What are the treatment options for a fibrous uterus?

Treatment Options for Fibrous Uterus (Uterine Fibroids)

Medical management should be trialed as first-line therapy for uterine fibroids before pursuing more invasive therapies in most cases. 1

Initial Assessment and Treatment Approach

• Treatment must be based on symptomatology (bleeding, pain, bulk symptoms), fibroid characteristics (size, location, number), patient age, and fertility desires 1, 2
• Asymptomatic fibroids generally require no intervention beyond monitoring for stability in size and growth 3
• For symptomatic fibroids, first-line medical management options include:
  • NSAIDs and tranexamic acid for acute bleeding episodes 2, 4
  • Estrogen-progestin oral contraceptives for reducing bleeding symptoms 5, 2
  • Progestin-containing intrauterine devices (IUDs) for long-term management of fibroid-related bleeding 5, 2

Medical Management Options

• First-line medical treatments for heavy menstrual bleeding:
  • Combined oral contraceptives effectively reduce bleeding symptoms 5, 2
  • Levonorgestrel intrauterine system (LNG-IUS) is effective for long-term management 2, 4
  • Tranexamic acid provides non-hormonal management of acute bleeding 2, 6
• Second-line medical treatments:
  • GnRH agonists and antagonists reduce bleeding symptoms and fibroid volume by 18-30% 2, 4
  • Selective progesterone receptor modulators (SPRMs) effectively treat both bleeding and bulk symptoms 2, 7
  • Add-back therapy (low-dose estrogen and progestin) can mitigate side effects of GnRH modulators 2

Surgical Management Options

• For reproductive-age patients with symptomatic fibroids desiring fertility:
  • Hysteroscopic myomectomy is first-line for pedunculated submucosal fibroids causing heavy bleeding 1, 8, 4
  • Laparoscopic or open myomectomy for intramural or subserosal fibroids 1, 2
• For reproductive-age patients with no desire for future fertility:
  • Laparoscopic or open myomectomy, medical management, MRgFUS, or UAE are all appropriate options 1
• For patients with fibroids and concurrent adenomyosis:
  • Medical management or UAE is recommended as initial therapy 1, 2
• For postmenopausal patients with symptomatic fibroids:
  • Hysterectomy is usually appropriate after negative endometrial evaluation 1, 4

Minimally Invasive Alternatives

• Uterine Artery Embolization (UAE):
  • Effective for patients desiring uterus-preserving therapy 2, 4
  • Demonstrates greater reduction in fibroid diameter (53%) compared to laparoscopic uterine artery occlusion (39%) 2
• MR-guided Focused Ultrasound (MRgFUS):
  • Non-invasive option but has higher reintervention rate (30%) compared to UAE (13%) 2
• Both UAE and MRgFUS may impact future fertility and pregnancy outcomes 2, 4

Important Considerations and Caveats

• Endometrial thickening must be evaluated with biopsy before addressing fibroid management to rule out endometrial hyperplasia or malignancy 8
• Perimenopausal women may benefit from short-term medical management while awaiting natural regression of fibroids during menopause 8, 5
• Rapid growth of fibroids should prompt closer monitoring as it can occasionally indicate malignant transformation, although leiomyosarcomas are extremely rare (less than 1 in 1000) 8, 3
• Anemia should be corrected prior to elective surgery; SPRMs and GnRH analogues are effective for this purpose 4
• Hysterectomy is the most definitive treatment for symptomatic fibroids but is only appropriate for women who have completed childbearing 4, 6