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Best Practice & Research Clinical Obstetrics and Gynaecology Vol. 22, No. 4, pp.

643–654, 2008
doi:10.1016/j.bpobgyn.2008.01.007 available online at http://www.sciencedirect.com

6 Asymptomatic uterine fibroids
Hema Divakar *
MD

Consultant Obstetrician Gynaecologist Divakars Speciality Hospital, 220, 9th Cross, 2nd Phase, JP Nagar, Bangalore 560076, India

It is estimated that at least 50% of fibroids are asymptomatic, but this figure is likely to be an underestimate as it is based on women in whom fibroids are found incidentally during another procedure (e.g. cervical screening), and there is little, if any, data from population studies on the true incidence of fibroids. If a prevalence of 50% by 50 years of age is accepted, a large number of ´ women have asymptomatic fibroids. Working on the cliche, ‘if it ain’t broken, don’t fix it’, it may seem surprising that there should be a chapter dedicated to the issue of asymptomatic fibroids, since the simplistic approach might be to leave the asymptomatic fibroids well alone. However, asymptomatic fibroids may become symptomatic in the future, so it may be wiser to treat fibroids before they grow to a size when they become symptomatic, or treatment becomes more challenging, especially in young women who may desire fertility at a later stage, and in view of the fact that many women are starting their families in their mid-thirties when they have a 30% chance of having a fibroid(s). Despite their common occurrence, fibroids are still poorly understood. It is not known why they form in the first place, what determines their number and ultimate size, the best treatment approaches, or the factors that determine which women develop symptoms. Even when women present with disorders such as infertility, pelvic pain and abnormal bleeding, it is not always possible to be certain that a given myoma is not simply an innocent bystander rather than the cause of the symptom. This chapter addresses the challenging issue of what to do when fibroids are diagnosed incidentally. Firstly, there is the need to ascertain that the pelvic mass palpated is indeed a fibroid, and not an early, more sinister tumour, especially if conservative management is adopted. In addition, there is the issue of size, position and potential for becoming symptomatic at a later date. With the availability of uterine-preserving and largely non-invasive treatment modalities, should more asymptomatic, younger women be offered treatment if it is deemed that their fibroids may cause problems as they grow? Where treatment is not offered, is it necessary to follow-up such women, and if so, with what modality of surveillance and how frequently? Key words: uterine myomas; fibroids; myomas and pregnancy; myomas and fertility; uterine sarcoma; myoma diagnosis; myoma symptoms; myomectomy; hysterectomy.

* Tel.: þ91 080 41209550; Fax: þ91 080 41209770. E-mail address: hemadivakar246@hotmail.com 1521-6934/$ - see front matter ª 2008 Elsevier Ltd. All rights reserved.

