What are the treatment options for uterine fibroids?

Treatment Options for Uterine Fibroids

For patients with uterine fibroids, treatment should follow a stepwise approach starting with medical management, followed by minimally invasive procedures, and finally surgical options, with the specific choice depending on symptom severity, fibroid characteristics, and fertility desires. 1, 2

Medical Management Options

First-Line Treatments

• Hormonal Options:

  • Progestin IUD (Levonorgestrel-releasing intrauterine system) - Most effective hormonal option for controlling bleeding symptoms 2
  • Combined Oral Contraceptives - Effective for bleeding control but less effective than progestin IUD 2

• Non-Hormonal Options:

  • NSAIDs - Can reduce bleeding by 20-40% and help with pain 2
  • Tranexamic acid - First-line non-hormonal medication for heavy menstrual bleeding (take only during menstruation) 2
    • Contraindicated in women with active thromboembolic disease or history of thrombosis

Second-Line Medical Treatments

• GnRH Agonists/Antagonists with Add-back Therapy - Can reduce bleeding and fibroid volume by 40-50% 2

  • Typically used temporarily or as a bridge to definitive therapy
  • May improve chances of pregnancy in infertile women with adenomyosis

• Iron supplementation - Essential for treating iron deficiency anemia that commonly accompanies heavy bleeding 2

Interventional Procedures

Uterine-Sparing Procedures

• Uterine Artery Embolization (UAE):

  • Improves symptom scores and quality of life for up to 7 years
  • Short-term (94%) and long-term (85%) symptom improvement
  • 18% hysterectomy rate for persistent symptoms
  • Particularly effective when fibroids predominate 2
  • Consider for women with severe symptoms who have failed medical management

• Hysteroscopic Myomectomy:

  • Indicated specifically for submucosal fibroids in patients desiring uterus preservation
  • Shorter hospitalization and faster recovery than other surgical approaches
  • Risks include uterine perforation, fluid overload, need for blood transfusion 1
  • Not effective for patients with significant intramural or subserosal fibroid burden

• Other Myomectomy Approaches (Laparoscopic or Open):

  • Preferred over UAE for women desiring future fertility
  • 23-33% recurrence rate of fibroids 2
  • Improved quality of life scores at 2 years compared to UAE 1

• Other Minimally Invasive Options:

  • MRI-guided focused ultrasound surgery (MRgFUS) - 18% decrease in fibroid diameter 2
  • Radiofrequency ablation - Emerging option for fibroid treatment 3
  • Endometrial ablation - Option for submucosal fibroids in women who have completed childbearing 4

Definitive Surgical Management

• Hysterectomy:
  • Only definitive treatment when other approaches fail 2
  • Most effective treatment for symptomatic fibroids with high patient satisfaction rates 4
  • Vaginal or laparoscopic routes preferred when possible 4
  • Consider risks including cardiovascular disease, mood disorders when performed at young age 2

Treatment Algorithm Based on Patient Goals

For Women Desiring Future Fertility:

1. Start with medical management (NSAIDs, hormonal treatments)
2. For submucosal fibroids: Consider hysteroscopic myomectomy
3. For other fibroid types: Consider myomectomy (laparoscopic or open)
   • Note: Pregnancy rates after myomectomy are suboptimal (<50% conception rate, <50% live birth rate among those who conceive) 2
4. Avoid: Endometrial ablation and hysterectomy (cause permanent infertility) 1

For Women Not Desiring Future Fertility:

1. Start with medical management (NSAIDs, hormonal treatments)
2. If inadequate response: Consider UAE, MRgFUS, or radiofrequency ablation
3. For definitive treatment: Consider hysterectomy

Important Considerations and Pitfalls

• Fibroid Location Matters:

  • Submucosal fibroids are best treated with hysteroscopic myomectomy
  • Intramural and submural fibroids have greater negative impact on fertility than subserosal fibroids 2
  • Treatment effectiveness varies by fibroid location and size

• Fertility Considerations:

  • Successful pregnancy has been reported after UAE, but comprehensive data on fertility is lacking 2
  • GnRH analogues may improve chances of pregnancy in infertile women with adenomyosis 2

• Common Pitfalls:

  • Treating asymptomatic fibroids unnecessarily
  • Using GnRH agonists long-term without add-back therapy (risk of bone loss)
  • Failing to address iron deficiency anemia in women with heavy bleeding
  • Choosing treatment without considering fibroid location and patient's fertility desires

The treatment approach must consider the patient's symptoms, fibroid characteristics, and reproductive goals, with medical management as the first step before proceeding to more invasive options 2, 3, 5.