Treatment Options for Symptomatic Uterine Fibroids

Medical management should be trialed as first-line therapy for symptomatic uterine fibroids before pursuing more invasive treatments. 1, 2

Medical Management Options

NSAIDs and estrogen-progestin oral contraceptives are recommended as first-line treatments for reducing bleeding symptoms associated with uterine fibroids 2, 3
Tranexamic acid is an effective nonhormonal alternative for patients who cannot use hormonal options 2, 3
Progestin-containing intrauterine devices (IUDs) effectively reduce bleeding symptoms and should be considered for long-term management 2, 3

GnRH agonists and oral GnRH antagonists effectively reduce bleeding symptoms and significantly decrease fibroid volume by 18-30% 2, 3
Combination treatment with low doses of estrogen and progestin (add-back therapy) mitigates hypoestrogenic side effects of GnRH modulators and is FDA-approved for fibroid-related heavy menstrual bleeding 1, 2
Progesterone receptor modulators (like ulipristal acetate) show promise but have limited availability in the US due to concerns about hepatotoxicity 1, 3

Hysteroscopic myomectomy is the procedure of choice for pedunculated submucosal fibroids <5 cm 2, 3
Laparoscopic myomectomy offers shorter hospital stays and faster return to usual activities compared to open myomectomy 2
Both laparoscopic and open myomectomy improve quality of life for up to 10 years 2

Hysterectomy provides definitive resolution of all fibroid-related symptoms and remains the most common treatment for uterine fibroids in the United States 1, 3
Hysterectomy should be performed via the least invasive route possible to minimize complications 1
Important considerations with hysterectomy include potential long-term effects such as increased risk of cardiovascular disease, osteoporosis, and dementia 1

Uterine Artery Embolization (UAE) is effective for patients desiring uterus-preserving therapy, improving symptom scores and quality of life for up to 7 years 2, 3
UAE demonstrates greater reduction in fibroid diameter (53%) compared to laparoscopic uterine artery occlusion (39%) 2
MR-guided Focused Ultrasound (MRgFUS) is another option but has a higher reintervention rate (30%) compared to UAE (13%) 2, 3
For pedunculated submucosal fibroids, MRgFUS can decrease fibroid volume by 66% with significant improvement in symptom scores 1

Start with NSAIDs, tranexamic acid, or hormonal contraceptives for mild symptoms 2
For moderate-severe symptoms, consider short-term GnRH modulators with add-back therapy to reduce fibroid size 2
Hysteroscopic myomectomy for submucosal fibroids <5cm; laparoscopic or open myomectomy for other fibroids 1, 2

Medical management as first-line therapy 1
Consider laparoscopic/open myomectomy, MRgFUS, or UAE as equivalent alternatives if medical management fails 1
For patients with concurrent adenomyosis, medical management or UAE is particularly appropriate 1

Hysterectomy is usually appropriate for postmenopausal patients with symptomatic fibroids and negative endometrial biopsy 1
Benefits include pathologic evaluation of the uterus to confirm absence of malignancy 1

Always rule out malignancy with endometrial biopsy, particularly in postmenopausal patients with fibroid growth or abnormal bleeding 1
Reintervention rate after UAE is approximately 7% for persistent symptoms 3
Cessation of GnRH modulator therapy leads to rapid recurrence of symptoms 1
Hysterectomy should be avoided if a less invasive procedure can provide adequate symptom relief due to higher complication rates 1