1 Thus. Despite the prevalence of this condition. including some as small as 2 mm. and the incidence of women with asymptomatic fibroids is derived from women who are found to have fibroids when they have presented for an entirely different reason (such as cervical screening) and who deny any symptoms that could be attributed to fibroids. after which new fibroids are rare. There is also the issue of the constitution of the woman herself.3 In this study.6 myomas. some women will be discovered with fibroids to the level of the umbilicus and beyond. but this figure is likely to be an underestimate. and therefore do not seek help. and some will attribute increased urinary frequency to the ageing process rather than large fibroids. It is not known why some fibroids cause symptoms while others do not. Thus. The absolute size that causes symptoms is unknown. It is often quoted that 50% of fibroids are asymptomatic. a pedunculated fibroid is likely to remain entirely asymptomatic unless it undergoes torsion. and myomas almost always cause morbidity rather than mortality.2 Fine serial sectioning of uteri from 100 consecutive women who underwent hysterectomy found myomas in 77% of cases. develop fibroids. Thus. This is likely to be because myomas are benign. although they tended to be smaller and less numerous. but there is insufficient research to prove that all submucous fibroids cause symptoms. the incidence was 40% by 35 years of age and almost 70% by 50 years of age. size and number of fibroids are important in determining whether or not they will cause symptoms.644 H.3 Myomas were found no less frequently in women who had a hysterectomy for other indications than uterine myomas. It is teleologically sound to suppose that the position. increasing to over 80% by 50 years of age. while those from postmenopausal women had an average of 4. while another with multiple fibroids will have no complaints. and robust data to support this statement are lacking. medical record review and sonography reported myoma incidence of 60% by 35 years of age among African-American women. whether symptomatic or asymptomatic. but again this is pure conjecture. but many woman with intramural fibroids that do not distort the cavity present with menorrhagia. Divakar PREVALENCE OF ASYMPTOMATIC UTERINE FIBROIDS Development of a fibroid or fibroids by the time of the menopause appears to be the rule rather than the exception. the hysterectomy specimens from premenopausal women had an average of 7. yet in reality they do have symptoms. These women would be considered asymptomatic. many women with myomas are asymptomatic. especially around the belly’! It is just as true that a woman with a single fibroid may present with severe symptoms. it appears that prevalence increases with age until the hormonal changes of the menopause. Intramural fibroids are particularly likely to be symptomatic when they impinge onto or distort the uterine cavity. myoma research is underfunded compared with other non-malignant diseases. some women with fibroids and menorrhagia may consider their menses perfectly normal. probably causing menorrhagia and/or intermenstrual bleeding. most women. rendering it difficult to determine whether the number of fibroids determines whether or not a woman develops symptoms. and yet deny any symptoms apart from the sensation that they were ‘putting on weight.2 myomas. perhaps due to enlargement rather than distortion of the endometrial surface area. On the other hand. A random sample of women aged 35–49 years who were screened by self-report. In Caucasian women. The true incidence of fibroids is likely to be underestimated. during the reproductive years.4 . submucous fibroids are likely to be symptomatic.

whether the fibroids are likely to grow. whether they need a hysterectomy. and they often have key anxieties that include the following:     if there is any possibility of malignancy.Asymptomatic uterine fibroids 645 In summary. although small myomas may be of no clinical significance. DIAGNOSIS OF ASYMPTOMATIC FIBROIDS By definition. Even if a doctor was available. if the index of suspicion is that they are indeed fibroids. Where ultrasound is equivocal. it is probable that the majority of fibroids are asymptomatic. other imaging modalities. This inevitably leads to additional anxiety in the woman until she is subjected to imaging. can be used but it is very unusual for asymptomatic fibroids to require sophisticated imaging modalities. However. Even after such confirmation. and not some other potentially more sinister pelvic pathology such as an ovarian cyst. whether the fibroid(s) will compromise fertility and pregnancy outcomes. will confirm or refute the diagnosis. range from 20% to 77%. the incidental finding of fibroids often engenders a certain amount of anxiety. most women with fibroids will . including hysterectomy. Previously ‘asymptomatic’ women may begin to attribute symptoms to these fibroids. the diagnosis is often obvious. in most instances. they underestimate the true incidence of this condition. Women are often very relieved that no intervention is necessary. by ultrasound in the first instance. the woman can be strongly reassured while she waits for the confirmatory ultrasound. including magnetic resonance imaging. women often need careful counselling with clear explanations so that they understand that no intervention may be required for their asymptomatic fibroids. Most women with asymptomatic fibroids will therefore be referred for ultrasound assessment. PSYCHOLOGICAL IMPACT OF THE DIAGNOSIS OF ASYMPTOMATIC FIBROIDS Since many women have no idea what a fibroid is. often without the ready availability of a doctor. particularly if they are concerned about major surgery.5 While hysterectomy is the only true curative therapy for fibroids. for example. and this. smears are often taken by a practice nurse. from clinical populations. which should be able to confirm fibroids. For the experienced clinician. but the figures often quoted are likely to be underestimates. and if there is any therapy to stop them growing. It does not help that the clinician who makes the clinical diagnosis of fibroids often cannot be absolutely certain that they are fibroids. but in current practice in the UK. They are found unexpectedly during an unrelated procedure such as taking a cervical smear. and  if waiting and watching will cause any harm. but because most imaging techniques lack resolution <1 cm. Prevalence estimates of fibroids. the diagnosis of asymptomatic fibroids is incidental. Approximately 50% of women who receive a diagnosis of fibroids will seek a second opinion. general practitioners may lack the confidence to diagnose the pelvic mass as a fibroid and nothing more sinister. and the most common question is ‘Do I need a hysterectomy?’.

