What are the treatment options for symptomatic uterine fibroids?

Treatment Options for Symptomatic Uterine Fibroids

The most effective treatment options for symptomatic uterine fibroids include medical management with first-line agents such as NSAIDs and hormonal contraceptives, followed by second-line GnRH modulators, and surgical interventions including myomectomy or hysterectomy for definitive treatment, with the choice depending on symptom severity, fibroid characteristics, and fertility desires. 1, 2

Medical Management Options

First-Line Treatments

• NSAIDs and estrogen-progestin oral contraceptive pills are recommended as first-line medical treatments for reducing bleeding symptoms associated with uterine fibroids 2
• Progestin-containing intrauterine devices (IUDs) effectively reduce bleeding symptoms and should be considered for long-term management of fibroid-related bleeding 1, 2
• Tranexamic acid is an effective nonhormonal alternative that can reduce bleeding symptoms in patients with fibroids who cannot use hormonal options 1, 2

Second-Line Treatments

• GnRH agonists (e.g., leuprolide acetate) and oral GnRH antagonists (e.g., elagolix, linzagolix, relugolix) are effective second-line options that both reduce bleeding symptoms and significantly reduce fibroid volume by 18-30% 1, 2
• These agents are commonly used for short courses to decrease fibroid size in preparation for surgery 1
• Monotherapy with GnRH modulators causes hypoestrogenic effects including headaches, hot flashes, hypertension, and bone mineral density loss 1, 3
• Combination treatment with low doses of estrogen and progestin (add-back therapy) mitigates these side effects and is FDA-approved for fibroid-related heavy menstrual bleeding 1, 4
• Progesterone receptor modulators (e.g., ulipristal acetate) show promise for reducing bleeding and bulk symptoms but have limited availability in the US due to concerns about hepatotoxicity 1

Surgical Management Options

Myomectomy

• Hysteroscopic myomectomy is the procedure of choice for pedunculated submucosal fibroids <5 cm, offering shorter hospitalization and faster recovery compared to other approaches 2
• Laparoscopic myomectomy is associated with shorter hospital stays and faster return to usual activities compared to open myomectomy 1
• Both laparoscopic and open myomectomy procedures are associated with improved quality of life for up to 10 years 1
• Less than half of patients trying to conceive achieve pregnancy after myomectomy at up to 3 years of follow-up 1

Hysterectomy

• Hysterectomy provides definitive resolution of all fibroid-related symptoms and remains the most common treatment for uterine fibroids, particularly appropriate for perimenopausal women with completed families 2, 5
• When possible, vaginal or laparoscopic approaches should be preferred to laparotomy 5

Minimally Invasive Alternatives

Uterine Artery Embolization (UAE)

• UAE is effective for patients with fibroids who desire uterus-preserving therapy, improving symptom scores and quality of life for up to 7 years 2
• The reintervention rate after UAE is approximately 7% for persistent symptoms 2
• UAE demonstrates greater reduction in fibroid diameter (53%) compared to laparoscopic uterine artery occlusion (39%) 1

Other Interventional Options

• MR-guided Focused Ultrasound (MRgFUS) can be considered, though it has a higher reintervention rate (30%) compared to UAE (13%) 1, 2
• Complications of MRgFUS are rare but include skin burns, nerve damage, vaginal discharge, bowel injury, deep vein thrombosis, and abdominal wall pain 1
• Laparoscopic uterine artery occlusion (LUAO) is associated with decreased post-procedural complications and rehospitalizations compared to UAE 1

Treatment Selection Algorithm

1. For mild symptoms with desire for future fertility:

   • Start with NSAIDs and/or tranexamic acid for acute bleeding episodes 2
   • Consider hormonal contraceptives or levonorgestrel IUD for ongoing management 1, 2

2. For moderate-severe symptoms with desire for future fertility:

   • Consider short-term GnRH modulators with add-back therapy to reduce fibroid size 1, 4
   • For submucosal fibroids <5cm, hysteroscopic myomectomy is recommended 2
   • For intramural or subserosal fibroids, laparoscopic or open myomectomy based on size, number, and location 1

3. For moderate-severe symptoms without desire for future fertility:

   • UAE offers a less invasive alternative to surgery with good long-term outcomes 1, 2
   • MRgFUS may be considered but has higher reintervention rates 1
   • Hysterectomy provides definitive treatment with high satisfaction rates 5

Important Considerations and Pitfalls

• Fertility may be preserved with myomectomy, UAE, or LUAO, though pregnancy rates vary and should be discussed with patients 1
• Medical treatments do not remove fibroids and symptoms typically return when treatment is stopped 6
• GnRH modulators should not be used long-term without add-back therapy due to bone mineral density loss 4, 3
• The choice between surgical approaches should consider the size, number, and location of fibroids, as well as surgeon expertise 5, 7
• Iron deficiency anemia secondary to heavy bleeding should be addressed as part of the comprehensive management plan 7