What are the diagnostic steps and treatment options for a reproductive‑age woman with symptomatic uterine fibroids, taking into account her desire for future fertility?

Management of Symptomatic Uterine Fibroids in Reproductive-Age Women Desiring Fertility

For reproductive-age women with symptomatic uterine fibroids who desire future fertility, hysteroscopic myomectomy is first-line surgical therapy for submucosal fibroids, while abdominal/laparoscopic myomectomy is the definitive fertility-sparing option for intramural or subserosal fibroids causing symptoms. 1, 2

Diagnostic Workup

Initial Assessment

• Perform pelvic ultrasound as the primary diagnostic imaging modality to characterize fibroid location (submucosal, intramural, subserosal), size, and number 1, 3
• Obtain hemoglobin levels to assess for anemia from heavy menstrual bleeding 1, 3
• Consider pregnancy testing before initiating any treatment 1
• Perform endometrial biopsy if the patient has risk factors for endometrial pathology or atypical bleeding patterns to exclude malignancy 1, 4

Advanced Imaging

• MRI provides superior mapping of fibroid location, size, and number when surgical planning is needed 1, 2
• MRI is particularly valuable before myomectomy to optimize surgical approach 2

Red Flag Features Requiring Urgent Evaluation

• Rapid fibroid growth, especially in postmenopausal women, requires immediate evaluation to exclude leiomyosarcoma 4, 3
• Severe sudden-onset pain with fever, nausea, and leukocytosis suggests fibroid degeneration 3

Medical Management Algorithm

First-Line Medical Options for Bleeding Control

• Levonorgestrel intrauterine system (52-mg) is highly effective for reducing heavy menstrual bleeding 4, 2, 5
• Tranexamic acid serves as an effective nonhormonal alternative 4, 2
• Combined oral contraceptives reduce bleeding symptoms 4, 2
• NSAIDs for pain management 4

Preoperative Medical Therapy

• GnRH agonists (leuprolide) or GnRH antagonists (elagolix, relugolix) significantly reduce fibroid volume and correct anemia preoperatively 4, 2, 5
• Always combine GnRH therapy with low-dose estrogen/progestin add-back therapy to mitigate hypoestrogenic side effects including bone loss, hot flashes, and headaches 4
• Selective progesterone receptor modulators (SPRMs) reduce fibroid volume and bleeding, though availability varies by region 1, 2, 5
• Correct anemia before elective surgery using these agents 2

Surgical Management for Fertility Preservation

Submucosal Fibroids

• Hysteroscopic myomectomy is first-line conservative surgical therapy for symptomatic intracavitary/submucosal fibroids 1, 2
• This approach preserves fertility with minimal uterine trauma 1

Intramural and Subserosal Fibroids

• Myomectomy (open, laparoscopic, or robotic) is the definitive fertility-sparing surgical option 1, 4, 2
• Base surgical planning on detailed mapping of fibroid location, size, and number using MRI 2
• Historical data shows 54-59.5% pregnancy rates after myomectomy in women with no other infertility factors 1

Intraoperative Blood Loss Reduction

• Use vasopressin, bupivacaine with epinephrine, misoprostol, peri-cervical tourniquet, or gelatin-thrombin matrix to reduce blood loss 2

Critical Morcellation Warning

• When morcellation is necessary, counsel patients that fibroids may rarely contain unexpected malignancy and laparoscopic power morcellation may spread cancer, worsening prognosis 2
• Avoid laparoscopic myomectomy on very large fibroids without appropriate expertise due to increased uterine rupture risk in subsequent pregnancy 4

Alternative Fertility-Sparing Interventions

Uterine Artery Embolization (UAE)

• UAE provides 95% symptomatic relief at 12 months with median uterine volume reduction of 35% and dominant fibroid reduction of 42% 4
• Achieves significant improvement in menorrhagia (83%), dysmenorrhea (77%), and urinary frequency (86%) at 3 months 4
• Permanent amenorrhea risk is age-dependent: <2-3% for women under 45 years, but up to 20% for women over 45 years 4
• Counsel patients that fecundity and pregnancy outcomes may be impacted 2
• UAE has high treatment failure rates for cervical fibroids—consider alternative approaches 4
• Multiple submucosal fibroids are associated with incomplete infarction requiring reintervention 4

Emerging Technologies

• MR-guided focused ultrasound and radiofrequency ablation show promise but lack long-term fertility outcome data 2, 6, 5

Location-Specific Treatment Considerations

Submucosal Fibroids

• Submucosal fibroids are most strongly associated with infertility, spontaneous abortion, preterm delivery, and abnormal presentation in labor 1
• Hysteroscopic resection is the preferred approach 1
• Pedunculated submucosal fibroids can undergo expulsion after UAE (50% complete expulsion rate) 4

Intramural Fibroids

• Myomectomy is appropriate when causing bulk symptoms or heavy bleeding 1, 2
• Ensure no cavity distortion is present, as this significantly impacts fertility 1

Critical Pitfalls to Avoid

• Do not use endometrial ablation in women desiring fertility—it is associated with high risk of pregnancy complications and is contraindicated 1
• Do not perform hysterectomy in women desiring fertility—infertility is permanent and irreversible 1
• Do not use GnRH agonists/antagonists as monotherapy beyond short courses without add-back therapy due to bone density loss 4
• Do not assume all pelvic masses are benign fibroids—rapid growth or postmenopausal growth requires endometrial biopsy to exclude malignancy 4, 3

Pregnancy Considerations

• Concern about possible complications related to fibroids in pregnancy is NOT an indication for prophylactic myomectomy except in women who have had a previous pregnancy with complications specifically related to fibroids 2
• Women with fibroids detected in pregnancy may require additional maternal and fetal surveillance 2