The latter is a cheap. for how long. In the older woman whose family is complete. .7 Therefore. many women will be relieved that no intervention is required. perhaps indefinitely. largely non-invasive and now widely available form of technology.6 The principal finding presented in the report is that there are no data supporting the use of prophylactic hysterectomy or myomectomy in women with asymptomatic fibroids. with ultrasound to assess fibroid behaviour. for some women with myomas who are mildly or moderately symptomatic. Where there is a significant pelvic mass and the clinical suspicion is a fibroid. Of the 106 women who initially chose watchful waiting. It would seem prudent to advise regular follow-up. mental health. Divakar never need a hysterectomy. what symptoms they may cause [with emphasis on the fact that her fibroid(s) are asymptomatic] and that no intervention is required while they remain asymptomatic. size of the fibroids. 24 women (23%) opted for hysterectomy during the course of the year. as the fibroids will generally cease to grow and are highly unlikely to become symptomatic. Once the diagnosis is confirmed. NON-INTERVENTION APPROACH FOR ASYMPTOMATIC FIBROIDS In the vast majority of women. These are dealt with in the section below on justifying intervention for asymptomatic fibroids. and the extent to which non-intervention really works.646 H. well-informed patient. most women will be reassured by a simple explanation of what fibroids are. Having been reassured about the benign nature of the fibroid(s). provided that they remain asymptomatic. perhaps annually. The rider to this is the age of the woman. watchful waiting may allow surgery to be deferred. the Agency for Healthcare Research and Quality has produced an evidence report on the management of fibroids. To optimize the management of women with asymptomatic fibroids. and the factors that influence the development of symptoms. providing her with sufficient information so that she can participate in the decision making regarding her care from the perspective of a knowledgeable. estimated rate of fibroid growth and the woman’s fertility plans. The surveillance can be discontinued with the onset of the menopause. it may often prove prudent to confirm the diagnosis by pelvic ultrasound scan. of course. With the limited data available. A nonrandomized study of women who had a uterine size of 18 weeks and who chose hysterectomy or watchful waiting found that 77% of women choosing observation self-reported no significant changes in the amount of bleeding. general health and activity indices were also unchanged. the key to successful management of asymptomatic fibroids is individualization. Furthermore. Being able to reassure the woman that the pelvic mass is indeed a simple benign fibroid will go a long way towards allaying the anxieties engendered by the initial finding of a pelvic mass. but one that is necessary for such a common pathology. Many studies have. Under its Evidence-based Practice Program. and to advise the woman to return should she develop symptoms. This is a tall order indeed. asymptomatic fibroids will be diagnosed during routine cervical screening or by pelvic imaging for a different reason altogether. population studies are needed to determine the true prevalence of symptoms. pain or degree of bothersome symptoms after 1 year. reported the not-insignificant morbidity and mortality associated with these procedures. the tailoring of advice to the individual woman depending upon her unique circumstances. Even large myomas qualify for ‘watchful waiting’ in appropriate women. no intervention is indicated regardless of the size of the fibroids.

