What are the treatment options for symptomatic uterine fibroids?

Treatment Options for Symptomatic Uterine Fibroids

The optimal treatment for symptomatic uterine fibroids should be selected based on symptom type (bleeding vs. pain), fibroid characteristics (size, number, location), patient's age, and fertility desires, with medical management as first-line for most patients and surgical options reserved for those who fail conservative measures. 1, 2

Medical Management Options

Non-Hormonal Treatments

• NSAIDs: Reduce bleeding by 20-40%, provide pain relief 1
• Tranexamic acid: First-line for heavy menstrual bleeding, taken only during menstruation
  • Contraindicated in women with active or high risk for thromboembolic disease 1

Hormonal Treatments

• Levonorgestrel IUD (Mirena): Most effective hormonal option for bleeding control and pain relief 1
• Combined oral contraceptives: Effective for controlling bleeding symptoms, especially with smaller lesions 1
• GnRH agonists: Reduce bleeding and lesion volume by 40-50%
  • Effective for short-term use (3-6 months)
  • Caution: Chronic use causes trabecular bone loss; add-back therapy recommended 1
• GnRH antagonists: Reduce bleeding and lesion volume by 40-50% 1
• Selective progesterone receptor modulators (SPRMs):
  • Ulipristal acetate achieves amenorrhea in 70-83% of patients
  • Median fibroid volume reduction of 65-67% 1
  • Can be administered intermittently long-term with good results 2

Interventional Procedures

• Uterine Artery Embolization (UAE):

  • Improves quality of life and symptom scores (up to 7 years follow-up)
  • Short-term symptom improvement: 94% of patients
  • Long-term symptom improvement: 85% of patients
  • Only 18% require subsequent hysterectomy 1

• MR-guided Focused Ultrasound (MRgFUS):

  • Uses high-intensity ultrasound waves to thermally ablate fibroids
  • Results in 18% decrease in fibroid diameter 1
  • Uterine-sparing, fertility-preserving option 3

• Radiofrequency ablation: Minimally invasive option (VizAblate™ and Acessa™) 3

Surgical Management

• Hysteroscopic myomectomy:

  • Indicated for submucosal fibroids
  • Offers shorter hospitalization and faster recovery 1

• Laparoscopic myomectomy:

  • Best for subserosal or intramural fibroids
  • Shorter hospital stays and faster recovery than open approach
  • Recommended for women desiring fertility preservation 1

• Open myomectomy:

  • Preferred for multiple fibroids or very large uteri
  • Improves quality of life for up to 10 years
  • Risk: Uterine rupture during subsequent pregnancy 1

• Hysterectomy:

  • Definitive treatment for women with completed childbearing
  • Very high patient satisfaction
  • Completely eliminates risk of recurrence 1

Treatment Algorithm Based on Patient Characteristics

For Women Desiring Future Fertility:

1. First line: Medical management with NSAIDs, tranexamic acid, or hormonal options
2. Second line: Myomectomy (hysteroscopic, laparoscopic, or open depending on fibroid location)
3. Alternative: UAE or MRgFUS (though impact on fertility less established)

For Women with Completed Childbearing:

1. First line: Medical management as above
2. Second line: UAE or MRgFUS if uterine preservation desired
3. Definitive treatment: Hysterectomy for severe symptoms or failed other treatments

For Perimenopausal Women:

1. First line: Short-term GnRH agonists/antagonists to bridge to menopause
2. Alternative: UAE for those who want to avoid surgery
3. Definitive: Hysterectomy if symptoms severely impact quality of life

Important Considerations

• 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 1

• Monitor treatment response by:

  • Following hemoglobin levels
  • Tracking fibroid size with ultrasound imaging 1

• Pitfall to avoid: Assuming all abnormal uterine bleeding is due to fibroids without excluding other causes, particularly in perimenopausal women

• Caution: Suspect leiomyosarcoma in postmenopausal women with fibroid growth without hormone replacement therapy 3