Surgical Management of Uterine Fibroids
When Surgery is Absolutely Indicated
Surgery is indicated when symptomatic fibroids fail medical management, with the specific approach determined by fertility goals: myomectomy for women desiring pregnancy, hysterectomy for those with completed childbearing, and minimally invasive alternatives (UAE, MRgFUS) for patients wanting uterine preservation without future fertility. 1
Absolute Indications for Surgical Intervention
- Heavy menstrual bleeding refractory to medical therapy warrants surgical intervention, particularly when submucosal fibroids are present 1
- Bulk symptoms (pelvic pressure, urinary frequency, constipation) that persist despite medical management require surgical consideration 1
- Infertility attributed to fibroids with cavity distortion justifies myomectomy, though evidence shows limited improvement in live birth rates 1
- Symptomatic anemia despite medical therapy necessitates escalation to interventional or surgical options 2
Critical caveat: Asymptomatic fibroids discovered incidentally require no intervention, regardless of size or location 1
Surgical Options Based on Fertility Goals
For Women Desiring Future Pregnancy
Hysteroscopic myomectomy is first-line for submucosal fibroids <5 cm, achieving 85% pregnancy rates and 65% live birth rates. 2
- Submucosal (FIGO Type 4) fibroids that protrude into the cavity should be removed hysteroscopically when symptomatic 2
- Intramural fibroids with cavity distortion warrant laparoscopic or open myomectomy via anterior uterine incision before attempting conception 2
- Intramural fibroids WITHOUT cavity distortion should NOT be removed—no fertility benefit exists and surgical risk is added 2
- Subserosal fibroids do not impair fertility and removal is not routinely indicated 2
Important pitfall: Cavity distortion is the critical determinant—implantation rates drop from 16% to 6% when distortion is present, and pregnancy rates fall from 30% to 10-16% 2
For Women Not Desiring Future Fertility
Hysterectomy provides definitive treatment with 90% patient satisfaction and eliminates all fibroid-related symptoms, including coexistent adenomyosis. 1, 2
- Hysterectomy immediately eliminates bulk symptoms and removes any future fibroid concerns 1
- Approximately 150,000-200,000 hysterectomies are performed annually in the US for fibroids 2
- Hysterectomy should NOT be first-line when less invasive options can provide similar symptom relief with fewer complications 1
Critical warning: Hysterectomy carries increased risk of ovarian failure even with ovarian preservation, plus long-term risks including cardiovascular disease, osteoporosis, and dementia 1
Minimally Invasive Alternatives
Uterine Artery Embolization (UAE)
UAE achieves 73-98% immediate symptom control and 72-73% sustained relief at 5 years, with 42-53% fibroid volume reduction at 3 months. 1, 2
Advantages over hysterectomy:
- Significantly shorter hospitalization and faster return to work 1
- Lower complication rates (<3% major complications) 2
- Equivalent quality of life at 2-5 years 1
Critical disadvantages:
- 28% reintervention rate by 5 years, 35% by 10 years 1, 2
- 23% treatment failure at 10 years in women <40 due to collateral ovarian artery recruitment 2
- Elevated pregnancy risks: up to 20% postpartum hemorrhage, increased miscarriage and preterm delivery 1
- Amenorrhea risk: 20% in women >45 years, 2-3% in women <45 years 2
Best candidates: Anterior wall fibroids respond best; cervical fibroids have high failure rates 2
MR-Guided Focused Ultrasound (MRgFUS)
MRgFUS provides quality-of-life improvements and 5-year reintervention rates similar to laparoscopic myomectomy, but long-term durability data remain insufficient. 2
- Uses high-intensity ultrasound for thermal ablation without incisional damage 2
- Fertility registry data: 54 pregnancies in 51 women, 41% live births, 93% term delivery rate among those who delivered 2
- Major limitation: Lack of long-term durability data 2
Endometrial Ablation
Endometrial ablation is indicated specifically for heavy menstrual bleeding refractory to medical therapy in patients who do NOT desire future pregnancy. 1
Critical warning: Carries elevated risks of extrauterine pregnancy, preterm delivery, and stillbirth if pregnancy occurs—requires counseling about pregnancy risks and need for reliable contraception 1
Preoperative Optimization Algorithm
Before elective surgery, correct anemia using GnRH agonists/antagonists or selective progesterone receptor modulators with concurrent iron supplementation. 1
- Document failure of medical management (hormonal therapies, tranexamic acid, GnRH agonists) 1
- Assess fertility desires to determine myomectomy vs. hysterectomy vs. UAE 1
- Evaluate for concurrent conditions (adenomyosis requires different approach—medical management or UAE preferred, hysterectomy definitive if medical fails) 1
- Optimize anemia preoperatively with GnRH agonists/antagonists plus iron supplementation 1
Special Clinical Scenarios
Concurrent Adenomyosis
Myomectomy alone is unlikely to address adenomyosis effectively—medical management or UAE are preferred initial approaches, with hysterectomy providing definitive treatment if medical management fails. 1
- UAE provides long-term symptomatic relief in 65-82% of cases with concurrent adenomyosis 2
Pedunculated Subserosal Fibroids
Pedunculated subserosal fibroids do not increase UAE complication rates, and symptom improvement is comparable to non-pedunculated fibroids. 2
Common Pitfalls to Avoid
- Do NOT perform myomectomy on intramural fibroids without cavity distortion—no fertility benefit, only added surgical risk 2
- Do NOT offer endometrial ablation without counseling about pregnancy risks and need for reliable contraception 1
- Do NOT use hysterectomy as first-line when UAE or myomectomy can provide similar symptom relief 1
- Do NOT ignore the higher reintervention rates with UAE (up to 32% require surgery within 2 years)—counsel patients accordingly 1