Sections

Gynecologic Myomectomy

Workup

Diagnostic Studies and Procedures

Laboratory studies

Recommended laboratory studies are as follows:

Pregnancy test: No patient should have a myomectomy until the possibility of pregnancy is excluded
A preoperative hemoglobin level should be obtained

Imaging studies

Ultrasonography

Uterine leiomyoma can usually be detected on pelvic examination. If any doubt remains or if the uterine enlargement must be confirmed or differentiated from a pelvic mass, ultrasonography is very useful. Leiomyomas can also be detected with CT scanning or MRI, but, in general, these tests are more expensive and do not help visualize the uterus as well as ultrasonography does.

HSG or sonohysterography

In the evaluation of the endometrial cavity, if a strong possibility exists that myomas are present within the endometrial cavity, an HSG or sonohysterography can aid in localization. This allows the preoperative detection of myomas that may be more amenable to hysteroscopic resection and may thereby preclude the need to enter the endometrial cavity during an abdominal procedure.

MRI

Myomectomy is possible only for myomas; therefore, one must reasonably believe that the uterine enlargement is from leiomyoma and not from adenomyosis. The presence of myomas can usually be confirmed based on ultrasonography or physical examination findings by the characteristic irregularities of a uterus with multiple fibroids. If any doubt remains, MRI has been found useful in differentiating leiomyoma from adenomyosis.^{[17, 18]}

Diagnostic procedure

Endometrial biopsy

Myomectomy is not an acceptable option if the patient has an endometrial malignancy. An endometrial biopsy should be performed prior to performing myomectomy in any patient older than 35 years who has a history of irregular bleeding.

Treatment & Management

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Media Gallery

Small uterine myomas visualized at laparoscopy.
Submucosal myoma visualized at hysteroscopy.
Submucosal myoma being resected hysteroscopically with a loop resectoscope.
Hysteroscopic myomectomy. A 24-year-old woman with menorrhagia and severe anemia in whom hormonal treatment failed. Sonohysterography showed multiple submucosal fibroids. She underwent hysteroscopic myomectomy after administration of Depo-Lupron. Part 1. Video courtesy of Tarek Bardawil, MD.
Hysteroscopic myomectomy. A 24-year-old woman with menorrhagia and severe anemia in whom hormonal treatment failed. Sonohysterography showed multiple submucosal fibroids. She underwent hysteroscopic myomectomy after administration of Depo-Lupron. Part 2. Video courtesy of Tarek Bardawil, MD.
Robotic myomectomy. A 32-year-old woman was found to have a large fibroid during pregnancy. Postpartum, the fibroid caused pelvic pain and dyspareunia. Pelvic ultrasonography revealed a 10-cm fundal transmural fibroid. Part 1. Video courtesy of Tarek Bardawil, MD.
Robotic myomectomy. A 32-year-old woman was found to have a large fibroid during pregnancy. Postpartum, the fibroid caused pelvic pain and dyspareunia. Pelvic ultrasonography revealed a 10-cm fundal transmural fibroid. Part 2. Video courtesy of Tarek Bardawil, MD.
Intramural myoma.
Pedunculated myoma.
Myoma identified on vaginal ultrasound.

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Table 1. Summary of Studies Reporting Need for Future Surgery for Myomas After Myomectomy

Study	Year	Follow-up, mo	Reoperation Rate
Finn and Muller^[100]	1950	24-120+	13%
Brown et al^[101]	1956	>72	17%
Malone^[102]	1969	>60	27%
Berkeley et al^[103]	1983	17	8%
Garcia and Tureck^[104]	1984	>10	6%
Rosenfeld^[105]	1986	>12	4%
Smith and Uhlir^[106]	1990	NR	5%
Verkauf^[107]	1992	42	6%
Gehlbach et al^[108]	1993	>12	12%
Acien and Querada^[109]	1996	4-144	8%
Stewart et al^[110]	2002	84 ± 35	35%
Hanafi^[111]	2005	2-136	17%

Table 2. Pregnancy Rates in Patients Undergoing Hysteroscopic Myomectomy

Author	Year	Study Size	Pregnancy Rate

Goldenberg et al^[118]	1995	15	47%
Vercellini et al^[119]	1999	40	37%
Fernandez et al^[120]	2001	59	27%
Bernard et al^[121]	2000	31	35%
Shokeir^[122]	2005	29	72%
Litta^[123]	2013	104	86%

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Author

Sarah Hagood Milton, MD Resident Physician, Department of Obstetrics and Gynecology, Virginia Commonwealth University Health System

Disclosure: Nothing to disclose.

Coauthor(s)

David Chelmow, MD Leo J Dunn Professor and Chair, Department of Obstetrics and Gynecology, Virginia Commonwealth University Medical Center

David Chelmow, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, American Society for Colposcopy and Cervical Pathology, Association of Professors of Gynecology and Obstetrics, Council of University Chairs of Obstetrics and Gynecology, Phi Beta Kappa, Sigma Xi, The Scientific Research Honor Society, Society for Academic Specialists in General Obstetrics and Gynecology, Society for Reproductive Investigation

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Michel E Rivlin, MD Former Professor, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine

Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Mississippi State Medical Association, Royal College of Surgeons of Edinburgh, Royal College of Obstetricians and Gynaecologists

Disclosure: Nothing to disclose.

Additional Contributors

Thomas Michael Price, MD Associate Professor, Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Director of Reproductive Endocrinology and Infertility Fellowship Program, Duke University Medical Center

Thomas Michael Price, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Obstetricians and Gynecologists, Phi Beta Kappa, Society for Reproductive Investigation, Society for Reproductive Endocrinology and Infertility, American Society for Reproductive Medicine

Disclosure: Received research grant from: Insigtec Inc<br/>Received consulting fee from Clinical Advisors Group for consulting; Received consulting fee from MEDA Corp Consulting for consulting; Received consulting fee from Gerson Lehrman Group Advisor for consulting; Received honoraria from ABOG for board membership.

Acknowledgements

Medscape Reference thanks Tarek Bardawil, MD, Assistant Professor, Department of Obstetrics and Gynecology, University of Miami Miller School of Medicine, for assistance with the video contribution to this article.

Gynecologic Myomectomy Workup

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