Overview

  • Case

  • Anatomy

  • Literature

HISTORY

42-year-old woman

Hypertension, dyslipidemia, diabetes

Heavy menstrual bleeding, pelvic pressure, fatigue

Enlarged uterus (~14 weeks size)

What’s your differential?

Differential?

  • Endometrial Cancer
  • Adenomyosis
  • Leiomyoma
  • Leiomyosarcoma

What is Your First Step in Imaging?

ACR Criteria

Ultrasound

Ultrasound

Ultrasound

Ultrasound

Diagnosis?

What kind?

Uterine fibroid types

https://www.mayoclinic.org/diseases-conditions/uterine-fibroids/symptoms-causes/

Uterine fibroid types

https://www.mayoclinic.org/diseases-conditions/uterine-fibroids/symptoms-causes/

FIGO Classification System

Submucosal Group

  • Type 0: pedunculated intracavitary

  • Type 1: <50% intramural

  • Type 2: ≥50% intramural

Uterine fibroid types

https://www.mayoclinic.org/diseases-conditions/uterine-fibroids/symptoms-causes/

FIGO Classification System

Other Group

  • Type 3: 100% intramural; contacts endometrium

  • Type 4: intramural

  • Type 5: subserosal ≥50% intramural

  • Type 6: subserosal <50% intramural

  • Type 7: subserosal pedunculated

  • Type 8: other, e.g. cervical, parasitic

Ultrasound

Ultrasound

Ultrasound

Ultrasound

What next?

ACR Criteria

MRI

MRI

Ultrasound

Cystic Degeneration

Cystic Degeneration

What next?

Treatment Modalities & Selection Criteria

Medical Management

  • First-line for most patients

  • Options: NSAIDs, tranexamic acid, combined oral contraceptives, progestins, LNG-IUS

  • Guideline: ACOG recommends starting with medical therapy for symptomatic management

What next?

Treatment Modalities & Selection Criteria

Myomectomy

  • Gold standard for fertility preservation

  • Approaches: Hysteroscopic (submucosal), laparoscopic (selected cases), abdominal (complex)

  • Consider: Fibroid size, number, location, and surgical expertise

What next?

Treatment Modalities & Selection Criteria

Hysterectomy

  • Definitive treatment for completed childbearing

  • Consider: Failed medical/conservative treatments, large symptomatic fibroids

  • Approach: Minimally invasive preferred when feasible

What next?

Treatment Modalities & Selection Criteria

Uterine Artery Embolization (UAE)

  • Ideal candidate: Women who desire uterine preservation but not future pregnancy

  • ACR Appropriateness: Usually appropriate for symptomatic fibroids

  • Evidence: 85-95% symptom improvement, equivalent to myomectomy at 2 years

Anatomy

Anatomy Mnemonic

I Love Going Places In My Very Own Underwear!

  • I: iliolumbar artery

  • L: lateral sacral artery

  • G: gluteal (superior and inferior) arteries

  • P: (internal) pudendal artery

  • I: inferior vesical (vaginal in females) artery.

  • M: middle rectal artery

  • V: vaginal artery (females only)

  • O: obturator artery

  • U: umbilical artery and uterine artery (females only)

Evidence

Patient Characteristics

Treatment Distribution by Location

Treatment Distribution by Race

Shared Decision-Making Essentials

Key Discussion Points:

  • Reproductive plans and timing

  • Symptom severity and impact on quality of life

  • Treatment risks and recovery expectations

  • Long-term outcomes and recurrence risks

  • Personal values and preferences

Shared Decision-Making Essentials

Key Discussion Points:

  • ACOG Practice Bulletin #228 (2021)

  • ACR Appropriateness Criteria®

  • SIR Guidelines for UAE

  • ESHRE Guidelines on Fibroid Management