From the Guidelines
Treatment for abnormal uterine bleeding with fibroids should prioritize medical management as the first-line approach, with NSAIDs and estrogen-progestin oral contraceptive pills being the preferred initial options. According to the most recent guidelines, first-line medical management includes NSAIDs and estrogen-progestin oral contraceptive pills, which reduce bleeding symptoms 1. Tranexamic acid is a nonhormonal alternative agent that may reduce bleeding symptoms in patients with fibroids 1.
Medical Management Options
- NSAIDs: reduce bleeding symptoms
- Estrogen-progestin oral contraceptive pills: reduce bleeding symptoms
- Tranexamic acid: nonhormonal alternative agent that may reduce bleeding symptoms
- GnRH agonists (eg, leuprolide acetate) and oral GnRH antagonists (eg, elagolix, linzagolix, and relugolix): second-line medical management options that reduce bleeding symptoms and tumor volume 1
- Progesterone receptor modulators such as ulipristal acetate: reduce both bleeding and bulk symptoms, but reports of hepatotoxicity are a barrier to its approval for use in the United States 1
Considerations for Treatment
- Patient's symptoms
- Fibroid characteristics
- Reproductive goals
- Desire for future fertility
- Patient preferences
- Fibroid size and location
- Severity of symptoms
Additional Treatment Options
- Uterine artery embolization
- Myomectomy
- Hysterectomy
- Radiofrequency ablation
- MRI-guided focused ultrasound
The choice of treatment should be individualized and based on the patient's specific needs and circumstances, with the goal of improving morbidity, mortality, and quality of life. As stated in the guidelines, medical management can be considered for patients with pedunculated submucosal uterine fibroids associated with heavy bleeding 1.
From the Research
Treatment Options for Abnormal Uterine Bleeding with Fibroids
- Medical management is the first-line approach for treating abnormal uterine bleeding, including cases with fibroids 2.
- Gonadotropin-releasing hormone agonists are indicated in patients with leiomyoma and abnormal uterine bleeding in preparation for surgical interventions 2.
- Medical therapy to reduce heavy menstrual bleeding includes hormonal contraceptives, tranexamic acid, and nonsteroidal anti-inflammatory drugs 3.
- Levonorgestrel-releasing intrauterine systems, combined oral contraceptives, and tranexamic acid are effective in treating heavy menstrual bleeding 2, 4.
- Oral hormonal therapies, such as combined oral contraceptives and progestin-only pills, can inhibit the hypothalamic-pituitary-ovarian axis and induce endometrial atrophy, making them effective in treating abnormal uterine bleeding 5.
Surgical Treatment Options
- Surgical treatment includes hysterectomy, myomectomy, uterine artery embolization, and magnetic resonance-guided focused ultrasound surgery 3.
- Endometrial ablation and hysterectomy are also surgical treatment options for abnormal uterine bleeding 4.
- Removal of a focal lesion, endometrial resection or destruction, and hysterectomy are surgical treatments that may be considered depending on the cause of abnormal uterine bleeding 6.
Considerations for Treatment
- Age, desire for future pregnancy, and etiology of abnormal uterine bleeding are key factors to consider before initiating treatment 6.
- Treatment efficiency can be assessed using the same tools as pretherapeutic evaluation, and improvement of quality of life has now become the main goal for most international guidelines addressing the subject 6.
- Oral hormonal therapies are convenient and reversible tools to manage abnormal uterine bleeding when other treatments are contraindicated or declined by the patient 5.