What are the treatment options for patients with uterine fibroids (Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) like ibuprofen, Gonadotropin-Releasing Hormone (GnRH) agonists)?

Treatment Options for Uterine Fibroids

The most appropriate treatment for uterine fibroids should be based on symptom severity, fibroid characteristics, and the patient's desire for future fertility, with medical management as first-line therapy for most patients with symptomatic fibroids. 1, 2

Medical Management Options

First-Line Medical Treatments

• NSAIDs (like ibuprofen) are recommended as first-line medical treatment for reducing bleeding symptoms and pain associated with uterine fibroids 1, 2
• Estrogen-progestin oral contraceptive pills effectively reduce bleeding symptoms and are considered first-line therapy 2, 1
• Progestin-containing intrauterine devices (IUDs) can significantly reduce heavy menstrual bleeding associated with fibroids 2, 1
• Tranexamic acid is an effective nonhormonal alternative that can reduce bleeding symptoms in patients who cannot use hormonal options 2, 1

Second-Line Medical Treatments

• GnRH agonists (e.g., leuprolide acetate) effectively reduce bleeding symptoms and significantly decrease fibroid volume by 18-30%, making them useful before surgery 2, 3
• Oral GnRH antagonists (e.g., elagolix, linzagolix, relugolix) also reduce bleeding and fibroid volume 2
• Both GnRH agonists and antagonists can cause hypoestrogenic side effects (headaches, hot flushes, bone mineral density loss) when used alone 2
• Combination treatment with low doses of estrogen and progestin can mitigate these side effects and is FDA-approved for fibroid-related heavy menstrual bleeding 2, 1
• GnRH analogs are typically limited to 3-4 months of use due to side effects and are often used as pre-operative treatment 4

Surgical Management Options

Uterus-Preserving Procedures

• Hysteroscopic myomectomy is indicated for submucosal fibroids in patients desiring uterus preservation, offering shorter hospitalization and faster recovery compared to other surgical approaches 2, 1
• Laparoscopic or open myomectomy is appropriate for subserosal or intramural fibroids, with laparoscopy associated with shorter hospital stays and faster recovery 2
• Both procedures improve quality of life for up to 10 years, though less than half of patients trying to conceive achieve pregnancy after myomectomy 2

Definitive Surgical Treatment

• Hysterectomy provides definitive resolution of all fibroid-related symptoms and remains the most common treatment for uterine fibroids, accounting for three-quarters of fibroid treatments in the United States 2, 1
• The least invasive route for hysterectomy should be chosen, as abdominal hysterectomy is associated with longer hospital stays, recovery time, and greater pain compared to vaginal or laparoscopic approaches 2
• Hysterectomy should be considered only after failure of less invasive options unless there are other indications for the procedure 2

Minimally Invasive Alternatives

• Endometrial ablation can be performed for patients with heavy menstrual bleeding who are refractory to medical therapy and do not desire future fertility 2
• Uterine Artery Embolization (UAE) is effective for patients with fibroids who desire uterus-preserving therapy, improving symptom scores and quality of life for up to 7 years 1
• The reintervention rate after UAE is approximately 7% for persistent symptoms 1

Treatment Algorithm Based on Patient Characteristics

For Patients Desiring Future Fertility:

1. Start with medical management (NSAIDs, hormonal contraceptives) 2, 1
2. For submucosal fibroids: Consider hysteroscopic myomectomy 2
3. For intramural/subserosal fibroids: Consider laparoscopic or open myomectomy 2
4. Consider GnRH agonists/antagonists for 3-4 months before surgery to reduce fibroid size and correct anemia 4, 3

For Patients Not Desiring Future Fertility:

1. Start with medical management (NSAIDs, hormonal contraceptives, IUDs) 2, 1
2. For persistent symptoms: Consider UAE or endometrial ablation 2, 1
3. For definitive treatment: Consider hysterectomy, preferably via vaginal or laparoscopic approach 2

Important Considerations

• Fibroid-associated symptoms peak in perimenopausal years and typically decline after menopause 2
• Black women have a higher incidence of fibroids (>80% by age 50) compared to white women (~70%) and may develop clinically significant disease at an earlier age 2
• Small, asymptomatic fibroids often do not require treatment 5
• The economic burden of symptomatic fibroids is substantial, with estimated societal costs ranging from $5.9 to $34.4 billion annually 2