What is the best management approach for a patient with multiple uterine fibroids (leiomyomas)?

Management of Multiple Uterine Fibroids

For patients with multiple uterine fibroids, medical management should be trialed first before pursuing more invasive therapies, with treatment selection based on symptom severity, desire for future fertility, and fibroid characteristics. 1

Initial Assessment Considerations

• Evaluate for symptoms including heavy menstrual bleeding, pelvic pressure, pain, fullness, and bladder or bowel symptoms 1, 2
• Assess the patient's desire for future fertility, as this significantly impacts treatment selection 1
• Determine fibroid characteristics including size, number, and location (submucosal, intramural, subserosal) through imaging, preferably ultrasonography 2
• Consider patient's age and proximity to menopause, as fibroids typically decrease in size during menopause 2, 3

First-Line Medical Management

• NSAIDs and estrogen-progestin oral contraceptive pills are recommended as first-line treatments for reducing bleeding symptoms 1, 4
• Progestin-containing intrauterine devices (IUDs) effectively reduce bleeding symptoms and are suitable for long-term management 1, 4
• Tranexamic acid is an effective nonhormonal alternative for reducing bleeding symptoms in patients who cannot use hormonal options 1, 4

Second-Line Medical Management

• GnRH agonists (e.g., leuprolide acetate) and oral GnRH antagonists (e.g., elagolix, linzagolix, relugolix) effectively reduce bleeding symptoms and significantly reduce fibroid volume by 18-30% 1
• These medications are particularly useful for short courses to decrease fibroid size in preparation for surgery 1
• Combination treatment with low doses of estrogen and progestin can mitigate hypoestrogenic side effects and is FDA-approved for fibroid-related heavy menstrual bleeding 1, 4
• Be aware that fertility is suppressed during treatment, and symptoms typically recur rapidly after cessation of therapy 1

Surgical Options Based on Fertility Desires

For Patients Desiring Future Fertility:

• Laparoscopic or open myomectomy is recommended for subserosal or intramural fibroids 1

  • Open myomectomy is preferred over laparoscopic approaches in patients with multiple fibroids or very large uteri 1
  • Laparoscopy offers shorter hospital stays and faster return to usual activities 1
  • Both procedures improve quality of life for up to 10 years 1
  • Counsel patients about potential uterine rupture during subsequent pregnancy 1

• Hysteroscopic myomectomy is indicated for submucosal fibroids 1

  • Particularly effective for pedunculated submucosal fibroids <5cm 1
  • Associated with shorter hospitalization and faster recovery compared to other surgical approaches 1

For Patients Not Desiring Future Fertility:

• Hysterectomy provides definitive resolution of all fibroid-related symptoms 1

  • Remains the most common treatment for uterine fibroids, accounting for 75% of fibroid treatments in the US 1
  • Associated with very high patient satisfaction scores (up to 90%) 1
  • Consider potential risks including earlier onset of menopause even with ovarian preservation 1

• Uterine Artery Embolization (UAE) is an effective minimally invasive alternative 1, 4

  • Improves symptom scores and quality of life for up to 7 years 4
  • Has a reintervention rate of approximately 7% for persistent symptoms 4
  • Location of fibroids affects outcomes, with cervical fibroids having higher treatment failure rates 1

• MR-guided Focused Ultrasound (MRgFUS) can be considered, though it has a higher reintervention rate (30%) compared to UAE (13%) 4

Special Considerations

• For patients with concurrent adenomyosis and fibroids, medical management or UAE is usually appropriate 1
• For pedunculated submucosal fibroids causing heavy bleeding, hysteroscopic myomectomy or medical management is recommended 1
• For postmenopausal patients with symptomatic fibroids, hysterectomy is usually appropriate after negative endometrial evaluation 1

Common Pitfalls and Caveats

• Sarcomatous change within fibroids is rare but should be considered with rapid growth; such cases warrant urgent referral 3
• Fertility outcomes after fibroid treatments vary significantly; less than half of patients trying to conceive achieve pregnancy after myomectomy, and less than half of these pregnancies result in live birth 1
• Medical treatments do not remove fibroids and symptoms typically return when treatment is stopped 5
• Treatment failure rates after UAE are higher (23%) in patients under 40 years of age, likely due to collateral vessel recruitment 1