6 per 1000) than would be saved from death due to removal of a leiomyosarcoma. ‘rapid uterine growth’ almost never indicates the presence of uterine sarcoma.2%. endometrial sampling and ultrasound (including colour Doppler) are unreliable for the diagnosis of leiyomyosarcoma. . Fibroid imaging is dealt with elsewhere in this issue. pain and postmenopausal bleeding. rather than other conditions such as ovarian lesions or adenomyosis.Asymptomatic uterine fibroids 647 JUSTIFYING INTERVENTIONS FOR ASYMPTOMATIC FIBROIDS When fibroids are asymptomatic and detected incidentally. it is imperative that the clinician is certain that s/he is dealing with a benign lesion that is indeed a fibroid. the age of the patient and clinical presentation may help to distinguish growing myomas from sarcoma. The American College of Obstetricians and Gynecologists does not consider the risk of leiomyosarcoma to be sufficiently high to justify routine hysterectomy in women with large asymptomatic fibroids. and anticipate and avoid problems related to increase in size. The incidence of malignant transformation is less than 1. although the latter are usually symptomatic.12 Intervening to enhance fertility The impact of fibroids on fertility is covered more extensively elsewhere in this issue. Thus. Magnetic resonance imaging is promising in distinguishing benign from malignant fibroids. No sarcomas were found in the 198 women who had a 6-week increase in uterine size over 1 year. Contrary to popular belief. usually presenting with rapid growth. reduce adverse pregnancy outcomes. Intervening to exclude malignancy If asymptomatic fibroids are to be managed conservatively.9 Leiomyosarcomas are more common in postmenopausal women.7% for women who are operated on for intra-uterine myomas in their sixties. but then they are not asymptomatic. enhance fertility. the possible justification for intervention may be considered as follows:     to to to to exclude malignancy. suffice here to summarize the key issues as they relate to asymptomatic fibroids.26%) women operated on for rapid growth of presumed myomas. Suffice here to say that basic ultrasound will often confirm the clinical diagnosis of fibroids and exclude an ovarian tumour.10. while there is a need to exclude ovarian pathology by ultrasound when asymptomatic fibroids have been diagnosed clinically. In premenopausal women. The incidence of leiomyosarcoma increases with age from as low as 0. The association between rapid growth of presumed myomas and sarcoma has not been substantiated.0% and has been estimated to be as low as 0. Cervical cytology. there is no evidence to advocate a hysterectomy for the sole purpose of alleviating the concern that there may be sarcomatous change. the incidence of leiomyosarcoma is unrelated to uterine size or the rate of uterine growth. Difficulties may arise with leiomyosarcoma or adenomyosis.1% for women of reproductive age to 1.11 In summary. One study found one sarcoma among 371 (0.8 These observations imply that more women of reproductive age die as a complication of hysterectomy performed for benign myomas (1–1.

