What are the treatment options for a FIGO (International Federation of Gynecology and Obstetrics) 4 uterine fibroid?

Treatment of FIGO Type 4 Uterine Fibroids

Hysteroscopic myomectomy is the definitive treatment for FIGO Type 4 (pedunculated submucosal) fibroids, offering shorter hospitalization, faster recovery, and equivalent symptom relief compared to other surgical approaches. 1

Understanding FIGO Type 4 Fibroids

FIGO Type 4 fibroids are pedunculated submucosal fibroids that project entirely into the uterine cavity with no intramural component. 2 This specific location makes them uniquely amenable to hysteroscopic removal. 1

Primary Treatment Approach

Hysteroscopic Myomectomy (First-Line Surgical Option)

• Hysteroscopic myomectomy is the procedure of choice for pedunculated submucosal fibroids less than 5 cm in diameter. 2
• This approach involves transvaginal, transcervical placement of a hysteroscope with removal using an electrosurgical wire loop or other instruments. 1
• The procedure provides shorter hospitalization and faster return to usual activities compared to laparoscopic or open myomectomy. 1
• Symptom improvement and quality of life scores are equivalent to other surgical approaches at 2-3 months. 1
• Risks include uterine perforation, fluid overload, need for blood transfusion, bowel or bladder injury, endomyometritis, and potential need for reintervention. 1

Alternative Treatment Options

Medical Management (Consider First in Appropriate Candidates)

• Medical management should be trialed as first-line therapy before pursuing invasive treatments for symptomatic fibroids. 3
• NSAIDs and estrogen-progestin oral contraceptive pills serve as first-line medical treatments for reducing bleeding symptoms. 2
• Tranexamic acid is an effective nonhormonal alternative for patients who cannot use hormonal options. 2
• GnRH agonists and oral GnRH antagonists are effective second-line options that reduce bleeding symptoms and significantly reduce fibroid volume by 18-30%. 2
• Progestin-containing intrauterine devices can effectively reduce bleeding symptoms for long-term management. 2

Uterine Artery Embolization (UAE)

• Patients undergoing UAE for submucosal fibroids can experience fibroid expulsion, with one retrospective study demonstrating a 50% rate of complete expulsion with low complication rates. 1
• UAE causes persistent decreases in pain and heavy menstrual bleeding, with an average decrease in fibroid size greater than 50% at 5 years. 1
• The reintervention rate is approximately 7% for persistent symptoms. 2
• UAE is associated with decreased risk of blood transfusion and shorter hospital stays compared to myomectomy. 1

MR-Guided Focused Ultrasound (MRgFUS)

• MRgFUS may be considered for symptomatic fibroids, though it has a higher reintervention rate (30%) compared to UAE (13%). 2
• This option provides a noninvasive alternative but with lower efficacy for symptom relief compared to UAE. 1

Special Considerations

For Patients Desiring Future Fertility

• Hysteroscopic myomectomy is usually appropriate for patients with reproductive dysfunction and FIGO Type 4 fibroids. 3
• The procedure preserves the uterus and restores normal uterine cavity architecture. 4
• Patients should be counseled that pregnancy is possible after treatment. 1

For Patients Not Desiring Future Fertility

• Hysterectomy provides definitive resolution of all fibroid-related symptoms and accounts for three-quarters of fibroid treatment in the United States. 1, 2
• If hysterectomy is indicated, the least invasive route should be performed (vaginal or laparoscopic preferred over abdominal). 1
• Vaginal hysterectomy is associated with shorter operating times and faster return to normal activities compared to abdominal hysterectomy. 1
• Laparoscopic hysterectomy is associated with faster return to normal activities, shorter hospital stays, and lower rates of wound infection compared to abdominal approach. 1

Critical Pitfalls to Avoid

• Do not perform endometrial ablation for FIGO Type 4 fibroids - there is no relevant literature supporting this approach for submucosal fibroids, and the protruding fibroid mass would not be adequately addressed. 1
• Ensure proper preoperative imaging (ultrasound or MRI) to accurately characterize fibroid size and confirm FIGO classification before selecting treatment approach. 4
• For fibroids larger than 5 cm, hysteroscopic myomectomy may require staged procedures or alternative approaches should be considered. 5
• Patients must be counseled about potential complications specific to hysteroscopic procedures, particularly fluid overload and uterine perforation. 1