Single Best Answer (SBA) · Uterine Fibroids
A 30-year-old woman presents with a six-month history of regular, heavy menstrual bleeding. Her cycles are regular with no intermenstrual bleeding. She hopes to conceive soon. Transvaginal ultrasound reveals a 5 cm posterior wall fibroid that partially bulges into the uterine cavity. What is the single most appropriate management option?
Show answer and explanation
Answer: D. Myomectomy
Symptomatic fibroid in a woman wanting fertility
This woman has heavy menstrual bleeding from a fibroid distorting the cavity, and her priority is fertility. The choice must control bleeding and preserve/optimise fertility.
Why myomectomy
- Myomectomy removes the fibroid while preserving the uterus, and gives the best fertility outcomes of the options - superior to uterine artery embolisation.
- A fibroid bulging into the cavity (submucous component) is the type most likely to impair fertility and cause heavy bleeding, so removing it is rational.
- Counsel that myomectomy carries a higher risk of blood loss and longer operating time than hysterectomy, and that hysterectomy may eventually be needed.
Why not the others
| Option | Problem here |
|---|---|
| LNG-IUS | Reduces bleeding but does not shrink fibroid; not for a woman trying to conceive (and higher expulsion with cavity distortion) |
| GnRH analogue | Shrinks fibroid temporarily but regrows within ~12 weeks of stopping; only a pre-op/bridging measure |
| UAE | Fertility outcomes inferior to myomectomy; concerns over ovarian failure and abnormal placentation - avoided when fertility is desired |
| Expectant | She is symptomatic, so not appropriate |
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