including predisposing to subfertility. Most clinicians would tend to advise removal of a presumed submucous fibroid for a number of reasons: (1) to be certain that it is indeed a benign lesion. size of fibroids. since research suggests that submucous myomas.13–2. resection of submucous myomas restored fertility to that of infertile controls without myomas who underwent IVF (RR 1. For the younger woman who wishes to conceive now.13 When there is no history of failure to conceive.13 In summary.13–0. (3) because removal is a relatively simple procedure (hysteroscopic resection is now widely practiced and has minimal complications). If the fibroids are already more than 14 weeks in size and slow growing. confidence intervals (CI) 0. In women undergoing in-vitro fertilization (IVF). It seems highly unlikely that a woman will present with an asymptomatic submucous fibroid. and indeed the vast majority will conceive. including studies published since 2001. estimated rate of fibroid growth and her fertility plans. whose fibroids are larger than 14 weeks in size but slow growing. and (4) because of the general acceptance that such a submucous lesion may compromise reproduction. she should be encouraged to try to conceive. There are special circumstances where a case can be made for intervention. it may be prudent to advise the woman incidentally diagnosed with asymptomatic intramural or subserosal fibroids to try to conceive without any intervention.648 H. and observed carefully for complications that may be attributable to the fibroids. if the fibroids are growing rapidly and/or she fails to conceive within 6 months. (2) because of the likelihood of the development of symptoms. The advice to a woman with asymptomatic fibroids to try to conceive without any intervention can be refined based on the patient’s age. A meta-analysis was performed and 11 studies. and their removal has not been shown to increase fertility. Divakar Neither intramural nor subserosal myomas appear to affect fertility rates.32. A more recent meta-analysis. The younger woman wishing to conceive in the future. or intramural fibroids with significant distortion of the uterine cavity. She should also be informed of treatment options including myomectomy and the less-invasive procedures referred to above. she can be kept under surveillance although she should be discouraged from leaving it too long to conceive. The younger woman who wishes to conceive now.70]. but it is not inconceivable. Other less-invasive treatment modalities. whose fibroids are less than 12–14 weeks in size and slow growing. Evidence does not support routine myomectomy . and/or rapidly growing. came to the same conclusions. and the vast majority will indeed conceive. However. CI 1. intramural and distorting the cavity. should also be encouraged to try to conceive and observed carefully. An argument could also be made for more detailed imaging of apparently asymptomatic fibroids in women wishing to conceive. including uterine artery embolization and magnetic resonance image-guided transcutaneous focused ultrasound ablation (MRgFUS). were analysed. especially where the fibroids are submucous. These data come from studies undertaken to clarify the relationship between myomas and infertility. most women with asymptomatic fibroids can be encouraged to try to conceive without any intervention being undertaken for the fibroids. she should be counselled for myomectomy. appear to decrease fertility as pregnancy rates decrease by 70% [relative risk (RR) 0. whose fibroids are less than 12–14 weeks in size and slow growing.72. miscarriage and later pregnancy complications.58). each with its own shortcomings. should also be discussed. and the woman should be informed of the limitations in our knowledge of the impact of these treatments on fertility. should be kept under surveillance with regular (at least annual) ultrasound scans to assess fibroid behaviour.

There were no significant differences. obstructed labour. However. malpresentation or other complications that could reasonably be attributed to fibroids when she does fall pregnant. Intervening to reduce adverse pregnancy outcomes It is often written in the literature that fibroids can cause a variety of complications throughout pregnancy including recurrent pregnancy loss. there are no prospective data regarding myomectomy in patients with prior adverse obstetrical outcomes due to premature labour or malpresentation. increased caesarean rates and increased rates of postpartum haemorrhage. but none required a caesarean hysterectomy. In a woman with recurrent pregnancy loss in whom extensive investigations fail to identify any cause but a submucous fibroid is found. Similarly. It is therefore illogical to perform major surgery for symptoms that may never develop. expense and time away from work or family.001). and the outcomes of 167 women with myomas were compared with women without myomas. placenta praevia. fibroids should be left well alone at the time of caesarean section. but the very high prevalence of asymptomatic fibroids suggests that. Intervening to anticipate and avoid problems related to increase in size Predicting future myoma growth or onset of new symptoms is not possible. However.15 However. P < 0. it has been recommended that . The rate of myomatous growth is highly variable. There are no prospective data regarding the effectiveness of myomectomy in recurrent pregnancy wastage. pain due to red degeneration. placental abruption. malpresentation. Could or should myomectomy be performed at the time of caesarean section? This is a vexing and controversial issue. any decision to perform myomectomy should take into account the risks of surgery. and concerns about discomfort. preterm labour. despite similar clinical management. 12 600 pregnant women were evaluated. for most obstetricians. postoperative adhesions. The investigators concluded that in experienced hands. a myomectomy should be considered. In a woman who has large asymptomatic fibroids in between pregnancies. premature rupture of membranes. One series reported 25 women who had removal of 84 myomas of 2–10 cm diameter at the time of caesarean section with a mean estimated blood loss of 876 mL (range 400–1700 mL). as are the symptoms. postpartum haemorrhage or retained placenta. most would advocate hysteroscopic resection. In one study. Historically. Most myomas do not increase in size even during pregnancy. the author wishes to stress that.Asymptomatic uterine fibroids 649 before assisted reproductive technology in women with asymptomatic fibroids that do not distort the endometrial cavity significantly or cause abnormal uterine bleeding14. in the incidence of preterm delivery. fetal growth restriction. It does seem teleologically sound to suppose that this is indeed the case. It has been suggested that in carefully selected women. Only cesarean section was more common among women with myomas (23% vs 12%. likelihood of subsequent caesarean delivery. but is greatly troubled by pain. there are circumstances in which the clinician might deem it prudent to intervene. myomectomy may be safely accomplished at the time of caesarean section. it is rare that the presence of a myoma during pregnancy leads to an unfavourable outcome. but resection of submucous fibroids improves fertility rates.16 Five women required a blood transfusion. anaesthesia. myomectomy may be performed safely in selected women during caesarean section. in reality.

