Do I need surgical removal of my uterine fibroids (leiomyomas) measuring 5 cm, 3 cm, and two 1 cm since I have no abnormal uterine bleeding and only premenstrual dysmenorrhea?

No, surgical removal is not necessary for your fibroids based on your current symptoms

Since you have no abnormal uterine bleeding and only premenstrual dysmenorrhea (menstrual cramps), your fibroids do not require surgical intervention at this time. The presence of fibroids alone—even a 5 cm fibroid—is not an indication for surgery when symptoms are minimal or manageable 1, 2.

Why Surgery Is Not Indicated in Your Case

Symptom-Based Treatment Approach

• The American College of Radiology emphasizes that treatment selection should be based on symptom severity, specifically abnormal bleeding, pelvic pain/pressure, and compression symptoms 2.
• Many uterine fibroids are asymptomatic and require no intervention, though follow-up is advisable to document stability in size 3.
• In two-thirds of fibroid cases, there are no symptoms requiring treatment 4.

Your Specific Presentation

• No abnormal uterine bleeding: This is the most common symptom requiring intervention, and you don't have it 1, 3.
• Only premenstrual dysmenorrhea: This mild symptom can be effectively managed with medical therapy rather than surgery 1.
• Your largest fibroid is 5 cm, which is significant but not automatically an indication for surgery in the absence of severe symptoms 4.

Recommended Management Strategy

Conservative Monitoring

• Follow-up imaging (ultrasound) should be performed to document stability in fibroid size over time 3.
• Women with fibroids >3 cm causing significant symptoms, pain, or pressure may consider surgery, but your symptoms don't meet this threshold 4.

Medical Management for Your Symptoms

• For menstrual cramps (dysmenorrhea): Non-steroidal anti-inflammatory drugs (NSAIDs) are effective first-line treatment 5.
• Oral contraceptives: May effectively manage your premenstrual symptoms, especially with smaller fibroids like your 1 cm lesions 1, 6.
• Tranexamic acid: A non-hormonal option if bleeding becomes problematic in the future, though it may cause pelvic pain as a side effect 1, 7.

When to Consider Intervention

Red Flags Requiring Referral

• Development of abnormal uterine bleeding or heavy menstrual bleeding (menorrhagia) 1, 7.
• Bulk symptoms: Urinary frequency, constipation, or significant pelvic pressure 1, 4.
• Rapid fibroid growth: Especially in postmenopausal years, which raises concern for malignancy 7, 4.
• Fertility concerns: If you're planning pregnancy and have difficulty conceiving 1, 6.
• Persistent intermenstrual bleeding or worsening pain despite medical management 4.

Size Thresholds for Consideration

• Fibroids >3 cm with significant symptoms warrant specialist evaluation 4.
• Uterus palpable abdominally or >12 cm on imaging suggests referral 4.
• Your 5 cm fibroid alone doesn't mandate surgery without corresponding symptoms 4.

Important Caveats

Fibroid Location Matters

• Submucosal fibroids (protruding into the uterine cavity) are most likely to cause heavy bleeding and may require hysteroscopic resection even when smaller 7.
• Intramural fibroids (within the uterine wall) cause bleeding less frequently 7.
• Subserosal fibroids (on the outer surface) generally don't cause bleeding but may cause bulk symptoms 7.
• Your ultrasound report should specify fibroid locations—if any are submucosal and you develop bleeding, earlier intervention may be warranted 7.

Future Fertility Considerations

• If you're planning pregnancy, discuss with your gynecologist whether your fibroid locations could affect fertility 6, 8.
• Intramural fibroids can negatively affect fertility, but treating asymptomatic fibroids doesn't necessarily improve outcomes 6.
• Myomectomy should be the first choice if surgery becomes necessary and you desire future pregnancy 2, 6.

Surgical Options If Symptoms Worsen

Uterine-Sparing Procedures

• Myomectomy: Removes fibroids while preserving the uterus, with 23-33% recurrence rates 1, 2.
• Uterine artery embolization (UAE): Achieves symptom control in ~80% of patients with 40-50% volume reduction, but has higher reintervention rates (36% vs 5% for myomectomy) 1, 2.
• MR-guided focused ultrasound: Non-invasive option achieving ~50% volume reduction, but limited fertility data 2, 6.

Definitive Treatment

• Hysterectomy: The gold standard with >90% satisfaction rates and zero recurrence risk, appropriate only when childbearing is complete 2, 6.

Bottom line: Continue monitoring with your gynecologist, manage your menstrual cramps with NSAIDs or hormonal therapy, and reserve surgical intervention for if/when symptoms significantly impact your quality of life.