What is the treatment approach for a calcified uterine fibroid?

Treatment Approach for Calcified Uterine Fibroids

Calcified fibroids require CT imaging for optimal delineation and have important treatment implications, as calcification typically indicates nonviable/autoinfarcted tissue that will not respond to uterine artery embolization (UAE), making surgical approaches the primary treatment option. 1

Diagnostic Imaging Considerations

CT pelvis is specifically indicated for calcified fibroids because it better delineates calcification compared to ultrasound and MRI, which directly impacts treatment planning 1. The pattern of calcification provides critical information:

• Peripheral rim calcification ("fetal head sign") suggests prior UAE treatment or chronic degeneration 1
• Central dystrophic calcification indicates hyaline degeneration and nonviable tissue 1
• Nonviable/autoinfarcted fibroids are found in up to 20% of UAE candidates and must be identified during treatment planning 1

Treatment Algorithm Based on Calcification Status

For Calcified (Nonviable) Fibroids

Surgical intervention is the primary treatment approach because calcified fibroids do not respond to UAE 1:

• Hysterectomy provides definitive resolution of all fibroid-related symptoms and is the most common treatment, accounting for three-quarters of fibroid treatment in the United States 1
• Myomectomy (laparoscopic or open) is appropriate for patients desiring uterine preservation, with equivalent quality of life improvement to UAE at 2 years 1
• Hysteroscopic myomectomy is indicated only if the calcified fibroid is pedunculated submucosal and <5 cm 1, 2

Critical Treatment Pitfall

Do not perform UAE on calcified/nonviable fibroids as they will not respond to embolization therapy 1. Postcontrast MRI imaging can assess fibroid viability when planning UAE, but the presence of calcification on CT already indicates nonviability 1.

Medical Management Limitations

Medical therapies have limited utility for calcified fibroids but may address bleeding symptoms temporarily 1:

• First-line options: NSAIDs and estrogen-progestin oral contraceptives reduce bleeding 1
• Second-line options: GnRH agonists (leuprolide) or antagonists (elagolix, relugolix) can reduce bleeding and are commonly used preoperatively to decrease fibroid size before surgery 1
• Tranexamic acid is a nonhormonal alternative for bleeding reduction 1

Surveillance Approach

For asymptomatic calcified fibroids, expectant management is appropriate as most fibroids decrease in size during menopause 3. However:

• Transvaginal ultrasound (TVUS) combined with transabdominal ultrasound (TAUS) is the preferred surveillance modality 1
• No specific consensus exists on imaging surveillance intervals for asymptomatic fibroids 1
• Rapid growth warrants urgent referral to exclude sarcomatous change, though this is rare 4

Symptomatic Management Decision Points

Refer for surgical evaluation if 4:

• Fibroids >3 cm in diameter causing significant symptoms
• Uterus palpable abdominally or >12 cm on imaging
• Persistent abnormal bleeding despite medical management
• Pressure symptoms (urinary frequency, constipation, pelvic pain)