but these are relatively new treatments. The Management of Uterine Fibroids Working Party of the New Zealand Guidelines Group recently expanded their guidelines20 as follows. a theoretical argument to be made for myomectomy in selected women with asymptomatic large fibroids.17 However. GUIDELINES FOR THE MANAGEMENT OF ASYMPTOMATIC FIBROIDS Guidelines for the management of asymptomatic fibroids will continue to evolve as more information on the molecular basis of tumourigenesis becomes available. when the uterus exceeds a size of 12 weeks. and their impact on fertility has yet to be carefully evaluated. enlarge. Thus. There is.17. but should be advised to seek medical advice if symptoms occur. their efficacy in shrinking really large fibroids has yet to be demonstrated. generally surgical. The advent of uterine artery embolization and focused ultrasound ablation may offer alternatives to these women. An argument is made that because of the possibility of increased morbidity during surgery for a large uterus. however. expectant management is a reasonable approach for most women with asymptomatic myomas. there was no increase in adverse short-term outcomes associated with hysterectomy for fibroids with uteri greater than 12 weeks in size.650 H. and understanding of the clinical presentation and natural history of fibroids increases. Myoma surgeons will know that myomectomy is easier with smaller and fewer fibroids. This belief has been found to be fallacious and obviated by various studies. hysterectomy should not be recommended routinely to asymptomatic women with large uteri as prophylaxis against increased operative morbidity associated with future growth. Removal of large numbers of large fibroids will leave a badly misshapen and scarred uterus. there could be women who may benefit from myomectomy even when they are asymptomatic.18 In a study of 104 consecutive patients undergoing hysterectomy for uterine fibroids.  Asymptomatic women with fibroids where the uterine size is less than 16 weeks (and where other causes of pelvic masses have been excluded) do not need further investigations. others have shown no differences in pre-operative complications. a more recent study found that complications of hysterectomy were more common when the hysterectomy was performed for fibroids in younger women.  Removal of fibroids that distort the uterine cavity may be indicated in infertile women where no other factors have been identified. and in women about to undergo IVF treatment. although there is no research evidence to support this.19 Nonetheless. Although some studies have shown increased morbidity.  Asymptomatic women with fibroids where the uterine size is more than 16 weeks should have specialist referral to discuss options including observation. At least two studies have shown that the complication rate for hysterectomy is no higher when the uterus is large (12–20 weeks) compared with when it is smaller (12 weeks or less). especially intramural fibroids. Divakar patients with asymptomatic uterine myomas should undergo treatment. surgery is a safer option when the uterus is smaller. While there is no research evidence to back up the argument. just as they will know that uterine distortion worsens as fibroids. and reproductive potential may be severely compromised. .

