What are the management options for uterine fibroids?

Management of Uterine Fibroids

The management of uterine fibroids should follow a stepwise approach, beginning with medical management for symptomatic patients, followed by minimally invasive procedures, and finally surgical options based on symptom severity, fibroid characteristics, and fertility desires. 1, 2

Initial Assessment and Management

• Asymptomatic fibroids: Expectant management with periodic follow-up to document stability in size and growth 3
• Symptomatic fibroids: Treatment based on:
  • Symptom type (bleeding, pain, pressure)
  • Fibroid location (submucosal, intramural, subserosal)
  • Patient's age and fertility desires
  • Fibroid size and number

Medical Management Options

First-line treatments:

• For heavy menstrual bleeding:
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) - reduce bleeding by 20-40% 2
  • Tranexamic acid - effective for heavy menstrual bleeding, taken only during menstruation 2
  • Hormonal contraceptives (combined oral contraceptives) - effective for controlling bleeding, especially with smaller lesions 2
  • Levonorgestrel-releasing intrauterine device (Mirena) - most effective hormonal option for bleeding control and pain relief 2

Second-line treatments:

• GnRH agonists: Reduce bleeding and fibroid volume by 40-50%, effective for short-term use (3-6 months) 2
  • Consider add-back therapy to minimize side effects
  • Useful as preoperative therapy to increase hemoglobin levels and reduce fibroid volume
• Selective progesterone receptor modulators (SPRMs): Can achieve amenorrhea in 70-83% of patients with median fibroid volume reduction of 65-67% 2

Minimally Invasive Procedures

Uterine Artery Embolization (UAE):

• Indication: Reproductive-age patients with fibroids who have no desire for future fertility 2
• Benefits: Improves symptom scores and quality of life, shorter hospital stay compared to hysterectomy 2
• Limitations: 20-25% incidence of symptom recurrence at 5-7 years, 18% hysterectomy rate for persistent symptoms 2

MR-guided Focused Ultrasound (MRgFUS):

• Uses high-intensity ultrasound waves to thermally ablate fibroids
• Results in approximately 18% decrease in fibroid diameter 2

Laparoscopic Uterine Artery Occlusion (LUAO):

• Less effective than UAE for fibroid reduction (39% vs. 53% diameter reduction) 2
• Useful as an adjunct to hysterectomy or myomectomy to decrease intraoperative blood loss 1

Surgical Management

Hysteroscopic Myomectomy:

• Indication: Submucosal fibroids in patients desiring uterus preservation 1
• Benefits: Shorter hospitalization and faster recovery than other surgical approaches 1
• Limitations: Less effective for patients with significant intramural or subserosal fibroid burden 1
• Risks: Uterine perforation, fluid overload, need for blood transfusion, bowel or bladder injury, endomyometritis, need for reintervention 1

Laparoscopic Myomectomy:

• Indication: Subserosal or intramural fibroids, especially for women desiring fertility preservation 1, 2
• Benefits: Shorter hospital stays and faster recovery than open myomectomy 1
• Outcomes: Improved quality of life for up to 10 years 1

Open Myomectomy:

• Indication: Multiple fibroids or very large uteri 1
• Outcomes: Improved quality of life for up to 10 years 1
• Risks: Potential for uterine rupture during subsequent pregnancy 1

Hysterectomy:

• Indication: Definitive treatment for women with completed childbearing 2
• Benefits: Very high patient satisfaction (90% reporting at least moderate satisfaction 2 years after procedure), completely eliminates risk of recurrence 2

Fertility Considerations

• Less than half of patients achieve pregnancy after myomectomy at up to 3 years of follow-up 1
• Of these pregnancies, less than half result in a live birth 1
• No significant difference in fertility outcomes among hysteroscopic, laparoscopic, and open myomectomy approaches 1
• The impact of hysteroscopic myomectomy on fertility remains debated due to lack of high-quality evidence on live birth rates 1

Important Clinical Considerations

• Monitor hemoglobin levels to ensure anemia is resolving
• Follow fibroid size with imaging (ultrasound) before and after treatment
• Preoperative medical therapy with GnRH agonists or SPRMs can:
  • Increase hemoglobin levels
  • Reduce fibroid and uterine volume
  • Decrease blood loss during surgery
  • Reduce operation time and complication rates

Treatment Algorithm

1. Asymptomatic fibroids: Expectant management with periodic follow-up
2. Symptomatic fibroids:
   • First step: Medical management based on symptom type
   • Second step (if medical management fails): Consider minimally invasive procedures
   • Third step (if needed): Surgical management based on fertility desires
     • Desire for fertility: Myomectomy (approach based on fibroid location)
     • No desire for fertility: UAE or hysterectomy