What are the treatment options for symptomatic uterine fibroids?

Treatment Options for Symptomatic Uterine Fibroids

The most effective treatment approach for symptomatic uterine fibroids begins with medical management using NSAIDs and estrogen-progestin oral contraceptive pills as first-line treatments, followed by minimally invasive procedures like uterine artery embolization if medical therapy fails, with hysterectomy reserved for definitive treatment when other options are unsuccessful or inappropriate. 1, 2

Medical Management Options

First-Line Treatments

• NSAIDs and estrogen-progestin oral contraceptive pills are recommended first-line medical treatments for reducing bleeding symptoms associated with uterine fibroids 1, 2
• Progestin-containing intrauterine devices (IUDs) effectively reduce bleeding symptoms and should be considered for long-term management of fibroid-related bleeding 2
• Tranexamic acid is an effective nonhormonal alternative that can reduce bleeding symptoms in patients with fibroids who cannot use hormonal options 1, 2

Second-Line Treatments

• GnRH agonists (e.g., leuprolide acetate) and oral GnRH antagonists (e.g., elagolix, linzagolix, relugolix) are effective second-line options that both reduce bleeding symptoms and significantly reduce fibroid volume by 18-30% 1, 2
• These medications can be used for short courses to decrease fibroid size in preparation for surgery 1
• Combination treatment with low doses of estrogen and progestin (add-back therapy) mitigates the hypoestrogenic side effects of GnRH modulators and is FDA-approved for fibroid-related heavy menstrual bleeding 1, 2
• Progesterone receptor modulators such as ulipristal acetate show efficacy in reducing both bleeding and bulk symptoms, but reports of hepatotoxicity have prevented approval in the United States 1

Minimally Invasive Interventions

Uterine Artery Embolization (UAE)

• UAE is effective for patients with fibroids who desire 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%) 1, 2
• The reintervention rate after UAE is approximately 7-13% for persistent symptoms 1, 3

MR-Guided Focused Ultrasound (MRgFUS)

• MRgFUS uses high-intensity ultrasound waves to thermally ablate fibroids without damaging intervening tissues 1
• Compared to placebo, MRgFUS demonstrates significantly greater improvement in quality of life and decrease in fibroid diameter (18% versus no change) 1
• However, MRgFUS has a higher reintervention rate (30%) compared to UAE (13%) and decreased symptom control 1, 2
• MRgFUS procedures are longer (6.75 hours versus 2.3 hours for UAE) but are associated with decreased postprocedural pain and faster recovery 1

Surgical Management Options

Myomectomy

• Hysteroscopic myomectomy is the procedure of choice for pedunculated submucosal fibroids <5 cm, offering shorter hospitalization and faster recovery compared to other approaches 2, 3
• Laparoscopic myomectomy is associated with shorter hospital stays and faster return to usual activities compared to open myomectomy 2
• Both laparoscopic and open myomectomy procedures are associated with improved quality of life for up to 10 years 2

Hysterectomy

• Hysterectomy provides definitive resolution of all fibroid-related symptoms and remains the most common treatment for uterine fibroids 3
• This option is most appropriate for perimenopausal women who have completed childbearing 3, 4
• When possible, vaginal or laparoscopic routes should be preferred to laparotomy 5

Treatment Selection Algorithm

For Patients Desiring Future Fertility

• For mild symptoms: Start with NSAIDs and/or tranexamic acid for acute bleeding episodes, and consider hormonal contraceptives or levonorgestrel IUD for ongoing management 2, 6
• For moderate-severe symptoms: Consider short-term GnRH modulators with add-back therapy to reduce fibroid size, and hysteroscopic myomectomy for submucosal fibroids <5cm 2, 6
• Myomectomy (hysteroscopic, laparoscopic, or open depending on fibroid location) is the preferred surgical approach 6

For Patients Not Concerned with Fertility

• First-line: Medical management with NSAIDs, hormonal contraceptives, or levonorgestrel IUD 1, 2
• Second-line: GnRH agonists or antagonists with add-back therapy 1, 6
• For persistent symptoms: Consider UAE or MRgFUS as less invasive alternatives to surgery 2, 3
• For definitive treatment: Hysterectomy provides permanent cure for symptomatic fibroids 6, 3

Special Considerations

• Endometrial thickening must be addressed before or concurrently with fibroid treatment, as it may indicate endometrial hyperplasia or malignancy 6
• The choice of treatment depends on fibroid size, location, and number, as well as the severity of symptoms and the patient's fertility desires 7, 8
• Perimenopausal women may benefit from short-term medical management while awaiting natural regression of fibroids during menopause 6
• Rapid growth of fibroids should be monitored closely, as it can occasionally indicate malignant transformation, although this is rare 6