What are the management options for a uterus with leiomyomas (uterine fibroids) in a postmenopausal woman?

From the Guidelines

Asymptomatic postmenopausal women with a myomatous uterus should be managed with observation, while symptomatic women may require medical or surgical intervention to alleviate symptoms and improve quality of life. The management of a myomatous uterus in postmenopausal women should prioritize minimizing morbidity, mortality, and optimizing quality of life.

Medical Management

Medical management options for symptomatic postmenopausal women with uterine fibroids include:

• Nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce bleeding and pain symptoms 1
• Estrogen-progestin oral contraceptive pills and progestin-containing intrauterine devices (IUDs) to reduce bleeding symptoms 1
• Tranexamic acid as a nonhormonal alternative to reduce bleeding symptoms 1
• Gonadotropin-releasing hormone (GnRH) agonists and antagonists to reduce bleeding and tumor volume, although these are typically used for short courses due to hypoestrogenic effects 1
• Progesterone receptor modulators such as ulipristal acetate, which can reduce bleeding and bulk symptoms, although its use is limited due to reports of hepatotoxicity 1

Surgical Management

Surgical management options for symptomatic postmenopausal women with uterine fibroids include:

• Hysterectomy, which provides definitive treatment and eliminates recurrence risk 1
• Minimally invasive approaches like vaginal, laparoscopic, or robotic hysterectomy, which are preferred when feasible
• Uterine artery embolization, which involves blocking blood flow to the fibroids, causing them to shrink

Monitoring and Evaluation

Any postmenopausal bleeding in women with fibroids requires prompt evaluation to rule out endometrial hyperplasia or cancer, typically with endometrial biopsy or hysteroscopy 1. Hormone replacement therapy is generally not contraindicated in women with fibroids but should be used cautiously as it may stimulate fibroid growth in some cases. The management approach should be individualized based on the woman's symptoms, fibroid characteristics, overall health status, and personal preferences.

From the Research

Myomatous Uterus Management in Post-Menopause

• Management of myomatous uterus in post-menopause can be tailored to the individual patient's needs, taking into account the size and location of the fibroids, as well as the patient's symptoms and medical history 2.
• Expectant management is often recommended for asymptomatic patients, as most fibroids decrease in size during menopause 2, 3.
• For symptomatic patients, medical therapy such as hormonal contraceptives, tranexamic acid, and nonsteroidal anti-inflammatory drugs can be effective in reducing heavy menstrual bleeding and pain 2, 4.
• Gonadotropin-releasing hormone agonists or selective progesterone receptor modulators may be considered for patients who need symptom relief preoperatively or who are approaching menopause 2.
• Surgical treatment options, such as hysterectomy or myomectomy, may be considered for patients with large or symptomatic fibroids, although these options should be reserved for appropriate indications 2, 3.
• Uterine artery embolization is an effective alternative for women with large symptomatic myomas who are poor surgical risks or wish to avoid major surgery 3.
• The use of menopausal hormone therapy (EPT) does not appear to increase the volume of uterine myomas in postmenopausal women, although clinically significant volume increases may occur in some cases 5.
• Regular follow-up and monitoring of fibroid size and symptoms is recommended for asymptomatic women, particularly those approaching menopause 3.