What is the initial approach to managing symptoms in a patient diagnosed with myoma uteri (uterine fibroids) on ultrasound?

Initial Management of Myoma Uteri (Uterine Fibroids) Diagnosed on Ultrasound

Medical management should be trialed as first-line therapy before pursuing more invasive treatments for patients with symptomatic uterine fibroids. 1

Diagnostic Confirmation

• Pelvic ultrasound (combining transabdominal and transvaginal) with Doppler is the first-line imaging modality for diagnosing uterine fibroids, with high sensitivity (90-99%) and specificity (98%) 2, 3
• MRI is superior to ultrasound for mapping fibroids, providing excellent delineation of location, size, number, and differentiating fibroids from adenomyosis and endometriosis 2, 3
• Saline infusion sonohysterography (SIS) improves delineation between endometrial pathologies and submucosal fibroids, showing good agreement with diagnostic hysteroscopy 2, 3

Initial Treatment Approach Based on Symptoms

For Heavy Menstrual Bleeding

1. First-line medical options:

   • NSAIDs and estrogen-progestin oral contraceptive pills to reduce bleeding symptoms 4
   • Tranexamic acid as a nonhormonal alternative to reduce bleeding 4
   • Progestogens or levonorgestrel-releasing intrauterine device 5

2. Second-line medical options:

   • GnRH agonists (e.g., leuprolide acetate) 4
   • Oral GnRH antagonists (e.g., elagolix, linzagolix, relugolix) 4
   • Both GnRH options can significantly reduce tumor volume and bleeding symptoms 4

For Bulk Symptoms (pressure, pain, fullness, bowel/bladder symptoms)

• Medical management with GnRH agonists or antagonists can reduce fibroid volume and alleviate bulk symptoms 4
• For persistent symptoms despite medical management, consider minimally invasive procedures based on patient characteristics 4, 1

Treatment Selection Based on Patient Characteristics

For Patients Desiring Future Pregnancy

• Hysteroscopic myomectomy for pedunculated submucosal fibroids <5 cm 4
• Laparoscopic or open myomectomy for intramural or subserosal fibroids 4, 1
• MR-guided Focused Ultrasound (MRgFUS) or Uterine Artery Embolization (UAE) may be considered in select cases 1

For Patients Not Desiring Future Fertility

• Medical management as first-line therapy 4, 1
• Uterine Artery Embolization (UAE) as an effective alternative to surgery 2, 1
• Hysteroscopic myomectomy for pedunculated submucosal fibroids 4
• Laparoscopic or open myomectomy for symptomatic fibroids 4, 1
• Hysterectomy for definitive treatment when symptoms are severe enough 2

For Patients with Concurrent Adenomyosis

• Medical management or UAE is usually appropriate 4
• Evidence from prospective cohort studies supports UAE for patients with adenomyosis and fibroids who fail conservative measures 4

Important Considerations and Potential Pitfalls

• Hypoestrogenic effects (headaches, hot flushes, hypertension, bone mineral density loss) may occur with GnRH agonists and antagonists as monotherapy 4
• Myomas that distort the uterine cavity (submucous or intramural with submucous component) can reduce fertility 6
• Risk of developing adhesions after myomectomy may reduce subsequent fertility 2
• Significant intraoperative blood loss is common during myomectomy due to good uterine vascularization 2
• Inadequate assessment of submucosal fibroids can lead to missed diagnosis of causes of abnormal uterine bleeding or infertility 2, 3

Follow-up After Initial Management

• For patients undergoing medical management, clinical reassessment after 3 months to evaluate symptom improvement 5
• For patients undergoing UAE, follow-up at 3-6 months to determine fibroid volume reduction and assess for incomplete fibroid infarction 4
• Consider MRI after UAE to ensure adequate fibroid infarction and exclude underlying leiomyosarcoma 4