What are the treatment options for symptomatic uterine fibroids?

Treatment Options for Symptomatic Uterine Fibroids

Start with NSAIDs and estrogen-progestin oral contraceptives as first-line therapy for symptomatic uterine fibroids, reserving surgical options like hysterectomy or minimally invasive procedures for patients who fail medical management or have severe symptoms. 1

First-Line Medical Management

Medical management should be attempted before pursuing invasive treatments according to the American College of Radiology. 1

For bleeding symptoms:

• NSAIDs and estrogen-progestin oral contraceptives are the initial treatments of choice, with moderate to high strength evidence for reducing bleeding. 1, 2
• Tranexamic acid serves as an effective nonhormonal alternative for patients with contraindications to hormonal therapy, significantly reducing bleeding symptoms. 1, 2
• Progestin-containing IUDs (levonorgestrel) effectively reduce bleeding and provide long-term management with high strength evidence. 1, 2

Second-Line Medical Management

GnRH agonists and oral GnRH antagonists (including relugolix) reduce bleeding symptoms and decrease fibroid volume by 18-30%, reserved for patients who fail first-line options. 1, 2

Critical considerations with GnRH modulators:

• Combination treatment with low-dose estrogen and progestin (add-back therapy) mitigates hypoestrogenic side effects and is FDA-approved for fibroid-related heavy menstrual bleeding. 1, 2
• Symptoms recur rapidly after discontinuation of therapy. 1
• Fertility is actively suppressed during treatment with relugolix, though it's chosen by patients desiring uterus preservation. 2

Surgical Management Algorithm

Hysterectomy provides definitive resolution of all fibroid-related symptoms and remains the most common treatment in the United States, accounting for three-quarters of fibroid treatments. 1, 3

Perform hysterectomy via the least invasive route possible to minimize complications. 1

Important caveats with hysterectomy:

• Long-term effects include increased risk of cardiovascular disease, osteoporosis, and dementia. 1
• Should be avoided if less invasive procedures can provide adequate symptom relief due to higher complication rates. 1

For fertility preservation:

• Hysteroscopic myomectomy is the procedure of choice for pedunculated submucosal fibroids <5cm, offering shorter hospitalization and faster recovery. 1, 2, 3
• Laparoscopic myomectomy provides shorter hospital stays and faster return to activities compared to open myomectomy, with improved quality of life for up to 10 years. 2

Minimally Invasive Alternatives

Uterine Artery Embolization (UAE) is the preferred minimally invasive option for uterus-preserving therapy, improving symptom scores and quality of life for up to 7 years. 1, 2, 3

UAE demonstrates superior fibroid diameter reduction (53%) compared to laparoscopic uterine artery occlusion (39%). 1, 2

• Reintervention rate after UAE is approximately 7% for persistent symptoms. 1, 3

MR-guided Focused Ultrasound (MRgFUS) has a higher reintervention rate (30%) compared to UAE (13%), making it a less favorable option. 1, 2, 3

• For pedunculated submucosal fibroids specifically, MRgFUS can decrease fibroid volume by 66% with significant symptom improvement. 1

Treatment Algorithm by Patient Characteristics

For reproductive age patients desiring future fertility:

Mild symptoms:

• Start with NSAIDs, tranexamic acid, or hormonal contraceptives. 1
• Consider levonorgestrel IUD for ongoing management. 2

Moderate-severe symptoms:

• Short-term GnRH modulators with add-back therapy to reduce fibroid size. 1, 2
• Hysteroscopic myomectomy for submucosal fibroids <5cm. 1, 2
• Laparoscopic or open myomectomy for other fibroid locations. 1

For postmenopausal patients:

• Hysterectomy is usually appropriate for symptomatic fibroids with negative endometrial biopsy. 1

Critical Pitfalls to Avoid

Always rule out malignancy with endometrial biopsy, particularly in postmenopausal patients with fibroid growth or abnormal bleeding. 1

Do not use GnRH modulators as long-term monotherapy without add-back therapy due to hypoestrogenic side effects. 1, 2

Recognize that cessation of GnRH modulator therapy leads to rapid symptom recurrence, requiring transition to definitive therapy if symptoms return. 1, 2