What medications are prescribed after a myomectomy?

Post-Myomectomy Medication Management

After myomectomy, implement a multimodal non-opioid-first analgesic regimen with scheduled acetaminophen and NSAIDs as the foundation, combined with perioperative antibiotic prophylaxis to prevent surgical site infection. 1, 2

Antibiotic Prophylaxis

• Administer prophylactic antibiotics perioperatively to reduce the risk of surgical site infection, which occurs in 6.8% of patients without antibiotics versus 2.9% with antibiotics (nearly fourfold reduction in infection risk). 2

• Cefazolin 1 gram IV should be given 30-60 minutes prior to surgical incision, with additional 500 mg to 1 gram doses every 6-8 hours intraoperatively for lengthy procedures (≥2 hours), followed by 500 mg to 1 gram every 6-8 hours for 24 hours postoperatively. 3

• For patients with penicillin allergy, clindamycin 300 mg three times daily for 10 days starting 2 days prior to surgery is an alternative. 1

Pain Management: Multimodal Non-Opioid Approach

First-Line Analgesics

• Acetaminophen 1 gram IV/PO every 6 hours should be started preoperatively or intraoperatively and continued throughout the postoperative period, as it is safer and more effective when administered at the beginning of postoperative analgesia compared to other single agents. 1, 4

• NSAIDs (ibuprofen 600 mg or diclofenac) should be administered three times daily when contraindications are absent, as they reduce morphine consumption and related side effects when used in multimodal analgesia. 1, 5

• The combination of acetaminophen with NSAIDs provides additive or synergistic effects on pain relief while reducing individual class-related side effects. 1

Opioid Management Strategy

• Opioids should be minimized and reserved strictly as rescue medication for breakthrough pain only, not scheduled routinely, as opioid usage should be reduced as much as possible in postoperative pain management strategies. 1, 4

• When opioids are necessary, use a pharmacological step-up approach with the lowest effective dosages and minimum durations. 1

• Oral tramadol is preferred over stronger opioids due to its lower addiction potential when rescue analgesia is needed. 4

• Most patients after myomectomy require minimal analgesia—studies show mean morphine requirements of only 12 mg in the recovery room before same-day discharge. 6

Adjunctive Medications

• Consider gabapentinoids (gabapentin or pregabalin) as part of multimodal analgesia, though systematic preoperative use is not universally mandated. 1, 4

• COX-2 inhibitors (coxibs) may be considered if there are no contraindications, providing strong recommendation with moderate quality evidence. 1

• Corticosteroids in decreasing daily doses (dexamethasone 8 mg on surgery day, 6 mg day 1,4 mg day 2 mg day 3) may reduce postoperative edema and sequelae if no medical contraindications exist. 1

Pain Assessment and Monitoring

• Regular pain assessment using validated scales (VAS or numeric rating scale) must occur at standard intervals, as pain drugs are often administered inappropriately without regular assessment. 1, 4

• Reassess patients 30-60 minutes after any pain intervention to evaluate both efficacy and adverse effects. 1, 4

• When significant worsening pain is reported, reevaluate for possible postoperative complications such as infected hematoma or other surgical complications. 1, 7

Special Considerations

• Younger age and female gender are risk factors for increased postoperative pain, requiring closer monitoring and potentially more aggressive multimodal analgesia. 1, 4

• Patients with chronic pain, psychiatric comorbidities (depression, anxiety, substance abuse), or obstructive sleep apnea require particular caution with opioid use to prevent cardiopulmonary complications. 1, 4

• NSAIDs should be used cautiously in the immediate postoperative period due to theoretical bleeding concerns, though evidence is mixed. 4

Patient Education

• Set expectations that some pain is normal after surgery, with the goal being adequate function rather than being completely pain-free. 1

• Emphasize that acetaminophen and NSAIDs taken around the clock are the primary method of pain control, with opioids reserved only for breakthrough pain. 1

• Counsel patients on safe storage and disposal of any leftover opioid medications to prevent misuse. 1