What is the management approach for a calcified uterine mass?

Management of Calcified Uterine Mass

Surgical intervention is the primary treatment approach for calcified uterine fibroids because they do not respond to uterine artery embolization (UAE) and require definitive management. 1

Initial Diagnostic Workup

Cross-sectional imaging with CT pelvis is the preferred modality for evaluating calcified uterine masses, as it provides superior delineation of calcification patterns compared to ultrasound or MRI, which directly impacts treatment planning. 1

Key Imaging Characteristics to Identify:

• Peripheral rim calcification suggests prior UAE treatment or chronic degeneration 1
• Central dystrophic calcification indicates hyaline degeneration and nonviable tissue 1
• "Popcorn appearance" with scattered calcified spots throughout the mass is characteristic of severely calcified leiomyomas 2
• Ultrasound typically shows heavy homogeneous acoustic shadowing that obscures structures beneath the mass surface, making it suboptimal for characterization 2

Essential Pre-Treatment Evaluation:

Before any intervention, patients must undergo: 3

• Complete gynecologic workup including Pap smear
• Endometrial biopsy if menometrorrhagia is present
• Cross-sectional imaging (CT or MRI) to exclude other pelvic pathology
• Exclusion of pregnancy and active pelvic inflammatory disease (absolute contraindications to UAE)

Critical caveat: Approximately 1 in 350 women undergoing surgery for presumed fibroids is found to have unsuspected uterine sarcoma, making tissue diagnosis important. 3

Treatment Algorithm Based on Patient Characteristics

For Postmenopausal Women with Symptoms:

Hysterectomy is the definitive treatment for postmenopausal patients with calcified fibroids causing heavy uterine bleeding or bulk symptoms (pressure, pain, fullness, bladder/bowel symptoms) after negative endometrial biopsy. 3 This provides complete resolution of all fibroid-related symptoms and is the most common treatment approach, accounting for three-quarters of fibroid treatment in the United States. 1

For Reproductive-Age Women Desiring Uterine Preservation:

Myomectomy (laparoscopic or open) is appropriate for patients wanting to preserve the uterus, with equivalent quality of life improvement to UAE at 2 years. 1 The American College of Radiology rates both laparoscopic and open myomectomy as "usually appropriate" for symptomatic reproductive-age patients. 3

Hysteroscopic myomectomy is indicated only if the calcified fibroid is pedunculated submucosal and less than 5 cm in size. 3, 1

Why UAE is Not Recommended:

Calcified fibroids represent nonviable/autoinfarcted tissue found in up to 20% of UAE candidates. 1 These fibroids do not respond to embolization because the calcification indicates the tissue is already devascularized and necrotic. 1 The American College of Radiology explicitly recommends surgical intervention as primary treatment for this reason. 1

Medical Management Role (Limited)

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

First-line options:

• NSAIDs
• Estrogen-progestin oral contraceptives 1

Second-line options for preoperative preparation:

• GnRH agonists (leuprolide) to reduce bleeding and decrease fibroid size before surgery 1
• GnRH antagonists (elagolix, relugolix) 1
• Tranexamic acid as nonhormonal alternative for bleeding reduction 1

Important limitation: These medications do not treat the calcified fibroid itself but only manage symptoms temporarily.

Surveillance for Asymptomatic Calcified Fibroids

Transvaginal ultrasound (TVUS) combined with transabdominal ultrasound (TAUS) is the preferred surveillance modality for asymptomatic calcified fibroids. 1 However, no specific consensus exists on imaging surveillance intervals. 1

Differential Diagnosis Considerations

When encountering a calcified pelvic mass, consider: 4

• Ovarian tumors (especially teratomas with teeth/bone fragments) 3
• Lithopedion (calcified ectopic pregnancy)
• Urinary tract neoplasms
• Inflammatory masses
• Epiploic calcifications

CT is distinctly helpful when macroscopic fat or calcifications of teeth/bone fragments are present to confirm the diagnosis of ovarian teratoma versus calcified fibroid. 3