Should uterine size be an indication for surgical intervention in women with myomas?

The quality assurance guidelines published by the American College of Obstetricians and Gynecologists advocate hysterectomy for women with fibroids once the size of the uterus equals or exceeds that at 12 weeks of gestation, regardless of the presence or absence of significant symptoms. Reasons frequently cited by gynecologists for the necessity for surgical intervention include (1) the inability to examine the ovaries, (2) the possible malignancy of the enlarged pelvic mass, (3) the potential for compromise of adjacent organ function if uterine or myomatous growth continues, (4) the greater risks of future surgical treatment if uterine or myomatous growth continues, (5) the potential for greater fertility after surgery on a smaller uterus, and (6) the possibility of continued uterine or myomatous growth resulting from hormone replacement therapy after menopause. A review of the literature reveals surprisingly scant data supporting each of these indications for surgical intervention. The availability of high-resolution ultrasonography and magnetic resonance imaging allows for expectant management in many cases where the uterus is at least 12 gestational weeks in size. The presence and severity of myoma-related symptoms should be the most important considerations in the individualization of treatment strategies.