What are the treatment options for leiomyoma (uterine fibroids)?

Treatment Options for Uterine Leiomyomas

For symptomatic uterine fibroids, treatment selection depends primarily on fertility desires: hysterectomy provides definitive cure with >90% satisfaction when fertility is not desired, while myomectomy is the surgical standard for fertility preservation, and medical therapies or minimally invasive procedures serve as temporizing or uterus-sparing alternatives. 1, 2

Treatment Algorithm Based on Clinical Context

For Women NOT Desiring Future Fertility

Hysterectomy is the gold standard with virtually zero recurrence risk and >90% patient satisfaction rates at 2 years, making it the most effective definitive treatment. 3, 1 The approach (abdominal, vaginal, or laparoscopic) should be determined by fibroid size and location, with laparoscopically-assisted vaginal hysterectomy showing advantages over abdominal approach for uteri 12-18 weeks in size. 3

Key consideration: Hysterectomy eliminates reproductive potential and carries risks of minor complications and occasionally major morbidity, but provides complete symptom resolution. 3

For Women Desiring Fertility Preservation or Uterus Retention

Surgical Options

Myomectomy is the primary fertility-preserving surgical option, with approximately 27% recurrence rate at 10 years (higher with multiple fibroids). 1, 2

• Hysteroscopic myomectomy should be first-line for symptomatic intracavitary (submucosal) fibroids. 2
• Laparoscopic myomectomy carries 2% major complication and 9% minor complication rates. 1
• Important: Women should wait 2-3 months after myomectomy before attempting pregnancy to allow proper healing. 1
• Critical pitfall: Intramural and submucosal fibroids significantly reduce pregnancy rates (16.4% and 10% respectively vs 30.1% without fibroids), while subserosal fibroids do not affect fertility outcomes (34.1% pregnancy rate). 3

Minimally Invasive Interventional Options

Uterine Artery Embolization (UAE) achieves technical success in >95% of cases, with 40-50% decrease in uterine volume and symptom control in approximately 80% of patients. 3, 1 However, UAE shows 20-25% symptom recurrence at 5-7 years, with higher failure rates in women <40 years of age. 1

Contraindications and special considerations for UAE:

• Higher failure rates with cervical fibroids and multiple submucosal fibroids 1
• Pedunculated subserosal fibroids are no longer considered contraindications 1
• Women choosing UAE should be counseled that fecundity and pregnancy may be impacted 2

MR-guided Focused Ultrasound Surgery (MRgFUS) uses high-intensity ultrasound to ablate fibroid tissue, though long-term outcome data remain limited. 1, 4

Myolysis techniques (using Nd:YAG laser, bipolar needles, monopolar cautery, or cryotherapy) can reduce fibroid volume by 40-80%. 1

Medical Management

First-Line Medical Therapies

For abnormal uterine bleeding:

• Levonorgestrel intrauterine system is highly effective (Level I evidence) 2
• Tranexamic acid (non-hormonal) reduces menorrhagia but may cause pelvic pain and fever 1, 5
• Oral contraceptives and progestins effectively manage bleeding symptoms, especially with smaller fibroids, though they have limited effect on fibroid size 1, 2

Second-Line Medical Therapies

Selective Progesterone Receptor Modulators (SPRMs) such as Ulipristal Acetate reduce fibroid volume by approximately 30% after a single course and up to 70% after 4 courses, with Level I, A evidence for symptomatic relief. 4, 2 SPRMs are effective for both bleeding and bulk symptoms. 2

GnRH agonists reduce fibroid volume by 35% and improve hemoglobin levels but cause significant hypoestrogenic side effects. 1, 4

Critical pitfall: GnRH agonist therapy without add-back results in approximately 1% bone loss per month and should not be used long-term. 1 Add-back therapy with low-dose sex steroids mitigates hypoestrogenic side effects while maintaining therapeutic efficacy. 3, 4

Preoperative Optimization

Anemia correction is mandatory before elective surgery. 2 SPRMs and GnRH analogues are effective at correcting anemia preoperatively (Level I-A evidence). 2

Intraoperative blood loss reduction: Use of vasopressin, bupivacaine with epinephrine, misoprostol, peri-cervical tourniquet, or gelatin-thrombin matrix should be considered (Level I-A evidence). 2

Critical Pitfalls and Caveats

Fibroid location matters significantly:

• Submucosal fibroids have 23% failure rate with endometrial ablation compared to 4% in normal uterine cavities 1
• Intramural fibroids without cavity distortion still significantly reduce IVF pregnancy rates (16.4% vs 30.1%) 3

Age impacts outcomes: UAE has higher failure rates in women <40 years, likely due to increased collateral vessel recruitment. 1

Malignancy risk: Approximately 1 in 350 women undergoing surgery for presumed fibroids has unsuspected uterine sarcoma. 6 When morcellation is necessary, patients must be informed about risks of spreading unexpected malignancy. 2

Asymptomatic fibroids: The majority of fibroids are asymptomatic and require no intervention. 2 Women with asymptomatic fibroids should be reassured that malignancy risk does not substantiate hysterectomy. 2

Special Populations

Pregnancy considerations: Concern about possible complications related to fibroids in pregnancy is NOT an indication for myomectomy except in women who have had previous pregnancy complications specifically related to fibroids. 2 Women with fibroids detected in pregnancy may require additional maternal and fetal surveillance. 2

Coexisting conditions: For women with coexisting adenomyosis, UAE shows 65-88% long-term symptomatic relief. 1 When fibroids coexist with endometriosis, surgical methods addressing both conditions simultaneously may be more appropriate. 1