What are the management options for uterine fibroids?

Management Options for Uterine Fibroids

The management of uterine fibroids should follow a stepwise approach starting with medical management, followed by minimally invasive procedures, and finally surgical options based on symptom severity, fibroid characteristics, and fertility desires. 1

Medical Management Options

First-Line Medical Treatments

• NSAIDs: Reduce bleeding by 20-40% and help with pain 1
• Tranexamic acid: First-line non-hormonal medication for heavy menstrual bleeding, taken only during menstruation 1, 2
• Hormonal contraceptives:
  • Estrogen-progestin oral contraceptives: Effective for controlling bleeding symptoms 2
  • Progestin-containing IUDs: Most effective hormonal option with significant improvement in pain and bleeding 1, 2

Second-Line Medical Treatments

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

  • Reduce bleeding and fibroid volume by 40-50% 1
  • Effective for short-term use (3-6 months) to decrease fibroid size before surgery 2
  • Cause hypoestrogenic side effects (headaches, hot flushes, bone mineral density loss) 2

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

  • Similar efficacy to GnRH agonists 2
  • Combination with low-dose estrogen and progestin mitigates hypoestrogenic side effects 2

• Progesterone receptor modulators (e.g., ulipristal acetate):

  • Reduce both bleeding and bulk symptoms 2
  • Can be administered intermittently, allowing menstruation during medication breaks 2
  • Effective for continuous use (3 months) and intermittent use (up to 2 years) 2
  • Amenorrhea rates: 70-83% depending on dosage 2
  • Median fibroid volume reduction: 65-67% 2
  • Caution: Reports of hepatotoxicity limit widespread use 2

Surgical Management Options

Uterus-Preserving Procedures

• Myomectomy:

  • Hysteroscopic myomectomy:

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

  • Laparoscopic myomectomy:

    • Preferred for intramural fibroids when feasible 1
    • Shorter hospital stays and faster return to usual activities compared to open myomectomy 2
    • Outcomes similar to robotic-assisted laparoscopic myomectomy 2

  • Open myomectomy:

    • Preferred for multiple fibroids or very large uteri 2, 1
    • Associated with improved quality of life for up to 10 years 2
    • Fertility considerations: Less than half of patients trying to conceive achieve pregnancy, and less than half of these pregnancies result in live birth 2, 1
    • Risk of uterine rupture during subsequent pregnancy 2

Minimally Invasive Procedures

• Uterine Artery Embolization (UAE):

  • Improves symptoms for up to 7 years with 85-94% symptom improvement 1
  • Particularly effective when fibroids predominate alongside adenomyosis 1
  • 18% hysterectomy rate for persistent symptoms 1
  • Option for symptomatic fibroids in women who do not want to become pregnant 3

• Laparoscopic Uterine Artery Occlusion (LUAO):

  • Used as adjunct to hysterectomy or myomectomy to decrease intraoperative blood loss 2
  • When performed alone, associated with decreased postprocedural complications compared to UAE 2
  • Less effective than UAE for fibroid reduction (39% vs. 53% diameter reduction) 2

• MR-guided Focused Ultrasound (MRgFUS):

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

Definitive Treatment

• Hysterectomy:
  • Most effective treatment for symptomatic fibroids 3
  • High rate of patient satisfaction 1
  • Recommended for perimenopausal women who have been informed of alternatives and risks 3
  • Vaginal or laparoscopic routes preferred to laparotomy when possible 3
  • Subtotal hysterectomy is a possible alternative to total hysterectomy 3

Treatment Algorithm Based on Patient Characteristics

For Women Desiring Future Fertility:

1. Start with medical management (NSAIDs, tranexamic acid, hormonal contraceptives)
2. For submucosal fibroids <4cm: Consider hysteroscopic resection 3
3. For intramural/subserosal fibroids: Consider laparoscopic or open myomectomy based on size and number 1
4. GnRH agonists/antagonists may be used preoperatively to shrink fibroids 2, 1

For Women Not Desiring Future Fertility:

1. Start with medical management (NSAIDs, tranexamic acid, hormonal contraceptives, progestin IUD)
2. For persistent symptoms: Consider UAE, MRgFUS, or myomectomy based on fibroid characteristics 1
3. For definitive treatment: Consider hysterectomy, especially for perimenopausal women 1, 3

For Asymptomatic Fibroids:

• Expectant management is recommended as most fibroids decrease in size during menopause 4
• Regular follow-up to document stability in size and growth 5

Important Considerations and Pitfalls

• Prolonged use of GnRH agonists/antagonists should be limited to 3-6 months due to bone mineral density loss 1
• Adequate counseling about fertility expectations is essential, as myomectomy improves but does not guarantee future fertility 1
• Sarcomatous change within fibroids is rare (less than one in 1000) but should be considered with rapid growth 6, 5
• Treatment should consider the location, size, number of fibroids, and presence of coexistent conditions like adenomyosis 7
• Management of iron deficiency and anemia should be addressed alongside fibroid treatment 7