From the Guidelines
Management of a myomatous uterus should prioritize a personalized approach, considering the patient's symptoms, fibroid characteristics, and reproductive goals, with medical management options including hormonal medications, and surgical options such as myomectomy or hysterectomy for persistent symptoms or large fibroids. For asymptomatic fibroids, watchful waiting with regular monitoring is appropriate. For symptomatic cases, first-line medical management includes NSAIDs and estrogen-progestin oral contraceptive pills, which reduce bleeding symptoms 1. Tranexamic acid is a nonhormonal alternative agent that may reduce bleeding symptoms in patients with fibroids 1.
Some key considerations in managing myomatous uteri include:
- The patient's age and symptom severity
- Fibroid size and location
- Desire for future pregnancy
- Personal preferences
- The potential benefits and risks of different treatment options, including medical management with GnRH agonists or antagonists, and surgical options such as myomectomy or hysterectomy 1
Recent studies have also highlighted the efficacy of progesterone receptor modulators such as ulipristal acetate in reducing both bleeding and bulk symptoms, although reports of hepatotoxicity are a concern 1. Ultimately, treatment selection should be individualized based on the patient's unique needs and circumstances, with a focus on minimizing morbidity, mortality, and improving quality of life. Minimally invasive options, such as uterine artery embolization and focused ultrasound surgery, may also be considered for women who are not candidates for, or prefer not to undergo, traditional surgical procedures 1.
From the Research
Myomatous Uterus Management Options
- Asymptomatic myomas may be managed by reassurance and careful follow up 2
- Medical therapy should be tried as a first line of treatment for symptomatic myomas, while surgical treatment should be reserved only for appropriate indications 2
- Management should be tailored to the size and location of fibroids; the patient's age, symptoms, desire to maintain fertility, and access to treatment; and the experience of the physician 3
Medical Therapy
- Hormonal contraceptives, tranexamic acid, and nonsteroidal anti-inflammatory drugs can be used to reduce heavy menstrual bleeding 3
- Gonadotropin-releasing hormone agonists or selective progesterone receptor modulators are an option for patients who need symptom relief preoperatively or who are approaching menopause 3
- GnRH analogs (agonists and antagonists) modulate the pulsatile release of GnRH and can be used in therapy, agonists instead as a preparation for surgery, and antagonists as a drug for long-term use 4
Surgical Treatment
- Hysterectomy has its place in myoma management in its definitiveness 2
- Myomectomy, rather than hysterectomy, should be performed when subsequent childbearing is a consideration 2
- Uterine artery embolization is an effective standard alternative for women with large symptomatic myomas who are poor surgical risks or wish to avoid major surgery 2
- Magnetic resonance-guided focused ultrasound surgery is also a surgical treatment option 3