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Uterine fibroids

Key sources
The following summarized guidelines for the evaluation and management of uterine fibroids are prepared by our editorial team based on guidelines from the Society of Obstetricians and Gynaecologists of Canada (SOGC 2023; 2019; 2015), the American College of Radiology (ACR 2022), the American Society for Reproductive Medicine (ASRM 2017), and the American Association of Gynecologic Laparoscopists (AAGL 2012).
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Guidelines

1.Screening and diagnosis

Clinical presentation
As per ASRM 2017 guidelines:
Insufficient evidence to conclude that uterine fibroids reduce the likelihood of achieving pregnancy with or without fertility treatment.
I
Insufficient evidence to determine that a specific fibroid size, number, or location (excluding submucosal fibroids or intramural fibroids impacting the endometrial cavity contour) is associated with a reduced likelihood of achieving pregnancy or an increased risk of early pregnancy loss.
I
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2.Diagnostic investigations

Diagnostic imaging: as per ACR 2022 guidelines, obtain pelvic/transvaginal ultrasound and duplex ultrasound as initial imaging of clinically suspected fibroids. Obtain pelvic/transvaginal ultrasound, duplex ultrasound, and MRI for treatment planning of known fibroids.
B

3.Diagnostic procedures

Hysteroscopy: recognize that hysteroscopy is highly sensitive and specific for the diagnosis of submucous leiomyomas, and is more sensitive and specific than hysterosalpingography and transvaginal ultrasound, but is inferior to MRI in characterizing the relationship of submucous fibroids to the myometrium and perimetrium.
A

4.Medical management

General principles: individualize the treatment of patients with uterine fibroids based on symptoms, size and location of fibroids, age, need and desire of the patient to preserve fertility or the uterus, the availability of therapy, and the experience of the clinician.
B

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  • Expectant management

  • Hormone therapy

  • Selective progesterone receptor modulators

5.Therapeutic procedures

Uterine artery embolization: as per SOGC 2015 guidelines, consider offering uterine artery occlusion by embolization or surgical methods for selected symptomatic patients with uterine fibroids wishing to preserve their uterus. Counsel patients choosing uterine artery occlusion for the treatment of uterine fibroids regarding possible risks, including the likelihood that fecundity and pregnancy may be impacted.
B

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  • Endometrial ablation

6.Perioperative care

Management of preoperative anemia: attempt to correct anemia with menstrual suppression and/or iron therapy before elective gynecologic surgery, as preoperative anemia (hemoglobin < 120 g/dL) has been associated with adverse outcomes.
B

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  • GnRH agonists

  • Management of postoperative bleeding

7.Surgical interventions

Myomectomy: as per SOGC 2023 guidelines, consider performing myomectomy in patients with FIGO type 0-2 (submucosal) fibroids and unexplained infertility, particularly if the patient is undergoing fertility treatments.
C
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More topics in this section

  • Hysterectomy

  • Technical considerations for surgery

8.Specific circumstances

Patients with acute uterine bleeding: consider offering conservative management with estrogens, selective progesterone receptor modulators, antifibrinolytics, Foley catheter tamponade, and/or operative hysteroscopic intervention in patients presenting with acute uterine bleeding associated with uterine fibroids.
C
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9.Patient education

General counseling: reassure asymptomatic patients with uterine fibroids that there is no evidence to substantiate major concern about malignancy and that hysterectomy is not indicated.
B

10.Preventative measures

Levonorgestrel-releasing intrauterine device: consider using a levonorgestrel-releasing intrauterine device to reduce the incidence of submucous fibroids.
C

11.Follow-up and surveillance

Post-treatment surveillance, imaging: obtain pelvic/transvaginal ultrasound, duplex ultrasound, and pelvic MRI for surveillance or post-treatment imaging of known fibroids.
B

More topics in this section

  • Post-treatment surveillance (hysteroscopy)