What are the management options for uterine fibroids?

Management Options for Uterine Fibroids

The management of uterine fibroids should follow a stepwise approach based on symptom severity, fibroid characteristics, and patient's reproductive goals, with options ranging from expectant management to medical therapy, minimally invasive procedures, and surgical interventions. 1, 2

Assessment and Initial Management

• Asymptomatic fibroids: Expectant management is recommended as most fibroids decrease in size during menopause 1
• Symptomatic fibroids: Treatment should be tailored based on:
  • Symptom type and severity (bleeding vs. pressure)
  • Fibroid size, number, and location
  • Patient's age and fertility desires
  • Access to treatment options

Medical Management Options

First-line treatments for abnormal uterine bleeding:

• Non-hormonal options:

  • NSAIDs: Reduce bleeding by 20-40% 3
  • Tranexamic acid: First-line for heavy menstrual bleeding, taken only during menstruation (contraindicated in women with active or high risk for thromboembolic disease) 3, 2

• Hormonal options:

  • Levonorgestrel IUD (Mirena): Most effective hormonal option for bleeding control and pain relief 3
  • Combined oral contraceptives: Effective for controlling bleeding, especially with smaller lesions 3, 2

Second-line treatments:

• GnRH agonists/antagonists: Reduce bleeding and lesion volume by 40-50%, effective for short-term use (3-6 months); chronic use causes bone loss; add-back therapy can minimize side effects 3, 2
• Selective progesterone receptor modulators (SPRMs): Emerging treatment with ulipristal acetate achieving amenorrhea in 70-83% of patients and median fibroid volume reduction of 65-67% 3, 4

Interventional Procedures

• Uterine Artery Embolization (UAE):

  • Indicated for patients who fail conservative measures
  • Improves quality of life and symptom scores for up to 7 years
  • Short-term and long-term symptom improvement in 94% and 85% of patients, respectively
  • Only 18% of patients require hysterectomy for persistent symptoms 3
  • Recommended for women with completed childbearing (fertility effects still debated) 5

• MR-guided Focused Ultrasound (MRgFUS):

  • Uses high-intensity ultrasound waves to thermally ablate lesions
  • Results in 18% decrease in fibroid diameter 3, 2

• Radiofrequency ablation:

  • Minimally invasive option for selected patients 4

Surgical Management

• Hysteroscopic myomectomy:

  • Indicated for submucosal fibroids
  • Offers shorter hospitalization and faster recovery 3
  • Preserves fertility

• Laparoscopic myomectomy:

  • Beneficial for subserosal or intramural fibroids
  • Shorter hospital stays and faster recovery than open myomectomy
  • Preserves fertility 3

• Open myomectomy:

  • Preferred for multiple fibroids or very large uteri
  • Improves quality of life for up to 10 years
  • Risk of uterine rupture during subsequent pregnancy 3

• Hysterectomy:

  • Definitive treatment for women with completed childbearing
  • Very high patient satisfaction
  • Completely eliminates risk of recurrence 3, 6

Treatment Algorithm Based on Clinical Presentation

1. For asymptomatic fibroids:

   • Expectant management with periodic monitoring

2. For symptomatic fibroids with desire for future fertility:

   • Start with medical management (NSAIDs, tranexamic acid, hormonal options)
   • If inadequate response: Consider myomectomy (hysteroscopic, laparoscopic, or open depending on fibroid location and size)
   • Consider UAE or MRgFUS in selected cases

3. For symptomatic fibroids with completed childbearing:

   • Medical management for mild symptoms
   • UAE for moderate to severe symptoms if uterine preservation desired
   • Hysterectomy for definitive treatment

Important Considerations and Pitfalls

• Fibroid location matters: Submucosal fibroids are more likely to cause bleeding, while subserosal fibroids may cause pressure symptoms 1
• Preoperative medical therapy: GnRH agonists or SPRMs can increase hemoglobin levels, reduce fibroid volume, decrease surgical blood loss, and reduce operation time 3
• Monitor for sarcomatous change: Rapid growth of fibroids, especially in perimenopausal women, warrants urgent referral to rule out malignancy 5
• Iron deficiency management: Consider iron replacement therapy for patients with chronic bleeding 2
• Referral indications:
  • Submucous fibroid with abnormal bleeding
  • Fibroids >3 cm in diameter or uterus palpable abdominally
  • Persistent intermenstrual bleeding
  • Age >45 where treatment has failed 5