What are the treatment options for a patient with myoma uteri (uterine fibroids)?

Treatment Options for Uterine Fibroids (Myoma Uteri)

Asymptomatic fibroids require no intervention, but symptomatic fibroids should be treated starting with medical management (levonorgestrel-releasing IUD or combined oral contraceptives as first-line), progressing to surgical options when medical therapy fails, with treatment selection based on fibroid location, symptom severity, and fertility desires. 1

Medical Management

First-Line Therapy for Heavy Menstrual Bleeding

• Levonorgestrel-releasing IUD or combined oral contraceptive pills have the strongest evidence for reducing menstrual blood loss and should be initiated first. 1
• NSAIDs can be added for concurrent pain control and provide modest bleeding reduction. 1
• For patients refusing hormonal options, tranexamic acid is the preferred nonhormonal alternative. 1

Second-Line Medical Therapy

• If first-line therapy fails, oral GnRH antagonists (relugolix, elagolix, or linzagolix) with mandatory hormone add-back therapy should be used to prevent bone loss. 1, 2
• GnRH antagonists reduce both bleeding symptoms and fibroid volume, particularly useful if the patient is anemic or surgery needs to be delayed. 2
• Long-term GnRH agonists or antagonists without add-back therapy cause significant bone mineral density loss and must be avoided. 1

Surgical Treatment Based on Fibroid Location

Submucosal Fibroids (FIGO Type 0-2, Including Type 3)

• Hysteroscopic myomectomy is first-line for submucosal fibroids <5 cm, offering shorter hospitalization, faster recovery, and restoration of normal uterine cavity architecture. 1, 2
• FIGO type 3 myomas are now classified as submucosal rather than intramural, making them amenable to transcervical resection via hysteroscopy. 2

Intramural and Subserosal Fibroids

• Laparoscopic or open myomectomy should be performed for patients desiring fertility preservation when hysteroscopic approach is not feasible. 1, 2
• Post-myomectomy pregnancy rates reach 54-59.5% in women with no other infertility factors. 1

Uterine-Preserving Minimally Invasive Options

• Uterine artery embolization achieves 73-98% symptom control for menorrhagia and bulk symptoms, with 72-73% maintaining control at 5 years. 1
• Mean fibroid volume reduction of 42% and uterine volume reduction of 35% at 3 months can be expected with uterine artery embolization. 1
• UAE is performed via femoral artery catheterization with polyvinyl alcohol particle injection to occlude uterine arteries. 3
• Cross-sectional imaging, preferably MRI, should be performed before UAE to confirm diagnosis and exclude other pelvic pathology. 3
• MRI after UAE is recommended to ensure adequate fibroid infarction and exclude underlying leiomyosarcoma. 3

Definitive Treatment

• Hysterectomy provides definitive resolution with satisfaction rates exceeding 90% and eliminating recurrence risk entirely. 1
• Hysterectomy is associated with increased long-term risks of cardiovascular disease, osteoporosis, bone fracture, and dementia. 1

Fertility Considerations

Impact by Fibroid Location

• Submucosal fibroids significantly impair fertility through impaired implantation, with pregnancy rates of only 10% in ART cycles compared to 30% without fibroids. 1
• Intramural fibroids without cavity distortion still reduce fertility, with pregnancy rates of 16.4% versus 30.1% in controls and implantation rates of 6.4% versus 15.7%. 1
• Subserosal fibroids do not affect fertility outcomes, with pregnancy rates and implantation rates equivalent to women without fibroids. 1

Pre-ART Management

• Surgical or medical treatment should be considered before ART in patients with intramural or submucosal fibroids. 1

Treatment Algorithm

Step 1: Assess Symptom Severity and Anemia

• Correct anemia with iron supplementation while initiating medical therapy. 2
• Perform imaging (transvaginal and transabdominal ultrasonography) to characterize exact fibroid location and size. 4, 2

Step 2: Initiate Medical Management

• Start levonorgestrel-releasing IUD or combined oral contraceptives for heavy menstrual bleeding. 1
• Add NSAIDs for pain control. 1
• If hormonal therapy is refused, use tranexamic acid. 1

Step 3: Escalate to GnRH Antagonists if First-Line Fails

• Initiate GnRH antagonists with mandatory add-back therapy. 1, 2
• Use this approach if patient is anemic or surgery needs to be delayed. 2

Step 4: Surgical Intervention Based on Location and Fertility Desires

• Submucosal fibroids <5 cm: Hysteroscopic myomectomy. 1, 2
• Intramural/subserosal fibroids with fertility preservation: Laparoscopic or open myomectomy. 1, 2
• No fertility preservation needed: Uterine artery embolization or hysterectomy. 1

Critical Pitfalls to Avoid

• Never use long-term GnRH therapy without add-back hormones due to bone loss risk. 1
• Approximately 1 in 350 women undergoing hysterectomy or myomectomy for fibroids has unsuspected uterine sarcoma. 3
• Rapid fibroid growth can occasionally indicate malignant transformation and should prompt urgent referral. 4
• Viable pregnancy and active pelvic inflammatory disease are absolute contraindications for UAE. 3
• Myomectomy with uterine cavity entry may increase obstetric-related uterine rupture risk. 3