Treatment Options for Symptoms of Multi-Fibroid Uterus
Medical management should be trialed as first-line therapy before pursuing more invasive treatments for patients with symptomatic uterine fibroids. 1
Common Symptoms of Multi-Fibroid Uterus
- Heavy and prolonged uterine bleeding, which can lead to anemia 1, 2
- Pelvic pain and pressure 1, 3
- Bulk symptoms (pressure, pain, fullness) 1
- Bowel and bladder symptoms (frequency, urgency, retention, constipation) 1, 4
- Reproductive dysfunction and infertility 1, 2
First-Line Medical Management
- NSAIDs and tranexamic acid for reducing bleeding symptoms 5, 2
- Hormonal contraceptives (estrogen-progestin oral contraceptives) for bleeding control 5, 4
- Progestin-containing intrauterine devices (IUDs) for long-term management of bleeding 5, 6
Second-Line Medical Management
- GnRH agonists and oral GnRH antagonists can reduce bleeding symptoms and fibroid volume by 18-30% 5, 3
- Combination treatment with low doses of estrogen and progestin can mitigate hypoestrogenic side effects 5
Surgical Options Based on Patient Characteristics
For Reproductive Age Patients Desiring Pregnancy
- Laparoscopic or open myomectomy is usually appropriate for patients with reproductive dysfunction 1
- MR-guided Focused Ultrasound (MRgFUS) or Uterine Artery Embolization (UAE) may be considered 1
For Reproductive Age Patients with No Desire for Future Fertility
- Laparoscopic or open myomectomy, medical management, MRgFUS, or UAE are all usually appropriate 1
- For patients with concurrent adenomyosis, medical management or UAE is usually appropriate 1
For Patients with Pedunculated Submucosal Fibroids
- Hysteroscopic myomectomy is the procedure of choice for submucosal fibroids <5 cm 5, 6
- Medical management should be trialed first 1
For Postmenopausal Patients
- Hysterectomy is usually appropriate for postmenopausal patients with negative endometrial findings 1, 4
- Provides definitive resolution of all fibroid-related symptoms 5, 7
Minimally Invasive Alternatives
- Uterine Artery Embolization (UAE) is effective for patients with adenomyosis and fibroids, with symptom improvement for up to 7 years 5, 3
- Reintervention rate after UAE is approximately 7% for persistent symptoms 5
- MR-guided Focused Ultrasound (MRgFUS) has a higher reintervention rate (30%) compared to UAE (13%) 5
Important Considerations
- The location, size, and number of fibroids should guide treatment selection 2, 3
- Treatment for fibroids should control symptoms while preserving future fertility if desired 3
- Hysterectomy remains the most common treatment for uterine fibroids in the United States, accounting for three-quarters of fibroid treatments 5, 7
- Rapid growth of fibroids should prompt urgent referral due to rare risk of sarcomatous change 7