What are the management options for uterine fibroids?

Management of Uterine Fibroids

For symptomatic uterine fibroids, treatment selection depends primarily on fertility desires, symptom type (bleeding vs. bulk), and fibroid characteristics, with first-line medical management using hormonal contraceptives or NSAIDs for bleeding control, progressing to GnRH antagonists with add-back therapy for inadequate response, and reserving surgical options (myomectomy for fertility preservation, hysterectomy for definitive cure) when medical management fails. 1, 2

Asymptomatic Fibroids

• Expectant management is recommended for asymptomatic fibroids, as most decrease in size during menopause without intervention 3
• Monitor with periodic imaging only if fibroids are large (>5 cm) or show rapid growth, which rarely indicates malignant transformation 4, 5

Medical Management Algorithm

First-Line Options for Heavy Menstrual Bleeding

• Start with estrogen-progestin oral contraceptive pills or levonorgestrel-releasing IUD as these effectively reduce bleeding symptoms with the strongest evidence base 1, 2, 6
• NSAIDs provide direct pain control and modest reduction in menstrual blood loss, making them appropriate for patients with both bleeding and pain 2, 6
• Tranexamic acid is the preferred nonhormonal alternative for patients who cannot or will not use hormonal options, with significant reduction in menstrual blood loss 1, 2

Second-Line Options When First-Line Fails

• Oral GnRH antagonists (relugolix, elagolix, or linzagolix) with hormone add-back therapy are the most effective second-line agents, significantly reducing both bleeding and fibroid volume 1, 2, 4
• These agents offer advantages over parenteral GnRH agonists including oral administration and rapid onset of action 2
• Combination treatment with low-dose estrogen and progestin is FDA-approved to mitigate hypoestrogenic side effects (hot flashes, bone loss) while maintaining efficacy 1, 2
• Critical caveat: Fertility is suppressed during treatment and symptoms recur rapidly after cessation, making these agents suitable only for temporary management or preoperative optimization 1, 2

Progesterone Receptor Modulators

• Ulipristal acetate reduces both bleeding and bulk symptoms and can be administered intermittently for up to 2 years with maintained efficacy 1, 2
• Amenorrhea rates reach 70-83% depending on dose (5-10 mg daily), with median fibroid volume reduction of 65-67% 1
• Major limitation: Reports of hepatotoxicity prevent FDA approval in the United States, though it remains available in other countries 1, 4

Surgical Management Based on Fertility Desires

For Patients Desiring Fertility Preservation

• Hysteroscopic myomectomy is the procedure of choice for submucosal fibroids <5 cm, offering shorter hospitalization and faster recovery than other surgical approaches 1
• Laparoscopic or open myomectomy is indicated for intramural or subserosal fibroids causing symptoms or cavity distortion 1, 4
• Preoperative imaging of the uterine cavity is mandatory before attempting conception, as UPA treatment can induce fibroid migration and cavity changes 1
• If cavity normalizes after medical treatment, patients may attempt natural or assisted conception without surgery 1, 4
• If cavity remains distorted, myomectomy is necessary for fertility optimization 1, 4

For Patients Not Desiring Fertility

• Hysterectomy provides definitive resolution of all fibroid-related symptoms and accounts for three-quarters of fibroid treatment in the United States, with high patient satisfaction rates 1
• Vaginal or laparoscopic routes should be preferred over laparotomy when feasible, as they are associated with shorter recovery and fewer complications 1

Minimally Invasive Interventional Options

Uterine Artery Embolization (UAE)

• UAE is an effective alternative to myomectomy and hysterectomy for symptomatic fibroids in patients not desiring pregnancy, with average fibroid size decrease >50% at 5 years 1, 4
• Lower complication rates and shorter hospitalization compared to hysterectomy 6
• Important caveat: Comprehensive data on fertility and pregnancy outcomes after UAE are lacking, and patients should be counseled accordingly 1
• Live birth rates of approximately 50% have been reported, but this should not be considered a fertility-preserving procedure 4

MR-Guided Focused Ultrasound (MRgFUS)

• MRgFUS uses high-intensity ultrasound waves to thermally ablate fibroids with significant improvement in quality of life and 18% decrease in fibroid diameter compared to placebo 4
• This is a non-invasive option for patients who want to avoid surgery 7, 3

Preoperative Optimization Strategy

• For anemic patients, correct anemia with iron supplementation while simultaneously initiating GnRH agonists or antagonists to control bleeding and reduce fibroid size 1, 4
• Short courses (3 months) of GnRH therapy effectively shrink fibroids and may facilitate minimally invasive surgical approaches 1, 2
• UPA pretreatment does not increase surgical difficulty and may improve ease of hysteroscopic or laparoscopic myomectomy 1

Special Clinical Scenarios

Pedunculated Submucosal Fibroids

• Hysteroscopic myomectomy is the definitive procedure of choice for pedunculated submucosal fibroids <5 cm 1
• Medical management can temporize bleeding symptoms but does not address the structural problem 1

Acute Pelvic Pain

• Suspect fibroid degeneration if patient presents with severe sudden-onset pain, fever, nausea, and leukocytosis 6
• This typically requires supportive care with NSAIDs and observation, as it is self-limited 6

Perimenopausal Patients

• Consider short-term medical management while awaiting natural fibroid regression during menopause, as fibroids shrink due to decreased circulating estrogen 4, 6

Critical Pitfalls to Avoid

• Never use long-term GnRH agonists or antagonists without add-back therapy, as this leads to significant bone mineral density loss 2, 6
• Most medical treatments provide only temporary symptom relief with rapid recurrence after discontinuation, requiring ongoing management or eventual surgical intervention 2, 6
• Endometrial ablation carries high risk of pregnancy complications and should never be used in patients desiring fertility 1
• Rapid fibroid growth in postmenopausal women warrants urgent referral to rule out leiomyosarcoma, though this remains rare 5
• Hysterectomy has been associated with increased long-term risks of cardiovascular disease, osteoporosis, bone fracture, and dementia in cohort studies 6