A 60-Year-Old Woman Comes to the Office Due to New-Onset

A 60-year-old woman comes to the office due to new-onset pelvic pressure.  The patient reports increasing pelvic pressure over the last 3 months, now with associated urinary frequency.  She has no abdominal pain, dysuria, or hematuria.  The patient reports some dyspnea on exertion; review of systems is otherwise negative.  The patient has a history of breast cancer at age 45; it was treated with radical mastectomy, chemotherapy, and adjuvant tamoxifen therapy.  The cancer has since been in remission and she had a normal mammogram last year.  The patient has no other chronic medical conditions.  She underwent menopause 8 years ago and has had no episodes of postmenopausal vaginal bleeding.  The patient has had no abnormal Pap tests, the last of which was 3 years ago.  She does not use tobacco, alcohol, or illicit drugs.  Blood pressure is 130/80 mm Hg, pulse is 80/min, and respirations are 18/min.  BMI is 26 kg/m².  Decreased breath sounds are noted over the lower base of the right lung.  Abdominal examination reveals normoactive bowel sounds and mild distension but no tenderness.  On bimanual examination, a 12-week-sized, irregularly shaped uterus is noted, but there are no adnexal masses.  Urinalysis is within normal limits.  Pelvic ultrasound shows a dense focal mass measuring 9 cm in the anterior fundus of the uterus, normal ovaries bilaterally, and a moderate amount of free fluid in the posterior cul-de-sac.  Which of the following is the best next step in management of this patient?

A)Administer gonadotropic-releasing hormone agonist
B)Observe and perform repeat ultrasound in 3 months
C)Perform hysterectomy
D)Perform myomectomy
E)Perform uterine artery embolization

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