What are the treatment options for cervical fibroids?

Treatment Options for Cervical Fibroids

The treatment of cervical fibroids should be based on symptoms, size and location of the fibroids, age, and desire to preserve fertility or the uterus, with options ranging from medical management to surgical interventions. 1

Classification and Prevalence

• Uterine fibroids are the most common benign tumors of the female reproductive tract, with a prevalence of up to 80% in women by age 50 1
• Fibroids can be classified as submucosal (projecting into the uterine cavity), intramural (within the uterine wall), or subserosal (projecting toward the external surface) 1
• Cervical fibroids specifically are located in the cervical region and may present with unique symptoms and treatment challenges 1

Symptoms

• Heavy menstrual bleeding (menorrhagia) is the most frequent symptom of fibroids, often resulting in iron deficiency anemia 2
• Cervical fibroids may cause additional symptoms such as:
  • Pelvic pressure and pain 1
  • Urinary frequency or retention 3
  • Constipation due to pressure on surrounding structures 3
  • Reproductive dysfunction including fertility issues 2

Treatment Algorithm

Medical Management Options

• First-line medical treatments:

  • Combined oral contraceptives to reduce bleeding 4
  • Levonorgestrel-releasing intrauterine devices to control bleeding symptoms 4
  • Tranexamic acid as a non-hormonal alternative for reducing bleeding 4
  • NSAIDs for pain management and reduction of bleeding 4

• Second-line medical treatments:

  • GnRH agonists (e.g., leuprolide acetate) can temporarily reduce fibroid size by 18-30% and control bleeding, often used before surgery 4, 5
  • GnRH antagonists (elagolix, linzagolix, relugolix) reduce bleeding and tumor volume 1
  • Selective progesterone receptor modulators (SPRMs) can reduce bleeding and pressure symptoms 1

Surgical Management Options

• Myomectomy is the preferred option for women who wish to preserve fertility 1

  • Hysteroscopic myomectomy is the first-line conservative surgical therapy for symptomatic submucosal fibroids 6
  • Laparoscopic myomectomy is suitable for fibroids <15 cm in size and no more than three fibroids with a size of 5 cm 7
  • Open myomectomy may be necessary for larger or multiple fibroids 8

• Hysterectomy is the definitive treatment for symptomatic fibroids in women who have completed childbearing 1, 6

  • Provides permanent cure with high satisfaction rates 6
  • Should be performed using the least invasive approach possible 6

Minimally Invasive Alternatives

• Uterine Artery Embolization (UAE):

  • Effective for patients with fibroids who desire uterus-preserving therapy 4
  • Reduces fibroid volume by 40-50% and controls symptoms in approximately 80% of cases 1
  • Has a reintervention rate of approximately 7% due to persistent symptoms 1, 4

• Magnetic Resonance-guided Focused Ultrasound Surgery (MRgFUS):

  • Non-invasive option for selected patients 1
  • Has a higher reintervention rate (30%) compared to UAE (13%) 4

• Laparoscopic radiofrequency ablation:

  • Emerging minimally invasive option 8
  • Promising results but requires further study 8

Pre-treatment Considerations

• Anemia should be corrected prior to proceeding with elective surgery 6
• Surgical planning for myomectomy should be based on mapping the location, size, and number of fibroids with appropriate imaging 6
• Asymptomatic fibroids generally do not require treatment but should be monitored for growth 3

Special Considerations for Cervical Fibroids

• Due to their location, cervical fibroids may be more challenging to access surgically 1
• Hysteroscopic approaches may be preferred for cervical fibroids that project into the cervical canal 7
• UAE may be particularly effective for cervical fibroids due to their blood supply 4

Treatment Outcomes and Expectations

• Hysterectomy provides definitive resolution of all fibroid-related symptoms 4
• The pregnancy rate after myomectomy is less than 50% in follow-ups of up to 3 years 1
• Medical treatments typically provide temporary relief but symptoms may return when treatment is discontinued 9

Pitfalls and Caveats

• Malignant transformation of fibroids (leiomyosarcoma) is extremely rare (less than one in 1000) 9
• When morcellation is necessary to remove fibroids, patients should be informed about the rare risk of spreading undiagnosed malignancy 6
• Uterine artery embolization may impact fertility and pregnancy outcomes and should be used cautiously in women desiring future pregnancy 6