Management of Multiple Intramural Uterine Fibroids — 23-Year-Old, Unmarried, No Menstrual Complaints, Pain Abdomen Only

Summary of MRI Findings

Key Clinical Considerations in This Patient

1. Young (23 yrs), unmarried → Uterus and fertility must be preserved — hysterectomy is absolutely contraindicated
2. No menstrual complaints (no menorrhagia, no dysmenorrhea) → Medical hormonal therapy for bleeding control is not needed
3. Only symptom: pain abdomen → Likely due to degenerative changes (red degeneration/hyaline degeneration seen on MRI) and mass effect
4. Multiple large fibroids (largest ~4.3 × 4.3 cm) with uterus ~10.9 cm → Significant fibroid burden
5. Uterocervical junction fibroid → Risk for obstructive complications

Management Approach

STEP 1 — Analgesia for Acute/Ongoing Pain

• NSAIDs (Ibuprofen 400–600 mg TDS or Mefenamic acid 500 mg TDS with food) — first-line for fibroid-related pain
• Adequate for degenerative/pressure pain; trial for 4–6 weeks
• Add antispasmodics (Drotaverine/Hyoscine) if crampy component

STEP 2 — Medical Therapy (to shrink fibroids preoperatively / reduce symptoms)

• Mechanism: Pituitary downregulation → hypoestrogenic state → fibroid shrinkage (typically 30–50% volume reduction over 3–6 months)
• Duration: 3–6 months preoperatively
• Benefits: Reduces fibroid volume, decreases vascularity, makes subsequent surgery easier with less blood loss
• Limitation: Effects are temporary — fibroids regrow within months of stopping. NOT a standalone definitive treatment in a 23-year-old with large/multiple fibroids
• Add-back therapy (low-dose estrogen/progestogen) if beyond 6 months to prevent bone loss
• — Katzung's Basic and Clinical Pharmacology, 16th Ed.

• Reduces fibroid size and controls symptoms; used intermittently

STEP 3 — Definitive Surgical Management: Myomectomy (Fertility-Preserving)

• Young, unmarried woman wanting uterine preservation
• Symptomatic (pain) multiple intramural fibroids
• Large fibroid burden with uterine enlargement

• Intramyometrial vasopressin injection to reduce blood loss
• Cell saver device if available
• Multilayer myometrial closure
• Adhesion barrier (e.g., Interceed) over uterine incisions
• Preoperative GnRH agonist for 3 months to reduce size and vascularity
• — Berek & Novak's Gynecology

What NOT to Do

• ❌ Hysterectomy — absolutely contraindicated in a 23-year-old desiring uterine/fertility preservation
• ❌ Uterine Artery Embolization (UAE) — not recommended in women desiring future fertility (risk of ovarian insufficiency, uterine necrosis, impaired implantation)
• ❌ Expectant management alone — given size of fibroids, mass effect on bladder/rectum, pain symptoms, and degenerative changes, watchful waiting is insufficient

Recommended Management Plan Summary

1. Immediate: NSAIDs ± antispasmodics for pain control
2. Preoperative: GnRH agonist (Leuprolide depot 3.75 mg IM monthly) × 3 months
   → to shrink fibroids, reduce vascularity, correct any anemia
3. Definitive: Abdominal/laparoscopic myomectomy (multiple intramural fibroids)
4. Postoperative: Counsel about recurrence risk (~27% at 10 years for multiple fibroids)
   → Future pregnancy will further reduce recurrence risk
5. Follow-up: Ultrasound at 6 months, then annually

Recurrence After Myomectomy

• With multiple fibroids initially removed: 59% develop new fibroids at ≥5 years of follow-up
• 11–26% require repeat surgery within 7–8 years
• Subsequent pregnancy reduces recurrence rate (16% vs 28% in non-gravid women)
• — Berek & Novak's Gynecology