What are the recommended interventions for each FIGO type of uterine fibroid (myoma)?

Management of Uterine Fibroids by FIGO Classification

The American College of Radiology recommends hysteroscopic myomectomy as first-line treatment for submucosal fibroids (FIGO Type 0-2), and laparoscopic or open myomectomy for intramural and subserosal fibroids (FIGO Type 3-7) when fertility preservation is desired. 1, 2, 3

FIGO Type 0 (Pedunculated Submucosal)

• Hysteroscopic myomectomy is the procedure of choice for pedunculated submucosal fibroids <5 cm, providing shorter hospitalization and faster recovery compared to laparoscopic or open approaches 1
• Symptom improvement and quality of life outcomes are equivalent to more invasive surgical approaches at 2-3 months 1
• Medical management with NSAIDs and estrogen-progestin oral contraceptives can reduce bleeding symptoms as first-line therapy 1
• Tranexamic acid serves as a nonhormonal alternative for bleeding reduction 1
• GnRH agonists (leuprolide) or antagonists (elagolix, relugolix) can be used for short-term preoperative fibroid size reduction 1

FIGO Type 1 (Submucosal <50% Intramural)

• Hysteroscopic myomectomy remains the primary surgical approach for Type 1 fibroids, though technical difficulty increases compared to Type 0 2, 3
• Saline infusion sonohysterography improves visualization and shows good agreement with diagnostic hysteroscopy for surgical planning 2
• Medical management options mirror Type 0, with ulipristal acetate capable of reducing fibroid volume by approximately 30% after a single course 2
• For fibroids causing abnormal uterine bleeding or infertility, hysteroscopic myomectomy is specifically indicated 2

FIGO Type 2 (Submucosal ≥50% Intramural)

• Hysteroscopic myomectomy can be attempted for Type 2 fibroids, but laparoscopic assistance may be required depending on the degree of intramural extension 2, 3
• The American College of Radiology guidelines position this as a transitional category where surgical approach depends on fibroid size and surgeon expertise 1, 2
• Preoperative ulipristal acetate for 3 months may reduce fibroid size sufficiently to facilitate hysteroscopic removal 2

FIGO Type 3 (Contacts Endometrium, 100% Intramural)

• Laparoscopic myomectomy becomes the preferred approach for Type 3 fibroids when fertility preservation is desired 2, 3
• This represents a critical decision point: hysteroscopic approaches are generally unsuitable, while laparoscopic or open myomectomy provides definitive treatment 1, 2
• Uterine artery embolization (UAE) achieves technical success in >95% of cases with 40-50% decrease in uterine volume and symptom control in approximately 80% of patients 3
• However, UAE should not be first-line for women seeking pregnancy due to increased risk of miscarriage, cesarean sections, and postpartum hemorrhage 3
• Women should wait 2-3 months after myomectomy before attempting pregnancy to allow proper healing 3

FIGO Type 4 (Intramural)

• Laparoscopic myomectomy is the gold standard surgical treatment for intramural fibroids when fertility preservation is important 3, 4
• Myomectomy (abdominal or laparoscopic) has a recurrence rate of 23-33% 3
• For women not desiring fertility, hysterectomy provides definitive resolution and accounts for three-quarters of fibroid treatment in the United States 1, 5
• UAE is an effective alternative to surgery with equivalent symptomatic improvement to myomectomy at 2 years 2, 3
• Important myomectomy risks include significant intraoperative blood loss and postoperative adhesions that may affect future fertility 2

FIGO Type 5 (Subserosal ≥50% Intramural)

• Laparoscopic myomectomy remains the preferred surgical approach for Type 5 fibroids 2, 3, 4
• The choice between laparoscopic and open approach depends on fibroid size, number, and surgeon experience 2, 4
• For large fibroids (>10 cm), open myomectomy via laparotomy may be necessary due to technical limitations 2
• Preoperative ulipristal acetate can reduce fibroid size by up to 70% after 4 courses, potentially minimizing surgical blood loss 2

FIGO Type 6 (Subserosal <50% Intramural)

• Laparoscopic myomectomy is appropriate for Type 6 fibroids, with lower technical difficulty compared to deeper intramural lesions 2, 3
• These fibroids are generally more amenable to minimally invasive approaches due to their predominantly subserosal location 4
• UAE remains an option for women not seeking fertility, with similar success rates as other FIGO types 3

FIGO Type 7 (Subserosal Pedunculated)

• Laparoscopic myomectomy is the procedure of choice for pedunculated subserosal fibroids 2, 3
• These fibroids are technically easier to remove laparoscopically due to their pedunculated nature 4
• Careful attention to vascular pedicle management is essential to minimize bleeding risk 2

FIGO Type 8 (Other Locations)

• Broad ligament fibroids require surgical myomectomy (laparoscopic or open) as the definitive fertility-preserving treatment 2
• MRI is the preferred modality for precisely defining size, location, and relationship to adjacent ureters, iliac vessels, and bladder 2
• UAE is contraindicated for broad ligament fibroids because these lesions often receive blood supply from ovarian or other pelvic arteries, making embolization technically difficult and less effective 2
• Meticulous preoperative imaging and intraoperative technique are required to protect ureters and pelvic vasculature 2

Special Considerations for Calcified Fibroids

• Surgical intervention is the primary treatment approach for calcified fibroids because they do not respond to UAE 5
• CT pelvis better delineates calcification compared to ultrasound and MRI, directly impacting treatment planning 5
• Hysterectomy provides definitive resolution, while myomectomy is appropriate for patients desiring uterine preservation 5

Medical Management Across All FIGO Types

• Oral contraceptives and progestins are first-line medical options for managing bleeding symptoms, though they have limited effect on fibroid size 3
• Ulipristal acetate demonstrates Level I, A evidence for symptomatic relief with 30% volume reduction after a single course 2
• GnRH agonists and antagonists effectively reduce tumor volume but are associated with hypoestrogenic effects including hot flushes and bone mineral density loss 1
• Combination treatment with low-dose estrogen and progestin mitigates hypoestrogenic symptoms and is FDA-approved for fibroid-related heavy menstrual bleeding 1

Critical Decision Points

• For women desiring fertility: myomectomy (hysteroscopic for Types 0-2, laparoscopic/open for Types 3-7) is the primary recommendation 2, 3
• For women not desiring fertility with severe symptoms: hysterectomy offers definitive treatment 1, 2, 5
• UAE is appropriate for women not seeking pregnancy who prefer uterus-preserving therapy, with up to 32% requiring surgical treatment within two years 1, 3
• Black women have >80% incidence of fibroids by age 50 compared to 70% in White women, requiring consideration in treatment planning 3