What are the treatment options for symptomatic leiomyomata (uterine fibroids)?

Treatment Options for Symptomatic Leiomyomata

For symptomatic uterine fibroids, treatment selection depends critically on fertility desires: hysterectomy provides definitive cure with >90% satisfaction for women not seeking fertility, while myomectomy is the first-line surgical option for those wishing to preserve reproductive potential, accepting a 27% recurrence rate at 10 years. 1, 2

Treatment Algorithm Based on Fertility Desires

For Women NOT Desiring Future Fertility

Hysterectomy is the gold standard treatment, offering virtually zero recurrence risk and elimination of presenting symptoms with satisfaction rates exceeding 90% at 2 years. 3, 1, 2 This should be performed via the least invasive approach possible—vaginal or laparoscopic routes are preferred when feasible based on uterine size and fibroid location. 4

Alternative: Uterine Artery Embolization (UAE) is appropriate when surgery is declined or contraindicated, achieving technical success in >95% of cases with 40-50% decrease in uterine volume and symptom control in approximately 80% of patients. 1, 2 However, UAE carries 20-25% symptom recurrence at 5-7 years, with higher failure rates (approaching 40%) in women <40 years of age due to increased collateral vessel recruitment. 1

For Women Desiring Fertility Preservation

Myomectomy is the first-line surgical choice, performed via hysteroscopy for intracavitary fibroids, or laparoscopy/laparotomy for intramural and subserosal lesions depending on size, number, and location. 1, 5, 4 Women must understand that myomectomy provides only an interval of symptom relief with recurrence rates of 27% at 10 years, higher with multiple fibroids. 1, 2 Patients should wait 2-3 months after myomectomy before attempting pregnancy to allow proper uterine healing. 1, 2

Critical caveat: UAE should NOT be first-line for women seeking pregnancy due to increased risks of miscarriage, cesarean sections, and postpartum hemorrhage. 2

Medical Management Options

Medical therapy alone is unlikely to provide definitive treatment but serves important roles in specific scenarios:

Preoperative Optimization

• Ulipristal Acetate (selective progesterone receptor modulator) reduces fibroid volume by approximately 30% after a single course and up to 70% after 4 courses, with Level I, A evidence for symptomatic relief. 5 This can be used preoperatively to reduce fibroid size and minimize surgical blood loss. 5
• GnRH agonists reduce fibroid volume by 35% and improve hemoglobin levels, making them effective for correcting anemia preoperatively. 1, 2, 4 However, they cause significant hypoestrogenic side effects including approximately 1% bone loss per month, limiting long-term use without add-back therapy. 1

Symptom Management for Bleeding

• Levonorgestrel intrauterine system effectively manages bleeding symptoms, especially in women with smaller fibroids, though it has limited effect on fibroid size. 1, 4
• Tranexamic acid (non-hormonal) reduces menorrhagia but may cause adverse effects including pelvic pain and fever. 1, 6
• Oral contraceptives and progestins may effectively manage bleeding symptoms in women with smaller fibroids. 1, 4

Minimally Invasive Interventional Options

Uterine Artery Embolization (UAE)

• Bilateral embolization deprives fibroids of vascular supply, resulting in 40-50% volume reduction. 3, 1, 2
• Best outcomes occur in properly selected patients: avoid in women <40 years (higher failure rates), those with cervical fibroids or multiple submucosal fibroids (higher treatment failure), and women desiring future pregnancy. 1, 2
• Expect temporary fever in 40% of patients and extreme pain in up to 20%. 2
• Pedunculated subserosal fibroids are no longer considered a contraindication despite previous concerns about fibroid detachment. 1

Emerging Technologies

• MR-guided Focused Ultrasound Surgery (MRgFUS) uses high-intensity ultrasound to ablate fibroid tissue non-invasively, achieving nearly 50% volume reduction at 1 year, but long-term data on outcomes and fertility are limited. 1, 2
• Myolysis techniques (Nd:YAG laser, bipolar needles, monopolar cautery, cryotherapy) can reduce fibroid volume by 40-80% via brief laparoscopic procedures, offering promise for uterus-preserving treatment, though long-term recurrence data are lacking. 3, 1, 2

Critical Pitfalls to Avoid

• Do not perform myomectomy based solely on fibroid presence in asymptomatic women—concern about possible pregnancy complications is NOT an indication for myomectomy except in women with previous pregnancy complications specifically related to fibroids. 4
• Fibroid location dramatically impacts treatment success: cervical fibroids and multiple submucosal fibroids have significantly higher treatment failure rates with UAE. 1
• GnRH agonist pretreatment may paradoxically worsen surgical outcomes by softening small intramural fibroids, making them impossible to palpate during myomectomy, leading to incomplete excision and apparent "rapid recurrence." 3
• Age matters for UAE: failure rates are substantially higher in women <40 years, likely exceeding 40% at long-term follow-up. 1
• When morcellation is necessary, patients must be informed about the rare possibility of unexpected malignancy and that laparoscopic power morcellation may spread cancer, potentially worsening prognosis. 4

Surgical Planning Essentials

• Correct anemia preoperatively using selective progesterone receptor modulators or GnRH agonists before elective surgery. 4
• Map fibroid location, size, and number with appropriate imaging (ultrasound with Doppler as first-line; MRI for superior delineation). 5, 4
• Reduce intraoperative blood loss by using vasopressin, bupivacaine with epinephrine, misoprostol, peri-cervical tourniquet, or gelatin-thrombin matrix at myomectomy. 4
• Hysteroscopic myomectomy is first-line conservative surgical therapy for symptomatic intracavitary fibroids. 4