What are the management options for uterine fibroids?

Management of Uterine Fibroids

Medical management should be trialed as first-line therapy for symptomatic uterine fibroids before pursuing more invasive treatments. 1

Initial Assessment and Treatment Algorithm

Step 1: Medical Management (First-Line)

• 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 (take only during menstruation) 2
  • Iron supplementation: For iron deficiency anemia secondary to heavy bleeding 2

• Hormonal options:

  • Progestin IUDs (e.g., Levonorgestrel-releasing intrauterine system): Most effective hormonal option for pain and bleeding control 2
  • Combined oral contraceptives: Effective for bleeding control but less effective than progestin IUDs 2
  • GnRH agonists/antagonists with add-back therapy: Can reduce bleeding and fibroid volume by 40-50%, typically used temporarily (3-6 months) or as bridge to definitive therapy due to bone mineral density concerns 2

Step 2: Minimally Invasive Procedures (If medical management fails)

• Uterine Artery Embolization (UAE):

  • Improves symptoms for up to 7 years with 85-94% symptom improvement 2
  • 18% hysterectomy rate for persistent symptoms 2
  • Usually appropriate for reproductive age patients with no desire for future fertility 1

• MR-guided Focused Ultrasound (MRgFUS):

  • Uses high-intensity ultrasound waves to thermally ablate fibroids 2
  • Results in 18% decrease in fibroid diameter 2
  • Usually appropriate for reproductive age patients with no desire for future fertility 1

Step 3: Surgical Options

• Hysteroscopic myomectomy:

  • Indicated for pedunculated submucosal fibroids 1
  • Shorter hospitalization and faster recovery than other surgical approaches 1
  • Risks include uterine perforation, fluid overload, blood transfusion 2

• Laparoscopic or open myomectomy:

  • Usually appropriate for reproductive age patients with symptomatic fibroids 1
  • Laparoscopic approach preferred when feasible (shorter hospital stays, faster recovery) 2
  • Open approach preferred for multiple fibroids or very large uteri 2

• Hysterectomy:

  • Usually appropriate for postmenopausal patients with symptomatic fibroids and negative endometrial evaluation 1
  • Definitive treatment when other approaches fail 2
  • Consider risks including cardiovascular disease and mood disorders when performed at young age 2

Treatment Considerations Based on Patient Characteristics

For Reproductive Age Patients Desiring Fertility

• Medical management or myomectomy (laparoscopic, open, or hysteroscopic depending on fibroid location) 1, 2
• Avoid endometrial ablation (high risk of pregnancy complications) and hysterectomy (causes permanent infertility) 1
• Myomectomy offers best chance for symptom control while preserving fertility, but doesn't guarantee future fertility 2

For Reproductive Age Patients with No Desire for Future Fertility

• Medical management, UAE, MRgFUS, or myomectomy are all usually appropriate 1

For Patients with Concurrent Adenomyosis

• Medical management or UAE is usually appropriate 1

For Postmenopausal Patients

• Hysterectomy is usually appropriate for symptomatic fibroids with negative endometrial evaluation 1

Important Considerations and Pitfalls

1. Fertility implications: Less than half of patients trying to conceive after myomectomy achieve pregnancy, and less than half of these pregnancies result in live birth 2

2. GnRH agonist limitations: Prolonged use should be limited to 3-6 months due to bone mineral density loss and other side effects 2, 3

3. Fibroid location matters: Treatment effectiveness varies based on fibroid location:

   • Submucosal fibroids: Hysteroscopic myomectomy is usually appropriate 1
   • Intramural/subserosal fibroids: Laparoscopic/open myomectomy, UAE, or MRgFUS 1, 2

4. Monitoring response: Follow hemoglobin levels and fibroid size with imaging before and after treatment to ensure adequate response 2

5. Risk of malignancy: Leiomyosarcomas are extremely rare (less than one in 1000), and fibroids do not increase risk of malignant uterine disease 4

By following this structured approach to uterine fibroid management, clinicians can effectively address symptoms while considering the patient's age, fertility desires, and fibroid characteristics to optimize outcomes related to morbidity, mortality, and quality of life.