What are the indications for uterine leiomyoma (fibroid) removal?

From the Guidelines

Uterine fibroids should be removed when they cause significant symptoms that impact quality of life, such as heavy or prolonged menstrual bleeding, severe pelvic pain or pressure, or when there are specific medical concerns like rapid fibroid growth or infertility due to fibroid distortion of the uterine cavity, as indicated by the most recent guidelines 1. The main indications for fibroid removal include:

• Heavy or prolonged menstrual bleeding leading to anemia
• Severe pelvic pain or pressure
• Urinary frequency or incontinence due to bladder compression
• Constipation from rectal pressure
• Rapid fibroid growth
• Infertility when fibroids distort the uterine cavity
• Recurrent pregnancy loss
• Fibroids that are very large (typically over 10 cm) or cause significant uterine enlargement (equivalent to a 12-week pregnancy or larger)
• Concern for malignancy (though rare) The approach to removal depends on factors like fibroid size, number, location, patient's age, and desire for future fertility, with options including myomectomy, hysterectomy, or minimally invasive procedures like uterine artery embolization, as supported by recent studies 1. The decision for fibroid removal should be individualized based on symptom severity, impact on quality of life, and the patient's reproductive goals after thorough discussion with a healthcare provider, considering the latest evidence from 2024 1. Key considerations in the decision-making process include:
• The patient's desire for future fertility, as certain procedures like hysterectomy eliminate reproductive potential 1
• The size, number, and location of the fibroids, which can influence the choice of procedure 1
• The patient's overall health and potential risks associated with each procedure, such as uterine perforation, fluid overload, or post-embolization syndrome 1
• The potential benefits of each procedure, including improved symptom relief, quality of life, and reduced risk of complications 1

From the Research

Indications for Uterine Fibroid Removal

The decision to remove uterine fibroids is typically based on the presence of symptoms and the impact of the fibroids on a woman's quality of life. Some common indications for uterine fibroid removal include:

• Heavy or prolonged menstrual bleeding (menorrhagia) 2, 3, 4, 5
• Pelvic pain or pressure 2, 3, 4
• Infertility or recurrent pregnancy loss 2, 3, 4
• Bowel or urinary symptoms (e.g. constipation, urinary frequency or urgency) 4
• Low back pain 4
• Dyspareunia (painful intercourse) 4

Factors Influencing Treatment Decisions

The choice of treatment for uterine fibroids depends on several factors, including:

• The number, size, and location of the fibroids 2, 3, 4
• The patient's age and desire to preserve fertility 2, 3, 4
• The presence and severity of symptoms 2, 3, 4
• The patient's overall health and medical history 3, 4
• The availability and accessibility of treatment options 3, 4

Treatment Options

Treatment options for uterine fibroids include:

• Medical therapy (e.g. hormonal contraceptives, tranexamic acid, nonsteroidal anti-inflammatory drugs) 3, 4
• Gonadotropin-releasing hormone (GnRH) agonists or selective progesterone receptor modulators (SPRMs) 2, 3, 6
• Surgical options (e.g. hysterectomy, myomectomy, uterine artery embolization, magnetic resonance-guided focused ultrasound surgery) 2, 3, 4, 6
• Pre-operative GnRH analogue therapy to reduce fibroid and uterine volume and control bleeding 6