From the Guidelines
Leiomyomas should be managed based on symptom severity, with a focus on minimizing morbidity and improving quality of life, and the most recent guidelines from 2024 recommend a multidisciplinary approach to treatment 1. When considering treatment options for leiomyomas, it is essential to take into account the patient's reproductive plans, fibroid size, and symptom severity.
- For asymptomatic fibroids, watchful waiting with regular monitoring is often appropriate, as symptoms may decline after menopause 1.
- For symptomatic cases, medical management may include hormonal options like combined oral contraceptives, progestins, or GnRH agonists to reduce bleeding and shrink fibroids temporarily, as well as NSAIDs like ibuprofen to manage pain.
- Minimally invasive procedures such as uterine artery embolization or focused ultrasound surgery may be considered for persistent symptoms, and surgical options like myomectomy or hysterectomy may be necessary for women who have completed childbearing. The development of leiomyomas is influenced by genetic alterations in smooth muscle cells and hormonal factors, including estrogen and progesterone, which is why they typically grow during reproductive years and regress after menopause 1. Regular gynecological exams are crucial for monitoring fibroid growth and adjusting treatment plans accordingly, and the economic burden of symptomatic fibroids on society is significant, with estimated annual costs ranging from $5.9 to $34.4 billion 1. The most effective treatment approach will depend on individual patient factors, and a recent multicenter, randomized, open-label trial found that myomectomy and uterine fibroid embolization resulted in equivalent symptomatic improvement at 2 years 1.
From the Research
Definition and Prevalence of Leiomyomas
- Leiomyomas, also known as uterine fibroids, are the most common benign tumor in reproductive-aged women 2.
- They are common, appearing in 70% of women by age 50, with 20% to 50% being symptomatic 3.
- Symptomatic fibroids can cause menstrual abnormalities, iron deficiency anemia, and bulk symptoms such as pelvic pressure and pain 3.
Treatment Options for Leiomyomas
- Treatment options for leiomyomas include expectant management, medical management (hormonal and non-hormonal), and surgical management (myomectomy or hysterectomy) 2.
- Hysterectomy is a definitive solution for symptomatic uterine fibroids, but it is not the preferred solution for women who wish to preserve fertility and/or their uterus 3.
- Medical treatments such as gonadotropin-releasing hormone analogues, selective progesterone receptor modulators, and oral contraceptives can be effective in reducing symptoms 3, 2.
- Conservative interventional treatments such as uterine artery embolization and myomectomy can also be effective in properly selected patients 3.
Management of Symptomatic Uterine Leiomyomas
- The management of symptomatic uterine leiomyomas should be individualized based on symptomatology, size and location of fibroids, age, need and desire of the patient to preserve fertility or the uterus, and the availability of therapy 3.
- The American College of Obstetricians and Gynecologists (ACOG) provides updated evidence-based recommendations for the medical, procedural, and surgical management of symptomatic leiomyomas 4.
- The use of morcellation in the surgical management of leiomyomas is addressed in a separate ACOG publication 4.
Leiomyosarcomas
- Leiomyosarcomas are malignant tumors that can be difficult to distinguish from benign leiomyomas preoperatively 5.
- The location of the primary tumor can help determine the best systemic therapy options for leiomyosarcoma 6.
- Systemic chemotherapy with either an anthracycline-based regimen or gemcitabine-based regimen is typically used as first-line therapy for metastatic disease 6.