What are the treatment options for shrinking uterine fibroids?

How to Shrink Uterine Fibroids

For shrinking fibroids, GnRH agonists (leuprolide) or oral GnRH antagonists (relugolix, elagolix, linzagolix) combined with low-dose estrogen-progestin add-back therapy are the most effective medical options, reducing fibroid volume by 18-30% and significantly improving symptoms. 1, 2, 3

Medical Treatment Options for Fibroid Shrinkage

First-Line Medical Management (Symptom Control, Minimal Shrinkage)

• Hormonal contraceptives and IUDs reduce bleeding symptoms but do not significantly shrink fibroids 1, 3
• Estrogen-progestin oral contraceptive pills are recommended as first-line for bleeding control 1, 3
• Progestin-containing IUDs (levonorgestrel) effectively reduce bleeding symptoms for long-term management 1, 3
• Tranexamic acid serves as a nonhormonal alternative for bleeding reduction without affecting fibroid size 1, 3

Second-Line Medical Management (Significant Fibroid Shrinkage)

GnRH Agonists:

• Reduce fibroid volume by 18-30% and significantly improve preoperative hemoglobin levels 2, 4
• A 3-month course achieves optimal balance between volume reduction and minimizing side effects 2
• Commonly used as preoperative preparation rather than long-term management 1, 2
• Examples include leuprolide acetate (parenteral administration) 1

Oral GnRH Antagonists:

• Include elagolix, linzagolix, and relugolix 1
• Provide similar fibroid volume reduction (18-30%) as agonists 1, 2
• Can be used for longer-term management compared to agonists 1

Critical Add-Back Therapy:

• Combination with low-dose estrogen and progestin is essential to mitigate hypoestrogenic side effects (hot flashes, headaches, hypertension, bone mineral density loss) 1, 2, 5
• This combination is FDA-approved for fibroid-related heavy menstrual bleeding 1, 2
• Add-back therapy maintains therapeutic efficacy while minimizing side effects 1, 2, 5
• Mean bone mineral density decrease is 4.9% over 24 weeks with monotherapy, substantially reduced with add-back 5

Progesterone Receptor Modulators:

• Ulipristal acetate reduces both bleeding and bulk symptoms with intermittent dosing 1
• Can be administered intermittently, allowing menstruation during medication breaks 1
• Demonstrated efficacy in randomized controlled trials for up to 2 years 1
• Major limitation: Reports of hepatotoxicity prevent FDA approval in the United States 1, 2

Minimally Invasive Procedures for Fibroid Shrinkage

Uterine Artery Embolization (UAE)

• Decreases uterine volume by 40-50% with symptomatic control in approximately 80% of patients 1
• Technical success rate exceeds 95% in experienced hands 1
• Demonstrates 53% reduction in fibroid diameter, superior to laparoscopic uterine artery occlusion (39%) 1, 3
• Provides symptom improvement and quality of life benefits for up to 7 years 3
• Complications to consider: More than 40% experience temporary fever, up to 20% report extreme pain 1

Myolysis (Laparoscopic Ablation)

• Reduces fibroid volume by 40-80% using Nd:YAG laser, bipolar needles, monopolar cautery, or cryotherapy 1
• Performed as a simple, brief laparoscopic procedure 1
• Limitation: Long-term recurrence risk remains unknown due to limited follow-up data 1

MR-Guided Focused Ultrasound (MRgFUS)

• Achieves 66% decrease in perfused fibroid volume with 30% decrease in diameter at 6 months 1
• Associated with 89% improvement in bulk symptoms 1
• Higher reintervention rate (30%) compared to UAE (13%) 3

Treatment Algorithm Based on Clinical Scenario

For Preoperative Fibroid Reduction:

• Use GnRH agonist or antagonist with add-back therapy for 3 months before myomectomy or hysterectomy 2, 4
• This approach corrects preoperative anemia, reduces intraoperative blood loss, and may allow vaginal rather than abdominal hysterectomy 4

For Patients Desiring Uterus Preservation:

• Start with GnRH antagonist (relugolix, elagolix, or linzagolix) plus add-back therapy for long-term management 1, 3
• Critical pitfall: Fertility is suppressed during treatment, and cessation leads to rapid symptom recurrence 1, 3, 5
• Consider transition to UAE or surgical options if symptoms recur rapidly after discontinuation 3, 5

For Patients Near Menopause:

• GnRH analogues with add-back therapy can bridge to natural menopause when fibroids typically shrink due to decreased estrogen 1, 6

For Patients Avoiding Surgery Long-Term:

• UAE provides durable fibroid shrinkage (40-50% volume reduction) without need for ongoing medication 1, 3
• MRgFUS is an alternative but has higher reintervention rates 3

Common Pitfalls and Caveats

GnRH Therapy Without Add-Back:

• Causes significant hypoestrogenic effects including hot flashes, headaches, hypertension, and bone mineral density loss 1, 2, 5
• Always use add-back therapy for treatment courses beyond 3 months 1, 2, 5

Expecting Permanent Results from Medical Therapy:

• All medical treatments result in rapid symptom and size recurrence after discontinuation 1, 3, 5
• GnRH analogues are not definitive long-term solutions without add-back therapy 5

UAE Complications:

• Temporary fever occurs in >40% of patients 1
• Extreme pain reported in up to 20% 1
• One death has been reported, though overall safety profile is favorable with thousands of procedures performed 1

Fibroid Location Matters:

• Intramural and submucosal fibroids significantly impact fertility outcomes and should be treated before assisted reproductive technology 1
• Subserosal fibroids do not significantly affect pregnancy or implantation rates 1