What are the treatment options for uterine fibroids?

Treatment Options for Uterine Fibroids

Hysterectomy is the most effective definitive treatment for symptomatic uterine fibroids with a 90% satisfaction rate at 2 years, particularly for patients with completed childbearing or no desire for future fertility. 1

Treatment Algorithm Based on Patient Factors

For Women Not Desiring Future Fertility:

1. Definitive Treatment:

   • Hysterectomy: Gold standard with highest satisfaction rates and eliminates recurrence risk 1
   • Surgical approach preference: Robotic-assisted laparoscopic or traditional laparoscopic approaches preferred over open procedures (shorter hospital stays, faster recovery) 1

2. Uterine-Preserving Options:

   • Uterine Artery Embolization (UAE): 94% short-term and 85% long-term symptom improvement 1
   • MR-guided Focused Ultrasound (MRgFUS): Results in 18% decrease in lesion diameter (less effective than other options) 1
   • Laparoscopic myolysis: Alternative for selected women with symptomatic intramural or subserous fibroids 2

3. Medical Management (temporary relief):

   • Progestin-containing IUDs: Effective for bleeding control and pain relief 1
   • Combined oral contraceptives: Helpful for controlling bleeding, especially with smaller lesions 1
   • GnRH agonists/antagonists: Reduce bleeding and lesion volume by 40-50% (limited by bone loss and side effects) 1
   • Non-hormonal treatments: NSAIDs and tranexamic acid (reduce bleeding by 20-40%) 1
   • Selective progesterone receptor modulators (SPRMs): Emerging treatment with ulipristal acetate achieving amenorrhea in 70-83% of patients 1

For Women Desiring Future Fertility:

1. Surgical Options:

   • Myomectomy: Primary option for women desiring fertility preservation 1
     • Laparoscopic approach: Beneficial for subserosal or intramural fibroids (shorter hospital stays, faster recovery) 1
     • Hysteroscopic myomectomy: First-line for symptomatic intracavitary fibroids 2

2. Medical Management:

   • Similar options as above, but primarily for symptom control before surgery or as temporary measures

Treatment Selection Based on Fibroid Location

1. Submucosal Fibroids:

   • Hysteroscopic resection recommended for fibroids <4cm, especially for women desiring pregnancy 2, 3
   • Associated with significant improvement in fertility outcomes

2. Intramural Fibroids:

   • Significantly reduce pregnancy rates (16.4% vs 30.1% in controls) 1
   • Myomectomy may be indicated for symptomatic fibroids or in infertile women 1, 2

3. Subserosal Fibroids:

   • Do not significantly impact pregnancy rates (34.1% vs 30.1% in controls) 1
   • Treatment only if symptomatic

Important Considerations and Pitfalls

• Malignancy Screening: Before any minimally invasive therapy in postmenopausal women with abnormal uterine bleeding, uterine sarcoma and endometrial cancer must be ruled out 1

• Fertility Impact: Less than half of patients achieve pregnancy after myomectomy at up to 3 years of follow-up, despite improved quality of life 1

• Recurrence Risk: Women choosing myomectomy should be counseled regarding the risk of requiring further intervention 2

• Pregnancy Complications: Concern of possible complications related to fibroids in pregnancy is not an indication for myomectomy, except in women who have experienced previous pregnancy complications related to these fibroids 2

• Fluid Management: Important to monitor ongoing fluid balance carefully during hysteroscopic removal of fibroids 2

• Asymptomatic Fibroids: The majority of fibroids are asymptomatic and will not require intervention or further investigations 2

Special Populations

• Black Women: Higher incidence (>80% by age 50) compared to White women (70% by age 50), suggesting genetic predisposition 1

• Perimenopausal Women: Hysterectomy may be the most appropriate option if families are complete 3

• Women with Iron Deficiency: Management of iron deficiency and anemia should be addressed alongside fibroid treatment 4