From the Guidelines
Treatment for uterine fibroid bleeding should start with first-line medical management, including NSAIDs, estrogen-progestin oral contraceptive pills, or tranexamic acid, as these options have been shown to reduce bleeding symptoms 16, 17. When considering treatment options, it's essential to evaluate the severity of symptoms, fibroid size and location, the woman's age, and desire for future pregnancy.
- First-line medical management includes:
- NSAIDs to reduce inflammation and bleeding
- Estrogen-progestin oral contraceptive pills to regulate menstrual cycles and reduce bleeding
- Tranexamic acid, a nonhormonal alternative agent that may reduce bleeding symptoms in patients with fibroids
- Second-line medical management includes parenteral GnRH agonists (e.g., leuprolide acetate) and oral GnRH antagonists (e.g., elagolix, linzagolix, and relugolix), which can reduce bleeding symptoms and tumor volume [18-23]. However, these agents are associated with hypoestrogenic effects, and combination treatment with low doses of estrogen and progestin may be necessary to mitigate these symptoms 19, 25.
- Progesterone receptor modulators, such as ulipristal acetate, have shown efficacy in reducing both bleeding and bulk symptoms and can be administered intermittently [26-30]. However, reports of hepatotoxicity have limited its approval for use in the United States 31, 32. According to the most recent study 1, medical management should be considered for patients with pedunculated submucosal uterine fibroids associated with heavy bleeding. In cases where medical management is not effective, procedural options such as uterine artery embolization, focused ultrasound surgery, myomectomy, or hysterectomy may be necessary 1.
From the Research
Treatment Options for Uterine Fibroid Bleeding
- Medical treatments used for uterine fibroids-related abnormal uterine bleeding include symptomatic agents, such as nonsteroidal anti-inflammatory drugs and tranexamic acid, and hormonal therapies, including combined oral contraceptives, gonadotropin-releasing hormone agonists or antagonists, levonorgestrel intrauterine systems, selective progesterone receptor modulators, and aromatase inhibitors 2
- Surgical options include fertility-sparing treatments, such as myomectomy, or nonconservative options, such as hysterectomy, especially in perimenopausal women who are not responding to any treatment 2
- Radiologic interventions are also available: uterine artery embolization, high-intensity focused ultrasound or magnetic resonance-guided focused ultrasound, and radiofrequency ablation 2, 3
Management of Iron Deficiency and Anemia
- The management of iron deficiency and iron deficiency anemia, as a consequence of acute and chronic bleeding, should be taken into account with the use of iron replacement therapy both during medical treatment and before and after a surgical procedure 2
Factors to Consider in Treatment Choice
- The location, size, multiple uterine fibroids, or coexistent adenomyosis should guide the choice of treatment with a shared decision-making process, considering long- and short-term treatment goals expected by the patient, including pregnancy desire or wish to preserve the uterus independently of reproductive goals 2
- The patient's age, symptoms, desire to maintain fertility, and access to treatment, as well as the experience of the physician, should also be considered in the management of uterine fibroids 4, 5
Emerging Medical Treatment Options
- Selective progesterone receptor modulators are currently being evaluated and have recently been approved for fibroid treatment 5
- Gonadotropin-releasing hormone agonists or selective progesterone receptor modulators are an option for patients who need symptom relief preoperatively or who are approaching menopause 4, 6