What are the treatment options for leiomyoma (uterine fibroids)?

Treatment Options for Leiomyoma (Uterine Fibroids)

For symptomatic uterine fibroids, treatment selection depends on fertility desires and symptom severity: hysterectomy provides definitive cure when fertility preservation is not needed, while uterine artery embolization (UAE) and myomectomy are the primary uterine-sparing options, with medical therapy serving as temporary or adjunctive management. 1, 2

Surgical Treatment Options

Hysterectomy

• Hysterectomy is the only curative treatment for symptomatic fibroids and achieves satisfaction rates exceeding 90%. 1, 2
• This is the definitive option when fertility preservation is not desired and symptoms are severe enough to warrant permanent resolution. 2
• The procedure can be performed via abdominal, vaginal, laparoscopic, or laparoscopically-assisted approaches depending on uterine size and fibroid location. 1
• Laparoscopically-assisted vaginal hysterectomy (LAVH) shows advantages over abdominal hysterectomy for uteri 12-18 weeks in size. 1
• Critical warning: Morcellation during minimally invasive hysterectomy increases risk of abdominopelvic recurrence and lower disease-free survival in women with underlying occult malignancy (approximately 1 in 350 cases), and is not recommended. 1

Myomectomy

• Myomectomy is the primary surgical option for women desiring fertility preservation or uterine conservation. 1, 2
• Can be performed via hysteroscopy (for intracavitary fibroids), laparoscopy, or laparotomy depending on fibroid size, number, and location. 1, 2
• Recurrence rates range from 23% to 33% regardless of surgical approach (abdominal or laparoscopic). 1
• Major complications occur in 2% and minor complications in 9% of laparoscopic myomectomies. 1
• Significant risks include intraoperative blood loss and postoperative adhesion formation that may affect future fertility. 2
• Hysteroscopic myomectomy should be first-line conservative surgical therapy for symptomatic intracavitary fibroids. 3

Minimally Invasive Interventional Options

Uterine Artery Embolization (UAE)

• UAE demonstrates clinical success rates of 81% to 100%, with 95% of patients reporting symptomatic alleviation and improved quality-of-life scores at 12 months. 1
• Achieves median uterine volume reduction of 35% and dominant fibroid volume reduction of 42%. 1
• Shows significant improvement in menorrhagia (83%), dysmenorrhea (77%), and urinary frequency (86%) at 3 months post-procedure. 1
• Major complications occur in less than 3% of patients, with up to 10% requiring readmission for pain control. 1
• Amenorrhea risk is age-dependent: less than 2-3% for women under 45 years, up to 20% for women over 45 years. 1
• During 3-year follow-up, 14.4% of patients undergo additional procedures (9.8% repeat UAE, 2.8% myomectomy, 1.8% hysterectomy). 1
• Absolute contraindications include viable pregnancy and active pelvic inflammatory disease. 1
• Pre-procedure requirements include full gynecologic workup with Pap smear, endometrial biopsy if menometrorrhagia present, and cross-sectional imaging (preferably MRI) to confirm diagnosis. 1
• Direct comparison studies show UAE has equivalent symptomatic improvement to myomectomy at 2 years, with reduction in procedural and recovery times and fewer adverse events. 1, 2

MR-Guided Focused Ultrasound Surgery (MRgFUS)

• Uses high-intensity ultrasound to ablate fibroid tissue under MRI guidance. 2
• Represents a non-invasive option for selected cases, though long-term data are limited. 3

Laparoscopic Uterine Artery Occlusion (LUAO)

• Limited published data as stand-alone treatment, with 9% myoma recurrence after median 23.6 months follow-up. 1
• Achieves shorter hospital stays and reduced procedural pain compared to UAE, with similar 3-month clinical success rates. 1

Medical Management Options

Gonadotropin-Releasing Hormone (GnRH) Agonists

• Effective for both bleeding symptoms and bulk-related symptoms through reduction in uterine and myoma volume. 1
• Major limitation: fibroids rapidly return to previous volume after discontinuation, and chronic use causes trabecular bone loss. 1
• Typically used for temporary situations, such as preoperative size reduction before surgical therapy. 1
• Effective at correcting anemia preoperatively and should be considered in anemic patients. 3

