What are the diagnosis and treatment options for a patient with symptoms suggestive of uterine fibroids?

Comprehensive Guide to Uterine Fibroids

Definition and Epidemiology

• Uterine fibroids (leiomyomas) are the most common benign gynecologic tumors, affecting over 60% of women aged 30-44 years 1
• Approximately 70% of fibroids remain asymptomatic and are discovered incidentally on imaging 1, 2
• About 30% of women with fibroids develop symptoms requiring treatment 1, 3
• Malignant transformation to leiomyosarcoma is extremely rare (less than 1 in 1000 cases) 4

Clinical Presentation

Symptomatic Manifestations

• Heavy menstrual bleeding (most common symptom) with resultant iron deficiency anemia 1, 2
• Bulk symptoms: pelvic pressure, pain, abdominal fullness, urinary frequency/urgency, constipation 5, 2
• Reproductive dysfunction including infertility and recurrent pregnancy loss 6
• Symptoms typically peak in the perimenopausal period and decline after menopause 7

Diagnostic Approach

Initial Evaluation

• Complete gynecologic history focusing on bleeding patterns, bulk symptoms, and fertility desires 2
• Abdominal, speculum, and bimanual pelvic examination 2

Imaging Studies

• Transvaginal and transabdominal ultrasound is the initial imaging modality of choice 2
• MRI with contrast provides superior characterization of fibroid location, size, and extent of disease to guide treatment planning 2
• Imaging helps classify fibroids by location: submucosal (intracavitary), intramural, or subserosal 7

Treatment Algorithm by Clinical Scenario

Medical Management (First-Line for Most Patients)

For Heavy Menstrual Bleeding

• Start with levonorgestrel-releasing IUD (52 mg) or combined oral contraceptives as first-line therapy 7, 1
• Add tranexamic acid if hormonal therapy is contraindicated or ineffective (53% of clinicians use this escalation strategy) 8
• Consider progestin-only contraceptives as alternative hormonal option 7

Second-Line Medical Options

• GnRH agonists (leuprolide) or GnRH antagonists for short-term symptom control and preoperative fibroid reduction 7, 1
• Must use add-back therapy (low-dose estrogen plus progestin) to prevent bone density loss with prolonged GnRH agonist use 7
• Selective progesterone receptor modulators (SPRMs) can be used intermittently long-term with good results on bleeding and fibroid size reduction 3

Nonhormonal Options

• NSAIDs for pain and bleeding control 1, 4
• Tranexamic acid as standalone therapy for patients preferring nonhormonal treatment 7

Surgical Management

Reproductive Age Patients Desiring Future Fertility

Hysteroscopic Myomectomy (First-Line for Submucosal Fibroids)

• Indicated for symptomatic intracavitary/submucosal fibroids with pregnancy rates of 85% and live birth rates of 65% 7
• Performed transvaginally through transcervical approach 5

Laparoscopic or Open Myomectomy

• Appropriate for subserosal or intramural fibroids in fertility-preserving cases 7, 9
• Less than half of patients attempting conception achieve pregnancy, and of those, less than half result in live births 7
• At 4 years, equally effective as UAE for reducing heavy menstrual bleeding 5
• Higher rates of new fibroid formation compared to UAE 5

Reproductive Age Patients NOT Desiring Future Fertility

Endometrial Ablation

• Minimally invasive option for heavy menstrual bleeding refractory to medical therapy 5
• Uses thermal energy to destroy uterine lining 5
• Only perform after failure of medical therapy due to elevated risks of ectopic pregnancy, preterm delivery, and stillbirth if pregnancy occurs 5
• Not effective for concurrent adenomyosis (high treatment failure rate) 5

Hysterectomy (Definitive Treatment)

• Provides definitive resolution of all fibroid symptoms with patient satisfaction rates up to 90% 8
• Accounts for three-quarters of fibroid treatment in the United States 5
• However, hysterectomy should NOT be first-line unless other uterine pathology exists (adenomyosis, endometriosis, high-risk cervical dysplasia, prolapse, malignancy) 5
• Associated with increased risks: cardiovascular disease, osteoporosis, bone fractures, dementia, and increased mortality especially when performed at young age 5
• Randomized trials show increased severe complications, longer hospitalization, and longer recovery compared to UAE despite similar symptom relief 5

Route Selection for Hysterectomy (if indicated)

