Treating Uterine Fibroids While Preserving Fertility

A 43-year-old Australian woman presented to the emergency department with concerns related to dyspnea, urinary frequency, and heavy menstrual bleeding. Her BMI was 36. She noted that she had been diagnosed with a large multi-fibroid uterus several years previously.

However, because she was living in the U.S. and had no health insurance, she had not opted for surgical treatment at that time. She told clinicians that at around that point in time, she developed iron deficiency anemia as a result of heavy menstrual bleeding. In 2018, she had been treated twice with blood transfusions to address this. She was taking iron supplements orally.

When the coronavirus pandemic struck, she returned to Australia, decided to seek treatment for her fibroids, and presented to the emergency department. She had never undergone any surgeries, nor had she ever been pregnant. She told clinicians that she wished to preserve her fertility.

Physical examination showed that her vital signs were within normal limits. Her uterus was palpable to just below the xiphisternum. The attending clinician noted that she had mild tenderness on abdominal palpation. A full blood count showed that her hemoglobin was 9.1 g/dL with a mean corpuscular volume of 73 fL. She had normal kidney function.

Ultrasound examination of her pelvis revealed multiple fibroids that had grossly enlarged her uterus, extending above the level of the umbilicus and into the right hypochondrium. The largest fibroid was a broad-based, right fundal, exophytic, subserosal fibroid measuring 147 × 114 × 180 mm. Imaging revealed numerous additional fibroids, including one large posterior intramural fibroid that was 124 × 111 × 103 mm in size.

The patient underwent additional assessment with MRI; this confirmed that fibroids had caused significant enlargement of her uterus, with some of the fibroids showing areas of T2 hyperintensity reflecting cystic degeneration. The largest exophytic fibroid at the right lateral uterine fundus extended into the upper abdomen above the level of the umbilicus; it bordered the inferior right lobe of the liver, causing compression of the right kidney and displacing bowel loops to the left upper quadrant. The largest intrauterine fibroid compressed the endometrial cavity and displaced it rightward. No aggressive features or characteristics suggested malignancy. These MRI findings mirrored those of a ultrasound and MRI that had been performed about 18 months prior in the U.S.

The patient was started on a regimen of tranexamic acid and medroxyprogesterone (Provera) to control her bleeding prior to surgery. While a hysterectomy was recommended, the patient did not want to consider that measure since she still hoped to have children. To assess the patient's fertility, the clinician ordered blood tests, which showed that her levels of anti-mullerian hormone, follicle stimulating hormone, and luteinizing hormone were all within normal parameters. The patient chose to undergo a myomectomy after being advised of the risk of proceeding to hysterectomy during surgery. The clinician arranged for a pre-operative iron transfusion.

The clinician performed an abdominal uterine myomectomy, which required a midline laparotomy that extended above the umbilicus to allow for the enlarged uterus. They made three uterine incisions on the fundal, posterior wall and anterior wall, and excised 29 fibroids in all, which ranged in size from 1 to 20 cm in diameter. The cavity was breached with the posterior incision and closed with 2-0 polydioxanone suture; multi-layered 1.0 vicryl sutures were used to close the remaining incisions. The uterus remained large (equivalent to 20 weeks' gestation) at the end of the procedure. Further examination revealed no large fibroids, and the clinician diagnosed the patients with diffuse adenomyosis. She lost an estimated 1.5 litres of blood during the surgery.

Post-operative testing showed her hemoglobin was 7.4 g/dL. The patient received transfusion of one unit of packed red bloods cells. After an uneventful recovery, the patient was discharged to home 5 days after surgery. Histopathology analysis showed benign leiomyomas with no atypical features. When she returned to the clinic 6 weeks after surgery for follow-up, she reported having one period, which she described as normal. She requested referral to a sperm donor program, and presented to a fertility service for further management.

Discussion

The clinician presenting this case of a 43-year-old woman with uterine fibroids who wished to preserve her uterus despite having significant symptoms noted that "desire for future pregnancy will always be a key driver in choice of management for fibroids."

Treating patients with multiple large fibroids with the additional objective of preserving fertility can make treatment decisions challenging, "particularly if hysterectomy would be the safer approach," wrote case author Lucy M. Holden, MD, of the department of obstetrics and gynecology at the Joondalup Health Campus in Australia.

These benign smooth muscle tumours – also called leiomyomas – develop from cells of the uterine myometrium and affect up to 80% of pre-menopausal women, Holden noted. While fibroids do not cause any symptoms in many women, women who do have symptoms "often report significant negative impact on their quality of life," which may cause them to consult a specialist regarding surgical treatment, she wrote.

This burden of fibroid symptoms was demonstrated in a multinational survey of more than 21,000 women (ages 15-49); those with a fibroid diagnosis were significantly more likely to report a wide range of bleeding symptoms than women without fibroids, as well as significantly more pain symptoms, such as pressure on the bladder (32.6% vs 15.0%), chronic pelvic pain (14.5% vs 2.9%), painful sexual intercourse (23.5% vs 9.1%), and pain occurring mid-cycle, after, and during menstrual bleeding (31.3%, 16.7%, 59.7%, vs 17.1%, 6.4%, 52.0%). Furthermore, many said that fibroids had had a negative impact on their life in the last 12 months, influencing their sexual life (42.9%), performance at work (27.7%), and relationship and family (27.2%).

While hysterectomy is currently considered the gold standard treatment for uterine fibroids, Holden noted, "uterine-sparing surgery is generally recommended in women of child-bearing age in an effort to preserve fertility, with minimally invasive surgical techniques preferred over hysterectomy."

Of less-invasive surgical approaches, "myomectomy is generally recommended over uterine artery embolization (UAE)" to minimize the need for additional procedures, Holden wrote. UAE has been linked with a higher risk of intrauterine adhesions, and its effect on fertility and outcomes of pregnancy is generally still not known.

In a recent comparison between uterine-artery embolization and myomectomy for uterine fibroids, perioperative and postoperative complications from the initial procedure occurred in 27 of 113 women (24%) in the uterine-artery embolization group and in 34 of 118 women (29%) in the myomectomy group (RR 1.2, 95% CI 0.8-1.9, P=0.40), although the difference in incidence did not reach statistical significance.

In this patient's case, hysterectomy was advised based on the size of the fibroids, as well as concerns about blood loss during the surgery, Holden noted. This patient's decision to avoid hysterectomy in order to preserve her fertility made it especially important to ascertain her fertility status. "Had her blood results shown a peri-menopausal state, then the desire for uterine preservation may have been moot. Ultimately, the surgical team worked to respect the patient's wishes for fertility preservation with referral to fertility services at the completion of her treatment," the case author noted.

Holden noted that there are many factors to consider when presented with a patient with fibroids who wishes to maintain her fertility, given that little is known about how fibroids affect fertility or how best to manage fibroids to preserve fertility. "Subserosal fibroids are unlikely to impair fertility, however submucosal and intramural fibroids are associated with decreased fertility and increased rates of miscarriage," she noted.

Patients with fibroids diagnosed before or during pregnancy require special care; fetal growth must be monitored in case of intrauterine growth restriction. And the risks of preterm birth and caesarean delivery are also increased. The location of the fibroid should be determined early in the course of a pregnancy to avoid an obstruction that might prevent vaginal delivery and to allow careful surgical planning in cases where a caesarean section may be needed. Patients with fibroids who become pregnant will require careful monitoring and planning for delivery under specialist care, Holden concluded.

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