From the Guidelines
Treatment for a category 3 fibroid should prioritize medical management with ulipristal acetate (5 mg daily) or GnRH agonists (leuprolide acetate 3.75 mg monthly injections for up to 6 months) to reduce symptoms and fibroid size, considering the patient's age, desire for future fertility, and quality of life concerns. The management of category 3 fibroids, which typically refer to intramural fibroids that distort the uterine cavity, involves a range of medical and surgical approaches. Medical management is often the first line of treatment and can include hormonal medications such as GnRH agonists, which reduce estrogen levels and shrink fibroids temporarily 1. Ulipristal acetate is another effective option for symptom control, reducing both bleeding and bulk symptoms and can be administered intermittently, allowing for menstruation during medication breaks 1.
For women with heavy bleeding, a levonorgestrel intrauterine system (Mirena) may help control symptoms. Non-hormonal options include tranexamic acid (1000 mg three times daily during menstruation) or nonsteroidal anti-inflammatory drugs for pain management. Some key points to consider in the management of category 3 fibroids include:
- The use of GnRH agonists and antagonists, which are effective at reducing bleeding symptoms and tumor volume, but may have hypoestrogenic effects and are commonly used for short courses to decrease fibroid size in preparation for surgery 1.
- The role of progesterone receptor modulators such as ulipristal acetate, which reduce both bleeding and bulk symptoms and can be administered intermittently, allowing for menstruation during medication breaks 1.
- The importance of considering the patient's age, desire for future fertility, symptom severity, and fibroid characteristics when selecting a treatment approach.
- The need to balance effectiveness against potential side effects, with consideration for the patient's reproductive goals and quality of life concerns.
Surgical options, such as myomectomy or hysterectomy, may be considered for women who have completed childbearing or have severe symptoms that do not respond to medical management. Uterine artery embolization offers a minimally invasive alternative that blocks blood flow to fibroids. Ultimately, the best approach depends on the individual patient's needs and circumstances, and treatment selection should be tailored to balance effectiveness against potential side effects, with consideration for the patient's reproductive goals and quality of life concerns 1.
From the Research
Treatment Options for Category 3 Fibroid
The treatment options for a category 3 fibroid are varied and depend on several factors, including the patient's age, fertility desires, and the size and location of the fibroid.
- Surgical Interventions: Surgical options include hysterectomy and myomectomy, which can be performed through hysteroscopy, laparoscopy, or laparotomy 2.
- Minimally Invasive Techniques: Other surgical and non-surgical minimally invasive techniques include interventions performed under radiologic or ultrasound guidance, such as uterine artery embolization and occlusion, myolysis, magnetic resonance-guided focused ultrasound surgery, radiofrequency ablation of fibroids, and endometrial ablation 2.
- Medical Treatment: Medical treatment options for fibroids are limited, but available medications include progestogens, combined oral contraceptives, and gonadotropin-releasing hormone agonists and antagonists, which are generally used for short-term treatment of fibroid-induced bleeding 2.
- Preoperative Medical Therapy: Preoperative medical therapy, such as gonadotropin-hormone-releasing analogues (GnRHa) and selective progesterone-receptor modulators (SPRMs), can be used to reduce uterine and fibroid volume, increase preoperative haemoglobin levels, and reduce bleeding before surgery 3.
Benefits and Risks of Treatment Options
The benefits and risks of each treatment option should be carefully considered. For example:
- GnRHa: GnRHa may reduce uterine and fibroid volume, increase preoperative haemoglobin levels, and reduce bleeding before surgery, but may also increase the risk of adverse events, such as hot flushes 3.
- SPRMs: SPRMs may reduce uterine volume, increase preoperative haemoglobin levels, and reduce bleeding before surgery, but the certainty of the evidence is moderate to low 3.
Individualized Treatment
Treatment of fibroids must be individualized based on the presence and severity of symptoms, the patient's desire for definitive treatment or fertility preservation, and the number, size, and location of the fibroids 2, 4.