What are the treatment options for uterine fibroids?

Treatment Options for Uterine Fibroids

The treatment of uterine fibroids should follow a stepwise approach based on symptom severity, fibroid location, size, and patient's fertility desires, with hysterectomy being the most definitive treatment for women who have completed childbearing and have severe symptoms. 1

Medical Management Options

First-Line Medical Treatments

• NSAIDs: Reduce pain and bleeding symptoms
• Estrogen-progestin oral contraceptive pills: Effective for reducing bleeding symptoms
• Progestin-containing IUDs: Effective for heavy menstrual bleeding
• Tranexamic acid: Non-hormonal option that reduces bleeding symptoms in fibroid patients 1

Second-Line Medical Treatments

• GnRH agonists (e.g., leuprolide acetate):

  • Reduce bleeding and significantly decrease fibroid volume
  • Often used for short courses to shrink fibroids before surgery
  • Side effects: hypoestrogenic effects (headaches, hot flushes, hypertension, bone mineral density loss)

• GnRH antagonists (e.g., elagolix, linzagolix, relugolix):

  • Reduce bleeding and fibroid volume
  • Similar side effects to GnRH agonists
  • Can be combined with low-dose estrogen and progestin to mitigate side effects 1

Important caveat: With both GnRH agonists and antagonists, fertility is suppressed during treatment, and symptoms rapidly recur after stopping therapy 1

• Progesterone receptor modulators (e.g., ulipristal acetate):
  • Reduce both bleeding and bulk symptoms
  • Can be administered intermittently
  • Efficacy demonstrated for up to 2 years
  • Note: Hepatotoxicity concerns have limited approval in the US 1

Surgical Management Options

Uterus-Preserving Procedures

1. Hysteroscopic Myomectomy:

   • Ideal for submucosal fibroids (especially pedunculated ones <5cm)
   • Shorter hospitalization and faster recovery than other surgical approaches
   • Risks: uterine perforation, fluid overload, bleeding, infection 1
   • Fertility outcomes: Pregnancy rates up to 85% with live birth rates of 65% in retrospective studies 1

2. Laparoscopic or Open Myomectomy:

   • Indicated for subserosal or intramural fibroids
   • Laparoscopic approach offers shorter hospital stays and faster recovery
   • Open approach preferred for multiple or very large fibroids
   • Improved quality of life for up to 10 years post-procedure 1
   • Caution: Risk of uterine rupture in subsequent pregnancies 1

3. Uterine Artery Embolization (UAE):

   • Minimally invasive option for women who want to preserve the uterus
   • Effective for reducing fibroid size and symptoms
   • Can be used in patients with adenomyosis and fibroids
   • Short and long-term symptom improvement in 94% and 85% of patients, respectively 1
   • Limited data on fertility outcomes; patients should be counseled accordingly

4. MR-Guided High-Frequency Focused Ultrasound (MRgFUS):

   • Non-invasive option for select fibroids
   • Can reduce fibroid volume and improve symptoms
   • Limited evidence for certain fibroid types 1

Definitive Treatment

Hysterectomy:

• Most common and definitive treatment for uterine fibroids
• Accounts for 75% of fibroid treatments in the US
• Provides complete resolution of all fibroid-related symptoms
• Options include transvaginal, laparoscopic, or abdominal approaches 1
• Only appropriate for women who have completed childbearing

Treatment Algorithm Based on Clinical Presentation

1. Asymptomatic fibroids:

   • Expectant management with periodic monitoring

2. Symptomatic fibroids with mild-moderate bleeding:

   • Start with first-line medical therapy (NSAIDs, hormonal contraceptives, tranexamic acid)
   • If inadequate response, consider second-line medical options

3. Symptomatic fibroids with severe bleeding or bulk symptoms:

   • For women desiring fertility:

     • Medical therapy as bridge to surgery or temporary relief
     • Consider myomectomy (hysteroscopic, laparoscopic, or open depending on fibroid location)
     • UAE may be an option but fertility outcomes less certain

   • For women who have completed childbearing:

     • Medical therapy for temporary symptom control
     • Consider UAE or MRgFUS for those wanting uterine preservation
     • Hysterectomy for definitive treatment

4. Fibroid-specific approaches:

   • Pedunculated submucosal fibroids: Hysteroscopic myomectomy is treatment of choice 1
   • Intramural/subserosal fibroids: Laparoscopic or open myomectomy

Important Clinical Considerations

• Fibroid recurrence is common after myomectomy and medical therapy
• GnRH agonists/antagonists are effective but limited by side effects and temporary results
• Fertility preservation requires careful selection of treatment modality
• Hysterectomy remains the only definitive treatment but eliminates fertility
• Location, size, and number of fibroids significantly impact treatment selection
• Patients with adenomyosis and fibroids may require different management approaches