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Management of Uterine Fibroids

Variant: 1   Reproductive age patient with uterine fibroids, symptomatic with heavy uterine bleeding or bulk symptoms (eg, pressure, pain, fullness, bladder, or bowel symptoms), and a desire to preserve fertility. Initial therapy.
Procedure Appropriateness Category
Hysteroscopic myomectomy Usually Appropriate
Laparoscopic or open myomectomy Usually Appropriate
Medical management Usually Appropriate
MR-guided high-frequency focused ultrasound ablation Usually Appropriate
Uterine artery embolization Usually Appropriate
Laparoscopic uterine artery occlusion Usually Not Appropriate
Endometrial ablation Usually Not Appropriate
Hysterectomy Usually Not Appropriate

Variant: 2   Reproductive age patient with uterine fibroids, symptomatic with heavy uterine bleeding or bulk symptoms (eg, pressure, pain, fullness, bowel, or bladder symptoms), and no desire for future fertility. Initial therapy.
Procedure Appropriateness Category
Laparoscopic or open myomectomy Usually Appropriate
Medical management Usually Appropriate
MR-guided high-frequency focused ultrasound ablation Usually Appropriate
Uterine artery embolization Usually Appropriate
Hysterectomy May Be Appropriate
Hysteroscopic myomectomy May Be Appropriate
Endometrial ablation Usually Not Appropriate
Laparoscopic uterine artery occlusion Usually Not Appropriate

Variant: 3   Reproductive age patient with uterine fibroids and concurrent adenomyosis, symptomatic with heavy uterine bleeding or bulk symptoms (eg, pressure, pain, fullness, bladder, or bowel symptoms), and no desire for future fertility. Initial therapy.
Procedure Appropriateness Category
Medical management Usually Appropriate
Uterine artery embolization Usually Appropriate
Hysterectomy May Be Appropriate
MR-guided high-frequency focused ultrasound ablation Usually Not Appropriate
Endometrial ablation Usually Not Appropriate
Hysteroscopic myomectomy Usually Not Appropriate
Laparoscopic or open myomectomy Usually Not Appropriate
Laparoscopic uterine artery occlusion Usually Not Appropriate

Variant: 4   Reproductive age patient with pedunculated submucosal uterine fibroids, symptomatic with heavy uterine bleeding. Initial therapy.
Procedure Appropriateness Category
Hysteroscopic myomectomy Usually Appropriate
Medical management Usually Appropriate
Uterine artery embolization May Be Appropriate
MR-guided high-frequency focused ultrasound ablation May Be Appropriate
Hysterectomy Usually Not Appropriate
Endometrial ablation Usually Not Appropriate
Laparoscopic or open myomectomy Usually Not Appropriate
Laparoscopic uterine artery occlusion Usually Not Appropriate

Variant: 5   Postmenopausal patient with uterine fibroids, symptomatic with heavy uterine bleeding or bulk symptoms (eg, pressure, pain, fullness, bladder, or bowel symptoms). Negative endometrial biopsy. Next step.
Procedure Appropriateness Category
Hysterectomy Usually Appropriate
Laparoscopic or open myomectomy May Be Appropriate
Uterine artery embolization May Be Appropriate
Hysteroscopic myomectomy May Be Appropriate
MR-guided high-frequency focused ultrasound ablation Usually Not Appropriate
Endometrial ablation Usually Not Appropriate
Laparoscopic uterine artery occlusion Usually Not Appropriate
Medical management Usually Not Appropriate

Variant: 6   Reproductive age patient with uterine fibroids desiring pregnancy and experiencing reproductive dysfunction. Initial therapy.
Procedure Appropriateness Category
Hysteroscopic myomectomy Usually Appropriate
Laparoscopic or open myomectomy Usually Appropriate
Uterine artery embolization May Be Appropriate
Medical management May Be Appropriate (Disagreement)
MR-guided high-frequency focused ultrasound ablation May Be Appropriate
Laparoscopic uterine artery occlusion Usually Not Appropriate
Endometrial ablation Usually Not Appropriate
Hysterectomy Usually Not Appropriate

