What are the treatment options for symptomatic leiomyoma (uterine fibroids)?

Treatment Options for Symptomatic Uterine Leiomyoma

For symptomatic uterine fibroids, treatment should be selected from medical management, minimally invasive procedures, or surgical options based on symptom severity, fibroid characteristics, and fertility desires, with hysterectomy being the most definitive solution for those not wishing to preserve fertility. 1

Medical Management

• GnRH agonists effectively reduce fibroid volume by approximately 35% and improve hemoglobin levels, making them suitable for short-term treatment or preoperative preparation, but cause significant hypoestrogenic side effects including bone loss of approximately 1% per month when used without add-back therapy 2, 3

• Add-back therapy (low-dose hormone replacement) with GnRH agonists can mitigate hypoestrogenic side effects while maintaining therapeutic efficacy for longer-term management 2

• Oral contraceptives and progestins may effectively manage bleeding symptoms, especially in women with smaller fibroids, though they have limited effect on fibroid size 1, 4

• Tranexamic acid, a non-hormonal agent, can help reduce menorrhagia associated with fibroids but may cause adverse effects such as pelvic pain and fever 1

• Selective progesterone receptor modulators (SPRMs) have shown promising results in reducing fibroid volume and controlling symptoms, though more long-term studies are needed 1, 5

Minimally Invasive Interventional Treatments

• Uterine Artery Embolization (UAE) has technical success in >95% of cases, resulting in 40-50% decrease in uterine volume and symptom control in approximately 80% of patients 1, 2

• Long-term follow-up shows 20-25% symptom recurrence at 5-7 years after UAE, with higher failure rates in patients <40 years of age 1

• Endometrial ablation is effective for abnormal uterine bleeding with >95% patient satisfaction, but has a 23% failure rate in treating patients with submucosal fibroids compared to 4% in patients with normal uterine cavities 1

• MR-guided Focused Ultrasound Surgery (MRgFUS) uses high-intensity ultrasound to ablate fibroid tissue, though data on long-term outcomes and fertility after this procedure are limited 1, 6

• Laparoscopic approaches using Nd:YAG laser, bipolar needles, monopolar cautery, or cryotherapy (myolysis) can reduce fibroid volume by 40-80%, offering a promising option for women seeking uterus-preserving treatment 1, 2

Surgical Management Options

• Hysterectomy is the definitive treatment for symptomatic fibroids with up to 90% of patients reporting at least moderate satisfaction 2 years after the procedure 1, 4

• Potential drawbacks of hysterectomy include loss of fertility, concerns regarding femininity, and increased risk for ovarian failure (nearly twofold) even with ovarian preservation 1

• Myomectomy is appropriate for women wishing to preserve fertility, with recurrence rates of approximately 27% at 10 years and higher rates in women with multiple fibroids 1

• Hysteroscopic myomectomy is considered first-line conservative surgical therapy for symptomatic intracavitary fibroids 4

• Laparoscopic myomectomy is associated with 2% major complication and 9% minor complication rates 1

Treatment Selection Algorithm

1. For women not desiring future fertility with severe symptoms:

   • Hysterectomy offers definitive treatment with high satisfaction rates 1, 4

2. For women desiring fertility preservation:

   • Myomectomy (hysteroscopic, laparoscopic, or abdominal depending on fibroid location and size) 1, 4
   • Consider preoperative GnRH agonists to reduce fibroid size and minimize surgical blood loss 1, 2

3. For women seeking uterine preservation but not immediate fertility:

   • UAE is effective for both bleeding and bulk symptoms with good long-term outcomes 1
   • MRgFUS for selected cases with appropriate fibroid characteristics 1, 6

4. For women with predominantly bleeding symptoms and smaller fibroids:

   • Medical management with hormonal options (oral contraceptives, progestins, LNG-IUS) 1, 4
   • Endometrial ablation for those not desiring future fertility 1

Important Considerations and Pitfalls

• Location of fibroids significantly impacts treatment success - cervical fibroids and multiple submucosal fibroids have higher treatment failure rates with UAE 1

• Age impacts treatment outcomes - UAE has higher failure rates in women <40 years, likely due to increased collateral vessel recruitment 1

• Pedunculated subserosal fibroids were previously considered a contraindication to UAE due to concerns about fibroid detachment, but recent studies show good outcomes without complications 1

• For women with coexisting adenomyosis, UAE has shown early success in controlling bleeding symptoms with long-term symptomatic relief ranging from 65% to 88% 1

• When fibroids coexist with endometriosis, surgical methods addressing both conditions simultaneously may be more appropriate 1