What are the treatment options for uterine fibroids?

Treatment for Uterine Fibroids

Start with first-line medical management using NSAIDs, tranexamic acid, combined oral contraceptives, or levonorgestrel IUD for bleeding control, then escalate to GnRH antagonists with hormone add-back therapy if symptoms persist, reserving surgical options for medical treatment failures or when definitive resolution is required. 1, 2

First-Line Medical Management

For patients presenting with heavy menstrual bleeding, begin with these options:

• NSAIDs and estrogen-progestin oral contraceptive pills are the recommended initial treatments that effectively reduce fibroid-related bleeding symptoms 3, 1, 4
• Levonorgestrel-releasing intrauterine devices provide effective long-term bleeding control and should be strongly considered for ongoing management 1, 2, 4
• Tranexamic acid serves as the preferred nonhormonal alternative for patients who cannot or prefer not to use hormonal options, with significant reduction in menstrual blood loss 3, 1, 4

Second-Line Medical Management

When first-line options fail or are inadequate:

• Oral GnRH antagonists (elagolix, linzagolix, relugolix) are the preferred second-line agents that reduce both bleeding symptoms and fibroid volume by 18-30% 1, 2, 4
• Combination hormone add-back therapy with low-dose estrogen and progestin is mandatory to mitigate hypoestrogenic side effects (hot flushes, bone mineral density loss, hypertension) while maintaining efficacy—this is FDA-approved specifically for fibroid-related heavy menstrual bleeding 3, 1, 4
• Parenteral GnRH agonists (leuprolide acetate) remain effective but are less preferred than oral antagonists due to administration route and side effect profile 3

Critical caveat: Fertility is completely suppressed during GnRH therapy, and symptoms recur rapidly after discontinuation—these are temporizing measures, not definitive treatments 1, 4

Progesterone Receptor Modulators

• Ulipristal acetate reduces both bleeding and bulk symptoms and can be administered intermittently with demonstrated efficacy for up to 2 years 3, 1
• However, this option has undergone extensive restrictions due to safety concerns and is no longer widely available 5

Surgical Management Based on Fibroid Location and Fertility Desires

For patients desiring future fertility:

• Hysteroscopic myomectomy is the procedure of choice for pedunculated submucosal fibroids <5 cm, offering shorter hospitalization, faster recovery, and quality of life improvement equivalent to more invasive approaches 3, 2
• Laparoscopic myomectomy is preferred over open myomectomy for other fibroid locations, with shorter hospital stays and faster return to activities while maintaining 10-year quality of life improvement 2, 4

For patients not desiring fertility or requiring definitive treatment:

• Hysterectomy provides definitive resolution of all fibroid-related symptoms and accounts for three-quarters of fibroid treatment in the United States 3
• However, hysterectomy should be avoided if less invasive procedures can provide adequate symptom relief due to higher complication rates, longer hospitalization, and prolonged recovery 2

Minimally Invasive Alternatives

For patients seeking uterus preservation without surgery:

• Uterine artery embolization (UAE) improves symptom scores and quality of life for up to 7 years, with 94% short-term and 85% long-term symptom improvement 3, 2, 4
• UAE demonstrates superior fibroid diameter reduction (53%) compared to laparoscopic uterine artery occlusion (39%) 2, 4
• The reintervention rate is approximately 7% for persistent symptoms 3, 2
• MR-guided focused ultrasound (MRgFUS) can be considered but has a higher reintervention rate (30%) compared to UAE (13%) 4

Treatment Algorithm

Step 1 - Mild symptoms with or without fertility desires:

• Start NSAIDs and/or tranexamic acid for acute bleeding episodes 1, 4
• Add hormonal contraceptives or levonorgestrel IUD for ongoing management 1, 4

Step 2 - Moderate-severe symptoms, first-line failure:

• Initiate GnRH antagonists with mandatory hormone add-back therapy 1, 2, 4
• Use short-term (typically 3 months) to reduce fibroid size and correct anemia 1

Step 3 - Medical management failure or patient preference for definitive treatment:

• If fertility desired: Hysteroscopic myomectomy for submucosal fibroids <5 cm, laparoscopic myomectomy for other locations 2, 4
• If fertility not desired but uterus preservation wanted: UAE as first choice 2, 4
• If definitive resolution required: Hysterectomy 3, 2

Special Populations and Critical Pitfalls

Postmenopausal patients:

• Always perform endometrial biopsy prior to intervention to rule out endometrial neoplasia and diagnose potential sarcoma 2
• Hysterectomy is usually the appropriate treatment for symptomatic fibroids in this population 2

Patients with adenomyosis and fibroids:

• UAE demonstrates improvement in quality of life and symptom scores, especially when fibroids predominate, with 18% requiring hysterectomy for persistent symptoms at 7-year follow-up 3

Critical pitfalls to avoid:

• Do not perform endometrial ablation in patients desiring future fertility due to high risk of pregnancy complications 2
• Do not use GnRH agonists or antagonists long-term without add-back therapy—this causes significant bone mineral density loss 1
• Do not counsel patients that medical management is curative—most treatments provide only temporary symptom relief with recurrence after discontinuation 1