What birth control method is recommended for a female patient of reproductive age with a history of uterine fibroids and previous myomectomy to reduce the risk of fibroid regrowth?

Birth Control for Risk Reduction of Fibroid Regrowth After Myomectomy

Combined oral contraceptives and levonorgestrel-releasing intrauterine systems are the most commonly used birth control options post-myomectomy, though the evidence for preventing fibroid regrowth is limited and mixed. 1

Primary Contraceptive Options Post-Myomectomy

Levonorgestrel-Releasing Intrauterine System (LNG-IUS)

• The LNG-IUS is a reasonable first-line contraceptive choice after myomectomy as it provides effective contraception while potentially controlling bleeding symptoms if fibroids recur. 1
• The local progestin delivery minimizes systemic progesterone exposure, which is theoretically advantageous since progesterone and its receptors are known to enhance fibroid proliferation. 1
• This option is particularly suitable for women who have completed childbearing but wish to preserve their uterus. 1

Combined Oral Contraceptives

• Combined hormonal contraceptives are considered acceptable for contraception post-myomectomy, though evidence for their effect on fibroid regrowth is inconsistent, with studies showing reduced, similar, or even increased risk of fibroid growth. 2
• These are most appropriate for patients with small residual fibroids and mild symptoms. 2
• The estrogen component may theoretically promote fibroid growth, though clinical significance remains unclear. 1

Important Caveat About Progesterone-Only Methods

• Progesterone-only contraceptives (such as depot medroxyprogesterone acetate) should be used with caution given that progesterone and progesterone receptors are required for cellular proliferation and fibroid growth. 1
• Fibroids express elevated levels of both PR-A and PR-B receptors compared to normal myometrium, making them potentially responsive to progestin-based contraception. 1

Selective Progesterone Receptor Modulators (SPRMs) - Not for Contraception

While ulipristal acetate (UPA) and other SPRMs show promise for preventing fibroid regrowth through intermittent treatment courses, they are not contraceptives and should not be used as such. 1

• UPA achieves 65-67% median volume reduction of fibroids with sustained effects for months after treatment cessation. 1
• Consider 1-2 additional courses of UPA post-myomectomy if symptoms recur, as this may delay or prevent need for repeat surgery. 1
• However, hepatotoxicity concerns have limited UPA approval in the United States. 3

GnRH Antagonists - Limited Role Post-Myomectomy

• GnRH antagonists (relugolix, elagolix, linzagolix) are highly effective for reducing fibroid volume and bleeding but suppress fertility and are not appropriate as contraceptives. 3, 2
• These agents may be considered if symptomatic fibroid regrowth occurs, but not for routine post-myomectomy contraception. 3, 2

Monitoring Strategy Post-Myomectomy

• Image the uterine cavity with ultrasound or MRI if symptoms suggest fibroid recurrence to assess size, location, and cavity distortion. 3
• If cavity remains normal and patient desires pregnancy, natural or assisted conception can be attempted without intervention. 1, 3
• If cavity becomes distorted by recurrent fibroids, repeat myomectomy may be necessary for fertility optimization. 1, 3

Clinical Pitfalls to Avoid

• Do not assume all hormonal contraceptives equally affect fibroid regrowth - the evidence is insufficient to make definitive claims about prevention. 2
• Avoid high-dose progestin-only methods in patients with known fibroid-prone biology given the role of progesterone in fibroid pathogenesis. 1
• Do not delay evaluation of recurrent symptoms - early imaging can guide timely medical or surgical intervention before significant regrowth occurs. 3