What are the management options for a woman with leiomyoma (uterine fibroids) experiencing heavy menstrual bleeding and pelvic pain?

Management of Uterine Leiomyomas

For women with symptomatic uterine fibroids causing heavy menstrual bleeding and pelvic pain, treatment selection depends critically on fertility desires: hysterectomy provides definitive resolution with highest satisfaction rates for those who have completed childbearing, while fertility-preserving options include myomectomy for those desiring pregnancy, or uterine artery embolization (UAE) for those wanting to retain their uterus without future pregnancy plans. 1, 2

Initial Assessment and Medical Management

First-Line Medical Therapy

• The levonorgestrel intrauterine system (IUD) should be the first-line medical treatment for heavy menstrual bleeding, with efficacy comparable to endometrial ablation or hysterectomy and the highest effectiveness among medical options 3
• Tranexamic acid reduces menstrual blood loss by 20-60% and serves as an effective non-hormonal alternative, particularly useful in patients who cannot use hormonal therapy 3, 2
• Combined oral contraceptives effectively reduce bleeding symptoms, especially in younger women who also desire contraception 3, 2
• Selective progesterone receptor modulators (SPRMs) reduce both fibroid volume and control symptoms, though long-term data remain limited 4, 2

Preoperative Medical Optimization

• GnRH agonists or antagonists should be used preoperatively in anemic patients to correct anemia and reduce fibroid volume by approximately 35%, but should not exceed short-term use due to 1% bone loss per month without add-back therapy 4, 2
• Add-back therapy with GnRH agonists mitigates hypoestrogenic side effects while maintaining therapeutic efficacy 4

Surgical Management Algorithm

For Women Who Have Completed Childbearing

• Hysterectomy is the most appropriate definitive treatment, providing complete resolution of all fibroid-related symptoms with up to 90% patient satisfaction at 2 years and elimination of recurrence risk 1, 4, 3, 2
• Choose the least invasive surgical route: vaginal > laparoscopic/robotic > abdominal, based on uterine size and surgical expertise 3, 2
• Vaginal and laparoscopic approaches are associated with shorter hospital stays, faster recovery, and lower complication rates compared to abdominal hysterectomy 3

For Women Desiring Future Pregnancy

• Laparoscopic or open myomectomy should be offered as first-line therapy for women with intramural or subserosal fibroids who desire pregnancy 4, 2
• Hysteroscopic myomectomy should be considered first-line conservative surgical therapy for symptomatic intracavitary fibroids 2, 5
• Surgical planning must be based on mapping the location, size, and number of fibroids with appropriate imaging (ultrasound or MRI) 6, 2
• Women should wait 2-3 months after myomectomy before attempting pregnancy to allow proper uterine healing 4
• Recurrence risk is approximately 27% at 10 years, with higher rates in women with multiple fibroids 1, 4

Critical Caveat for Myomectomy

• When morcellation is necessary, patients must be informed that fibroids may rarely contain unexpected malignancy and laparoscopic power morcellation may spread cancer, potentially worsening prognosis 2

Minimally Invasive Interventional Options

Uterine Artery Embolization (UAE)

• UAE is appropriate for women who wish to preserve their uterus but do not desire future pregnancy, with technical success in >95% of cases and 40-50% decrease in uterine volume 1, 4
• Symptom control occurs in approximately 80% of patients initially, with 94% short-term improvement and 85% long-term improvement 1, 3
• UAE should NOT be first-line in women seeking pregnancy due to increased miscarriage and cesarean section rates 4
• Long-term follow-up shows 20-25% symptom recurrence at 5-7 years, with higher failure rates (>40%) in patients <40 years of age 1
• Location matters: cervical fibroids and multiple submucosal fibroids have higher treatment failure rates with UAE 1

Pedunculated Subserosal Fibroids

• Despite previous concerns about fibroid detachment, recent studies show good outcomes without complications after UAE for pedunculated subserosal fibroids 1
• Patient preference for UAE should be respected as long as patients are well-informed on current evidence 1

MR-Guided Focused Ultrasound (MRgFUS)

• MRgFUS should NOT be offered as first-line for reproductive-age women desiring pregnancy, with only 41% of pregnancies resulting in live births compared to 65% with myomectomy 4
• Registry data shows 28% spontaneous abortion rate, nearly double the general population 4
• MRgFUS achieves approximately 50% fibroid volume reduction at 1 year but viable tumor cells persist in 26% of specimens 4
• May be considered only for poor surgical candidates or patients who refuse surgery despite counseling 4

Special Clinical Scenarios

Coexisting Adenomyosis

• UAE has shown effectiveness for patients with both fibroids and adenomyosis, with long-term symptomatic relief ranging from 65% to 88% at median follow-up of 27.9 months 1
• Adenomyosis frequently coexists with fibroids in women in their 40s and contributes significantly to menorrhagia and anemia 3

Coexisting Endometriosis

• When fibroids coexist with endometriosis, surgical methods addressing both conditions simultaneously may be more appropriate than UAE 1

Acute Heavy Uterine Bleeding

• Conservative management options include estrogens, antifibrinolytics, Foley catheter tamponade, and/or operative hysteroscopic intervention 2
• In centers where available, intervention by UAE may be considered 2
• Hysterectomy may become necessary in some cases when conservative measures fail 2

Intraoperative Techniques to Reduce Blood Loss

The following interventions reduce blood loss at myomectomy and should be considered: vasopressin, bupivacaine and epinephrine, misoprostol, peri-cervical tourniquet, or gelatin-thrombin matrix 2

Fertility Considerations

Impact on Fertility

• Intramural fibroids negatively affect fertility, with significantly decreased implantation rates per embryo transferred in IVF cycles 1
• Submucosal fibroids are associated with higher miscarriage rates (41% preoperatively vs 19% postoperatively after myomectomy) 1
• Subserosal fibroids do not significantly impact implantation rates 1

When to Intervene for Infertility

• Removal of fibroids that distort the uterine cavity may be indicated in infertile women where no other factors have been identified 5
• However, treating asymptomatic fibroids does not necessarily improve fertility outcomes 4

Common Pitfalls to Avoid

• Do not use GnRH agonist therapy long-term without add-back therapy due to significant bone loss (approximately 1% per month) 4
• Do not assume all fibroids require treatment - the majority are asymptomatic and require no intervention 1, 2
• Do not offer hysterectomy for asymptomatic fibroids solely due to concern about malignancy - there is no evidence to substantiate this approach 2, 5
• Do not fail to correct anemia preoperatively - selective progesterone receptor modulators and GnRH analogues are effective at correcting anemia and should be used before elective surgery 2
• Do not overlook non-gynecological causes when evaluating pelvic pain or bulk symptoms, particularly urinary tract pathology and musculoskeletal conditions 6