What are the management options for uterine fibroids (Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) such as ibuprofen, Gonadotropin-Releasing Hormone (GnRH) agonists like leuprolide)?

Management of Uterine Fibroids

Medical Management: First-Line Approach

For symptomatic uterine fibroids, begin with medical management before considering invasive interventions, starting with hormonal therapies for bleeding symptoms and reserving GnRH agonists like leuprolide for second-line treatment or preoperative fibroid reduction. 1

First-Line Medical Options

• Estrogen-progestin oral contraceptive pills and progestin-containing IUDs are the preferred initial medical treatments, effectively reducing bleeding symptoms associated with fibroids 1
• Tranexamic acid serves as an effective nonhormonal alternative for reducing bleeding symptoms in patients who cannot tolerate or prefer to avoid hormonal therapy 1
• NSAIDs (such as ibuprofen) can be used for symptomatic relief of pain and bleeding, though they are less effective than hormonal options for controlling heavy menstrual bleeding 1, 2

Second-Line Medical Options

• GnRH agonists (e.g., leuprolide acetate) and oral GnRH antagonists (e.g., elagolix, linzagolix, relugolix) effectively reduce both bleeding symptoms and tumor volume, making them particularly useful for short courses (3-4 months) to decrease fibroid size before surgery 1, 3
• Important caveat: As monotherapy, GnRH agonists and antagonists cause hypoestrogenic effects including headaches, hot flushes, hypertension, and bone mineral density loss 1
• Combination treatment with low-dose estrogen and progestin mitigates hypoestrogenic symptoms and is FDA-approved for fibroid-related heavy menstrual bleeding 1
• Critical limitation: Fertility is suppressed during GnRH treatment, and symptoms rapidly recur after cessation of therapy 1

Emerging Medical Options

• Progesterone receptor modulators (ulipristal acetate) reduce both bleeding and bulk symptoms and can be administered intermittently, allowing menstruation during medication breaks 1
• Barrier to use: Reports of hepatotoxicity prevent approval for use in the United States despite demonstrated efficacy in randomized controlled trials 1

Surgical Management: Definitive Treatment

For Patients Desiring Future Fertility

• Hysteroscopic myomectomy is first-line conservative surgical therapy for symptomatic intracavitary (submucosal) fibroids, with retrospective studies showing pregnancy rates of 85% and live birth rates of 65% 1, 4
• Laparoscopic or open myomectomy is appropriate for subserosal or intramural fibroids in patients wishing to preserve fertility, though less than half of patients trying to conceive achieve pregnancy, and of these, less than half result in live births 1, 5, 4
• Surgical planning requires mapping the location, size, and number of fibroids with appropriate imaging before myomectomy 4
• Preoperative optimization: Correct anemia before elective surgery using selective progesterone receptor modulators or GnRH analogues, which are effective at correcting anemia 4
• Intraoperative blood loss reduction: Use vasopressin, bupivacaine with epinephrine, misoprostol, peri-cervical tourniquet, or gelatin-thrombin matrix 4

For Patients Not Desiring Future Fertility

• Hysterectomy is the most effective and definitive treatment for symptomatic uterine fibroids, associated with high patient satisfaction rates 1, 4, 2
• Route selection: Perform hysterectomy by the least invasive approach possible—vaginal or laparoscopic routes are preferred over laparotomy when feasible 4, 2

Minimally Invasive Interventional Options

Uterine Artery Embolization (UAE)

• UAE is an effective option for symptomatic fibroids in properly selected patients who wish to preserve their uterus but have not improved with medical treatment 1, 4, 2
• Reintervention rate: Approximately 13% at 2 years, which is lower than MRgFUS 1
• Fertility considerations: Women choosing UAE should be counseled that fecundity and pregnancy may be impacted 4
• Pregnancy outcomes: Total pregnancy rates of 69% for UAE, with live births of 50% and abortion rates of 34% 1

MR-Guided Focused Ultrasound (MRgFUS)

• MRgFUS uses high-intensity ultrasound waves to thermally ablate fibroids, resulting in coagulative necrosis without damage to intervening tissues 1
• Efficacy: Demonstrates significantly greater improvement in quality of life and 18% decrease in fibroid diameter compared to placebo 1
• Major limitation: Higher reintervention rate (30%) compared to UAE (13%) and decreased symptom control at all time points (6,12, and 24 months) 1
• Advantages: Associated with decreased postprocedural pain, lower narcotic use, and faster recovery compared to UAE 1
• Major adverse event rate: Only 0.2% compared to 12.6% for surgical approaches (myomectomy or hysterectomy) 1
• Procedure duration: Significantly longer than UAE (6.75 hours versus 2.3 hours) and occasionally performed over 2 days 1

Laparoscopic Uterine Artery Occlusion (LUAO)

• LUAO decreases heavy menstrual bleeding and fibroid diameter, with lower postprocedural complications and rehospitalizations compared to UAE 1
• Less effective than UAE: Results in smaller reduction in fibroid diameter (39% versus 53%) and lower frequency of complete infarction (23% versus 82%) 1
• Similar fertility outcomes: Total pregnancy rates of 67% for LUAO versus 69% for UAE, with comparable live birth and abortion rates 1

Treatment Algorithm Based on Clinical Scenario

Asymptomatic Fibroids

• Conservative management only—treatment is indicated only when fibroids cause symptoms, not based on size or location alone 6
• Reassurance: No evidence substantiates major concern about malignancy; hysterectomy is not indicated 4

Symptomatic Fibroids with Heavy Menstrual Bleeding

1. Start with levonorgestrel IUD or oral contraceptives 1
2. Add tranexamic acid if hormonal therapy is contraindicated or ineffective 1
3. Progress to GnRH agonists/antagonists with add-back therapy if first-line options fail 1
4. Consider surgical options if medical management fails or is not tolerated 4

Symptomatic Fibroids with Bulk Symptoms (Pressure, Pain, Urinary Frequency)

1. Trial GnRH agonists/antagonists or selective progesterone receptor modulators for symptom reduction 1
2. Consider UAE or MRgFUS for uterus-preserving options if medical management fails 1, 5
3. Proceed to hysterectomy for definitive treatment if fertility preservation is not desired 4, 2

Reproductive Dysfunction/Infertility

• Hysteroscopic myomectomy for submucosal fibroids less than 4 cm 1, 4, 2
• Laparoscopic or open myomectomy for subserosal or intramural fibroids affecting fertility 1, 5, 4
• Counsel patients: Myomectomy carries potential for future intervention, and pregnancy rates remain suboptimal even after surgery 1, 4

Critical Warnings and Pitfalls

Morcellation Risk

• Inform patients that when morcellation is necessary to remove specimens, fibroids may rarely contain unexpected malignancy, and laparoscopic power morcellation may spread cancer, potentially worsening prognosis 4

Pregnancy Complications

• Myomectomy is associated with uterine rupture during subsequent pregnancy in case reports 1
• Women with fibroids detected in pregnancy may require additional maternal and fetal surveillance 4

Medical Management Limitations

• High rates of symptom recurrence after discontinuation of medical therapy, particularly with GnRH agonists/antagonists 1
• Bone density loss with prolonged GnRH agonist use requires add-back therapy 1