What is the initial approach to managing myoma (uterine fibroids) in the uterus?

Initial Management of Uterine Myomas (Fibroids)

Medical management with NSAIDs and estrogen-progestin oral contraceptive pills should be the first-line treatment for symptomatic uterine fibroids, particularly for bleeding symptoms in women with small fibroids. 1

First-Line Medical Therapy

The least invasive approach prioritizes medical management before considering procedural interventions:

For Bleeding Symptoms

• NSAIDs and estrogen-progestin oral contraceptive pills effectively reduce bleeding symptoms and should be initiated first 1
• Tranexamic acid serves as a nonhormonal alternative for reducing bleeding symptoms 1
• Oral contraceptives manage bleeding effectively, especially in women with small fibroids 1

Second-Line Medical Options

• GnRH agonists (leuprolide acetate) and oral GnRH antagonists (elagolix, linzagolix, relugolix) significantly reduce both bleeding symptoms and tumor volume by 18-30% 1, 2
• These agents are particularly effective for bulk-related symptoms due to their ability to reduce uterine and myoma volume 1
• Combination treatment with low-dose estrogen and progestin mitigates hypoestrogenic side effects (headaches, hot flushes, bone loss) and is FDA-approved for fibroid-related heavy menstrual bleeding 1

Critical Limitations of Medical Therapy

• Once GnRH agents are discontinued, fibroids rapidly return to their previous volume and symptoms typically recur 1
• Chronic GnRH agonist use causes trabecular bone loss, limiting their use to temporary situations 1
• These agents are most commonly used for short courses to decrease fibroid size before surgical therapy 1

Surgical Management Algorithm

When medical management fails or is inappropriate, surgical approach depends on fibroid location and patient goals:

For Pedunculated Submucosal Fibroids <5 cm

• Hysteroscopic myomectomy is the procedure of choice, offering shorter hospitalization, faster recovery, and equivalent quality-of-life outcomes to more invasive approaches at 2-3 months 1, 3, 4
• This should be considered first-line conservative surgical therapy for symptomatic intracavitary fibroids 5

For Uterine Preservation in Other Fibroid Types

• Myomectomy (abdominal or laparoscopic) is appropriate when fertility preservation is desired, though recurrence rates range from 23-33% 1
• Uterine artery embolization (UAE) provides reduction in procedural/recovery times and fewer adverse events compared to myomectomy, with similar clinical success rates 1
• UAE causes persistent decreases in pain and heavy menstrual bleeding, with average fibroid size reduction >50% at 5 years 3

Important Reintervention Considerations

• UAE has higher long-term reintervention rates (36%) compared to myomectomy (5%), particularly for fibroids >5 cm 1
• Myomectomy carries 2% major and 9% minor complication rates 1

For Definitive Treatment

• Hysterectomy provides definitive resolution of all fibroid-related symptoms and demonstrates significantly better health-related quality-of-life advantage long-term 1
• Hysterectomy accounts for three-quarters of fibroid treatment in the United States 1
• Meta-analysis shows UAE offers greater short-term benefits (shorter hospital stay, decreased blood loss) with similar long-term quality-of-life but increased reintervention rates 1

Critical Pitfalls to Avoid

• Never perform morcellation without counseling patients about the risk of spreading occult malignancy, which can worsen prognosis 1, 5
• Do not recommend hysterectomy as initial treatment for pedunculated submucosal fibroids, as less invasive approaches are equally effective 1
• Avoid endometrial ablation for submucosal fibroids—there is no supporting literature for this approach 1, 3, 4
• Correct anemia preoperatively using selective progesterone receptor modulators or GnRH analogues before elective surgery 5
• Consider vasopressin, bupivacaine/epinephrine, misoprostol, peri-cervical tourniquet, or gelatin-thrombin matrix to reduce blood loss at myomectomy 5

Special Populations

Asymptomatic Fibroids

• Reassurance and careful follow-up are appropriate—there is no evidence to substantiate major concern about malignancy, and hysterectomy is not indicated 5
• The majority of fibroids are asymptomatic and require no intervention 5

Pregnancy Considerations

• Myomectomy is not indicated for fibroids detected in pregnancy except in women with previous pregnancy complications specifically related to fibroids 5
• Women with fibroids in pregnancy may require additional maternal and fetal surveillance 5
• Counsel patients choosing UAE that fecundity and pregnancy may be impacted 5