 Women who have fibroids detected in pregnancy may require additional fetal surveillance when the placenta is implanted over or in close proximity to a fibroid. 3. most women will be reassured by a simple explanation of what fibroids are. it would be prudent to confirm the diagnosis by pelvic ultrasound scan. she should be counselled for myomectomy. whose fibroids are larger than 14 weeks but slow growing. including uterine artery embolization and MRgFUS. Once the diagnosis is made. of course. should also be discussed. Other less invasive treatment modalities. In the older woman whose family is complete. whose fibroids are less that 12–14 weeks in size and slow growing. However. SUMMARY AND CONCLUDING REMARKS While there is no absolute right or wrong in the ‘correct’ management of women with an asymptomatic fibroid(s). In the vast majority of women. estimated rate of fibroid growth and the woman’s fertility plans. provided that they remain asymptomatic. if they do so. but that the clinician feels that it is justified in this particular instance. both with and without guidelines. safety and lack of research evidence). Where there is a significant pelvic mass and the clinical suspicion is a fibroid. Having been reassured about the benign nature of fibroids. and the woman should be informed of the limitations in knowledge of the impact of these treatments on fertility. However.1% and therefore not a justification for intervention. she should be encouraged to try to conceive. iii. many women will be relieved that no intervention is required. if the fibroids are rapidly growing and/or she fails to conceive within 6 months. 2. the following approach is suggested. In the younger woman who wishes to conceive now.  The size of the fibroids does not influence removal. Clinicians are. and observed carefully for complications that may be attributable to the fibroids.Asymptomatic uterine fibroids 651  Concern about possible complications related to fibroids in pregnancy is not an indication for myomectomy.g. asymptomatic fibroids will be diagnosed during routine cervical screening or by pelvic imaging for a different reason. she should be encouraged to try to conceive and be observed carefully. they should make it clear to the patient that this treatment or intervention may not always be recommended because of concerns (e. i. what symptoms they may cause [with emphasis on the fact that her fibroid(s) are asymptomatic] and that no intervention is required while they remain asymptomatic. at liberty to offer treatments beyond the above recommendations. Clear documentation and informed consent is the key to avoiding medico-legal concerns. In the younger woman who wishes to conceive now.  The possibility of sarcomatous degeneration is less than 0. ii. 1. size of the fibroids. except in women who have experienced a previous pregnancy with complications related to these fibroids. no intervention is indicated regardless of the size of the fibroids. . The rider to this is the age of the woman.

v. and in women about to undergo IVF treatment  the possibility of sarcomatous degeneration in fibroids is less than 0. including myomectomy and the less-invasive procedures listed above. one of the highest priorities for future research should be the development of standardized reporting measures of disease severity and outcomes of therapy that will facilitate comparison of studies. no one or two approaches will ever be a panacea for treatment related to asymptomatic fibroids. or lack of evidence. Availability of less-invasive procedures means that women who are largely asymptomatic may also wish to consider these treatment options. she can be kept under surveillance although she should be discouraged from leaving it too long to conceive. The bottom line from the above is the need to tailor the advice to the individual woman. Therefore. physicians must counsel patients carefully and consider associated symptoms. Divakar iv. whose fibroids are larger than 14 weeks in size and slow growing. Therefore. and should be given as much information as possible to help make informed decisions. Practice points  the unique and interesting feature of fibroids is a varied spectrum of clinical presentations where at least 50% of women remain asymptomatic with quiescent tumours  the diagnosis of uterine fibroids is generally straightforward in most situations with precise clinical judgement and diagnostic imaging  the diagnosis of fibroids causes much concern and anxiety to the patient. In-depth counselling on the evidence. vi. for a specific treatment is an important consideration in the management of asymptomatic uterine fibroid tumours. as sensitive and caring physicians. Any intervention should be clinically justified and regression near menopause is anticipated  removal of fibroids that distort the uterine cavity may be indicated in infertile women where no other factors are identified. Until there are better randomized trials comparing treatment options.652 H. In the younger woman who wishes to conceive in the future. clinicians and policymakers do not have the data they need to make truly informed decisions about appropriate management. depending upon her unique circumstances. providing her with sufficient information so that she can participate in the decision making regarding her care from the perspective of a knowledgeable. There is no doubt that patients. Certainly. she should be kept under surveillance with regular (at least annual) ultrasound scans to assess fibroid behaviour. well-informed patient. we must endeavour to allay her fears and have an informed discussion  small asymptomatic fibroids are best left alone. She should also be informed of treatment options. In the younger woman who wishes to conceive in the future.5% and therefore is not an indication for intervention . observation is all that is required. whose fibroids are less than 12–14 weeks in size and slow growing. individual expectations and quality of life.

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