What are the treatment options for a patient with a FIGO (International Federation of Gynecology and Obstetrics) 3 Myoma (Uterine Fibroid)?

Treatment of FIGO Type 3 Myoma

Hysteroscopic myomectomy is the procedure of choice for FIGO type 3 myomas, as these are now classified as submucosal fibroids rather than intramural, making them amenable to transcervical resection. 1, 2, 3

Understanding FIGO Type 3 Classification

• FIGO type 3 myomas are submucosal fibroids with <50% of the fibroid protruding into the endometrial cavity, with the majority of the mass within the myometrium 2, 3
• The FIGO classification system reclassified type 3 myomas from intramural to submucosal category, which has important treatment implications 3
• These fibroids are frequently associated with heavy menstrual bleeding, chronic pelvic pain, and infertility requiring intervention 2

Primary Treatment Approach: Hysteroscopic Myomectomy

Hysteroscopic myomectomy (also called transcervical resection of myoma or TCRM) should be the first-line surgical approach for symptomatic FIGO type 3 myomas. 1, 2, 3

Evidence Supporting Hysteroscopic Approach

• Hysteroscopic myomectomy is associated with shorter hospitalization and faster return to usual activities compared to laparoscopic or open myomectomy 1
• Data from large registries demonstrate that improvement in symptom scores and quality of life is equivalent to more invasive surgical approaches at 2-3 months 1
• A systematic review of 56 patients with type 3 myomas showed hysteroscopic myomectomy is safe and feasible, with only 3 patients (5.4%) requiring an additional procedure for complete removal 3
• No major complications were reported in the systematic review, with only 5 cases of post-surgical synechiae documented 3
• For patients desiring fertility, cumulative live birth rates improved from 14.3% before surgery to 42.9% after hysteroscopic myomectomy 3

Important Caveats

• Complete resection in a single procedure may not always be achievable for type 3 myomas due to their predominantly intramural location 3
• Approximately 5-10% of patients may require a second hysteroscopic procedure to completely remove the fibroid 3
• Post-operative intrauterine adhesions occur in approximately 9% of cases, which should be discussed during informed consent 3

Medical Management as Pretreatment or Alternative

When to Use Medical Therapy

GnRH antagonists (relugolix, elagolix, or linzagolix) should be initiated if the patient is anemic or if surgery needs to be delayed, as these agents reduce both bleeding symptoms and fibroid volume. 1, 4

• First-line medical management includes NSAIDs and estrogen-progestin oral contraceptive pills to reduce bleeding symptoms 1
• Tranexamic acid is a nonhormonal alternative that may reduce bleeding in patients with fibroids 1
• GnRH agonists (leuprolide acetate) and antagonists are effective at significantly reducing tumor volume and are commonly used for short courses to decrease fibroid size in preparation for surgery 1, 4
• Combination treatment with low doses of estrogen and progestin mitigates hypoestrogenic side effects (headaches, hot flushes, bone loss) and is FDA-approved for fibroid-related heavy menstrual bleeding 1, 4

Limitations of Medical Therapy

• Fertility is suppressed during treatment with GnRH agonists/antagonists 1
• Cessation of therapy leads to rapid recurrence of symptoms 1
• Ulipristal acetate (progesterone receptor modulator) is effective but reports of hepatotoxicity prevent its approval in the United States 1, 4

Alternative Surgical Approaches

When Hysteroscopic Approach is Not Feasible

If hysteroscopic myomectomy is technically not feasible or fails, laparoscopic or open myomectomy should be considered, particularly for patients desiring fertility preservation. 1, 4

• Laparoscopic or open myomectomy may be necessary if the fibroid cannot be adequately accessed hysteroscopically 4
• Myomectomy has a recurrence rate of 23-33% over time, which patients should understand 1

For Patients Not Desiring Fertility

• Uterine artery embolization (UAE) achieves >50% reduction in fibroid size at 5 years with approximately 80% symptomatic control 1, 4
• MR-guided focused ultrasound (MRgFUS) results in 18% decrease in fibroid diameter with significant quality of life improvement 4
• Hysterectomy provides definitive resolution of all fibroid-related symptoms but is not appropriate for patients desiring uterine preservation 1, 4

Clinical Algorithm for FIGO Type 3 Myoma

1. Assess anemia status: If anemic, correct with iron supplementation while initiating medical therapy 4
2. Evaluate fertility desires: Document whether patient desires future pregnancy 4
3. Initiate medical management: Use GnRH antagonists with add-back therapy to control bleeding and reduce fibroid size 1, 4
4. Perform imaging: Use ultrasound or MRI to characterize exact fibroid location and size before surgery 4
5. Proceed with hysteroscopic myomectomy: This is the definitive treatment for symptomatic FIGO type 3 myomas 1, 2, 3
6. Plan for possible second procedure: Counsel patient that 5-10% may need repeat hysteroscopy for complete resection 3
7. Monitor for adhesions: Evaluate for intrauterine synechiae if patient has post-operative amenorrhea or subfertility 3

Key Pitfalls to Avoid

• Do not perform laparoscopic or open myomectomy as first-line for FIGO type 3 myomas when hysteroscopic approach is feasible 1
• Do not use hysterectomy as initial treatment when less invasive approaches are available and equally effective 1
• Do not rely on medical management alone for long-term control, as symptoms recur after cessation 1
• Do not assume complete resection will be achieved in one hysteroscopic procedure; prepare patient for possible staged approach 3