What are the management options for uterine fibroids?

Management Options for Uterine Fibroids

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

Assessment and Diagnosis

• Uterine fibroids affect approximately 70% of women by age 50, with 20-50% being symptomatic 2
• Common symptoms include:
  • Abnormal uterine bleeding (heavy, irregular, prolonged)
  • Bulk symptoms (pelvic pressure, pain, urinary frequency/urgency)
  • Infertility or reproductive dysfunction
  • Iron deficiency anemia
• Transvaginal ultrasound is the preferred initial imaging modality 3
• MRI may be used for more detailed mapping of fibroid location, size, and number 1

Treatment Algorithm

Asymptomatic Fibroids

• Expectant management is recommended 3
• Regular monitoring for changes in size or development of symptoms

Medical Management for Symptomatic Fibroids

For Heavy Menstrual Bleeding:

1. First-line options:

   • Tranexamic acid (non-hormonal, taken only during menstruation) 1
   • NSAIDs (reduce bleeding by 20-40%) 1
   • Progestin-containing IUDs (most effective hormonal option) 1

2. Second-line options:

   • Combined hormonal contraceptives 1
   • Oral progestins 1

3. Short-term use options (3-6 months):

   • GnRH agonists (e.g., leuprolide acetate) - reduce fibroid volume by 40-50% 1
   • GnRH antagonists (e.g., elagolix, relugolix) 1
   • Progesterone receptor modulators (e.g., ulipristal acetate) - amenorrhea rate of 70-83% 1

For Bulk Symptoms:

• GnRH agonists/antagonists 1
• Progesterone receptor modulators 1

Minimally Invasive Procedures

1. Uterine Artery Embolization (UAE):

   • 85-94% symptom improvement 1
   • Effective for both bleeding and bulk symptoms
   • 18% hysterectomy rate for persistent symptoms 1
   • Contraindicated in women desiring future pregnancy 2

2. MR-guided Focused Ultrasound (MRgFUS):

   • Results in 18% decrease in fibroid diameter 1
   • Non-invasive option with promising results

3. Laparoscopic Uterine Artery Occlusion (LUAO):

   • Less effective than UAE (39% vs. 53% diameter reduction) 1

Surgical Management

1. For submucosal fibroids:

   • Hysteroscopic myomectomy - shorter hospitalization and faster recovery than other surgical approaches 4, 1

2. For intramural/subserosal fibroids:

   • Laparoscopic myomectomy (preferred when feasible) - shorter hospital stays and faster recovery than open approach 1
   • Open myomectomy (for multiple or very large fibroids) 1

3. Definitive treatment:

   • Hysterectomy - most effective treatment for symptomatic fibroids when fertility preservation is not desired 4, 1
   • Options include vaginal, laparoscopic, or abdominal approaches, with preference for least invasive route 4

Special Considerations

Fertility Preservation

• Myomectomy is the preferred surgical option for women desiring future pregnancy 2
• Less than half of patients trying to conceive after myomectomy achieve pregnancy 1
• UAE and other uterine-sparing procedures may impact fertility and should be used cautiously in women planning pregnancy 2

Perimenopause/Postmenopause

• For postmenopausal women with symptomatic fibroids and negative endometrial biopsy, hysterectomy is usually appropriate 4
• Increased suspicion for malignancy is warranted in postmenopausal women with fibroid growth or persistent bleeding 4

Pre-surgical Optimization

• Correct anemia before elective surgery 2
• Consider GnRH agonists/antagonists or selective progesterone receptor modulators to reduce fibroid size and correct anemia preoperatively 2

Treatment Risks and Limitations

• Hysterectomy risks include increased cardiovascular disease risk, osteoporosis, and mood disorders when performed at a young age 1
• GnRH agonists/antagonists should be limited to 3-6 months due to bone mineral density loss 1
• Progesterone receptor modulators require caution due to reports of hepatotoxicity 1
• Morcellation during myomectomy carries risk of spreading occult malignancy 2

By following this structured approach to uterine fibroid management, clinicians can provide effective treatment while minimizing risks and preserving fertility when desired.