What are the treatment options for uterine fibroid bleeding?

Treatment of Uterine Fibroid Bleeding

The treatment of uterine fibroid bleeding 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 Treatments:

• Tranexamic acid: Recommended as a first-line non-hormonal medication for heavy menstrual bleeding, taken only during menstruation. Reduces bleeding by 20-40% but is contraindicated in women with active or history of thromboembolic disease 1
• NSAIDs: Can reduce bleeding by 20-40% and help with pain, though less effective than tranexamic acid 1
• Progestin-containing IUDs: Most effective hormonal option with significant improvement in pain and bleeding 1
• Oral contraceptives: Effective for controlling bleeding symptoms, especially with small fibroids, though less effective than progestin IUDs 1

Second-line Treatments:

• GnRH agonists: Reduce bleeding and fibroid volume by 40-50%, effective for short-term use (3-6 months). Drawbacks include fibroids returning to previous size after discontinuation and chronic use causing trabecular bone loss 1
• Selective progesterone receptor modulators (e.g., ulipristal acetate): Achieve amenorrhea in 70-83% of patients and median fibroid volume reduction of 65-67% 1

Minimally Invasive Procedures

When medical management fails or is contraindicated, consider:

• Uterine Artery Embolization (UAE): Improves symptom scores and quality of life for up to 7 years, with shorter hospital stay and decreased blood loss compared to hysterectomy. Note that 18% of patients may eventually require hysterectomy for persistent symptoms 1
• MR-guided Focused Ultrasound (MRgFUS): Uses high-intensity ultrasound waves to thermally ablate fibroids, resulting in an 18% decrease in fibroid diameter 1
• Laparoscopic uterine artery occlusion (LUAO): Less effective than UAE for fibroid reduction (39% vs. 53% diameter reduction) 1

Surgical Options

For Women Desiring Fertility Preservation:

• Hysteroscopic myomectomy: Recommended for submucosal fibroids, with shorter hospitalization and faster recovery than other surgical approaches 1
• Laparoscopic myomectomy: Preferred for intramural/subserosal fibroids when feasible, with shorter hospital stays and faster recovery than open approach 1
• Open myomectomy: Preferred for multiple fibroids or very large uteri, associated with improved quality of life for up to 10 years. Note that recurrence rate is 23-33% 1

For Women Not Desiring Fertility Preservation:

• Hysterectomy: Most definitive treatment with options including vaginal, laparoscopic, or abdominal approaches. When possible, vaginal or laparoscopic routes should be preferred 1, 2

Treatment Algorithm Based on Fibroid Location and Fertility Desires

For Submucosal Fibroids:

1. If fertility desired: Hysteroscopic resection for fibroids <4cm 2
2. If fertility not desired: Medical management → Hysteroscopic myomectomy or endometrial ablation (for completed families) → Hysterectomy

For Intramural/Subserosal Fibroids:

1. If fertility desired: Medical management → Laparoscopic or open myomectomy
2. If fertility not desired: Medical management → UAE or other minimally invasive procedures → Hysterectomy

Important Considerations and Caveats

• Fertility impact: Less than half of patients trying to conceive after myomectomy achieve pregnancy. UAE and other uterine-sparing procedures may impact fertility and should be used cautiously in women planning pregnancy 1

• Monitoring: Follow hemoglobin levels to ensure anemia is resolving, and monitor fibroid size with imaging before and after treatment 1

• Iron deficiency management: Treatment of iron deficiency anemia should be considered both during medical treatment and before/after surgical procedures 3

• Fibroid characteristics: The location, size, number of fibroids, and presence of coexistent adenomyosis should guide treatment choice 3

• Perimenopausal considerations: For perimenopausal women not responding to other treatments, hysterectomy is associated with high patient satisfaction 2