Do uterine fibroids need to be removed?

Should Uterine Fibroids Be Removed?

Not all uterine fibroids require removal—asymptomatic fibroids need only observation, while symptomatic fibroids should be treated based on specific symptoms, fibroid location, and fertility desires, starting with medical management and progressing to surgical options when medical therapy fails. 1

Asymptomatic Fibroids: Observation Only

• Asymptomatic fibroids require no intervention, as they appear in 70% of women by age 50 but only 20-50% become symptomatic. 2
• Women with asymptomatic fibroids should be reassured that malignancy risk is extremely rare (less than 1 in 1000) and hysterectomy is not indicated. 3, 2
• Follow-up imaging is advisable to document stability in size, but no treatment is necessary unless symptoms develop. 3

When Fibroids Must Be Addressed

Heavy Menstrual Bleeding

Start with first-line medical management before considering surgery:

• Begin with levonorgestrel-releasing IUD or combined oral contraceptive pills, which have the strongest evidence for reducing menstrual blood loss. 1, 2
• Add NSAIDs for concurrent pain control and modest bleeding reduction. 1
• For patients refusing hormonal options, use tranexamic acid as the preferred nonhormonal alternative. 1
• If first-line therapy fails, escalate to oral GnRH antagonists with mandatory hormone add-back therapy to prevent bone loss. 1
• Correct anemia with iron supplementation while simultaneously starting GnRH therapy to control bleeding. 1, 2

Bulk Symptoms (Pelvic Pressure, Urinary Frequency, Constipation)

• GnRH analogues and selective progesterone receptor modulators effectively reduce fibroid size and bulk symptoms. 2
• Medical therapy provides only temporary relief—symptoms rapidly recur after discontinuation, requiring ongoing management or eventual surgery. 1

Infertility and Fibroids

Fibroid location determines the need for removal:

• Submucosal fibroids (FIGO Type 4) significantly impair fertility through impaired implantation, with pregnancy rates of only 10% in ART cycles compared to 30% without fibroids. 4
• Intramural fibroids without cavity distortion still reduce fertility, with pregnancy rates of 16.4% versus 30.1% in controls and implantation rates of 6.4% versus 15.7%. 4
• Subserosal fibroids do not affect fertility outcomes, with pregnancy rates (34.1%) and implantation rates (15.1%) equivalent to women without fibroids. 4
• Surgical or medical treatment should be considered before ART in patients with intramural or submucosal fibroids, as post-myomectomy pregnancy rates reach 54-59.5% in women with no other infertility factors. 4

Surgical Treatment Algorithm

For Patients Desiring Fertility Preservation

Hysteroscopic myomectomy is first-line for submucosal fibroids <5 cm:

• This approach offers shorter hospitalization, faster recovery, and restoration of normal uterine cavity architecture compared to laparoscopic or open approaches. 5, 1
• Symptom improvement and quality of life scores are equivalent to other surgical approaches by 2-3 months. 5

Laparoscopic myomectomy for intramural/subserosal fibroids:

• Best suited for fibroids <15 cm with no more than three fibroids of 5 cm size. 6
• Advantages include small incisions, short hospital stay, less postoperative pain, and rapid recovery. 6
• Preoperative imaging is mandatory to map fibroid location, size, and number for surgical planning. 2
• Use vasopressin, bupivacaine with epinephrine, misoprostol, peri-cervical tourniquet, or gelatin-thrombin matrix to reduce blood loss. 2

For Patients Not Desiring Future Pregnancy

Uterine artery embolization (UAE) is highly effective:

• Achieves 73-98% symptom control for menorrhagia and bulk symptoms, with 72-73% maintaining control at 5 years. 7
• Mean fibroid volume reduction of 42% and uterine volume reduction of 35% at 3 months. 7
• At 5 years, average fibroid size decrease exceeds 50%. 5, 1
• Major complications occur in less than 3% of patients, though up to 10% require readmission for pain control. 7

Patient selection considerations for UAE:

• Women under 40 have higher treatment failure rates (23% at 10 years) due to collateral vessel recruitment. 7
• Anterior wall fibroids have favorable outcomes; cervical fibroids have high failure rates. 7
• Risk of amenorrhea is 20% for women over 45 years but only 2-3% for those under 45. 7
• Repeat UAE successfully treats most patients if symptoms recur. 7

Hysterectomy provides definitive resolution:

• Satisfaction rates exceed 90% and eliminates recurrence risk entirely. 4
• Accounts for three-quarters of fibroid treatment in the United States. 5
• Should be performed by the least invasive approach possible (vaginal, laparoscopic-assisted, or abdominal based on uterine size). 4, 2
• Critical caveat: Cohort studies associate hysterectomy with increased long-term risks of cardiovascular disease, osteoporosis, bone fracture, and dementia. 1

Critical Pitfalls to Avoid

• Never use long-term GnRH agonists or antagonists without add-back therapy—this causes significant bone mineral density loss. 1
• Do not perform endometrial ablation for submucosal fibroids—there is no supporting literature for this approach. 5
• When morcellation is necessary, inform patients about the rare risk (<1 in 1000) of unexpected malignancy and potential for cancer spread. 2
• Do not recommend myomectomy for fibroids detected in pregnancy unless the patient had previous pregnancy complications specifically related to fibroids—concern about possible complications is not an indication. 2
• Avoid UAE in women desiring future fertility due to concerns about decreased ovarian reserve and high risks of miscarriage, preterm delivery, and postpartum bleeding. 6