Panel Members
Mina S. Makary, MDa; Kylie Zane, MDb; Gloria L. Hwang, MDc; Charles Y. Kim, MDd; Osmanuddin Ahmed, MDe; Erica M. Knavel Koepsel, MDf; Eric J. Monroe, MDg; Matthew J. Scheidt, MDh; Amanda R. Smolock, MD, PhDi; Elizabeth A. Stewart, MDj; Ashish P. Wasnik, MDk; Jason W. Pinchot, MDl.
Summary of Literature Review
Introduction/Background
Initial Therapy Definition
Discussion of Procedures by Variant
Variant 1: Reproductive age patient with uterine fibroids, symptomatic with heavy uterine bleeding or bulk symptoms (eg, pressure, pain, fullness, bladder, or bowel symptoms), and a desire to preserve fertility. Initial therapy.
Variant 1: Reproductive age patient with uterine fibroids, symptomatic with heavy uterine bleeding or bulk symptoms (eg, pressure, pain, fullness, bladder, or bowel symptoms), and a desire to preserve fertility. Initial therapy.
A. Endometrial ablation
Variant 1: Reproductive age patient with uterine fibroids, symptomatic with heavy uterine bleeding or bulk symptoms (eg, pressure, pain, fullness, bladder, or bowel symptoms), and a desire to preserve fertility. Initial therapy.
B. Hysterectomy
Variant 1: Reproductive age patient with uterine fibroids, symptomatic with heavy uterine bleeding or bulk symptoms (eg, pressure, pain, fullness, bladder, or bowel symptoms), and a desire to preserve fertility. Initial therapy.
C. Hysteroscopic myomectomy
Variant 1: Reproductive age patient with uterine fibroids, symptomatic with heavy uterine bleeding or bulk symptoms (eg, pressure, pain, fullness, bladder, or bowel symptoms), and a desire to preserve fertility. Initial therapy.
D. Laparoscopic or open myomectomy
Variant 1: Reproductive age patient with uterine fibroids, symptomatic with heavy uterine bleeding or bulk symptoms (eg, pressure, pain, fullness, bladder, or bowel symptoms), and a desire to preserve fertility. Initial therapy.
E. Laparoscopic uterine artery occlusion
Variant 1: Reproductive age patient with uterine fibroids, symptomatic with heavy uterine bleeding or bulk symptoms (eg, pressure, pain, fullness, bladder, or bowel symptoms), and a desire to preserve fertility. Initial therapy.
F. Medical management
Variant 1: Reproductive age patient with uterine fibroids, symptomatic with heavy uterine bleeding or bulk symptoms (eg, pressure, pain, fullness, bladder, or bowel symptoms), and a desire to preserve fertility. Initial therapy.
G. MR-guided high-frequency focused ultrasound ablation
Variant 1: Reproductive age patient with uterine fibroids, symptomatic with heavy uterine bleeding or bulk symptoms (eg, pressure, pain, fullness, bladder, or bowel symptoms), and a desire to preserve fertility. Initial therapy.
H. Uterine artery embolization
Variant 2: Reproductive age patient with uterine fibroids, symptomatic with heavy uterine bleeding or bulk symptoms (eg, pressure, pain, fullness, bowel, or bladder symptoms), and no desire for future fertility. Initial therapy.
Variant 2: Reproductive age patient with uterine fibroids, symptomatic with heavy uterine bleeding or bulk symptoms (eg, pressure, pain, fullness, bowel, or bladder symptoms), and no desire for future fertility. Initial therapy.
A. Endometrial ablation
Variant 2: Reproductive age patient with uterine fibroids, symptomatic with heavy uterine bleeding or bulk symptoms (eg, pressure, pain, fullness, bowel, or bladder symptoms), and no desire for future fertility. Initial therapy.
B. Hysterectomy
Variant 2: Reproductive age patient with uterine fibroids, symptomatic with heavy uterine bleeding or bulk symptoms (eg, pressure, pain, fullness, bowel, or bladder symptoms), and no desire for future fertility. Initial therapy.
C. Hysteroscopic myomectomy
Variant 2: Reproductive age patient with uterine fibroids, symptomatic with heavy uterine bleeding or bulk symptoms (eg, pressure, pain, fullness, bowel, or bladder symptoms), and no desire for future fertility. Initial therapy.
D. Laparoscopic or open myomectomy
Variant 2: Reproductive age patient with uterine fibroids, symptomatic with heavy uterine bleeding or bulk symptoms (eg, pressure, pain, fullness, bowel, or bladder symptoms), and no desire for future fertility. Initial therapy.
E. Laparoscopic uterine artery occlusion
Variant 2: Reproductive age patient with uterine fibroids, symptomatic with heavy uterine bleeding or bulk symptoms (eg, pressure, pain, fullness, bowel, or bladder symptoms), and no desire for future fertility. Initial therapy.
F. Medical management
Variant 2: Reproductive age patient with uterine fibroids, symptomatic with heavy uterine bleeding or bulk symptoms (eg, pressure, pain, fullness, bowel, or bladder symptoms), and no desire for future fertility. Initial therapy.
