What are the management options for uterine fibroids (myoma uteri) in a premenopausal woman, taking into account age, desire for future fertility, symptom severity, fibroid size and location, and any comorbid conditions?

Management of Uterine Fibroids (Myoma Uteri)

Start with medical management using levonorgestrel IUD or combined oral contraceptives for bleeding symptoms, reserving surgical intervention for failed medical therapy, fertility concerns with cavity-distorting fibroids, or when definitive treatment is desired. 1

Initial Assessment and Classification

Determine fibroid location using transvaginal ultrasound, as this dictates treatment approach:

• Submucosal fibroids (especially FIGO Type 4): Project into uterine cavity, cause heavy bleeding, impair fertility 2, 3
• Intramural fibroids: Within uterine wall, may or may not distort cavity 2
• Subserosal fibroids: Project outward from uterus, typically cause bulk symptoms only 2, 4

Evaluate for cavity distortion using hysteroscopy, hysterosonography, or MRI when fertility is a concern, as intramural and submucosal fibroids that distort the cavity significantly reduce implantation rates (6.4% vs 15.7% in controls) 2, 4

Medical Management Algorithm

For Heavy Menstrual Bleeding:

First-line options (choose based on contraceptive needs):

• Levonorgestrel IUD: Most effective hormonal option 1, 5
• Combined oral contraceptives: Effective for bleeding control 1, 5
• Tranexamic acid: Nonhormonal alternative when hormones contraindicated 1, 6

Second-line when first-line fails:

• GnRH agonists (leuprolide) or antagonists with estrogen-progestin add-back therapy to prevent bone loss 1, 5
• Selective progesterone receptor modulators (SPRMs): Reduce bleeding and fibroid volume 1, 5
• Use these for 3-6 months maximum or as preoperative preparation 1, 5

For Bulk Symptoms (Pelvic Pressure, Urinary Frequency):

• Trial GnRH agonists/antagonists or SPRMs for symptom reduction 1
• If medical management fails, proceed to interventional options 1

Critical limitation: All medical therapies have high symptom recurrence rates after discontinuation, making them temporizing rather than definitive solutions 1, 5

Surgical Management Based on Fertility Desires

For Women Desiring Future Pregnancy:

Submucosal fibroids (FIGO Type 4):

• Hysteroscopic myomectomy is mandatory for pedunculated submucosal fibroids <5 cm, as these significantly impair fertility 3, 5, 4
• Pregnancy rates after hysteroscopic myomectomy reach 85% with 65% live birth rates 1
• Provides shortest hospitalization and fastest recovery 3

Intramural fibroids WITHOUT cavity distortion:

• Do not perform myomectomy - there is fair evidence recommending against it, as these fibroids do not significantly impact fertility and surgery introduces unnecessary risks 4
• Pregnancy and implantation rates are not significantly different from controls when cavity is intact 2

Intramural fibroids WITH cavity distortion or submucosal component:

• Surgical removal recommended before attempting conception or ART, as pregnancy rates drop to 16.4% (intramural) and 10% (submucosal) compared to 30.1% in controls 2, 4
• Use laparoscopic or open myomectomy via anterior uterine incision to minimize adhesions 5, 4
• Laparoscopic approach offers quicker recovery and less pain but requires surgical expertise 5, 4

Subserosal fibroids:

• Do not remove - these do not impact fertility and surgery is unnecessary 2, 4

Critical warning for fertility patients: Avoid uterine artery embolization (UAE), as it causes lower pregnancy rates, higher miscarriage rates, and loss of ovarian reserve, especially in women >40 years 5, 4

For Women NOT Desiring Future Pregnancy:

Hysterectomy (definitive treatment):

• Most effective treatment with highest patient satisfaction 2, 1, 5
• Accounts for 150,000-200,000 procedures annually in the US for fibroids 2
• Use least invasive approach possible (vaginal > laparoscopic > abdominal) 5
• Eliminates all fibroid symptoms and treats coexistent adenomyosis 2

Uterus-preserving options when hysterectomy declined:

Uterine Artery Embolization (UAE):

• 73-98% symptom control for bleeding and bulk symptoms 7
• 72-73% maintain symptom relief at 5 years 2, 7
• Mean fibroid volume reduction of 42% at 3 months 7
• Age matters: Women <40 years have 23% treatment failure at 10 years vs lower rates in older women 2, 7
• Location matters: Avoid for cervical fibroids (high failure rates); anterior wall location favorable 7
• Amenorrhea risk: 2-3% if age <45 years, 20% if age >45 years 2, 7
• Major complications <3%, but 10% require readmission for pain 2
• Repeat UAE effective if symptoms recur 2, 7

MR-Guided Focused Ultrasound (MRgFUS):

• Uses high-intensity ultrasound for thermal ablation without tissue damage 1
• Lacks long-term durability data 2

Laparoscopic Uterine Artery Occlusion (LUAO):

• Decreases bleeding and fibroid diameter with lower complications than UAE 1

Preoperative Optimization

Correct anemia before elective surgery:

• Use SPRMs or GnRH agonists preoperatively - both effectively correct anemia and reduce fibroid size 5
• Consider 3-month course to optimize surgical conditions 1, 5

Intraoperative blood loss reduction:

• Use vasopressin, bupivacaine-epinephrine, misoprostol, peri-cervical tourniquet, or gelatin-thrombin matrix 5

Special Situations

Acute Heavy Bleeding:

• Conservative management: High-dose estrogens, SPRMs, tranexamic acid, or Foley catheter tamponade 5
• Operative hysteroscopy for accessible submucosal fibroids 5
• UAE if available and patient hemodynamically stable 5
• Hysterectomy may be necessary if conservative measures fail 5

Asymptomatic Fibroids:

• Reassurance only - no intervention needed, malignancy risk is negligible, hysterectomy not indicated 5
• Symptoms typically decline after menopause, making expectant management appropriate for perimenopausal women 1

Pregnancy Considerations:

• Myomectomy NOT indicated prophylactically before pregnancy unless prior pregnancy had fibroid-related complications 5
• Women with fibroids in pregnancy require additional maternal-fetal surveillance 5

Critical Pitfalls to Avoid

Never perform endometrial ablation for submucosal fibroids - no supporting evidence and high risk of pregnancy complications if fertility desired 3, 1

Morcellation warning: Inform patients that power morcellation may spread unexpected malignancy (rare), potentially worsening prognosis 5

Do not use medical therapy as stand-alone treatment in infertile women - these medications suppress ovulation or disrupt endometrial development, interfering with conception 4

Hysterosalpingogram is inadequate for fibroid evaluation and classification - use transvaginal ultrasound, hysteroscopy, or MRI instead 4