Selective Progesterone Receptor Modulators (SPRMs)

• Ulipristal acetate reduces fibroid volume by approximately 30% after a single course and up to 70% after 4 courses. 2
• Supported by Level I, A evidence for symptomatic relief. 2
• Can be administered intermittently long-term with good results on bleeding and fibroid size reduction. 4
• Effective for both abnormal uterine bleeding and bulk symptoms. 3

Levonorgestrel Intrauterine System (LNG-IUS)

• Effective medical treatment for women with abnormal uterine bleeding associated with fibroids (Level I evidence). 3

Other Hormonal Options

• Oral contraceptives may effectively manage bleeding symptoms, especially in women with small fibroids. 1
• Progestins and danazol have demonstrated efficacy (Level II-2 evidence). 3

Non-Hormonal Options

• Tranexamic acid is a non-hormonal agent that decreases menstrual blood loss, though its role specifically for fibroid-related bleeding remains unclear. 1
• May cause fibroid necrosis and reduce menorrhagia, but adverse effects include pelvic pain and fever. 1
• Non-steroidal anti-inflammatory drugs (NSAIDs) have been shown to decrease menstrual blood loss. 5

Treatment Algorithm Based on Clinical Scenarios

For Women NOT Desiring Fertility Preservation

• If symptoms are severe: Hysterectomy via least invasive approach provides definitive cure with high satisfaction rates. 2, 3
• If surgery is contraindicated or patient prefers non-surgical option: UAE is validated alternative with good long-term outcomes. 2

For Women Desiring Fertility Preservation

• For intracavitary/submucosal fibroids: Hysteroscopic myomectomy is first-line therapy. 3
• For intramural or subserosal fibroids: Myomectomy via laparoscopy or laparotomy depending on size, number, and location. 2
• Consider preoperative SPRM therapy to reduce fibroid size and minimize surgical blood loss. 2
• Important: Submucosal and intramural fibroids significantly reduce pregnancy rates (10% and 16.4% respectively) and implantation rates (4.3% and 6.4% respectively) in assisted reproductive technology, warranting treatment before fertility interventions. 1
• Subserosal fibroids do not significantly affect fertility (pregnancy rate 34.1%, implantation rate 15.1%) and may not require treatment. 1

For Acute Uterine Bleeding

• Conservative management options include estrogens, SPRMs, antifibrinolytics, Foley catheter tamponade, and/or operative hysteroscopic intervention. 3
• UAE may be considered in centers where available. 3
• Hysterectomy may become necessary in some cases. 3

Diagnostic Workup Requirements

Imaging

• Pelvic ultrasound (transabdominal and transvaginal) with Doppler is first-line diagnostic method with 90-99% sensitivity and 98% specificity. 1, 2
• MRI provides superior delineation of fibroid location, size, and number compared to ultrasound, and can differentiate fibroids from adenomyosis and endometriosis. 1, 2
• MRI after UAE is recommended to ensure adequate fibroid infarction and exclude underlying leiomyosarcoma. 1
• Saline infusion sonohysterography improves visualization between endometrial pathologies and submucosal fibroids. 1, 2

Pre-Treatment Assessment

• Full gynecologic workup including Pap smear every 3 years. 1
• Endometrial biopsy if patient has menometrorrhagia. 1
• Anemia should be corrected prior to elective surgery. 3

Critical Pitfalls to Avoid

• Do not assume all fibroids are benign: approximately 1 in 350 women undergoing hysterectomy or myomectomy for fibroids has unsuspected uterine sarcoma. 1
• Do not use morcellation techniques due to risk of spreading occult malignancy. 1
• Do not rely on medical therapy alone for large fibroids (e.g., 10x8x9 cm), as volume reduction is unlikely to provide complete symptom resolution. 2
• Do not perform UAE in women with viable pregnancy or active pelvic inflammatory disease. 1
• Do not overlook the impact of submucosal and intramural fibroids on fertility outcomes before assisted reproductive technology. 1
• Recognize that up to 20% of UAE candidates have non-viable or autoinfarcted fibroids that will not respond to embolization. 6