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 for refractory cases or when fertility preservation through myomectomy is needed. 1

Medical Management: First-Line Approach

Initial therapy should prioritize medical management before pursuing invasive treatments. 1

First-Line Medications

• NSAIDs and estrogen-progestin oral contraceptives are the recommended initial treatments for reducing bleeding symptoms, with moderate to high strength evidence supporting their use 1, 2, 3

• Tranexamic acid serves as an effective nonhormonal alternative for patients with contraindications to hormonal therapy, providing significant reduction in bleeding symptoms 1, 2, 3

• Levonorgestrel-releasing intrauterine devices (52-mg) effectively reduce bleeding symptoms and should be considered for long-term management, with high strength evidence 1, 2, 4

Second-Line Medical Options

• GnRH agonists (such as leuprolide) and oral GnRH antagonists (such as relugolix) reduce bleeding symptoms and decrease fibroid volume by 18-30%, with moderate to high strength evidence 1, 2, 3

• Add-back therapy with low-dose estrogen and progestin is FDA-approved for fibroid-related heavy menstrual bleeding and mitigates hypoestrogenic side effects of GnRH modulators 1, 2, 3

• Relugolix functions as second-line therapy after failure of or contraindications to hormonal contraceptives, IUDs, or tranexamic acid, though fertility is actively suppressed during treatment 2

Critical Pitfall with Medical Management

• Cessation of GnRH modulator therapy leads to rapid symptom recurrence, limiting their role to short-term use or preoperative fibroid size reduction 1

Surgical Management: Definitive Options

For Patients Desiring Future Fertility

• Hysteroscopic myomectomy is the procedure of choice for pedunculated submucosal fibroids <5 cm, offering shorter hospitalization and faster recovery 2, 3

• Laparoscopic myomectomy is associated with shorter hospital stays and faster return to usual activities compared to open myomectomy, with both approaches improving quality of life for up to 10 years 2

• For moderate-severe symptoms with fertility desire, use short-term GnRH modulators with add-back therapy to reduce fibroid size before myomectomy 1, 2

For Patients Not Desiring Future Fertility

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

• Hysterectomy should be performed via the least invasive route possible to minimize complications 1

• Important consideration: Hysterectomy carries potential long-term effects including increased risk of cardiovascular disease, osteoporosis, and dementia, with moderate strength evidence 1

• For postmenopausal patients, hysterectomy is usually appropriate for symptomatic fibroids after negative endometrial biopsy 1

Minimally Invasive Alternatives: Uterus-Preserving Options

Uterine Artery Embolization (UAE)

• UAE is effective for patients desiring uterus-preserving therapy, improving symptom scores and quality of life for up to 7 years 1, 2, 3

• UAE demonstrates greater reduction in fibroid diameter (53%) compared to laparoscopic uterine artery occlusion (39%) 1, 2

• Reintervention rate after UAE is approximately 7% for persistent symptoms, which is lower than other minimally invasive options 1, 3

MR-Guided Focused Ultrasound (MRgFUS)

• MRgFUS has a higher reintervention rate (30%) compared to UAE (13%), making it a less favorable option for most patients 1, 2, 3

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

Treatment Algorithm Based on Clinical Scenario

Reproductive Age with Mild Symptoms and Fertility Desire

1. Start with NSAIDs and/or tranexamic acid for acute bleeding episodes 2
2. Consider hormonal contraceptives or levonorgestrel IUD for ongoing management 2

Reproductive Age with Moderate-Severe Symptoms and Fertility Desire

1. Use short-term GnRH modulators with add-back therapy to reduce fibroid size 1, 2
2. Proceed to hysteroscopic myomectomy for submucosal fibroids <5cm 1, 2
3. Proceed to laparoscopic or open myomectomy for other fibroid locations 1

Reproductive Age Without Fertility Desire

1. Trial first-line medical management (NSAIDs, oral contraceptives, IUD) 1, 2
2. Consider UAE for uterus preservation with lower reintervention rates 1, 2
3. Proceed to hysterectomy for definitive resolution if medical management fails 1

Postmenopausal Patients

1. Always rule out malignancy with endometrial biopsy, particularly with fibroid growth or abnormal bleeding 1
2. Hysterectomy is usually appropriate after negative endometrial biopsy 1

Critical Pitfalls to Avoid

• Never proceed to hysterectomy if a less invasive procedure can provide adequate symptom relief, as hysterectomy has higher complication rates 1

• Always obtain endometrial biopsy in postmenopausal patients with fibroid growth or abnormal bleeding to rule out malignancy before treatment 1

• Avoid long-term GnRH modulator monotherapy without add-back therapy due to hypoestrogenic side effects and rapid symptom recurrence after discontinuation 1, 2

• Consider transition to definitive therapy if symptoms recur rapidly after discontinuation of medical therapy or if the patient desires permanent resolution 2