Reassurance is Appropriate for a 2 cm Asymptomatic Subserosal Fibroid
For a patient with a 2 cm asymptomatic subserosal fibroid desiring pregnancy, reassurance is the recommended approach, as subserosal fibroids do not significantly impact fertility or pregnancy outcomes.
Evidence Supporting Reassurance
Subserosal Fibroids and Fertility
- Subserosal fibroids do not appear to significantly impact fertility, with pregnancy rates (34.1%) and implantation rates (15.1%) similar to women without fibroids (30.1% and 15.7% respectively) 1
- The American College of Radiology notes that subserosal fibroids, which project outward from the uterus, typically cause minimal to no bleeding symptoms 2
- Removal of subserosal fibroids is not recommended for fertility purposes 3
Size Considerations
- At 2 cm, this fibroid is small and unlikely to cause complications during pregnancy 4, 5
- Most fibroids do not exhibit significant volume changes during pregnancy, and when they do grow, it occurs primarily in the first trimester 6
- Large submucosal and retro-placental fibroids pose greater risks, but subserosal fibroids of this size do not fall into this high-risk category 6
Why Myomectomy is Not Indicated
Lack of Benefit
- The evidence clearly demonstrates that subserosal fibroids have little or no effect on fertility 7
- Treatment of subserosal myomas of reasonable size is not necessary for fertility reasons 7
- Myomectomy would expose the patient to unnecessary surgical risks without fertility benefit 3
Surgical Risks to Consider
- Myomectomy carries risks including uterine perforation, need for blood transfusion, bowel or bladder injury, and need for reintervention 8
- Case reports have associated laparoscopic and open myomectomy with uterine rupture during subsequent pregnancy 8
- Postoperative adhesion formation could potentially impair fertility 3
When Intervention Would Be Appropriate
Fibroids Requiring Treatment
- Submucosal fibroids should be removed to improve conception and pregnancy rates, as they have the most detrimental effect on fertility with pregnancy rates of only 10% 1, 3
- Intramural fibroids >4 cm may negatively influence fertility and warrant consideration for removal before assisted reproductive technology 1, 7
- Symptomatic fibroids causing heavy bleeding, bulk symptoms, or pain would require treatment 8
Red Flags Requiring Monitoring
- Rapid growth of fibroids can occasionally indicate malignant transformation, though this is rare 9
- Development of symptoms during pregnancy such as pain from red degeneration would require management 5
Practical Management Plan
- Proceed with attempting conception without surgical intervention 1
- Monitor the fibroid with routine prenatal ultrasound during pregnancy 5
- Most pregnancies are unaffected by the presence of subserosal fibroids 6
- The patient can be reassured that obstetric outcomes are not significantly affected by subserosal fibroids of this size 5