Is a 55-year-old woman with a large subserosal posterior wall leiomyoma (uterine fibroid) attached to the fundus and body of the uterus indicated for hysterectomy?

From the Guidelines

Hysterectomy is a viable treatment option for a 55-year-old woman with a large subserosal posterior wall leiomyoma attached to the fundus and body of the uterus, especially if she is experiencing significant symptoms and has completed childbearing. The decision to proceed with hysterectomy should be based on a thorough evaluation of the patient's symptoms, overall health status, and preferences, as well as a careful consideration of the potential risks and benefits of the procedure 1.

Key Considerations

• The patient's age and likely postmenopausal or perimenopausal status make fertility preservation less of a concern.
• A thorough evaluation, including imaging studies (ultrasound, MRI) and possibly endometrial sampling, should be performed to rule out malignancy.
• Less invasive alternatives, such as myomectomy, uterine artery embolization, or hormonal management, could be considered if symptoms are mild or if the patient wishes to avoid major surgery.
• The subserosal location of the fibroid may cause pressure symptoms rather than bleeding issues, which should be taken into account when making treatment decisions.

Treatment Options

• Hysterectomy is a curative procedure that can provide significant symptom relief and improve quality of life for women with large uterine leiomyomas 1.
• The choice of surgical approach (abdominal, vaginal, laparoscopic, or laparoscopically assisted) should be tailored to the individual patient's circumstances and preferences.
• The decision to perform a total or supracervical hysterectomy should be based on the patient's individual needs and preferences, as well as the surgeon's expertise and experience.

From the Research

Indications for Hysterectomy

• A large subserosal posterior wall leiomyoma attached to the fundus and body of the uterus in a 55-year-old woman may be indicated for hysterectomy, considering the patient's age and potential symptoms caused by the fibroid 2, 3.
• The main indications for hysterectomy include uterine leiomyomas, dysfunctional uterine bleeding, endometriosis/adenomyosis, chronic pelvic pain, and genital prolapse 3.
• However, current literature recommends conservative management of most nonmalignant gynecologic conditions, with hysterectomy reserved for refractory cases 3.

Alternative Treatment Options

• Alternative treatment options for uterine fibroids include medical treatment, such as gonadotropin-releasing hormone agonists, and minimally invasive techniques, such as uterine artery embolization, myolysis, and magnetic resonance-guided focused ultrasound surgery 2, 4.
• A gonadotropin-releasing hormone agonist may be used to manage perimenopausal women with symptomatic uterine myomas, with a success rate of over 80% in one study 5.
• Magnetic resonance-guided high-intensity focused ultrasound is a promising technique for decreasing menorrhagia and dysmenorrhea in symptomatic women, with few adverse effects reported 4.

Considerations for Treatment Choice

• The choice of treatment depends on the patient's age, fertility desires, and the number, size, and location of the fibroids 2.
• Women experiencing chronic pelvic pain should be counseled against hysterectomy until a more clear etiology has been identified 6.
• Treatment of fibroids must be individualized based on the presence and severity of symptoms and the patient's desire for definitive treatment or fertility preservation 2.