What are the treatment options for a patient with symptomatic fibroids, including heavy menstrual bleeding and pelvic pain?

Treatment of Symptomatic Uterine Fibroids

All patients with symptomatic fibroids causing heavy menstrual bleeding and pelvic pain should start with medical management before considering any invasive procedures, regardless of fertility goals. 1, 2

Initial Medical Management Algorithm

First-Line Hormonal Options for Heavy Menstrual Bleeding

• Levonorgestrel-releasing IUD is the most effective hormonal treatment for controlling heavy menstrual bleeding and should be your first choice. 1, 2
• Combined oral contraceptives are equally effective for bleeding control if the IUD is not tolerated or desired. 1, 2

First-Line Non-Hormonal Options

• Tranexamic acid is the best non-hormonal alternative for patients who cannot tolerate or refuse hormonal therapy, significantly reducing menstrual blood loss. 1, 2
• NSAIDs reduce both bleeding and pain symptoms simultaneously. 2

Second-Line Medical Options

• GnRH agonists (like leuprolide) or oral GnRH antagonists reduce fibroid volume by 18-30% and control bleeding symptoms. 1, 2
• These agents require add-back therapy with low-dose estrogen and progestin to prevent bone density loss and hypoestrogenic symptoms during prolonged use. 1
• Selective progesterone receptor modulators reduce both bleeding and pressure symptoms. 2

Critical Pitfall: Symptoms recur at high rates after discontinuing medical therapy, particularly with GnRH agonists/antagonists, so patients must understand this is not a permanent solution. 1

Surgical and Interventional Management

The choice between procedures depends on three factors: fertility desires, symptom severity, and fibroid location. 2

For Patients Desiring Future Fertility

• Hysteroscopic myomectomy is first-line conservative surgical therapy for submucosal fibroids causing bleeding, with pregnancy rates of 85% and live birth rates of 65%. 1, 2
• Laparoscopic myomectomy is indicated for ≤3 fibroids <15 cm (subserosal or intramural location). 2, 3
• Open myomectomy is reserved for multiple fibroids or very large uteri. 2

Important Caveat: Less than half of patients attempting conception after myomectomy achieve pregnancy, and of those who do, less than half result in live births. 1

For Patients Not Desiring Future Fertility

Uterine-Preserving Options

• Uterine artery embolization (UAE) reduces fibroid volume by 40-53% and controls symptoms in 80-94% of cases short-term, 85% long-term. 2
• UAE has a reintervention rate of approximately 7% for persistent symptoms. 4
• MR-guided focused ultrasound surgery (MRgFUS) uses high-intensity ultrasound to thermally ablate fibroids without damaging intervening tissues. 1
• MRgFUS has a higher reintervention rate (30%) compared to UAE (13%). 4
• Laparoscopic uterine artery occlusion (LUAO) has lower postprocedural complications and rehospitalizations compared to UAE. 1

Definitive Treatment

• Hysterectomy provides definitive resolution with 90% patient satisfaction rates and is the most effective treatment for symptomatic fibroids. 1, 2

Special Clinical Scenarios

Multiple Fibroids with Concurrent Adenomyosis

• Medical management or UAE are the preferred initial approaches. 2, 4
• Hysterectomy provides definitive treatment if medical management fails. 2

Preoperative Optimization

• Correct anemia before elective surgery using GnRH agonists/antagonists or selective progesterone receptor modulators plus concurrent iron supplementation. 2
• GnRH agonists are particularly useful for short courses to decrease fibroid size before surgery. 1

Reproductive Age Women with Anemia Despite Medical Therapy

• Escalation to interventional or surgical options is necessary when medical therapy fails to control anemia. 1

Critical Warning: Fertility is suppressed during GnRH agonist/antagonist treatment; discontinuation is required before attempting conception. 2