What is the initial management approach for a woman with a leiomyomatous uterus and fibroids, considering symptom relief and fertility preservation?

Management of Leiomyomatous Uterus and Fibroids

For symptomatic uterine fibroids, initiate medical management with a levonorgestrel-releasing IUD (20 μg/d) as first-line therapy, which reduces menstrual blood loss by 71-95% and provides superior symptom control compared to other medical options. 1, 2

Initial Diagnostic Workup

Before initiating treatment, complete the following assessment:

• Physical examination: Perform abdominal, speculum, and bimanual pelvic evaluation to characterize fibroid location, shape, and mobility 3
• Imaging: Obtain pelvic ultrasound or MRI to characterize fibroid location, size, and number 3
• Laboratory testing: Check pregnancy test, hemoglobin levels, and consider endometrial biopsy if presentation raises concern for other causes of heavy menstrual bleeding 3

Critical caveat: Asymptomatic fibroids require no intervention regardless of size or location, and malignancy risk is extremely low (less than 1 in 1000). 4, 5

Medical Management Algorithm

First-Line Therapy (For Heavy Menstrual Bleeding)

Levonorgestrel-releasing IUD (LNG-IUD 20 μg/d) is the preferred initial treatment because:

• Reduces menstrual blood loss by 71-95% 2
• Provides local mechanism with lower systemic hormone levels 2
• Superior to combined oral contraceptives in randomized trials 2
• Efficacy comparable to endometrial ablation 2

Second-Line Medical Options

If LNG-IUD is contraindicated or declined:

• Combined oral contraceptives: Reduce painful and heavy menstrual bleeding, though less effective than LNG-IUD 2
• Tranexamic acid: Ideal nonhormonal alternative for patients who cannot or prefer not to use hormonal therapy 1, 2
• NSAIDs: Reduce menstrual blood loss and bleeding symptoms, but avoid in cardiovascular disease 2

Third-Line Medical Options (For Preoperative Use or Approaching Menopause)

Oral GnRH antagonists (elagolix, linzagolix, relugolix):

• Reduce fibroid volume by 18-30% 2
• Highly effective for heavy menstrual bleeding 2
• Mandatory requirement: Must use combination low-dose estrogen and progestin add-back therapy to prevent bone loss 2
• Long-term use without add-back therapy causes significant bone mineral density loss 1

Important limitation: Medical therapies do not treat bulk symptoms (pelvic pressure, bowel/bladder dysfunction) and provide only temporary symptom relief with rapid recurrence after discontinuation. 2

Surgical Management Based on Fertility Desires

For Patients Desiring Future Fertility

Myomectomy is the recommended surgical approach, with technique determined by fibroid location: 3, 4, 1

Hysteroscopic myomectomy for:

• Submucosal fibroids causing heavy menstrual bleeding 3
• Offers shorter hospitalization and faster return to activities compared to laparoscopic/open approaches 3
• Post-myomectomy pregnancy rates reach 54-59.5% in women with no other infertility factors 1

Laparoscopic or open myomectomy for:

• Subserosal or intramural fibroids 3
• Open approach preferred for multiple fibroids or very large uteri 3
• Laparoscopy associated with shorter hospital stays versus open surgery 3

Preoperative optimization requirements:

• Correct anemia before elective surgery using GnRH agonists/antagonists or selective progesterone receptor modulators 4, 6
• Provide concurrent iron supplementation 4
• Consider vasopressin, bupivacaine/epinephrine, misoprostol, peri-cervical tourniquet, or gelatin-thrombin matrix to reduce blood loss 6

Critical fertility counseling points:

• Submucosal fibroids significantly impair fertility (pregnancy rates only 10% in ART cycles vs 30% without fibroids) 1
• Intramural fibroids without cavity distortion still reduce fertility (pregnancy rates 16.4% vs 30.1% in controls) 1
• Subserosal fibroids do not affect fertility outcomes 1

For Patients NOT Desiring Future Fertility

Treatment hierarchy based on symptom severity and patient preference:

Option 1: Uterine Artery Embolization (UAE)

• Achieves 73-98% symptom control for menorrhagia and bulk symptoms 1
• 72-73% maintain control at 5 years 1
• Mean fibroid volume reduction of 42% and uterine volume reduction of 35% at 3 months 1
• Significantly shorter hospitalization and faster return to work compared to hysterectomy 3, 4
• Major limitation: Up to 32% require surgical reintervention within 2 years 4

Option 2: Hysterectomy (Definitive Treatment)

• Most effective treatment with 90% patient satisfaction rates 3, 4, 1
• Definitive resolution of all fibroid-related symptoms 4, 1
• Eliminates any future fibroid concerns 4
• Perform by least invasive approach possible 6
• Long-term risks: Increased cardiovascular disease, osteoporosis, bone fracture, dementia, and ovarian failure even with ovarian preservation 4, 1

Option 3: MR-Guided Focused Ultrasound (MRgFUS)

• Usually appropriate alternative to myomectomy or UAE 3
• Limited long-term fertility data (41% live birth rate in registry data) 3

Special Clinical Scenarios

Concurrent adenomyosis:

• Medical management or UAE are preferred initial approaches 3
• UAE provides 65-82% long-term symptomatic relief (median 27.9 months follow-up) 3, 2
• More recent studies show 73-88% symptomatic control with median follow-up 24-65 months 3, 2
• Myomectomy alone unlikely to address adenomyosis effectively 4
• Hysterectomy provides definitive treatment if medical management fails 3

Pedunculated submucosal fibroids with heavy bleeding:

• Hysteroscopic myomectomy or medical management is usually appropriate 3
• Trial medical management before pursuing surgery 3

Postmenopausal patients with symptoms:

• Hysterectomy is usually appropriate after negative endometrial biopsy 3

Procedures to AVOID in Specific Contexts

Endometrial ablation:

• Associated with high risk of pregnancy complications (elevated risks of extrauterine pregnancy, preterm delivery, stillbirth) 3, 4
• Should not be offered without counseling about pregnancy risks and need for reliable contraception 4

Hysterectomy in fertility-desiring patients:

• Causes permanent, irreversible infertility 3, 4
• Should not be performed as first-line when less invasive options can provide similar symptom relief 4

UAE in patients actively seeking pregnancy:

• Carries elevated risks of miscarriage (35%), cesarean sections (66%), and postpartum hemorrhage (13.9-20%) 3, 4
• Myomectomy is superior for fertility preservation 3
• UAE may be considered only for poor surgical candidates or surgically unresectable fibroids 3

Common Pitfalls to Avoid

• Do not perform hysterectomy as first-line treatment when less invasive options (UAE, myomectomy, medical management) can provide similar symptom relief with fewer complications 4
• Do not use laparoscopic power morcellation without informing patients that fibroids may rarely contain unexpected malignancy and morcellation may spread cancer, worsening prognosis 6
• Do not use long-term GnRH agonists/antagonists without add-back therapy due to significant bone mineral density loss 1, 2
• Do not assume medical therapy will treat bulk symptoms—medical options only address bleeding and pain, not pelvic pressure or bowel/bladder dysfunction 2