What are the treatment options for uterine fibroids?

Treatment of Uterine Fibroids

Start with first-line medical management using combined oral contraceptives, levonorgestrel-releasing IUD, or NSAIDs for bleeding control, escalate to GnRH antagonists with hormone add-back therapy if inadequate response, and reserve surgical intervention (hysteroscopic myomectomy for submucosal fibroids <5 cm, laparoscopic/open myomectomy for other locations, or hysterectomy for completed fertility) when medical management fails. 1, 2

Initial Medical Management Algorithm

First-line options should be selected based on symptom type and patient preferences:

• For heavy menstrual bleeding: Start with estrogen-progestin oral contraceptive pills or levonorgestrel-releasing IUD, as these have the strongest evidence base for reducing bleeding symptoms 3, 1, 2
• For bleeding with pain: Use NSAIDs, which provide direct pain control and modest reduction in menstrual blood loss 3, 1, 2
• For patients refusing or unable to use hormonal therapy: Tranexamic acid is the preferred nonhormonal alternative with significant reduction in menstrual blood loss 3, 1, 2

Second-line medical therapy when first-line fails:

• Oral GnRH antagonists (elagolix, linzagolix, relugolix) with hormone add-back therapy are the most effective agents, significantly reducing both bleeding and fibroid volume 3, 1, 2
• Critical pitfall: Never use GnRH agonists or antagonists long-term without add-back therapy due to significant bone mineral density loss 2
• GnRH agonists (leuprolide acetate) are also effective but share the same hypoestrogenic side effects requiring add-back therapy 3, 1
• Selective progesterone receptor modulators (ulipristal acetate) reduce both bleeding and bulk symptoms and can be administered intermittently 3, 1

Surgical Management Based on Fertility Goals

For patients desiring future pregnancy:

• Submucosal fibroids <5 cm: Hysteroscopic myomectomy is the procedure of choice, offering shorter hospitalization and faster recovery than other surgical approaches 3, 1, 2
• Intramural or subserosal fibroids: Laparoscopic or open myomectomy is indicated for symptomatic fibroids or those causing cavity distortion 1, 2, 4
• Important caveat: Pregnancy rate after myomectomy is less than 50% in follow-ups of up to 3 years 1
• Preoperative imaging of the uterine cavity is mandatory before attempting conception 2

For patients not desiring future fertility:

• Hysterectomy provides definitive resolution of all fibroid-related symptoms and accounts for three-quarters of fibroid treatment in the United States 3
• Warning: Hysterectomy has been associated with increased long-term risks of cardiovascular disease, osteoporosis, bone fracture, and dementia in cohort studies 2

Minimally Invasive Interventional Options

Uterine Artery Embolization (UAE):

• Effective alternative to myomectomy and hysterectomy for symptomatic fibroids in patients not desiring pregnancy 1, 2, 4
• Reduces fibroid volume by 40-50% with average fibroid size decrease >50% at 5 years 1, 2
• Controls symptoms in approximately 80% of cases 1
• Reintervention rate of approximately 7% for persistent symptoms 3, 1

MR-Guided Focused Ultrasound (MRgFUS):

• Non-invasive option using high-intensity ultrasound waves to thermally ablate fibroids 2, 4
• Provides significant improvement in quality of life and 18% decrease in fibroid diameter compared to placebo 2
• May be considered for selected patients with symptomatic fibroids 4

Preoperative Optimization Strategy

For anemic patients requiring surgery:

• Correct anemia with iron supplementation while simultaneously initiating GnRH agonists or antagonists to control bleeding and reduce fibroid size 2
• Short courses of GnRH therapy effectively shrink fibroids and may facilitate minimally invasive surgical approaches 3, 2
• Anemia should be corrected before elective surgery 1

Treatment Selection by Clinical Scenario

Reproductive age patients desiring pregnancy with:

• Asymptomatic fibroids: No intervention required 1
• Symptomatic submucosal fibroids: Hysteroscopic myomectomy 1
• Symptomatic intramural or subserosal fibroids: Laparoscopic or open myomectomy 1

Reproductive age patients without desire for fertility:

• Mild symptoms: Medical treatment (combined oral contraceptives, levonorgestrel-releasing IUD, NSAIDs) 1
• Moderate to severe symptoms: Myomectomy, UAE, or MRgFUS 1

Perimenopausal patients:

• Mild symptoms: Medical treatment until menopause 1
• Severe symptoms: Hysterectomy or UAE 1

Patients with concurrent adenomyosis:

• Medical management or UAE is usually appropriate 4
• UAE shows short-term (<12 months) and long-term (>12 months) improvement in symptoms in 94% and 85%, respectively, with a 7% rate of hysterectomy for persistent symptoms 3

Critical Management Pitfalls

• Most medical treatments provide only temporary symptom relief with rapid recurrence after discontinuation, requiring ongoing management or eventual surgical intervention 2
• Fertility is suppressed during GnRH agonist/antagonist treatment, and cessation leads to rapid recurrence of symptoms 3
• Surgical planning for myomectomy should be based on location, size, and number of fibroids with appropriate imaging 1