Gonadotropin-releasing hormone agonists 32
Table 2 includes the differential diagnosis of uterine masses. 27, 28 Risk factors for leiomyosarcoma include radiation of the pelvis, increasing age, and use of tamoxifen, 29, 30 which has implications for surgical management of fibroids. Some predictors of malignancy on magnetic resonance imaging include age older than 45 years (odds ratio = 20), intratumoral hemorrhage (OR = 21), endometrial thickening (OR = 11), T2-weighted signal heterogeneity (OR = 10), menopausal status (OR = 9.7), and nonmyometrial origin (OR = 4.9). 25 There are no reliable means to differentiate benign from malignant tumors without pathologic evaluation. 25, 26 Adding sonohysterography or hysteroscopy improves sensitivity for detecting submucosal myomas. 4 Transvaginal ultrasonography is about 90% to 99% sensitive for detecting uterine fibroids, but it may miss subserosal or small fibroids. 24 In the United States, ultrasonography is the preferred initial imaging modality for fibroids. Fibroids are sometimes found in asymptomatic women during routine pelvic examination or incidentally during imaging. The evaluation of fibroids is based mainly on the patient's presenting symptoms: abnormal menstrual bleeding, bulk symptoms, pelvic pain, or findings suggestive of anemia. 19 Therefore, fibroids in pregnant women warrant additional maternal and fetal surveillance. 10.5%), and intrauterine fetal death with growth restriction (3.9% vs. 2.4%), delivery before 37 weeks' gestation (15.1% vs. 3.1%), pre-term premature rupture of membranes (3.3% vs. 24.2%), as well as increases in the risk of breech presentation (5.3% vs. Although studies have had conflicting results on the change in fibroid size during pregnancy, 17, 18 a large retrospective study of women with uterine fibroids found a significantly increased risk of cesarean delivery compared with a control group (33.1% vs. Women with intramural fibroids had no differences in pregnancy rates after undergoing myomectomy. 16 However, no statistically significant difference was noted in the ongoing pregnancy/live birth rate. 15 One meta-analysis included two studies that showed improvement in spontaneous conception rates in women who underwent myomectomy for submucosal fibroids (relative risk = 2.034 95% confidence interval, 1.081 to 3.826 P =. 14 However, there is no evidence from randomized controlled trials to support myomectomy to improve fertility.
Uterine fibroids may be associated with infertility, and some experts recommend that women with infertility be evaluated for fibroids, with potential removal if the tumors have a submucosal component. Surgical treatment includes hysterectomy, myomectomy, uterine artery embolization, and magnetic resonance–guided focused ultrasound surgery. Gonadotropin-releasing hormone agonists or selective progesterone receptor modulators are an option for patients who need symptom relief preoperatively or who are approaching menopause. Medical therapy to reduce heavy menstrual bleeding includes hormonal contraceptives, tranexamic acid, and nonsteroidal anti-inflammatory drugs. Management should be tailored to the size and location of fibroids the patient's age, symptoms, desire to maintain fertility, and access to treatment and the experience of the physician. Expectant management is recommended for asymptomatic patients because most fibroids decrease in size during menopause. Ultrasonography is the preferred initial imaging modality. Fibroids can cause abnormal uterine bleeding, pelvic pressure, bowel dysfunction, urinary frequency and urgency, urinary retention, low back pain, constipation, and dyspareunia. Many are discovered incidentally on clinical examination or imaging in asymptomatic women. Uterine fibroids are common benign neoplasms, with a higher prevalence in older women and in those of African descent.
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