What are the management options for uterine fibroids?

Management of Uterine Fibroids

Initial Medical Management Should Be First-Line

Trial medical management before pursuing invasive therapies for symptom control, regardless of fertility desires 1. This approach allows for symptom relief while avoiding surgical risks and preserving all future options.

For Heavy Menstrual Bleeding

• NSAIDs and combined oral contraceptive pills effectively reduce fibroid-related bleeding symptoms 1
• Tranexamic acid is the preferred nonhormonal alternative for patients who cannot or prefer not to use hormonal options, with significant reduction in menstrual blood loss 1
• GnRH antagonists (relugolix, elagolix, or linzagolix) are effective for reducing both bleeding symptoms and fibroid volume 2
• Combination treatment with low-dose estrogen and progestin can mitigate hypoestrogenic side effects when using GnRH antagonists 2

Preoperative Optimization

• GnRH agonists/antagonists or selective progesterone receptor modulators can reduce bleeding and improve hemoglobin before surgery 1
• Correct anemia with iron supplementation while simultaneously initiating medical therapy 2

Critical Caveat About Medical Therapy

• Medical treatments provide only temporary symptom relief, with symptoms typically recurring rapidly after discontinuation 1

Surgical Management Algorithm

For Patients Desiring Future Pregnancy

• Laparoscopic myomectomy is the primary surgical option, offering shorter hospital stays and faster recovery compared to open surgery 1
• Open myomectomy should be reserved for multiple fibroids or very large uteri where laparoscopic approach is technically challenging 1
• Hysteroscopic myomectomy is recommended for submucosal fibroids <4 cm, performed in one or two separate procedures 2
• If the uterine cavity is restored to normal after medical treatment, patients may attempt conception without surgery 2
• If the cavity remains distorted after medical therapy, surgical intervention may be necessary for fertility optimization 2

For Patients Not Desiring Future Fertility

• Hysterectomy provides definitive resolution with patient satisfaction rates up to 90% and should be offered as the most effective treatment 1
• Vaginal or laparoscopic routes should be preferred to laparotomy when possible 1

Minimally Invasive Alternatives

Uterine Artery Embolization (UAE)

• UAE demonstrates superior outcomes with 94% short-term and 85% long-term symptom improvement, maintaining quality of life for up to 7 years 1
• Average decrease in fibroid size >50% at 5 years, with reintervention rate of approximately 13% 1, 2
• Reported live birth rates of approximately 50% for patients desiring fertility 2
• UAE is an effective treatment with low long-term morbidity and must be offered as a validated alternative to myomectomy and hysterectomy 1

MR-Guided Focused Ultrasound (MRgFUS)

• Can be considered but has limitations, with a 30% reintervention rate compared to UAE's 13% 1
• Significant improvement in quality of life with 18% decrease in fibroid diameter compared to placebo 2

Special Clinical Scenarios

Postmenopausal Patients

• Hysterectomy is the appropriate next step for symptomatic postmenopausal patients after negative endometrial evaluation 1

Patients with Endometrial Thickening

• Endometrial thickening ≥1.67 cm requires immediate evaluation with endometrial biopsy to rule out hyperplasia or malignancy before addressing fibroid management 2

Patients with Concurrent Adenomyosis

• Medical management or UAE is usually appropriate 3

Asymptomatic Fibroids

• Expectant management is recommended for asymptomatic patients because most fibroids decrease in size during menopause 1

Important Clinical Pitfalls

• Rapid fibroid growth should prompt close monitoring, as it can occasionally indicate malignant transformation, although this is rare 2
• Perform appropriate imaging (ultrasound or MRI) to characterize fibroid location, size, and number before treatment planning 2
• Neither combined estrogen-progestogen contraception nor hormone treatment of menopause is contraindicated in women with fibroids 4