What are the treatment options for uterine fibroids?

Treatment Options for Uterine Fibroids

Treatment for uterine fibroids should follow a stepwise approach, beginning with medical management for symptom control, followed by minimally invasive procedures, and surgical interventions when necessary, with the specific treatment determined by symptom severity, fibroid characteristics, and fertility desires.

Medical Management Options

First-Line Medical Treatments

• NSAIDs and estrogen-progestin oral contraceptive pills effectively reduce bleeding symptoms associated with fibroids 1, 2
• Progestin-containing intrauterine devices (IUDs) provide effective long-term management of bleeding symptoms 1, 2
• Tranexamic acid is a valuable nonhormonal alternative for reducing bleeding symptoms in patients who cannot use hormonal options 1, 2

Second-Line Medical Treatments

• GnRH agonists (e.g., leuprolide acetate) and oral GnRH antagonists (e.g., elagolix, linzagolix, relugolix) effectively reduce bleeding symptoms and significantly decrease fibroid volume by 18-30% 1
• These medications are particularly useful for short-term treatment to decrease fibroid size before surgery 1
• Combination treatment with low doses of estrogen and progestin can mitigate hypoestrogenic side effects (headaches, hot flushes, bone mineral density loss) and is FDA-approved for fibroid-related heavy menstrual bleeding 1, 2
• Important limitation: Symptoms typically recur rapidly after discontinuation of therapy 1

Emerging Medical Options

• Progesterone receptor modulators (e.g., ulipristal acetate) show promise in reducing both bleeding and bulk symptoms 1
• These can be administered intermittently, allowing for menstruation during medication breaks 1, 3
• However, concerns about hepatotoxicity have limited FDA approval in the United States 1, 2

Minimally Invasive Interventional Procedures

Uterine Artery Embolization (UAE)

• Effective uterus-preserving therapy that improves symptom scores and quality of life for up to 7 years 2
• Results in greater fibroid diameter reduction (53%) compared to laparoscopic uterine artery occlusion (39%) 1
• Higher frequency of complete fibroid infarction (82% with UAE vs. 23% with LUAO) 1
• Reintervention rate of approximately 7-13% for persistent symptoms 2

MR-Guided Focused Ultrasound (MRgFUS)

• Uses high-intensity ultrasound waves to thermally ablate fibroids without damaging surrounding tissues 1
• Demonstrates approximately 18% reduction in fibroid diameter 1
• Higher reintervention rate (30%) compared to UAE (13%) 1
• Complications are rare but may include skin burns, nerve damage, vaginal discharge, and bowel injury 1

Laparoscopic Uterine Artery Occlusion (LUAO)

• Associated with decreased postprocedural complications and rehospitalizations compared to UAE 1
• Less effective than UAE in reducing fibroid diameter (39% vs. 53%) 1
• Pregnancy outcomes appear similar to UAE (total pregnancy rates: 67% LUAO vs. 69% UAE) 1

Surgical Management

Hysteroscopic Myomectomy

• Procedure of choice for pedunculated submucosal uterine fibroids <5 cm 1, 2
• Offers shorter hospitalization and faster recovery compared to laparoscopic or open myomectomy 1, 2
• Provides equivalent improvement in symptom scores and quality of life compared to more invasive approaches 1

Laparoscopic or Open Myomectomy

• Preserves the uterus while removing fibroids 1, 4
• Open approach may be preferred for patients with multiple fibroids or very large uteri 1
• Laparoscopic approach offers shorter hospital stays and faster return to usual activities 1
• Both approaches improve quality of life for up to 10 years 1
• Fertility outcomes: less than half of patients trying to conceive achieve pregnancy within 3 years 1

Hysterectomy

• Provides definitive resolution of all fibroid-related symptoms 1, 2
• Remains the most common treatment for uterine fibroids, accounting for three-quarters of fibroid treatments in the United States 1, 2
• May be performed transvaginally, laparoscopically, or abdominally 1

Treatment Selection Considerations

• Fibroid characteristics: Size, number, and location (submucosal, intramural, subserosal) 4, 5
• Symptom severity: Heavy menstrual bleeding, pelvic pressure, pain 5, 6
• Fertility desires: Hysteroscopic, laparoscopic, or open myomectomy for those desiring future fertility 1, 5
• Age and menopausal status: Hysterectomy may be more appropriate for perimenopausal women not responding to other treatments 5
• Comorbidities: Medical management may be preferable for poor surgical candidates 2, 5

Pitfalls and Caveats

• GnRH agonists and antagonists should not be used indefinitely due to hypoestrogenic side effects and high cost 1, 7
• Medical treatments generally provide temporary symptom relief, with fibroids returning to pretreatment size approximately 6 months after discontinuing treatment 7
• Consider iron replacement therapy for patients with iron deficiency anemia resulting from chronic bleeding 5
• Leiomyosarcoma (malignant transformation) is rare but should be suspected in postmenopausal women with fibroid growth 6