Uterine Fibroids · Observe/Medical vs Surgery + Approach

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Symptoms + fertility wish + location/size
   Symptoms + fertility wish + location/size? (Individualize by symptoms, fibroid number/size/location (FIGO type) and fertility wishes.)
   • Asymptomatic (and not a large submucosal fibroid) → Asymptomatic → observe and follow up
   • Symptomatic, try medical/minimally invasive conservative first → Medical/minimally invasive conservative
   • Symptomatic, needs surgery — wishes to preserve the uterus/fertility → Preserve uterus = myomectomy · approach by location
   • Symptomatic, needs surgery — no fertility wish/wants definitive cure → Hysterectomy (definitive)
2. [End] Asymptomatic → observe and follow up
   Asymptomatic → observe and follow up (perimenopausal may await postmenopausal atrophy); periodic ultrasound for size and symptoms.
3. [End] Medical/minimally invasive conservative
   Medical: for abnormal bleeding → LNG-IUS, tranexamic acid, COC/oral progestin; GnRH agonist/antagonist mainly for preoperative shrinkage and anemia correction (long-term limited by side effects/bone loss). Uterus-sparing interventional: UAE, HIFU, radiofrequency ablation. Failure/intolerance → surgery.
4. [Decision] Preserve uterus = myomectomy · approach by location
   Myomectomy approach (by location)?
   • Submucosal (FIGO 0–2), causing abnormal bleeding → Hysteroscopic myomectomy
   • Intramural/subserosal, pedunculated → Laparoscopic myomectomy
   • Large/multiple/unfavorable location → Abdominal myomectomy
5. [End] Hysteroscopic myomectomy
   Hysteroscopic myomectomy — submucosal (FIGO 0-1-2) causing bleeding, preserves fertility; minimally invasive/outpatient; mind the irrigation fluid and proportion resected in one session.
6. [End] Laparoscopic myomectomy
   Laparoscopic myomectomy — intramural/subserosal/pedunculated; fast recovery; ensure secure closure and assess uterine rupture risk in future pregnancy, avoid unprotected morcellation.
7. [End] Abdominal myomectomy
   Abdominal myomectomy — large/multiple/unfavorable location; secure exposure and closure but more invasive with longer recovery.
8. [End] Hysterectomy (definitive)
   Hysterectomy = definitive (no fertility wish); vaginal/laparoscopic/abdominal by uterine size and surgeon experience; lower recurrence than myomectomy but more invasive with longer recovery and loss of fertility.

Source guidelines & references

• Uterine fibroid management (FIGO best-practice medical therapy; ACOG management of benign uterine disease)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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