What is the management for a G1P0 (Gravida 1, Para 0) woman with abnormal uterine bleeding and multiple myomas (fibroids) classified as FIGO 2, 4, and 6?

Management of G1P0 with Abnormal Uterine Bleeding and Multiple Myomas (FIGO 2,4,6)

For a G1P0 woman with abnormal uterine bleeding and multiple myomas (FIGO types 2,4, and 6), myomectomy should be offered as the first-line surgical treatment to preserve fertility, with hysteroscopic resection for the submucosal component (FIGO 2) and laparoscopic or open myomectomy for the intramural (FIGO 4) and subserosal (FIGO 6) components. 1

Initial Assessment and Workup

• Rule out malignancy first: Endometrial biopsy is mandatory before proceeding with any fibroid treatment in women with abnormal uterine bleeding 1
• Obtain detailed imaging: MRI is preferred over ultrasound to map the exact location, size, and number of fibroids, which is essential for surgical planning 2
• Correct anemia preoperatively: Check hemoglobin and iron levels; anemia must be corrected before elective surgery 2

Understanding FIGO Classification Impact on Bleeding

• FIGO Type 2 (submucosal): This fibroid protrudes into the uterine cavity and causes the most severe bleeding symptoms due to direct endometrial disruption 3
• FIGO Type 4 (intramural): Can cause heavy bleeding when it distorts the endometrial cavity or reaches significant size 3
• FIGO Type 6 (subserosal): Projects outward from the uterus and typically causes minimal to no bleeding symptoms 3

The submucosal component (Type 2) is the primary driver of abnormal uterine bleeding in this patient 3.

Fertility-Preserving Surgical Approach

Hysteroscopic Myomectomy for FIGO Type 2

• First-line for submucosal fibroids: Hysteroscopic myomectomy is the procedure of choice for the FIGO Type 2 fibroid if <5 cm 1
• Shorter recovery: Associated with shorter hospitalization and faster return to activities compared to laparoscopic or open approaches 1
• Equivalent outcomes: Improvement in symptom scores and quality of life is equivalent to more invasive surgical approaches at 2-3 months 1

Laparoscopic or Open Myomectomy for FIGO Types 4 and 6

• Standard for intramural and subserosal fibroids: Laparoscopic or open myomectomy is appropriate for FIGO Types 4 and 6 when uterus preservation is desired 4
• Open approach preferred when: Multiple fibroids are present or the uterus is very large 4
• Improved quality of life: Myomectomy showed improved quality of life scores at 2 years compared to UAE, though this difference was no longer significant at 4 years 1

Surgical Planning and Risk Mitigation

• Map all fibroids preoperatively: Use MRI to identify location, size, and number before surgery 2
• Reduce blood loss: Use vasopressin, bupivacaine with epinephrine, misoprostol, peri-cervical tourniquet, or gelatin-thrombin matrix to reduce bleeding 2
• Morcellation counseling: If morcellation is necessary, inform the patient about risks including potential spread of unexpected malignancy (rare but serious) 2
• Recurrence risk: Myomectomy carries potential for further intervention due to fibroid recurrence 2

Medical Management Options

Preoperative Medical Treatment

• GnRH agonists or antagonists: Effective at correcting anemia and should be considered preoperatively in anemic patients; achieve 18-50% fibroid volume reduction over 3-4 months 1, 5
• Selective progesterone receptor modulators (SPRMs): Reduce both bleeding and bulk symptoms; can be administered intermittently 1

Bridge Therapy While Awaiting Surgery

• First-line agents for bleeding control: NSAIDs, tranexamic acid, combined oral contraceptives, or levonorgestrel IUD 1, 4, 6
• Levonorgestrel IUD caveat: Only if the FIGO Type 2 fibroid does not significantly distort the uterine cavity to prevent expulsion 5
• Tranexamic acid: Nonhormonal alternative that reduces menstrual blood loss 1, 4

Why UAE is NOT First-Line in This Patient

Uterine artery embolization should NOT be considered first-line in women seeking pregnancy 1:

• Increased miscarriage rate: 35% miscarriage rate after UAE compared to controls 1
• Increased cesarean sections: 66% cesarean section rate 1
• Increased postpartum hemorrhage: 13.9% rate 1
• Limited evidence: There is very limited evidence that myomectomy may be superior to UAE in women planning future pregnancy 1

UAE can be considered only in specific situations: poor surgical candidates, fibroids not surgically resectable, or after repeated myomectomies 1.

MR-Guided Focused Ultrasound (MRgFUS)

• Limited fertility data: Only 54 pregnancies reported in 51 women; 41% resulted in live births and 28% in spontaneous abortions 1
• Pregnancy complications: 43% of pregnancies had associated complications with no clear pattern 1
• Not recommended as first-line: Insufficient data on fertility outcomes for G1P0 patients 1

Critical Pitfalls to Avoid

• Do not perform endometrial ablation: Contraindicated in women desiring pregnancy; associated with high risk of pregnancy complications 1
• Do not perform hysterectomy: Infertility is permanent and irreversible 1
• Do not ignore anemia: Correct preoperatively with iron supplementation and consider GnRH agonists/antagonists or SPRMs 2
• Do not skip malignancy workup: Endometrial biopsy is mandatory before proceeding with treatment 1

Counseling Points for This Patient

• Pregnancy outcomes after myomectomy: Explain potential consequences on future pregnancy including risk of uterine rupture, need for cesarean delivery, and recurrence requiring repeat surgery 2
• Recurrence risk: Approximately 20-30% of patients may require further intervention after myomectomy 2
• Timing of pregnancy: Consider attempting pregnancy 3-6 months after myomectomy once adequate healing has occurred 2