A 42-year-old nulliparous woman presents with a 2-year history of progressive dysmenorrhoea, heavy menstrual bleeding, and pelvic pain. Pelvic examination reveals a firm, irregularly enlarged uterus (approximately 12 weeks size). Transvaginal ultrasound shows a 6 cm intramural fibroid with significant distortion of the endometrial cavity and adenomyosis in the junctional zone. She has not responded adequately to NSAIDs and combined oral contraceptives over 6 months. She is not interested in pregnancy. What is the most appropriate management?

Explanation

## Clinical Scenario Analysis This patient has completed her reproductive years (nulliparous by choice, not interested in pregnancy), symptomatic fibroids with adenomyosis, and failed medical management. The combination of intramural fibroid with endometrial cavity distortion and coexisting adenomyosis significantly limits conservative options. ## Why Hysterectomy is the Best Answer **Key Point:** Hysterectomy is the definitive, gold-standard treatment for women with symptomatic fibroids who have completed childbearing and have failed medical management. **High-Yield:** Indications for hysterectomy in fibroid disease: 1. Completed childbearing (✓ this patient) 2. Severe, refractory symptoms (✓ dysmenorrhoea, menorrhagia, pelvic pain) 3. Failed medical therapy (✓ NSAIDs + COCs for 6 months) 4. Coexisting pathology (✓ adenomyosis) 5. Large fibroid with cavity distortion (✓ 6 cm intramural with endometrial involvement) **Clinical Pearl:** Adenomyosis is a critical factor. Unlike fibroids alone, adenomyosis cannot be surgically cured by myomectomy alone—hysterectomy is the only definitive treatment. The presence of adenomyosis here makes conservative approaches less effective and hysterectomy the logical choice. ## Comparison of Options in This Context | Option | Fertility | Symptom Relief | Adenomyosis Cure | Best For | | --- | --- | --- | --- | --- | | Myomectomy | Preserved | Partial (fibroid only) | No | Young, desire pregnancy | | Hysterectomy | Lost | Complete | Yes | Completed childbearing, adenomyosis | | UAE | Reduced | Moderate | No | Older women, high surgical risk | | GnRH agonist | Preserved | Temporary | No | Bridge to surgery, preop shrinkage | **Mnemonic:** **CHAFE** = Completed childbearing, Hysterectomy, Adenomyosis, Failed medical therapy, Endometrial distortion → Hysterectomy is definitive.