Table II.

Fibroids assessment and treatment options.

History
General gynaecological history Focus on fibroid-related symptoms (see below) and their impact on reduced quality of life
Symptoms
Abnormal uterine bleeding Heavy menstrual bleeding Intermenstrual bleeding (IMB) Bulk, pressure symptoms Abdominal and pelvic pain (e.g. menstrual and non-menstrual pain/discomfort, dyspareunia) Abdominal distension Urinary and bowel symptoms (e.g. frequency, retention) Reproductive problems Infertility Miscarriage / preterm birth
Examination
Abdominal and bimanual pelvic examination to assess the size, composition and mobility of the fibroid uterus Consider vaginal speculum examination based upon bleeding / discharge symptoms and smear history
Investigations
Blood tests Full Blood Count (Hb+MCV), ferritin, iron binding capacity Imaging Transvaginal (TVS) / optional addition of transabdominal (TAS) ultrasound in case of large uterus MRI (for example if TVS/TAS inadequate (e.g. large and/or multifibroid uterus/ coexistence of adenomyosis) or to provide more information about fibroid vascularity, necrosis and proximity to adjacent organs. Hysteroscopy +/- biopsy Indicated if endometrial hyperplasia or cancer suspected Consider to aid hysteroscopic surgical planning (technique, equipment, need for down-regulation, multi-stage procedures etc.) for submucosal fibroids
Treatment options*
Medical	Non-steroidal anti-inflammatory drugs (NSAIDS) Tranexamic Acid (TXA) Combined oral contraceptive pill (COCP) Progestogens (local (Levonorgestrel releasing intrauterine system (LNG-IUS) and systemic (oral / parenteral) Gonadotrophin releasing hormone analogues (GnRHa) Pre-operative use to reduce fibroid volume Prolonged use (>3-6months) to manage symptoms in conjunction with add-back hormone replacement therapy (HRT) Oral GnRH antagonists (including combination therapies containing HRT) Selective progesterone receptor modulators (SPRMs) Liver function should be monitored before, during, and after treatment courses
Surgical	Myomectomy: Hysteroscopic or abdominal (Open or laparoscopic including robotic) Hysterectomy
Non-surgical	Uterine artery embolisation (UAE) Ablation (Transabdominal (laparoscopic guided) or transvaginal/transcervical (ultrasound guided) radiofrequency ablation or MRI guided focused ultrasound ablation)

Hb = Haemoglobin, MCV = Mean Corpuscular Volume, MRI = Magnetic Resonance Imaging

* No treatment may be necessary for minimal or no symptoms.