G. MR-guided high-frequency focused ultrasound ablation
Variant 2: Reproductive age patient with uterine fibroids, symptomatic with heavy uterine bleeding or bulk symptoms (eg, pressure, pain, fullness, bowel, or bladder symptoms), and no desire for future fertility. Initial therapy.
H. Uterine artery embolization
Variant 3: Reproductive age patient with uterine fibroids and concurrent adenomyosis, symptomatic with heavy uterine bleeding or bulk symptoms (eg, pressure, pain, fullness, bladder, or bowel symptoms), and no desire for future fertility. Initial therapy.
Variant 3: Reproductive age patient with uterine fibroids and concurrent adenomyosis, symptomatic with heavy uterine bleeding or bulk symptoms (eg, pressure, pain, fullness, bladder, or bowel symptoms), and no desire for future fertility. Initial therapy.
A. Endometrial ablation
Variant 3: Reproductive age patient with uterine fibroids and concurrent adenomyosis, symptomatic with heavy uterine bleeding or bulk symptoms (eg, pressure, pain, fullness, bladder, or bowel symptoms), and no desire for future fertility. Initial therapy.
B. Hysterectomy
Variant 3: Reproductive age patient with uterine fibroids and concurrent adenomyosis, symptomatic with heavy uterine bleeding or bulk symptoms (eg, pressure, pain, fullness, bladder, or bowel symptoms), and no desire for future fertility. Initial therapy.
C. Hysteroscopic myomectomy
Variant 3: Reproductive age patient with uterine fibroids and concurrent adenomyosis, symptomatic with heavy uterine bleeding or bulk symptoms (eg, pressure, pain, fullness, bladder, or bowel symptoms), and no desire for future fertility. Initial therapy.
D. Laparoscopic or open myomectomy
Variant 3: Reproductive age patient with uterine fibroids and concurrent adenomyosis, symptomatic with heavy uterine bleeding or bulk symptoms (eg, pressure, pain, fullness, bladder, or bowel symptoms), and no desire for future fertility. Initial therapy.
E. Laparoscopic uterine artery occlusion
Variant 3: Reproductive age patient with uterine fibroids and concurrent adenomyosis, symptomatic with heavy uterine bleeding or bulk symptoms (eg, pressure, pain, fullness, bladder, or bowel symptoms), and no desire for future fertility. Initial therapy.
F. Medical management
Variant 3: Reproductive age patient with uterine fibroids and concurrent adenomyosis, symptomatic with heavy uterine bleeding or bulk symptoms (eg, pressure, pain, fullness, bladder, or bowel symptoms), and no desire for future fertility. Initial therapy.
G. MR-guided high-frequency focused ultrasound ablation
Variant 3: Reproductive age patient with uterine fibroids and concurrent adenomyosis, symptomatic with heavy uterine bleeding or bulk symptoms (eg, pressure, pain, fullness, bladder, or bowel symptoms), and no desire for future fertility. Initial therapy.
H. Uterine artery embolization
Variant 4: Reproductive age patient with pedunculated submucosal uterine fibroids, symptomatic with heavy uterine bleeding. Initial therapy.
Variant 4: Reproductive age patient with pedunculated submucosal uterine fibroids, symptomatic with heavy uterine bleeding. Initial therapy.
A. Endometrial ablation
Variant 4: Reproductive age patient with pedunculated submucosal uterine fibroids, symptomatic with heavy uterine bleeding. Initial therapy.
B. Hysterectomy
Variant 4: Reproductive age patient with pedunculated submucosal uterine fibroids, symptomatic with heavy uterine bleeding. Initial therapy.
C. Hysteroscopic myomectomy
Variant 4: Reproductive age patient with pedunculated submucosal uterine fibroids, symptomatic with heavy uterine bleeding. Initial therapy.
D. Laparoscopic or open myomectomy
Variant 4: Reproductive age patient with pedunculated submucosal uterine fibroids, symptomatic with heavy uterine bleeding. Initial therapy.
E. Laparoscopic uterine artery occlusion
Variant 4: Reproductive age patient with pedunculated submucosal uterine fibroids, symptomatic with heavy uterine bleeding. Initial therapy.
F. Medical management
Variant 4: Reproductive age patient with pedunculated submucosal uterine fibroids, symptomatic with heavy uterine bleeding. Initial therapy.
G. MR-guided high-frequency focused ultrasound ablation
Variant 4: Reproductive age patient with pedunculated submucosal uterine fibroids, symptomatic with heavy uterine bleeding. Initial therapy.
H. Uterine artery embolization
Variant 5: Postmenopausal patient with uterine fibroids, symptomatic with heavy uterine bleeding or bulk symptoms (eg, pressure, pain, fullness, bladder, or bowel symptoms). Negative endometrial biopsy. Next step.
Variant 5: Postmenopausal patient with uterine fibroids, symptomatic with heavy uterine bleeding or bulk symptoms (eg, pressure, pain, fullness, bladder, or bowel symptoms). Negative endometrial biopsy. Next step.
