What are the guidelines for managing uterine fibroids?

Management Guidelines for Uterine Fibroids

The management of uterine fibroids should be guided by symptom severity, fibroid location and size, patient age, and fertility desires, with progestin-containing IUDs being the most effective hormonal option for bleeding control and pain relief in symptomatic patients who wish to preserve fertility. 1

Initial Evaluation and Classification

• Before any treatment, postmenopausal women with abnormal uterine bleeding must be evaluated to rule out uterine sarcoma and endometrial cancer 1
• Regular monitoring should include hemoglobin levels and lesion size with imaging (ultrasound) 1
• Fibroids are classified by location:
  • Submucosal: Extend into the uterine cavity
  • Intramural: Within the myometrium
  • Subserosal: Extend outward from the uterus

Medical Management Options

First-Line Treatments

• Hormonal Options:

  • Levonorgestrel IUD (Mirena): Most effective hormonal option for bleeding control and pain relief, with significant improvements compared to oral contraceptives 1
  • Combined oral contraceptives: Effective for controlling bleeding with smaller lesions 1

• Non-Hormonal Options:

  • NSAIDs: Can reduce bleeding by 20-40% 1
  • Tranexamic acid: First-line non-hormonal medication for heavy menstrual bleeding, taken only during menstruation (contraindicated in women with active or high risk of thromboembolic disease) 1

Second-Line Treatments

• GnRH agonists/antagonists: Reduce bleeding and lesion 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):

  • Ulipristal acetate (UPA) achieves amenorrhea in 70-83% of patients with median fibroid volume reduction of 65-67% 1
  • Emerging treatment option showing promising results 2, 3

Surgical Management

Fertility-Preserving Options

• Hysteroscopic myomectomy:

  • First-line for submucosal fibroids 4
  • Shorter hospitalization and faster recovery than other surgical approaches 1
  • Improvement in symptom scores equivalent to other approaches at 2-3 months 1

• Laparoscopic myomectomy:

  • Best for subserosal or intramural fibroids 1
  • Shorter hospital stays and faster recovery than open myomectomy 1
  • Ideal for fibroids <15 cm and no more than three fibroids of 5 cm size 5

• Open myomectomy:

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

Minimally Invasive Procedures

• Uterine Artery Embolization (UAE):

  • Short-term symptom improvement in 94% of patients 1
  • Long-term symptom improvement in 85% of patients 1
  • Not recommended for women desiring future fertility due to concerns of decreased ovarian reserve and pregnancy complications 5

• MR-guided Focused Ultrasound (MRgFUS):

  • Results in 18% decrease in lesion diameter 1
  • Promising but lacks long-term data 4

• Laparoscopic uterine artery occlusion (LUAO):

  • Less effective than UAE (39% vs. 53% diameter reduction) 1
  • Not recommended as first-line treatment 1

Definitive Treatment

• Hysterectomy:
  • Only definitive treatment for fibroids 1, 4
  • Very high patient satisfaction 1
  • Should be performed using least invasive route possible (vaginal, laparoscopic, or robotic-assisted) 1
  • Best option for women who have completed childbearing 5

Treatment Algorithm Based on Symptoms and Fertility Desires

For Women Desiring Fertility Preservation:

1. Asymptomatic fibroids: Expectant management with regular monitoring 6, 4

2. Symptomatic fibroids:

   • First try: Medical management with levonorgestrel IUD, combined oral contraceptives, or non-hormonal options 1
   • If medical management fails:
     • Submucosal fibroids: Hysteroscopic myomectomy 1, 4
     • Intramural/subserosal fibroids: Laparoscopic myomectomy if ≤3 fibroids or <15cm; open myomectomy for larger/multiple fibroids 1, 5

For Women Not Desiring Future Fertility:

1. Asymptomatic fibroids: Expectant management 6, 4

2. Symptomatic fibroids:

   • First try: Medical management as above 1
   • If medical management fails:
     • Minimally invasive options: UAE (85-94% symptom improvement) 1
     • Definitive treatment: Hysterectomy via least invasive approach 1

Important Considerations and Pitfalls

• Preoperative preparation: Correct anemia before elective surgery using SPRMs or GnRH analogues 4

• Surgical techniques to reduce blood loss: Consider vasopressin, bupivacaine and epinephrine, misoprostol, peri-cervical tourniquet, or gelatin-thrombin matrix 4

• Morcellation risks: When morcellation is necessary, inform patients about rare risk of spreading undetected malignancy 4

• Pregnancy after myomectomy: Less than half of patients achieve pregnancy after myomectomy at up to 3 years of follow-up 1

• Acute uterine bleeding: Consider conservative management with estrogens, SPRMs, antifibrinolytics, Foley catheter tamponade, and/or operative hysteroscopic intervention; UAE where available; hysterectomy may be necessary in some cases 4