• Vaginal or laparoscopic approach preferred over abdominal 5, 8
• Vaginal: shorter operating times, faster return to activities, better quality of life 5
• Laparoscopic/robotic: faster recovery, shorter hospital stays, lower wound infection rates 5
• Abdominal: longest hospital stay, recovery time, highest pain and infection risk 5
• Preserve ovaries unless other indication for removal to avoid premature menopause and cardiovascular risks 5

Minimally Invasive Interventional Options

Uterine Artery Embolization (UAE)

• Effective option for symptomatic fibroids in patients wishing to preserve uterus who failed medical treatment 7, 9
• Causes >50% decrease in fibroid size at 5 years with persistent decreases in pain and bleeding 5
• Superior to MRgFUS with lower reintervention rates (13% vs 30%) and better fibroid diameter reduction (53%) 8
• Reintervention rate approximately 7% for persistent symptoms 9
• Secondary hysterectomy rates: 28% at 5 years, 35% at 10 years 5
• Lower blood transfusion risk and shorter hospital stays compared to myomectomy 5
• Promising evidence that UAE is comparable to myomectomy for fertility outcomes (81% pregnancy rate, 48% live birth rate in prospective studies) 5
• Particularly appropriate for concurrent adenomyosis with fibroids: 94% short-term and 85% long-term symptom improvement 8
• Common side effect: post-embolization syndrome (flu-like symptoms with pain, nausea, fevers, leukocytosis) 5

MR-Guided Focused Ultrasound (MRgFUS)

• Uses high-intensity ultrasound waves to thermally ablate fibroids causing coagulative necrosis 7
• No damage to intervening tissues 7
• Higher reintervention rate (30%) compared to UAE 8
• Meta-analyses show UAE provides better symptom relief, quality of life, and lower reintervention rates 5

Laparoscopic Uterine Artery Occlusion (LUAO)

• Decreases heavy menstrual bleeding and fibroid diameter 7
• Lower postprocedural complications and rehospitalizations compared to UAE 7

Radiofrequency Ablation

• Available minimally invasive option performed under radiologic or ultrasound guidance 3, 2

Special Population: Concurrent Adenomyosis with Fibroids

Medical Management

• Levonorgestrel-releasing IUD is the single most effective medical therapy for heavy menstrual bleeding in adenomyosis 8
• Add tranexamic acid as first escalation step (most common approach) 8

Interventional Therapy

• UAE is preferred initial approach alongside medical management, providing 94% short-term and 85% long-term symptom improvement 8
• Quality of life benefits last up to 7 years 8

Definitive Treatment

• Hysterectomy provides definitive resolution when medical management and UAE fail 8
• Simultaneously treats adenomyosis, fibroids, and any concurrent endometriosis 8

Postmenopausal Women

• Expectant management is particularly appropriate as fibroid symptoms typically decline after menopause 7

Adjunctive Management

Iron Deficiency and Anemia

• Common consequence of acute and chronic bleeding from fibroids 1
• Iron replacement therapy should be used during medical treatment and before/after surgical procedures 1

Vitamin D Supplementation

• Treating vitamin D deficiency may reduce fibroid tumor size or halt progression 2

Critical Warnings and Pitfalls

Medical Therapy Limitations

• High rates of symptom recurrence after discontinuation, particularly with GnRH agonists/antagonists 7
• Medical options do not remove tumors; symptoms return when treatment stops 4
• Bone density loss with prolonged GnRH agonist use mandates add-back therapy 7

Hysterectomy Risks

• Avoid hysterectomy as first-line unless less invasive procedures are unsuitable or other uterine pathology exists 5
• Even with ovarian preservation, associated with cardiovascular disease, mood disorders, osteoporosis, and dementia 5
• Short-term complications: abscess, VTE, ureteral/bowel/bladder injury, bleeding requiring transfusion, vaginal cuff complications 5

Endometrial Ablation Cautions

• Not a form of contraception; pregnancy after ablation carries high risk of ectopic pregnancy, preterm delivery, and stillbirth 5
• High failure rate with concurrent adenomyosis 5

Fertility Considerations

• Pregnancy is possible after UAE despite no desire for fertility; counsel patients accordingly 5
• Endometrial ablation absolutely contraindicated in anyone with any future fertility desires 5

Follow-Up Recommendations

• Asymptomatic fibroids require periodic follow-up to document stability in size and growth 4, 6
• Monitor for symptom development or progression 4