What is the recommended birth control regimen for managing uterine myomas (fibroids)?

Birth Control for Uterine Myomas

Estrogen-progestin oral contraceptive pills and progestin-containing intrauterine devices (levonorgestrel IUD) are the recommended first-line birth control options for managing bleeding symptoms associated with uterine fibroids. 1

First-Line Hormonal Birth Control Options

Combined Oral Contraceptive Pills

• Combined estrogen-progestin oral contraceptive pills effectively reduce heavy menstrual bleeding associated with fibroids and are recommended by the American College of Radiology as first-line therapy. 1, 2
• These pills control bleeding symptoms but do not reduce fibroid size, so they are appropriate for symptom management rather than fibroid volume reduction. 3
• They are particularly suitable for women with small fibroids who primarily need bleeding control. 3

Levonorgestrel Intrauterine Device (IUD)

• The levonorgestrel IUD is the most effective first-line treatment for reducing menstrual blood loss in women with fibroids. 3
• This option provides long-term management of bleeding symptoms and should be strongly considered for ongoing contraception and symptom control. 1, 2
• Like oral contraceptives, the levonorgestrel IUD addresses bleeding symptoms only and does not shrink fibroids. 3

Important Clinical Considerations

When Birth Control Is Appropriate

• Birth control methods are ideal for women with heavy menstrual bleeding as their primary symptom who desire contraception. 1
• These options work best for patients with smaller fibroids who do not require fibroid volume reduction. 3

Limitations and Pitfalls

• Neither oral contraceptives nor progestin IUDs reduce fibroid size, so they are inappropriate if fibroid volume reduction is needed (such as for bulk symptoms or preoperative preparation). 3
• Symptoms typically persist as long as fibroids remain, though bleeding is controlled with these methods. 1
• Most medical treatments provide only temporary symptom relief, requiring ongoing management. 1

Alternative Hormonal Options for Specific Scenarios

Second-Line Options When First-Line Fails

• If combined oral contraceptives or levonorgestrel IUD provide inadequate bleeding control, progress to oral GnRH antagonists (elagolix, linzagolix, or relugolix) with hormone add-back therapy. 1
• These agents both reduce bleeding symptoms and significantly decrease fibroid volume by 18-30%. 2
• Combination treatment with low-dose estrogen and progestin as add-back therapy is FDA-approved to mitigate hypoestrogenic side effects while maintaining efficacy. 1, 2

When Fibroid Volume Reduction Is Required

• If the patient needs fibroid shrinkage (for bulk symptoms or surgical preparation), birth control pills and IUDs are not appropriate—GnRH agonists or antagonists are required instead. 1, 3
• Fertility is suppressed during GnRH treatment, and symptoms recur rapidly after cessation. 1, 3