What is the initial treatment for uterine fibroids?

Initial Treatment of Uterine Fibroids

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

Assessment and Initial Approach

• If fibroids are small and asymptomatic (which occurs in approximately two-thirds of cases), no treatment is required 2
• Treatment decisions should be guided by:
  • Presence and severity of symptoms
  • Size and location of fibroids
  • Patient's age and fertility desires
  • Fibroid characteristics (number, size, location)

Medical Management Options (First-Line)

For Heavy Menstrual Bleeding:

1. Non-hormonal options:

   • Tranexamic acid - recommended first-line non-hormonal medication, taken only during menstruation (reduces bleeding by more than 40%) 1
   • NSAIDs - can reduce bleeding by 20-40% and help with pain, though less effective than tranexamic acid 1

2. Hormonal options:

   • 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, but less effective than progestin IUDs 1

For Short-Term Treatment (Pre-surgical or Approaching Menopause):

• GnRH agonists - reduce bleeding and fibroid volume by 40-50%, effective for short-term use (3-6 months) 1

  • Caution: Fibroids return to previous size after discontinuation
  • Side effect: Chronic use causes trabecular bone loss

• Selective progesterone receptor modulators (e.g., ulipristal acetate) - achieve amenorrhea in 70-83% of patients with median fibroid volume reduction of 65-67% 1

Minimally Invasive Procedures (Second-Line)

When medical management fails to control symptoms, consider:

1. Uterine Artery Embolization (UAE):

   • Improves symptom scores and quality of life for up to 7 years
   • Shorter hospital stay and decreased blood loss compared to hysterectomy
   • Note: 18% hysterectomy rate for persistent symptoms 1

2. MR-guided Focused Ultrasound (MRgFUS):

   • Uses high-intensity ultrasound waves to thermally ablate fibroids
   • Results in 18% decrease in fibroid diameter 1

3. Laparoscopic uterine artery occlusion (LUAO):

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

Surgical Options (Third-Line)

For Women Desiring Fertility Preservation:

• Myomectomy (removal of fibroids while preserving the uterus):
  • Hysteroscopic myomectomy - recommended for submucosal fibroids
  • Laparoscopic myomectomy - preferred for intramural/subserosal fibroids when feasible
  • Open myomectomy - preferred for multiple fibroids or very large uteri
  • Note: Recurrence rate of 23-33% 1

For Women Not Desiring Future Fertility:

• Hysterectomy - most definitive treatment, with options including:
  • Vaginal approach
  • Laparoscopic approach
  • Abdominal approach 1

Special Considerations

Fertility Implications:

• Myomectomy is preferred for women desiring pregnancy, but 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 1

When to Refer for Specialist Care:

• Submucous fibroid with abnormal bleeding
• Fibroids >3 cm in diameter or uterus palpable abdominally
• Persistent intermenstrual bleeding
• Age >45 where treatment has failed or been ineffective
• Rapid growth (rare but concerning for sarcomatous change) 2

Monitoring and Follow-up

• Monitor hemoglobin levels to ensure anemia is resolving
• Follow fibroid size with imaging (ultrasound) before and after treatment 1
• For asymptomatic fibroids, follow up to document stability in size and growth 3