What are the management options for uterine fibroids?

Management Options for Uterine Fibroids

The management of uterine fibroids should follow a stepwise approach, starting with medical therapy before considering minimally invasive or surgical interventions, with treatment selection based on symptom severity, desire for fertility, and fibroid characteristics. 1

Medical Management (First-Line)

• NSAIDs and estrogen-progestin oral contraceptives are recommended as first-line treatments for reducing bleeding symptoms associated with fibroids 1, 2
• Tranexamic acid is an effective nonhormonal alternative for patients who cannot use hormonal options 1, 2
• Progestin-containing intrauterine devices (IUDs) effectively reduce bleeding symptoms and should be considered for long-term management 1, 3
• GnRH agonists and oral GnRH antagonists effectively reduce bleeding symptoms and significantly decrease fibroid volume by 18-30% 1, 2
• Combination treatment with low doses of estrogen and progestin (add-back therapy) mitigates hypoestrogenic side effects of GnRH modulators 1, 2

Minimally Invasive Options

• Uterine Artery Embolization (UAE) is effective for patients desiring uterus preservation, with persistent decreases in pain, heavy menstrual bleeding, and average fibroid size reduction of >50% at 5 years 4
• UAE is associated with decreased risk of blood transfusion, shorter hospital stays, and lower rates of new fibroid formation compared to myomectomy 4
• MR-guided Focused Ultrasound (MRgFUS) is another option but has a higher reintervention rate (30%) compared to UAE (13%) 1
• For pedunculated submucosal fibroids, hysteroscopic myomectomy is the procedure of choice 2

Surgical Management

• Hysteroscopic myomectomy involves transvaginal, transcervical removal of submucosal fibroids and is associated with shorter hospitalization and faster recovery compared to other surgical approaches 4
• Laparoscopic or open myomectomy is appropriate for intramural or subserosal fibroids, especially when fertility preservation is desired 4
• Hysterectomy provides definitive resolution of all fibroid-related symptoms but should be considered only when less invasive options are not suitable 4
• If hysterectomy is indicated, the least invasive route should be chosen (vaginal or laparoscopic preferred over abdominal) to minimize complications 4

Treatment Algorithm Based on Patient Characteristics

For Reproductive Age Patients Desiring Fertility:

• First-line: Medical management with NSAIDs, tranexamic acid, or hormonal contraceptives for mild symptoms 1
• For moderate-severe symptoms: Short-term GnRH modulators with add-back therapy to reduce fibroid size 1
• Surgical options: Hysteroscopic myomectomy for submucosal fibroids <5cm; laparoscopic or open myomectomy for other fibroids 1, 3
• UAE may be considered, but patients should be counseled that pregnancy is possible though rates may be lower than with myomectomy 4

For Reproductive Age Patients Not Desiring Fertility:

• First-line: Medical management as above 1
• Second-line: UAE, MRgFUS, or myomectomy based on fibroid location and symptoms 4
• For patients with concurrent adenomyosis: UAE shows better outcomes 4
• Hysterectomy if other treatments fail or if definitive treatment is desired 4

For Postmenopausal Patients:

• Endometrial biopsy is essential to rule out malignancy before any intervention 4
• Hysterectomy is usually appropriate for symptomatic fibroids with negative endometrial biopsy 4
• For submucosal fibroids causing postmenopausal bleeding, hysteroscopic myomectomy may be considered 4

Important Considerations and Pitfalls

• Always rule out malignancy with endometrial biopsy, particularly in postmenopausal patients with fibroid growth or abnormal bleeding 4
• Hysterectomy is associated with potential long-term effects including increased risk of cardiovascular disease, osteoporosis, and dementia 4
• Reintervention rate after UAE is approximately 7% for persistent symptoms 1
• Cessation of GnRH modulator therapy leads to rapid recurrence of symptoms, limiting its use to short-term treatment 1
• The natural history of fibroids is shrinkage and symptom resolution with menopause, which should be considered in perimenopausal patients 4