What are the treatment options for a patient with uterine fibroids experiencing heavy menstrual bleeding and pelvic pain?

Treatment of Uterine Fibroids with Heavy Menstrual Bleeding and Pelvic Pain

For patients with symptomatic uterine fibroids causing heavy menstrual bleeding and pelvic pain, treatment selection depends primarily on fertility desires: offer hysteroscopic myomectomy for submucosal fibroids with fertility preservation goals, laparoscopic/open myomectomy for intramural/subserosal fibroids desiring pregnancy, or hysterectomy for definitive treatment when childbearing is complete. 1

Initial Medical Management

First-Line Pharmacotherapy for Bleeding Control

• Tranexamic acid and NSAIDs are appropriate initial symptomatic agents for heavy menstrual bleeding without addressing fibroid size 2, 3, 4
• Combined oral contraceptives or 52-mg levonorgestrel-releasing intrauterine devices provide hormonal control of bleeding symptoms 2, 4
• Selective progesterone receptor modulators (SPRMs) like ulipristal acetate achieve amenorrhea in 72-83% of patients after the first course, with 65-67% median fibroid volume reduction 1
  • Can be administered for up to 4 courses with sustained efficacy 1
  • Particularly useful as bridge therapy before surgery to improve quality of life and facilitate minimally invasive approaches 1

Preoperative Medical Optimization

• GnRH agonists or antagonists reduce fibroid size and control bleeding preoperatively 2, 3, 4
• Iron supplementation is essential for anemic patients before surgical intervention 1, 2

Surgical Management Algorithm

For Patients Desiring Fertility Preservation

Submucosal Fibroids:

• Hysteroscopic myomectomy is the procedure of choice for submucosal fibroids causing bleeding 1
• Offers shorter hospitalization and faster return to activities compared to abdominal approaches 1
• Quality of life improvement equivalent to other surgical approaches at 2-3 months 1
• Critical caveat: Patients with significant intramural/subserosal burden or concomitant adenomyosis are less likely to achieve symptom relief 1

Intramural or Subserosal Fibroids:

• Laparoscopic myomectomy is preferred for smaller fibroid burden with benefits of shorter hospital stays and faster recovery 1
• Open myomectomy is indicated for multiple fibroids or very large uteri 1
• Both approaches show equivalent fertility outcomes in large prospective registries 1

Comparative Outcomes:

• Myomectomy (any approach) demonstrates improved quality of life scores versus uterine artery embolization at 2 years, though this difference becomes non-significant at 4 years 1

For Patients with Completed Childbearing

Hysterectomy is the most effective definitive treatment for symptomatic fibroids when fertility preservation is not desired 5, 3

Minimally Invasive Interventional Options

Radiologically Guided Procedures

• Uterine artery embolization (UAE) is an alternative to surgery for patients seeking uterine preservation 5, 3, 6
• Radiofrequency ablation and MRI-guided focused ultrasound are additional non-surgical options 3, 6, 4
• These interventions are appropriate for patients who wish to avoid surgery but do not prioritize future fertility 5

Treatment Selection Framework

Step 1: Assess Fertility Desires and Anemia Status

• If anemic: Initiate iron supplementation plus medical therapy for menstrual suppression 1
• If not anemic but surgery delayed: Consider SPRM pretreatment to bridge to surgery, improve quality of life, and shrink fibroids 1

Step 2: Characterize Fibroid Location via Imaging

• Pelvic ultrasound (transvaginal + transabdominal) is the initial diagnostic modality with 90-99% sensitivity 7
• MRI provides superior delineation when multiple fibroids are present or surgical planning requires detailed anatomic mapping 7

Step 3: Match Treatment to Fibroid Type and Patient Goals

Submucosal fibroids + fertility desired:

• Hysteroscopic myomectomy 1

Intramural/subserosal fibroids + fertility desired:

• Laparoscopic myomectomy (limited burden) or open myomectomy (extensive disease) 1

Symptomatic fibroids + childbearing complete:

• Offer 1-2 courses of SPRM for symptom control 1
• If positive clinical response, suspend treatment until symptom recurrence 1
• If inadequate response or symptoms recur, proceed to hysterectomy 5, 3

Desire for uterine preservation without fertility:

• Consider UAE, radiofrequency ablation, or MRI-guided focused ultrasound 5, 3, 6

Critical Pitfalls to Avoid

• Do not perform endometrial ablation in patients desiring fertility due to high risk of pregnancy complications 1
• Do not rely solely on hysteroscopic myomectomy for patients with significant intramural/subserosal burden or adenomyosis, as symptom relief is unlikely 1
• Do not assume rapid fibroid growth indicates malignancy, but recognize that leiomyosarcoma risk is approximately 2.94 per 1,000 in perimenopausal women with rapid growth, warranting endometrial biopsy 7
• Image the uterine cavity preoperatively when using SPRM pretreatment, as fibroids may migrate and alter surgical planning 1

Expectant Management

• Asymptomatic fibroids require no intervention, though follow-up is advisable to document stability 5, 3
• Most fibroids decrease in size during menopause, making expectant management reasonable for perimenopausal patients with mild symptoms 3