What are the treatment options for uterine fibroids (leiomyomas)?

Treatment Options for Uterine Fibroids

Treatment for uterine fibroids should be guided by symptom severity, fibroid characteristics, and the patient's fertility desires, with less invasive options preferred over hysterectomy when possible. 1, 2

Medical Management Options

First-Line Treatments

• Non-hormonal options:

  • NSAIDs: Reduce bleeding by 20-40% and help with pain 2
  • Tranexamic acid: First-line non-hormonal medication for heavy menstrual bleeding, taken only during menstruation 2
    • Caution: Contraindicated in women with active or history of thromboembolic disease 2

• Hormonal options:

  • Progestin-releasing IUDs: Preferred due to local action, lower systemic hormone levels, and long duration 2
  • Combined oral contraceptives: Effective for managing bleeding symptoms, especially with small fibroids 1
  • Iron supplementation: Essential for treating iron deficiency anemia from heavy bleeding 2

Second-Line Treatments

• GnRH agonists/antagonists with add-back therapy:
  • Effectively reduce bleeding and fibroid size by 40-50% 1
  • Typically used as temporary treatment or bridge to definitive therapy 1
  • Limitation: Once discontinued, fibroids quickly return to previous size and symptoms recur 1
  • Side effect: Chronic use results in trabecular bone loss 1

Procedural Interventions

Uterine-Sparing Options

1. Uterine Artery Embolization (UAE):

   • Effectiveness: 85-94% symptom improvement, >50% decrease in fibroid size at 5 years 2
   • Benefits: Shorter hospital stay, decreased blood loss compared to surgery 1
   • Considerations: Higher reintervention rates (36%) compared to myomectomy (5%), especially for fibroids >5cm 1

2. Myomectomy:

   • Hysteroscopic myomectomy: Procedure of choice for pedunculated submucosal fibroids <5cm 2
   • Laparoscopic/open myomectomy: For intramural or subserosal fibroids 2
   • Recurrence rate: 23-33% with either abdominal or laparoscopic approach 1
   • Complication rates: 2% major, 9% minor with laparoscopic approach 1

3. Other minimally invasive options:

   • MR-guided focused ultrasound (MRgFUS): Uses high-intensity ultrasound waves to thermally ablate fibroids 2
   • Endometrial ablation: For patients with heavy menstrual bleeding who don't desire future pregnancy 1
     • Warning: Not a form of contraception; elevated risk of extrauterine pregnancy, preterm delivery, and stillbirth 1

Definitive Treatment

• Hysterectomy:
  • Most common treatment for uterine fibroids (75% of fibroid treatments in US) 1
  • Provides definitive resolution of all fibroid-related symptoms 1
  • Approach: Least invasive route should be chosen (vaginal or laparoscopic preferred over abdominal) 1, 2
  • Considerations:
    • Associated with elevated risk of cardiovascular disease, mood disorders, and increased mortality when performed at young age 1
    • Higher rate of severe complications, longer hospitalization, and longer return to regular activities compared to UAE 1

Treatment Algorithm Based on Patient Characteristics

For Women Desiring Future Fertility:

1. Start with medical management: NSAIDs, hormonal contraceptives, or tranexamic acid
2. If inadequate response: Consider GnRH agonists/antagonists with add-back therapy
3. For persistent symptoms: Consider myomectomy (hysteroscopic for submucosal, laparoscopic for others)
4. Avoid: Endometrial ablation, hysterectomy

For Women Not Desiring Future Fertility:

1. For mild to moderate symptoms: Start with NSAIDs and/or hormonal treatments
2. For severe symptoms: Consider UAE as first-line procedural intervention
3. If other approaches fail: Hysterectomy offers definitive treatment

Important Considerations

• Fibroid location significantly impacts treatment success and fertility outcomes 1
• Intramural and submucosal fibroids have greater negative impact on fertility than subserosal fibroids 1
• Morcellation during minimally invasive hysterectomy should be avoided due to risk of spreading occult malignancy 1
• Leiomyosarcomas are extremely rare (less than one in 1000) 3

By following this structured approach to treatment selection, patients with uterine fibroids can achieve optimal symptom control while preserving fertility when desired and minimizing risks associated with more invasive procedures.