A 40-year-old gravida 4, para 4 woman presents to the office for heavy menstrual bleeding and bulk symptoms secondary to uterine leiomyoma. She reports regular menses with heavier bleeding over the past year and more recently has developed episodic intermenstrual bleeding. She notes bulk symptoms of dull pelvic pain, urinary frequency, occasional constipation, and dyspareunia. Attempts have been made to manage her symptoms with combined oral contraceptive tablets and non-steroidal anti-inflammatory drugs for several months; however, neither provided significant relief. During this visit she requests hysterectomy. Her past obstetrical history is significant for two term vaginal deliveries, the largest fetus weighing 3700 g at birth, and two cesarean deliveries at term, the latter with concomitant bilateral tubal ligation. She has no past medical or surgical history.