms and Fertility Desires

For Women Desiring Future Fertility:

1. Laparoscopic or Open Myomectomy

   • Indicated specifically for intramural fibroids 1
   • Laparoscopy offers shorter hospital stays and faster recovery compared to open myomectomy 1
   • Associated with improved quality of life for up to 10 years post-procedure 1
   • Open myomectomy may be preferred for multiple fibroids or very large uteri 1

2. Medical Management (Temporary/Pre-surgical)

   • GnRH agonists can reduce fibroid volume by approximately 35% before surgery 2
   • Not recommended as standalone treatment for women desiring fertility as they suppress ovulation 2

3. Avoid UAE in This Population

   • Lower pregnancy rates and higher miscarriage rates compared to myomectomy 1, 2
   • May compromise fertility with reports of intrauterine necrosis 2
   • Associated with potential loss of ovarian reserve, especially in older patients 2

For Women Not Desiring Future Fertility:

1. Uterine Artery Embolization (UAE)

   • Effective for intramural fibroids with 85-94% symptom improvement 2
   • Less invasive than surgical options
   • May be less effective for fibroids >5 cm 2

2. Hysterectomy

   • Most definitive treatment with 90% satisfaction rate at 2 years 2
   • Recommended when other treatments have failed or for women with completed childbearing 1
   • Vaginal or laparoscopic approaches preferred over abdominal when possible 3

3. Medical Management Options

   • Progestin-containing IUDs for bleeding control and pain relief 2
   • Combined oral contraceptives for controlling bleeding symptoms 2
   • GnRH agonists/antagonists (short-term use due to bone loss concerns) 2
   • Selective progesterone receptor modulators (SPRMs) can achieve amenorrhea in 70-83% of patients 2
   • Non-hormonal treatments like NSAIDs and tranexamic acid can reduce bleeding by 20-40% 2

Impact on Fertility and Pregnancy

• Intramural fibroids significantly reduce pregnancy and implantation rates (16.4% vs 30.1% in controls) 2
• Less than half of patients achieve pregnancy after myomectomy at up to 3 years of follow-up 2
• The effect of intramural fibroids on fertility appears to be small and less significant when the endometrium is not involved 4

Surgical Considerations and Complications

• Minimize blood loss during myomectomy by:

  • Correcting anemia preoperatively 2
  • Using GnRH agonists to reduce fibroid volume before surgery 2
  • Considering laparoscopic uterine artery occlusion as an adjunct to reduce intraoperative bleeding 1

• Potential complications of myomectomy:

  • Uterine rupture during future pregnancies (higher risk if uterine cavity entered during surgery) 1
  • Recurrence rate of 27% at 10 years, higher in patients with multiple fibroids 1
  • Adhesion formation (can be reduced with barriers such as oxidized regenerated cellulose) 2

Key Pitfalls to Avoid

1. Don't remove subserosal fibroids in women with unexplained infertility as they don't appear to impact fertility 4

2. Don't recommend UAE for women desiring future pregnancy due to potential negative impacts on fertility 4

3. Don't rely on hysterosalpingogram to evaluate and classify fibroids; combination of hysteroscopy and transvaginal ultrasound or hysterosonography is preferred 4

4. Don't ignore rapid growth of fibroids, as this may rarely indicate sarcomatous change requiring urgent referral 5

5. Don't use medical therapy as standalone treatment for fibroids in infertile patients as it may interfere with ovulation and implantation 4