What are the treatment options for symptomatic uterine fibroids?

Treatment Options for Symptomatic Uterine Fibroids

The most effective treatment approach for symptomatic uterine fibroids depends on symptom severity, fibroid characteristics, and the patient's fertility desires, with options ranging from medical management to minimally invasive procedures to definitive surgical interventions. 1, 2

Medical Management Options

First-line Medical Treatments

• For heavy menstrual bleeding:
  • Levonorgestrel intrauterine device (IUD): Most effective hormonal option for bleeding control and pain relief 1
  • Tranexamic acid: Reduces bleeding by 34-54% when taken only during menstruation 1, 3
  • NSAIDs: Can reduce bleeding by 20-40% 1
  • Combined oral contraceptives: Effective for controlling bleeding, especially with smaller fibroids 1, 4

Second-line Medical Treatments

• GnRH agonists/antagonists: Reduce bleeding and fibroid volume by 40-50%, but limited to short-term use due to bone loss 1
  • Add-back therapy can minimize side effects while maintaining efficacy
• 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% 1
• Aromatase inhibitors: Promising results in recent studies 4

Minimally Invasive Procedures

• Uterine Artery Embolization (UAE):

  • 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 1
  • Appropriate for women who want to preserve their uterus but not fertility

• MR-guided Focused Ultrasound (MRgFUS):

  • Uses high-intensity ultrasound waves to thermally ablate fibroids
  • Results in 18% decrease in fibroid diameter 1, 5

• Radiofrequency ablation:

  • Newer technique showing promising results 4, 5

Surgical Management

• Hysterectomy:

  • Only definitive treatment with very high patient satisfaction
  • Completely eliminates risk of recurrence
  • Should be performed using least invasive route possible (vaginal, laparoscopic, or robotic-assisted) 1
  • Best option for perimenopausal women not responding to other treatments 4

• Myomectomy:

  • Indicated for women desiring fertility preservation
  • Improves quality of life for up to 10 years
  • Different approaches based on fibroid location:
    • Hysteroscopic myomectomy: For submucosal fibroids 1
    • Laparoscopic myomectomy: For subserosal or intramural fibroids 1
    • Open myomectomy: Preferred for multiple fibroids or very large uteri 1

• Endometrial ablation: Option for women with abnormal bleeding who have completed childbearing 4, 6

Treatment Algorithm Based on Patient Factors

1. For women with mild to moderate symptoms:

   • Start with NSAIDs and/or tranexamic acid for bleeding control
   • If inadequate response, add hormonal therapy (LNG-IUD or combined oral contraceptives)

2. For women with severe symptoms wanting to preserve fertility:

   • Consider myomectomy (approach based on fibroid location)
   • For preoperative optimization or short-term symptom relief: GnRH agonists or SPRMs

3. For women with severe symptoms not desiring fertility:

   • UAE for those wanting to preserve the uterus
   • Hysterectomy for definitive treatment, especially near menopause

4. For women approaching menopause:

   • Consider short-term medical management as fibroids typically shrink after menopause
   • GnRH agonists with add-back therapy as a bridge to menopause

Important Considerations and Pitfalls

• Iron deficiency management: Always assess and treat iron deficiency anemia resulting from heavy bleeding 4
• Fibroid location matters: Submucosal fibroids respond better to hysteroscopic approaches, while intramural and subserosal fibroids require different approaches
• Pregnancy considerations: Risk of uterine rupture during pregnancy after myomectomy must be discussed 1
• Contraindications: Tranexamic acid is contraindicated in women with active thromboembolic disease or history of thrombosis 1
• Coexisting conditions: Adenomyosis often coexists with fibroids and may influence treatment approach 1