What are the treatment options for symptomatic uterine fibroids?

Treatment Options for Symptomatic Uterine Fibroids

Treatment for symptomatic uterine fibroids should be selected based on symptom severity, patient's age, fertility desires, and fibroid characteristics, with hysterectomy being the most effective definitive treatment for women with completed childbearing, while medical management and myomectomy are preferred for those desiring future fertility. 1

Understanding Uterine Fibroids

• Common benign tumors affecting women of reproductive age
• Higher incidence in Black women (>80% by age 50) compared to White women (70% by age 50) 1
• Approximately 30% of cases become symptomatic, causing:
  • Abnormal uterine bleeding/heavy menstrual bleeding
  • Pelvic pressure or pain
  • Bowel dysfunction
  • Urinary frequency, urgency, or retention
  • Low back pain
  • Dyspareunia 2, 3

Treatment Algorithm

Step 1: Medical Management Options

For women with mild to moderate symptoms or those needing temporary relief:

1. First-line treatments for bleeding control:

   • NSAIDs - reduce bleeding by 20-40% 1
   • Tranexamic acid - reduces bleeding during menstruation 2
   • Hormonal contraceptives:
     • Progestin-containing IUDs (Levonorgestrel/Mirena) - superior for bleeding control and pain relief 1
     • Combined oral contraceptives - effective for smaller fibroids 1

2. Second-line hormonal treatments:

   • GnRH agonists/antagonists - reduce fibroid volume by 35-50%, useful before surgery 1, 4
   • Selective progesterone receptor modulators (SPRMs) - achieve amenorrhea in 70-83% of patients with 65-67% fibroid volume reduction 1, 4
   • Mifepristone - promising for reducing uterine and myoma size 1

Step 2: Surgical Management

For women with persistent symptoms despite medical therapy:

1. Fertility-preserving options:

   • Myomectomy - preferred for women desiring future fertility 1, 5
     • Hysteroscopic resection for submucosal fibroids <4cm 6
     • Laparoscopic approach for subserosal or intramural fibroids (shorter hospital stays, faster recovery) 1
     • Open myomectomy for multiple or large fibroids

2. Minimally invasive procedures:

   • Uterine Artery Embolization (UAE) - 94% short-term and 85% long-term symptom improvement 1
     • Less effective for fibroids >5cm
     • May compromise fertility (intrauterine necrosis in 43% of cases) 1
   • MR-guided Focused Ultrasound (MRgFUS) - 18% decrease in fibroid diameter 1
   • Radiofrequency ablation of fibroids 5
   • Endometrial ablation (for submucosal fibroids in women with completed childbearing) 6

3. Definitive treatment:

   • Hysterectomy - most effective treatment with 90% satisfaction rate at 2 years 1
     • Eliminates recurrence risk
     • Preferred for perimenopausal women with no fertility desires
     • Vaginal or laparoscopic approaches preferred when possible 6

Special Considerations

For Women Desiring Fertility

• Intramural fibroids significantly reduce pregnancy rates (16.4% vs 30.1% in controls) 1
• Subserosal fibroids do not significantly impact pregnancy rates 1
• Hysteroscopic resection of submucosal fibroids recommended regardless of symptoms 6
• Less than half of patients achieve pregnancy after myomectomy at up to 3 years follow-up 1

Preoperative Preparation

• Correct anemia before surgery 1
• Consider GnRH agonists to reduce fibroid volume before surgery 1
• Appropriate imaging (ultrasound/MRI) to determine fibroid location and vascularity 1

Common Pitfalls and Caveats

1. Overlooking anemia - Always monitor hemoglobin levels in women with fibroid-related bleeding 1
2. Inappropriate UAE use - Not recommended as first-line for women desiring fertility 1
3. Medical therapy limitations - Most medications provide temporary relief rather than permanent resolution 4
4. Surgical adhesion risks - Use adhesion prevention barriers during myomectomy and confine incisions to anterior uterine surface when possible 1
5. Hysterectomy considerations - May lead to earlier onset of menopause even with ovarian preservation 1

Treatment Selection Factors

• Symptom severity
• Patient's age
• Fertility desires
• Fibroid characteristics (size, number, location)
• Economic considerations 1, 2

Regular monitoring with imaging (ultrasound) is recommended before and after treatment to assess fibroid size and response to therapy 1.