A. Endometrial ablation
Variant 5: Postmenopausal patient with uterine fibroids, symptomatic with heavy uterine bleeding or bulk symptoms (eg, pressure, pain, fullness, bladder, or bowel symptoms). Negative endometrial biopsy. Next step.
B. Hysterectomy
Variant 5: Postmenopausal patient with uterine fibroids, symptomatic with heavy uterine bleeding or bulk symptoms (eg, pressure, pain, fullness, bladder, or bowel symptoms). Negative endometrial biopsy. Next step.
C. Hysteroscopic myomectomy
Variant 5: Postmenopausal patient with uterine fibroids, symptomatic with heavy uterine bleeding or bulk symptoms (eg, pressure, pain, fullness, bladder, or bowel symptoms). Negative endometrial biopsy. Next step.
D. Laparoscopic or open myomectomy
Variant 5: Postmenopausal patient with uterine fibroids, symptomatic with heavy uterine bleeding or bulk symptoms (eg, pressure, pain, fullness, bladder, or bowel symptoms). Negative endometrial biopsy. Next step.
E. Laparoscopic uterine artery occlusion
Variant 5: Postmenopausal patient with uterine fibroids, symptomatic with heavy uterine bleeding or bulk symptoms (eg, pressure, pain, fullness, bladder, or bowel symptoms). Negative endometrial biopsy. Next step.
F. Medical management
Variant 5: Postmenopausal patient with uterine fibroids, symptomatic with heavy uterine bleeding or bulk symptoms (eg, pressure, pain, fullness, bladder, or bowel symptoms). Negative endometrial biopsy. Next step.
G. MR-guided high-frequency focused ultrasound ablation
Variant 5: Postmenopausal patient with uterine fibroids, symptomatic with heavy uterine bleeding or bulk symptoms (eg, pressure, pain, fullness, bladder, or bowel symptoms). Negative endometrial biopsy. Next step.
H. Uterine artery embolization
Variant 6: Reproductive age patient with uterine fibroids desiring pregnancy and experiencing reproductive dysfunction. Initial therapy.
Variant 6: Reproductive age patient with uterine fibroids desiring pregnancy and experiencing reproductive dysfunction. Initial therapy.
A. Endometrial ablation
Variant 6: Reproductive age patient with uterine fibroids desiring pregnancy and experiencing reproductive dysfunction. Initial therapy.
B. Hysterectomy
Variant 6: Reproductive age patient with uterine fibroids desiring pregnancy and experiencing reproductive dysfunction. Initial therapy.
C. Hysteroscopic myomectomy
Variant 6: Reproductive age patient with uterine fibroids desiring pregnancy and experiencing reproductive dysfunction. Initial therapy.
D. Laparoscopic or open myomectomy
Variant 6: Reproductive age patient with uterine fibroids desiring pregnancy and experiencing reproductive dysfunction. Initial therapy.
E. Laparoscopic uterine artery occlusion
Variant 6: Reproductive age patient with uterine fibroids desiring pregnancy and experiencing reproductive dysfunction. Initial therapy.
F. Medical management
Variant 6: Reproductive age patient with uterine fibroids desiring pregnancy and experiencing reproductive dysfunction. Initial therapy.
G. MR-guided high-frequency focused ultrasound ablation
Variant 6: Reproductive age patient with uterine fibroids desiring pregnancy and experiencing reproductive dysfunction. Initial therapy.
H. Uterine artery embolization
Summary of Highlights
Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Gender Equality and Inclusivity Clause
The ACR acknowledges the limitations in applying inclusive language when citing research studies that predates the use of the current understanding of language inclusive of diversity in sex, intersex, gender, and gender-diverse people. The data variables regarding sex and gender used in the cited literature will not be changed. However, this guideline will use the terminology and definitions as proposed by the National Institutes of Health.
Appropriateness Category Names and Definitions

Appropriateness Category Name

Appropriateness Rating

Appropriateness Category Definition

Usually Appropriate

7, 8, or 9

The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.

May Be Appropriate

4, 5, or 6

The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.

May Be Appropriate (Disagreement)

5

The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.

Usually Not Appropriate

1, 2, or 3

The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.
References
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Disclaimer
The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked.  Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document.  The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged.  The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination