What are the treatment options for symptomatic uterine leiomyoma?

Treatment Options for Symptomatic Uterine Leiomyoma

For symptomatic uterine leiomyomas, the levonorgestrel-releasing intrauterine system (LNG-IUS) is the most effective first-line medical treatment for reducing menstrual blood loss, while hysterectomy remains the definitive treatment with the highest long-term satisfaction rates for women who have completed childbearing. 1, 2

Initial Medical Management

First-Line Hormonal Options

• The levonorgestrel-releasing IUD (Mirena) is FDA-approved and represents the most effective first-line treatment for reducing menstrual blood loss in women with fibroids, particularly those with smaller tumors 1, 2, 3
• Combined oral contraceptives effectively manage bleeding symptoms, especially in women with smaller fibroids, though they have limited effect on fibroid size 1, 2
• Progestins (such as lynestrenol) provide modest reduction in fibroid volume and moderate hemoglobin improvement before surgery 4

First-Line Non-Hormonal Options

• Tranexamic acid is the preferred non-hormonal agent that significantly reduces menstrual blood loss, particularly when hormonal options are contraindicated or declined by the patient 1, 2
• NSAIDs provide effective pain control and modest reduction in bleeding 2
• Both tranexamic acid and NSAIDs can be used for acute hemorrhagic episodes 4

Second-Line Medical Management

GnRH Agonists and Antagonists

• GnRH agonists reduce fibroid volume by 35% and effectively correct anemia preoperatively, but require add-back therapy to prevent bone loss (approximately 1% per month without add-back) 1, 2, 5
• Add-back therapy with low-dose estrogen/progestin combination mitigates hypoestrogenic side effects (hot flashes, bone loss) while maintaining therapeutic efficacy 1, 2
• GnRH agonists are primarily indicated to stop excessive bleeding, improve hemoglobin prior to surgery, or temporarily delay surgery for medical optimization 6
• A critical pitfall: preoperative GnRH agonist use may soften small intramural fibroids, making them impalpable during myomectomy and leading to apparent "rapid recurrence" when viable fibroids are left behind 6

Selective Progesterone Receptor Modulators (SPRMs)

• SPRMs (including ulipristal acetate and mifepristone) reduce fibroid volume and control both bleeding and bulk symptoms more effectively than first-line options 1, 3
• Mifepristone reduces fibroid size and improves symptoms but carries risk of endometrial hyperplasia requiring monitoring 4

Minimally Invasive Interventional Treatments

Uterine Artery Embolization (UAE)

• UAE achieves technical success in >95% of cases, resulting in 40-50% decrease in uterine volume and symptom control in approximately 80% of patients 1, 2
• Long-term data show 20-25% symptom recurrence at 5-7 years, with higher failure rates (approaching 40%) in women <40 years of age due to increased collateral vessel recruitment 1
• Location matters critically: cervical fibroids and multiple submucosal fibroids have higher treatment failure rates with UAE 1
• Pedunculated subserosal fibroids are no longer considered a contraindication despite historical concerns about detachment 1
• UAE is effective for concurrent adenomyosis with 65-88% long-term symptomatic relief 1

Other Ablative Techniques

• MR-guided Focused Ultrasound Surgery (MRgFUS) uses high-intensity ultrasound to ablate fibroid tissue, though long-term outcome data and fertility effects remain limited 1
• Laparoscopic myolysis (using Nd:YAG laser, bipolar needles, monopolar cautery, or cryotherapy) reduces fibroid volume by 40-80% 1
• Endometrial ablation achieves >95% patient satisfaction for abnormal bleeding but has a 23% failure rate with submucosal fibroids compared to 4% in normal uterine cavities 1

Surgical Management

Hysterectomy

• Hysterectomy is the most effective and definitive treatment with up to 90% of patients reporting at least moderate satisfaction at 2 years and significantly better long-term quality of life compared to all other options 1, 2, 7
• The least invasive approach possible (vaginal or laparoscopic) should be prioritized 7

Myomectomy

• Myomectomy is appropriate for women wishing to preserve fertility or their uterus, with recurrence rates of approximately 27% at 10 years and higher rates in women with multiple fibroids 1, 7
• Hysteroscopic myomectomy is first-line conservative surgical therapy for symptomatic intracavitary (submucosal) fibroids 7
• Laparoscopic myomectomy carries 2% major complication and 9% minor complication rates 1
• Critical surgical planning requires mapping location, size, and number of fibroids with appropriate imaging before proceeding 7
• Women should wait 2-3 months after myomectomy before attempting pregnancy to allow proper uterine healing 1

Important Surgical Considerations

• Anemia must be corrected preoperatively using GnRH agonists/antagonists or SPRMs for 3 months 2, 7
• Vasopressin, bupivacaine with epinephrine, misoprostol, peri-cervical tourniquet, or gelatin-thrombin matrix reduce blood loss at myomectomy and should be used 7
• When morcellation is necessary, patients must be counseled that fibroids may rarely contain unexpected malignancy and laparoscopic power morcellation may spread cancer, worsening prognosis 7

Treatment Algorithm Based on Clinical Scenario

For Heavy Menstrual Bleeding

1. Start with LNG-IUS or tranexamic acid as first-line 1, 2
2. If inadequate response, advance to GnRH agonists/antagonists with add-back therapy or SPRMs 1, 2
3. If medical management fails: hysteroscopic myomectomy for submucosal fibroids, UAE for appropriate candidates, or hysterectomy for definitive treatment 1, 2, 7

For Bulk Symptoms (Pelvic Pressure/Pain)

1. SPRMs or GnRH agonists with add-back therapy are effective medical options 1
2. UAE provides 40-50% volume reduction in appropriate candidates 1
3. Myomectomy or hysterectomy for surgical management 1, 7

For Women Desiring Future Fertility

1. Avoid UAE due to potential fertility impact 7
2. Myomectomy is the primary surgical option, with understanding of 27% recurrence risk at 10 years 1, 7
3. Medical management with SPRMs or short-term GnRH agonists can temporize symptoms 1, 3

For Acute Hemorrhagic Episodes

1. High-dose estrogens, tranexamic acid, or Foley catheter tamponade for immediate control 7, 4
2. Operative hysteroscopic intervention if accessible 7
3. UAE in centers where available 7
4. Hysterectomy may become necessary in refractory cases 7

Critical Pitfalls to Avoid

• Do not use GnRH agonists long-term without add-back therapy due to 1% bone loss per month 1
• Age <40 years predicts higher UAE failure rates; counsel these patients accordingly 1
• Preoperative GnRH agonist use should be limited to uteri >600 ml or when anemia correction is needed, as it may complicate complete fibroid removal during myomectomy 6, 5
• Asymptomatic fibroids require no intervention; reassure patients that malignancy risk is minimal and hysterectomy is not indicated 7
• When fibroids coexist with endometriosis, surgical methods addressing both conditions simultaneously are more appropriate than UAE alone 1