What are the management options for uterine fibroids?

Management of Uterine Fibroids

The management of uterine fibroids should be tailored based on symptom severity, fibroid characteristics, patient age, and fertility desires, with options ranging from medical management to surgical interventions. 1, 2

Assessment and Classification

• Symptomatic Status: Many fibroids (up to 70%) are asymptomatic and require no intervention beyond monitoring for stability 2, 3
• Common Symptoms:
  • Heavy menstrual bleeding (most common)
  • Pelvic pressure/pain
  • Urinary frequency or retention
  • Constipation
  • Dyspareunia
  • Infertility (in some cases)

Treatment Algorithm

1. Medical Management

For Heavy Menstrual Bleeding:

• First-line options:
  • Tranexamic acid: Reduces bleeding by 20-40%, taken only during menstruation 1
    • Contraindicated in women with active or high risk for thromboembolism
  • NSAIDs: Effective for pain and can reduce bleeding 1, 2
  • Levonorgestrel IUD (Mirena): Most effective hormonal option for bleeding control and pain relief 1
  • Combined oral contraceptives: Effective for controlling bleeding, especially with smaller lesions 1, 4

For Bulk Symptoms and Pre-surgical Management:

• GnRH agonists: Reduce bleeding and fibroid volume by 40-50%
  • Effective for short-term use (3-6 months)
  • Caution: Chronic use causes trabecular bone loss; consider add-back therapy 1
• Selective progesterone receptor modulators (SPRMs):
  • Ulipristal acetate achieves amenorrhea in 70-83% of patients
  • Can reduce fibroid volume by 65-67% 1, 5
  • Can be used intermittently long-term with good results 5

2. Interventional Procedures

• Uterine Artery Embolization (UAE):

  • Indicated for women who fail conservative measures and wish to preserve the uterus
  • Improves quality of life and symptom scores (up to 7 years follow-up)
  • Short-term and long-term symptom improvement in 94% and 85% of patients, respectively
  • Only 18% require subsequent hysterectomy for persistent symptoms 1, 3

• MR-guided Focused Ultrasound (MRgFUS):

  • Uses high-intensity ultrasound waves to thermally ablate fibroids
  • Results in approximately 18% decrease in fibroid diameter 1, 5
  • Promising but lacks long-term data 3

• Radiofrequency Ablation:

  • Emerging minimally invasive option 5, 4

3. Surgical Management

• Hysteroscopic Myomectomy:

  • First-line conservative surgical therapy for symptomatic intracavitary fibroids
  • Shorter hospitalization and faster recovery than other surgical approaches 1, 3

• Laparoscopic Myomectomy:

  • Beneficial for subserosal or intramural fibroids
  • Especially for women desiring fertility preservation
  • Shorter hospital stays and faster recovery than open myomectomy 1
  • Note: When morcellation is necessary, patients should be informed about rare risk of spreading undiagnosed malignancy 3

• Open Myomectomy:

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

• Hysterectomy:

  • Most definitive treatment for women with completed childbearing
  • Very high patient satisfaction
  • Completely eliminates risk of recurrence 1, 3
  • Should be performed by least invasive approach possible 3

Special Considerations

Pre-operative Optimization

• Anemia Correction: Should be addressed before elective surgery
  • SPRMs and GnRH analogues effectively correct anemia preoperatively 3
  • Iron replacement therapy for ID and ID anemia 4

Fertility Considerations

• Myomectomy is indicated for women desiring fertility preservation
• Less than half of patients achieve pregnancy after myomectomy at up to 3 years follow-up 1
• Pregnancy complications related to fibroids are not an indication for myomectomy unless there was a previous pregnancy with complications related to these fibroids 3

Perimenopause Considerations

• Expectant management may be reasonable as fibroids often decrease in size during menopause 6
• Short-term GnRH agonist therapy may bridge symptomatic women to menopause 6

Common Pitfalls to Avoid

1. Unnecessary intervention for asymptomatic fibroids - most require no treatment 2, 3
2. Overlooking medical options before proceeding to invasive procedures
3. Failure to correct anemia before elective surgery 3
4. Not considering fertility desires when selecting treatment approach
5. Overestimating malignancy risk - leiomyosarcomas are extremely rare (less than 1 in 1000) 2

By following this structured approach to uterine fibroid management, clinicians can optimize outcomes while respecting patient preferences regarding fertility preservation and symptom relief.