From the Guidelines
Treatment of fibroids during perimenopause should focus on managing symptoms until natural menopause occurs, with a preference for minimally invasive approaches to reduce the risk of surgical complications and preserve fertility, as supported by the most recent guidelines from the Journal of the American College of Radiology 1.
Symptom Management
For mild symptoms, watchful waiting with regular monitoring is often appropriate, as fibroids typically shrink due to decreasing estrogen levels after menopause. Non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or naproxen can help manage pain and heavy bleeding.
Medical Therapy
Hormonal options include combined hormonal contraceptives, which can reduce bleeding, or a levonorgestrel intrauterine device (Mirena), which provides targeted hormonal therapy and can significantly reduce menstrual flow, as noted in the ACR Appropriateness Criteria for fibroids 1. For more severe symptoms, GnRH agonists like leuprolide can temporarily shrink fibroids and reduce bleeding, though they're typically limited to 3-6 months due to side effects like bone loss. Tranexamic acid can reduce heavy bleeding without hormonal effects.
Procedural Options
Procedural options include uterine artery embolization, which blocks blood flow to fibroids, or focused ultrasound surgery for targeted treatment. Myomectomy (surgical removal of fibroids while preserving the uterus) or hysterectomy (complete uterine removal) are definitive surgical options, with hysterectomy being curative, as stated in the study published in the Journal of the American College of Radiology 1.
Treatment Choice
Treatment choice depends on fibroid size and location, symptom severity, proximity to menopause, and desire for future fertility, considering the high prevalence of fibroids and their impact on quality of life, as highlighted in the ACR Appropriateness Criteria for fibroids 1. Uterine-sparing therapies, such as myomectomy and uterine fibroid embolization (UFE), are viable options, with a recent multicenter, randomized, open-label trial comparing myomectomy to UFE showing equivalent symptomatic improvement at 2 years 1.
From the Research
Treatment Options for Fibroids in Perimenopause
- Medical therapy to reduce heavy menstrual bleeding includes hormonal contraceptives, tranexamic acid, and nonsteroidal anti-inflammatory drugs 2
- Gonadotropin-releasing hormone agonists or selective progesterone receptor modulators are an option for patients who need symptom relief preoperatively or who are approaching menopause 2
- Surgical treatment includes hysterectomy, myomectomy, uterine artery embolization, and magnetic resonance-guided focused ultrasound surgery 2
- Aromatase inhibitors, selective estrogen receptor modulators, and antiprogestogens for medical management and minimally surgical techniques are promising treatments for fibroids in perimenopausal women 3
Preoperative Medical Therapy
- Gonadotropin-hormone-releasing analogues (GnRHa) induce a low-oestrogen state that shrinks fibroids, but they have unacceptable side effects if used long-term 4
- Selective progesterone-receptor modulators (SPRMs) probably reduce uterine volume and increase haemoglobin level before surgery, and may reduce fibroid volume and fibroid-related bleeding 4
- Ulipristal acetate, a selective progesterone receptor modulator, is indicated for fibroid management and provides fast control of bleeding and causes sustained fibroid volume reduction in the vast majority of cases 5
Hormone Therapy in Menopausal Women with Fibroids
- Hormone therapy is an effective treatment option for menopausal women, although prolonged use is associated with a slightly increased risk of breast cancer, thromboembolism, and stroke 6
- The effect of hormone treatment on fibroids is variable and statistically insignificant in many cases, but newer selective estrogen receptor modulators may be better alternatives in women with asymptomatic fibroids 6