What are the next steps in managing multiple uterine fibroids and nonspecific endometrial thickening?

Management of Multiple Uterine Fibroids and Endometrial Thickening

For a patient with multiple solid uterine fibroids that have increased in size and nonspecific endometrial thickening (1.67 cm), the next step should be endometrial biopsy to rule out endometrial hyperplasia or malignancy, followed by appropriate treatment of the fibroids based on symptomatology and fertility desires.

Evaluation of Endometrial Thickening

• Endometrial thickening of 1.67 cm (16.7 mm) requires immediate evaluation with endometrial biopsy to rule out endometrial hyperplasia or malignancy, especially with concurrent uterine fibroids 1
• This should be the priority before addressing the fibroid management, as endometrial pathology could significantly impact treatment decisions 1

Assessment of Fibroid-Related Symptoms

After endometrial evaluation, management should be guided by:

• Presence and severity of symptoms (heavy menstrual bleeding, pelvic pressure, pain) 1
• Impact on quality of life 1
• Fertility desires 1
• Size, number, and location of fibroids (already documented as multiple solid masses with increasing size) 1

Treatment Options Based on Fertility Desires

If Fertility Preservation is Desired:

• Myomectomy (removal of fibroids while preserving the uterus) is the preferred surgical approach 1

  • Hysteroscopic myomectomy for submucosal fibroids 1
  • Laparoscopic or open myomectomy for intramural or subserosal fibroids 1
  • Note that less than half of patients achieve pregnancy after myomectomy, and of these, less than half result in live births 1

• Medical management as a temporary measure or to reduce fibroid size before surgery 1:

  • First-line: NSAIDs, estrogen-progestin oral contraceptives, or progestin-containing IUDs to reduce bleeding 1, 2
  • Second-line: GnRH agonists (leuprolide acetate) or antagonists (elagolix, linzagolix, relugolix) to reduce fibroid size and bleeding 1
  • Note: These medications suppress fertility during treatment 1

If Fertility is Not Desired:

• Hysterectomy provides definitive treatment and permanent cure for symptomatic fibroids 1, 3

  • Most appropriate for women with completed childbearing and multiple symptomatic fibroids 1, 3

• Uterine Artery Embolization (UAE) is a less invasive alternative to surgery 1, 4

  • Effective for reducing fibroid size and symptoms 1
  • Associated with lower reintervention rates compared to MRgFUS (13% vs 30%) 1

• MR-guided Focused Ultrasound (MRgFUS) is another minimally invasive option 1

  • Can reduce fibroid diameter by approximately 18% 1
  • Has higher reintervention rates compared to UAE 1

• Medical management options include 1, 2:

  • First-line: NSAIDs, estrogen-progestin oral contraceptives, progestin-containing IUDs, tranexamic acid 1
  • Second-line: GnRH agonists or antagonists (with add-back therapy to prevent bone loss) 1, 5

Special Considerations

• The increasing size of fibroids noted on ultrasound warrants closer monitoring, as rapid growth can occasionally indicate malignant transformation (though rare) 3
• Endometrial thickening must be addressed before or concurrently with fibroid treatment 1
• For perimenopausal women, short-term medical management may be appropriate while awaiting natural regression of fibroids during menopause 1, 4

Treatment Algorithm

1. Immediate step: Endometrial biopsy to evaluate endometrial thickening
2. If endometrial pathology is ruled out:
   • For women desiring fertility: Consider myomectomy (approach based on fibroid location)
   • For women not desiring fertility: Consider hysterectomy, UAE, or MRgFUS
3. If medical management is preferred:
   • Start with first-line agents (NSAIDs, hormonal contraceptives)
   • Progress to second-line agents if needed (GnRH modulators)
4. Follow-up: Repeat imaging in 3-6 months to assess response to treatment