What are the treatment options for symptomatic uterine fibroids?

Treatment Options for Symptomatic Uterine Fibroids

Start with medical management using levonorgestrel IUD or oral contraceptive pills as first-line therapy, escalate to GnRH modulators if bleeding persists, and reserve surgical interventions (myomectomy for fertility preservation or hysterectomy for definitive cure) for medical treatment failures or bulk symptoms. 1, 2

Medical Management Algorithm

First-Line Hormonal Therapy

• Levonorgestrel-releasing intrauterine device or estrogen-progestin oral contraceptive pills are the preferred initial treatments for fibroid-related bleeding symptoms. 1, 2
• These hormonal options effectively reduce menstrual blood loss without removing the fibroids themselves. 1

First-Line Nonhormonal Alternative

• Tranexamic acid serves as the primary nonhormonal option for patients who cannot tolerate or wish to avoid hormonal therapy. 1
• NSAIDs can be added for bleeding control and pain management. 2

Second-Line Medical Therapy

• GnRH agonists (like leuprolide) or oral GnRH antagonists reduce bleeding symptoms and decrease fibroid volume by 18-30%. 1, 2
• Combination treatment with low-dose estrogen and progestin must be added to mitigate hypoestrogenic side effects (hot flashes, bone density loss) and is FDA-approved for fibroid-related heavy menstrual bleeding. 1, 2
• GnRH modulators are particularly useful for short courses (typically 3-6 months) to decrease fibroid size before planned surgery. 1

Surgical Management Based on Fertility Desires

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
• Hysteroscopic resection is recommended for submucosal fibroids less than 4 cm, regardless of whether they are symptomatic, when pregnancy is desired. 3
• Laparoscopic or open myomectomy is appropriate for subserosal or intramural fibroids in fertility-seeking patients, though less than half achieve pregnancy, and of these, less than half result in live births. 1
• Laparoscopic myomectomy offers shorter hospital stays and faster return to usual activities compared to open myomectomy. 2

For Patients Not Desiring Fertility

• Hysterectomy is the most effective and definitive treatment for symptomatic uterine fibroids, associated with high patient satisfaction rates and eliminates risk of new fibroid formation. 1, 2
• Vaginal or laparoscopic routes should be preferred over laparotomy when feasible. 3
• Subtotal hysterectomy by laparotomy has lower complication rates than total hysterectomy, though rates are equivalent by laparoscopy. 3

Minimally Invasive Interventional Options

Uterine Artery Embolization (UAE)

• UAE is an effective uterus-preserving option for symptomatic fibroids in properly selected patients who have not improved with medical treatment, improving symptom scores and quality of life for up to 7 years. 1, 2
• Reintervention rate after UAE is approximately 7% for persistent symptoms. 2, 4
• UAE demonstrates greater fibroid diameter reduction compared to laparoscopic uterine artery occlusion. 2
• UAE should be avoided if surgery was planned and fibroids are >20 weeks in size. 5

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
• This option may be considered for patients with symptomatic fibroids who wish to preserve their uterus. 4

Laparoscopic Uterine Artery Occlusion (LUAO)

• LUAO decreases heavy menstrual bleeding and fibroid diameter, with lower postprocedural complications and rehospitalizations compared to UAE. 1
• Isolated laparoscopic ligation of uterine arteries is a potential alternative to UAE and complements myomectomy by reducing intraoperative bleeding. 3

Treatment Algorithm Based on Symptom Type

For Heavy Menstrual Bleeding

• Start with levonorgestrel IUD or oral contraceptives. 1, 2
• Add tranexamic acid if hormonal therapy is contraindicated or ineffective. 1
• Progress to GnRH agonists/antagonists with add-back therapy if first-line options fail. 1

For Bulk Symptoms (Pressure, Pain, Fullness)

• Trial GnRH agonists/antagonists or selective progesterone receptor modulators for symptom reduction. 1
• Consider UAE or MRgFUS for uterus-preserving options if medical management fails. 1
• Proceed to myomectomy or hysterectomy for definitive treatment. 1, 2

Special Population: Postmenopausal Patients

• Always pursue endometrial biopsy prior to intervention to rule out endometrial neoplasia and diagnose potential sarcoma. 2
• Hysterectomy is usually appropriate for symptomatic fibroids in postmenopausal patients. 2

Critical Warnings and Pitfalls

Medical Therapy Limitations

• High rates of symptom recurrence occur after discontinuation of medical therapy, particularly with GnRH agonists/antagonists. 1
• Bone density loss with prolonged GnRH agonist use requires add-back therapy with low-dose estrogen and progestin. 1
• Medical options do not remove tumors and symptoms may return when treatment is stopped. 6

Surgical Considerations

• Do not perform endometrial ablation in patients desiring future fertility due to high risk of pregnancy complications. 2
• Hysterectomy should be avoided if a less invasive procedure can provide adequate symptom relief due to higher complication rates, longer hospitalization, and longer recovery compared to UAE. 2
• Physicians must explain to women the potential consequences of myomas and myomectomy on future pregnancy. 3

Fertility Considerations

• Interstitial (intramural) fibroids have a negative effect on fertility, but treating them does not improve fertility outcomes. 3
• Myomectomy for intramural fibroids is therefore indicated only for symptomatic relief, not fertility enhancement. 3