What are the treatment options for uterine fibroids?

Treatment Options for Uterine Fibroids

For symptomatic uterine fibroids, treatment selection follows a hierarchical approach starting with medical management (NSAIDs, combined oral contraceptives, or tranexamic acid), escalating to minimally invasive procedures (hysteroscopic myomectomy for submucosal fibroids, UAE for others), and reserving hysterectomy for definitive resolution when fertility is not desired. 1, 2, 3

Medical Management: First-Line Approach

Safest Initial Options

• NSAIDs represent the safest first-line treatment for fibroid-related bleeding with minimal systemic effects and decades of established safety data 1
• Combined hormonal contraceptives (estrogen-progestin pills) provide effective bleeding control with well-documented safety profiles 1
• Tranexamic acid is the preferred nonhormonal alternative for patients with contraindications to hormones or those preferring nonhormonal therapy, achieving significant menstrual blood loss reduction 1, 3
• Levonorgestrel-releasing intrauterine devices offer effective long-term bleeding control 3

Second-Line Medical Options (More Effective, Less Safe)

• Oral GnRH antagonists (elagolix, linzagolix, relugolix) with mandatory low-dose estrogen-progestin add-back therapy achieve 18-30% fibroid volume reduction and represent the most effective medical option 1, 3
• Combination hormone add-back therapy is mandatory to prevent hypoestrogenic side effects including hot flashes, headaches, hypertension, and bone mineral density loss 1, 3
• Ulipristal acetate should not be used due to significant hepatotoxicity concerns preventing FDA approval 1

Critical Medical Management Limitations

• All medical treatments provide only temporary symptom relief with rapid recurrence after discontinuation, making them unsuitable as definitive long-term therapy 1, 2
• Medical therapy should be trialed before invasive procedures unless contraindications exist 1

Surgical Management: Location-Specific Approach

Submucosal Fibroids (<5 cm)

• Hysteroscopic myomectomy is the procedure of choice for submucosal fibroids, offering shorter hospitalization, faster recovery, and equivalent symptom improvement at 2-3 months compared to laparoscopic or open approaches 4, 3
• Preoperative assessment must include fibroid size, location within the cavity, degree of cavity invasion, and residual myometrial thickness to the serosa using hysteroscopy combined with transvaginal ultrasound or hysterosonography 5
• Risks include uterine perforation, fluid overload, blood transfusion need, bowel or bladder injury, endomyometritis, and reintervention 4
• Patients with significant intramural or subserosal fibroid burden causing bulk symptoms or heavy bleeding with concomitant adenomyosis are unlikely to experience symptom relief from hysteroscopic myomectomy alone 4

Exophytic (Subserosal) Fibroids

• Laparoscopic myomectomy is the primary surgical option for symptomatic exophytic fibroids in patients desiring pregnancy, with shorter hospital stays and faster recovery than open surgery 2
• Open myomectomy should be reserved for multiple fibroids or very large uteri where laparoscopic approach is technically challenging 2
• Anterior uterine incisions should be used when fibroids are removed abdominally to minimize postoperative adhesion formation 5
• Subserosal fibroids without symptoms should not be removed as they do not impact fertility 5

Intramural Fibroids

• There is fair evidence to recommend against myomectomy for intramural fibroids with hysteroscopically confirmed intact endometrium and otherwise unexplained infertility, regardless of size 5
• If the patient has no other treatment options, benefits must be weighed against surgical risks on an individualized basis 5

Minimally Invasive Radiologic Interventions

Uterine Artery Embolization (UAE)

• UAE demonstrates superior long-term outcomes with 94% short-term and 85% long-term symptom improvement, maintaining quality of life for up to 7 years 2, 3
• UAE achieves 53% fibroid diameter reduction, superior to laparoscopic uterine artery occlusion at 39% 3
• UAE has a lower reintervention rate (13%) compared to MR-guided focused ultrasound (30%) 2, 3
• Women seeking future pregnancy should not generally be offered UAE due to lower pregnancy rates, higher miscarriage rates, and adverse pregnancy outcomes compared to myomectomy, plus potential loss of ovarian reserve especially in older patients 5

MR-Guided Focused Ultrasound (MRgFUS)

• MRgFUS can be considered but has limitations with a 30% reintervention rate 2
• This modality is less established than UAE for long-term symptom control 6

Radiofrequency Ablation

• Radiofrequency ablation (VizAblate™ and Acessa™) represents newer minimal access treatment options 6

Definitive Surgical Treatment

Hysterectomy

• Hysterectomy provides definitive resolution of all fibroid-related symptoms with patient satisfaction rates up to 90% and accounts for three-quarters of fibroid treatment in the United States 3
• Hysterectomy is appropriate for symptomatic postmenopausal patients after negative endometrial evaluation 2
• This option should be offered as the most effective treatment for patients not desiring future fertility 2

Special Population Considerations

Fertility Preservation

• Submucosal fibroids should be removed in women with otherwise unexplained infertility to improve conception and pregnancy rates 5
• High-quality evidence on live birth rates following hysteroscopic myomectomy is lacking, with conflicting data from two single-center randomized trials showing no difference in one study and improved pregnancy rates in another (though the latter could not be externally validated) 4
• Neither study reported live birth rates, making fertility improvement claims uncertain 4

Postmenopausal Patients

• Postmenopausal patients with symptomatic fibroids require endometrial biopsy before any treatment to rule out endometrial neoplasia and potential sarcoma 1, 3
• Sarcomatous change is rare but normally associated with rapid growth and requires urgent referral 7

Asymptomatic Fibroids

• Asymptomatic fibroids require no medical treatment, only observation, regardless of size or location 1

Preoperative Optimization

• GnRH agonists/antagonists or selective progesterone receptor modulators can effectively reduce bleeding and improve hemoglobin before surgery 2

Ancillary Management

Iron Deficiency and Anemia

• Iron replacement therapy should be used both during medical treatment and before and after surgical procedures to manage iron deficiency and iron deficiency anemia resulting from acute and chronic bleeding 8

Diagnostic Modalities

• Pelvic ultrasound is the gold standard for fibroid diagnosis 6
• MRI further characterizes fibroid location, size, and number but cannot accurately differentiate fibroids from sarcomas 4, 3
• Saline infusion sonohysterography shows good agreement (kappa 0.80) with diagnostic hysteroscopy for classifying submucosal fibroids and accurately depicts the percentage intracavitary component 3
• Hysterosalpingogram is not appropriate to evaluate and classify fibroids 5

Treatment Algorithm Summary

For heavy menstrual bleeding without bulk symptoms:

• Start with NSAIDs + combined oral contraceptives (if no contraindications) 1
• Alternative: tranexamic acid for nonhormonal preference 1

For heavy bleeding with significant bulk symptoms after first-line failure:

• Escalate to oral GnRH antagonists with mandatory hormone add-back therapy 1

For submucosal fibroids causing symptoms:

• Hysteroscopic myomectomy (<5 cm) 3

For exophytic fibroids causing symptoms:

• Laparoscopic myomectomy (fertility desired) 2
• UAE (fertility complete, uterus preservation desired) 2

For definitive resolution when childbearing complete:

• Hysterectomy 3