What are the treatment options for symptomatic uterine fibroids?

Treatment Options for Symptomatic Uterine Fibroids

Start with NSAIDs and estrogen-progestin oral contraceptives as first-line therapy for symptomatic uterine fibroids, escalating to GnRH modulators with add-back therapy for moderate-severe symptoms, and reserve surgical interventions for refractory cases or when fertility preservation requires myomectomy. 1

First-Line Medical Management

Medical management should be attempted before pursuing invasive treatments. 1

For bleeding control:

• NSAIDs and estrogen-progestin oral contraceptive pills are the recommended initial treatments with moderate to high strength evidence for reducing fibroid-related bleeding. 1, 2
• Tranexamic acid serves as an effective nonhormonal alternative for patients who cannot use hormonal options, with significant reduction in bleeding symptoms. 1
• Levonorgestrel-releasing intrauterine devices (52-mg) effectively reduce bleeding and should be considered for long-term management with high strength evidence. 1, 3, 4

Second-Line Medical Therapy

When first-line options fail or symptoms are moderate-severe:

• GnRH agonists and oral GnRH antagonists (such as relugolix) reduce bleeding and decrease fibroid volume by 18-30% with moderate to high strength evidence. 1, 2
• Combination treatment with low-dose estrogen and progestin (add-back therapy) is FDA-approved for fibroid-related heavy menstrual bleeding and mitigates hypoestrogenic side effects of GnRH modulators. 1, 2
• Relugolix functions as second-line therapy after failure of or contraindications to hormonal contraceptives, IUDs, or tranexamic acid. 2

Critical pitfall: Cessation of GnRH modulator therapy leads to rapid recurrence of symptoms, so plan for definitive therapy if long-term control is needed. 1 Fertility is actively suppressed during relugolix treatment despite being chosen for uterus preservation. 2

Treatment Algorithm Based on Fertility Desires

For reproductive-age patients desiring future fertility:

• Mild symptoms: Start with NSAIDs, tranexamic acid, or hormonal contraceptives. 1
• Moderate-severe symptoms: Use short-term GnRH modulators with add-back therapy to reduce fibroid size preoperatively. 1, 3
• Submucosal fibroids <5cm: Hysteroscopic myomectomy is the procedure of choice, offering shorter hospitalization and faster recovery. 2, 3
• Other fibroid locations: Laparoscopic myomectomy is associated with shorter hospital stays and faster return to usual activities compared to open myomectomy, with both approaches improving quality of life for up to 10 years. 2, 3

Critical pitfall: Do not perform endometrial ablation in patients desiring future fertility due to high risk of pregnancy complications. 3

Minimally Invasive Alternatives for Uterus Preservation

For patients not desiring future fertility but wanting to preserve the uterus:

• Uterine Artery Embolization (UAE) is effective for uterus-preserving therapy, improving symptom scores and quality of life for up to 7 years with moderate to high strength evidence. 1, 2, 3
• UAE demonstrates greater fibroid diameter reduction (53%) compared to laparoscopic uterine artery occlusion (39%). 1, 2
• Reintervention rate after UAE is approximately 7-13% for persistent symptoms. 1, 3
• MR-guided Focused Ultrasound (MRgFUS) has a higher reintervention rate (30%) compared to UAE (13%), making it a less favorable option. 1, 2
• For pedunculated submucosal fibroids specifically, MRgFUS can decrease fibroid volume by 66% with significant symptom improvement. 1

Definitive Surgical Management

Hysterectomy provides definitive resolution of all fibroid-related symptoms and remains the most common treatment for uterine fibroids in the United States with high strength evidence. 1, 3

When to choose hysterectomy:

• Hysterectomy should be performed via the least invasive route possible (vaginal or laparoscopic preferred over laparotomy) to minimize complications. 1
• Hysterectomy should be avoided if a less invasive procedure can provide adequate symptom relief due to higher complication rates, longer hospitalization, and longer recovery. 1, 3
• For postmenopausal patients, hysterectomy is usually appropriate for symptomatic fibroids after negative endometrial biopsy. 1, 3

Important considerations: Potential long-term effects include increased risk of cardiovascular disease, osteoporosis, and dementia with moderate strength evidence. 1

Special Population: Postmenopausal Patients

Always rule out malignancy with endometrial biopsy prior to intervention, particularly in postmenopausal patients with fibroid growth or abnormal bleeding, to exclude endometrial neoplasia and diagnose potential sarcoma. 1, 3