What are the treatment options for a patient with a myomatous uterus?

Treatment of Myomatous Uterus

For women with symptomatic uterine fibroids, treatment selection depends primarily on fertility desires: hysteroscopic myomectomy for submucosal fibroids in those wanting pregnancy, laparoscopic/open myomectomy for intramural fibroids with fertility preservation, uterine artery embolization for those not seeking pregnancy, and hysterectomy for definitive treatment when childbearing is complete. 1, 2

Initial Medical Management

First-Line Medical Options

• Oral contraceptives and progestins effectively manage bleeding symptoms, particularly in women with smaller fibroids, though they have limited effect on fibroid size 2
• Tranexamic acid (non-hormonal) reduces menorrhagia but may cause pelvic pain and fever 1, 2
• NSAIDs provide symptomatic relief for bleeding and pain 3

Advanced Medical Therapy

• GnRH antagonists (relugolix, elagolix, linzagolix) should be initiated if the patient is anemic or surgery needs delay, as these reduce both bleeding and fibroid volume 3
• GnRH agonists reduce fibroid volume by approximately 35% and improve hemoglobin levels, but cause significant hypoestrogenic side effects limiting long-term use 1, 2
• Add-back therapy with GnRH agonists mitigates hypoestrogenic side effects while maintaining efficacy 2
• Selective progesterone receptor modulators (SPRMs) show promise for symptom control and fibroid volume reduction 2, 4

Critical Pitfall: GnRH agonist therapy without add-back results in approximately 1% bone loss per month and should not be used long-term 2

Surgical Management Algorithm

For Women Desiring Fertility Preservation

Submucosal Fibroids (FIGO Types 0-3)

• Hysteroscopic myomectomy is the procedure of choice for FIGO type 3 and other submucosal myomas, offering shorter hospitalization and faster recovery compared to laparoscopic or open approaches 3, 5
• Hysteroscopic resection in one or two procedures is recommended for submucosal fibroids <4 cm, regardless of symptoms 6

Intramural/Subserosal Fibroids

• Laparoscopic or open myomectomy should be offered as first therapeutic choice for women planning future pregnancy 1, 2
• Laparoscopic myomectomy is optimal for fibroids <15 cm with no more than three fibroids of 5 cm size 7
• Women should wait 2-3 months after myomectomy before attempting pregnancy to allow proper healing 1, 2
• Recurrence rate is 23-33% using abdominal or laparoscopic approaches, with approximately 27% recurrence at 10 years 1, 2
• Major complication rate is 2% and minor complication rate is 9% 1, 2

Critical Pitfall: Intramural fibroids negatively affect fertility, but treating asymptomatic fibroids does not necessarily improve fertility outcomes 2

For Women NOT Seeking Pregnancy

Uterine Artery Embolization (UAE)

• UAE achieves technical success in >95% of cases, resulting in 40-50% decrease in uterine volume and symptom control in approximately 80% of patients 1, 2
• UAE achieves >50% reduction in fibroid size at 5 years 3
• UAE should NOT be first-line for women seeking pregnancy due to increased risk of miscarriage, cesarean sections, and postpartum hemorrhage 1, 2
• Long-term follow-up shows 20-25% symptom recurrence at 5-7 years, with higher failure rates in patients <40 years of age 2
• Complications include temporary fever in 40% of patients and extreme pain in up to 20% 1

Critical Pitfall: Cervical fibroids and multiple submucosal fibroids have higher treatment failure rates with UAE 2

Other Minimally Invasive Options

• MR-guided Focused Ultrasound (MRgFUS/HIFU) achieves approximately 50% fibroid volume reduction at 1 year and 40% at 24 months 2
• HIFU is restricted to patients with fewer than 6 leiomyomas and total fibroid volume <900 cm³ 2
• HIFU has severely limited evidence for fertility, with only 41% of pregnancies resulting in live births compared to 65% with myomectomy 2
• Myolysis techniques (Nd:YAG laser, bipolar needles, monopolar cautery, cryotherapy) can reduce fibroid volume by 40-80% 1, 2
• Endometrial ablation is effective for abnormal uterine bleeding with >95% patient satisfaction, but has 23% failure rate with submucosal fibroids compared to 4% with normal cavities 2

Definitive Treatment

Hysterectomy

• Hysterectomy is the most effective and definitive treatment with high satisfaction rates exceeding 90%, offering symptom elimination and zero recurrence risk 1, 2
• For perimenopausal women who have been informed of alternatives and risks, hysterectomy is the most effective treatment for symptomatic fibroids 6
• When possible, vaginal or laparoscopic routes should be preferred to laparotomy 6
• Subtotal hysterectomy by laparotomy has lower complication rate than total hysterectomy, though rates are the same by laparoscopy 6

Treatment Selection Based on Fibroid Location

By FIGO Classification

• FIGO Type 0-3 (Submucosal): Hysteroscopic myomectomy first-line 3, 5
• FIGO Type 3-6 (Intramural): Laparoscopic/open myomectomy if fertility desired; UAE or hysterectomy if not 1, 2
• FIGO Type 7-8 (Subserosal): Laparoscopic myomectomy or UAE 2

Critical Pitfall: Pedunculated subserosal fibroids were previously considered a contraindication to UAE due to concerns about fibroid detachment, but recent studies show good outcomes without complications 2

Special Considerations

Coexisting Conditions

• For women with coexisting adenomyosis, UAE shows early success with long-term symptomatic relief ranging from 65% to 88% 2
• When fibroids coexist with endometriosis, surgical methods addressing both conditions simultaneously may be more appropriate 2

Age-Related Factors

• UAE has higher failure rates in women <40 years, likely due to increased collateral vessel recruitment 2
• Black women have >80% incidence of fibroids by age 50, whereas White women have approximately 70% incidence 8