What are the treatment guidelines for fibroids?

Treatment Guidelines for Uterine Fibroids

The optimal treatment for uterine fibroids should follow a stepwise approach based on symptom severity, fibroid characteristics, and patient's fertility desires, with medical management as first-line for mild symptoms and surgical interventions reserved for more severe cases or when medical management fails. 1

Assessment and Initial Approach

• Approximately two-thirds of fibroids are asymptomatic and require no intervention 2

• Common symptoms requiring treatment include:

  • Abnormal uterine bleeding/menorrhagia
  • Pelvic pressure or pain
  • Urinary frequency, urgency, or retention
  • Bowel dysfunction/constipation
  • Infertility concerns
  • Dyspareunia

• Ultrasonography is the preferred initial imaging modality 3

Medical Management Options

First-Line Treatments

• For heavy menstrual bleeding:
  • NSAIDs: Reduce bleeding by 20-40% 4
  • Tranexamic acid: First-line non-hormonal medication, taken only during menstruation (contraindicated in women with active or high risk for thromboembolic disease) 4
  • Hormonal contraceptives: Effective for controlling bleeding symptoms, especially with smaller lesions 4
  • Levonorgestrel IUD (Mirena): Most effective hormonal option for bleeding control and pain relief 4

Second-Line Treatments

• GnRH agonists:

  • Reduce bleeding and fibroid volume by 40-50%
  • Effective for short-term use (3-6 months)
  • Can be used preoperatively to increase hemoglobin levels and reduce fibroid volume
  • Long-term use causes bone loss; add-back therapy recommended for extended use 4

• Selective Progesterone Receptor Modulators (SPRMs):

  • Emerging treatment option
  • Ulipristal acetate achieves amenorrhea in 70-83% of patients
  • Can reduce fibroid volume by 65-67% 4, 5

Interventional and Surgical Management

Minimally Invasive Options

• Uterine Artery Embolization (UAE):

  • Recommended for women who fail conservative measures
  • 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% of patients require subsequent hysterectomy 4, 5
  • Appropriate for women who do not desire future fertility 5

• MR-guided Focused Ultrasound (MRgFUS):

  • Uses high-intensity ultrasound waves to thermally ablate fibroids
  • Results in approximately 18% decrease in fibroid diameter 4

Surgical Options

• Hysteroscopic Myomectomy:

  • First-line conservative surgical therapy for symptomatic intracavitary/submucosal fibroids 6
  • Recommended for submucosal fibroids <4cm, especially when fertility is desired 5
  • Shorter hospitalization and faster recovery than other surgical approaches 4

• Laparoscopic or Open Myomectomy:

  • Indicated for women with symptomatic fibroids >3cm who wish to preserve fertility 2, 6
  • Laparoscopic approach offers shorter hospital stays and faster recovery 4
  • Open myomectomy preferred for multiple fibroids or very large uteri 4
  • Patients should be counseled about risk of requiring further intervention 6

• Hysterectomy:

  • Definitive treatment for women with completed childbearing 4
  • Associated with high patient satisfaction 6
  • Completely eliminates risk of recurrence 4
  • Vaginal or laparoscopic routes preferred when possible 5

Treatment Selection Algorithm

1. Asymptomatic fibroids: Expectant management, especially if approaching menopause 3

2. Symptomatic fibroids with mild-moderate symptoms:

   • Start with medical management based on predominant symptom
   • For bleeding: NSAIDs, tranexamic acid, hormonal methods
   • For pain: NSAIDs, hormonal methods

3. Symptomatic fibroids with severe symptoms or failed medical management:

   • If fertility desired:

     • Submucosal fibroids: Hysteroscopic myomectomy
     • Intramural/subserosal fibroids: Laparoscopic or open myomectomy

   • If fertility not desired:

     • UAE or MRgFUS as alternatives to surgery
     • Hysterectomy if definitive treatment preferred

Important Considerations and Pitfalls

• Fertility considerations: Removal of fibroids that distort the uterine cavity may be indicated in infertile women with no other identified factors 6

• Pregnancy concerns: Fibroids may enlarge during pregnancy and undergo red degeneration causing pain; additional fetal surveillance may be needed when placenta is implanted near fibroids 2, 6

• Malignancy risk: Sarcomatous change within fibroids is rare but associated with rapid growth; such cases should be referred urgently 2

• Postmenopausal women: Hormone replacement therapy may cause fibroid growth but rarely causes clinical symptoms 6

• Monitoring: Follow hemoglobin levels and fibroid size with imaging before and after treatment 4