What is the optimal management of symptomatic uterine fibroids in a premenopausal woman who wishes to preserve fertility and avoid surgery?

Management of Symptomatic Uterine Fibroids

Start with medical management using levonorgestrel-releasing IUD (20 μg/d) or combined oral contraceptives as first-line therapy for heavy menstrual bleeding, and reserve surgical or interventional options for patients who fail medical therapy or have specific indications based on fertility goals and fibroid characteristics. 1, 2

Initial Diagnostic Assessment

Before initiating treatment, obtain the following:

• Pelvic ultrasound or MRI to map fibroid location (submucosal/intramural/subserosal), size, number, and relationship to the uterine cavity 1, 2
• Laboratory testing including hemoglobin level to assess for anemia and pregnancy test 2
• Physical examination with bimanual pelvic evaluation to assess uterine size, mobility, and presence of bulk symptoms 2

Medical Management Algorithm

For Heavy Menstrual Bleeding

First-line options:

• Levonorgestrel-releasing IUD (20 μg/d) reduces menstrual blood loss by 71-95% and is the preferred initial therapy 2, 3
• Combined oral contraceptives are equally effective for bleeding control 1

Second-line (if hormonal therapy contraindicated or patient preference):

• Tranexamic acid as a nonhormonal alternative that effectively reduces menstrual blood loss 1, 2

Third-line (preoperative or short-term use):

• GnRH agonists (e.g., leuprolide) or oral GnRH antagonists reduce both bleeding and fibroid volume, particularly useful for preoperative fibroid reduction and anemia correction 1, 4
• Must use add-back therapy (low-dose estrogen plus progestin) to mitigate hypoestrogenic symptoms and prevent bone density loss with prolonged use 1

For Bulk Symptoms (Pelvic Pressure, Pain, Urinary/Bowel Symptoms)

• GnRH agonists/antagonists or selective progesterone receptor modulators (SPRMs) for symptom reduction 1
• Medical therapy alone provides temporary relief; symptoms typically recur after discontinuation 1

Surgical and Interventional Management

For Patients Desiring Future Fertility

Hysteroscopic myomectomy is first-line conservative surgical therapy for:

• Submucosal fibroids (especially pedunculated, <5 cm) causing heavy menstrual bleeding 1, 2, 3
• Achieves pregnancy rates of 85% and live birth rates of 65% 1

Laparoscopic or open myomectomy (via anterior uterine incision) for:

• Intramural fibroids with cavity distortion or subserosal fibroids causing bulk symptoms 1
• Do NOT remove intramural fibroids without cavity distortion—no fertility benefit and adds surgical risk 1

Critical caveat: Less than half of patients attempting conception after myomectomy achieve pregnancy, and of those, less than half result in live births 1

For Patients NOT Desiring Future Fertility

Hysterectomy (via least invasive route possible):

• Most effective and definitive treatment with 90% patient satisfaction rates 5, 2, 4
• Eliminates all fibroid-related symptoms and risk of recurrence 5
• However, avoid as first-line when less invasive options can provide similar symptom relief due to increased complications, longer hospitalization, and long-term risks including cardiovascular disease, osteoporosis, and dementia 5

Uterine Artery Embolization (UAE):

• Preferred minimally invasive alternative for patients who failed medical management but wish to preserve the uterus 1, 2, 4
• Achieves 73-98% immediate symptom control and 72-73% symptom relief maintained at 5 years 5, 1
• Mean fibroid volume reduction of 42-53% at 3 months 5, 4
• Lower complication rates and shorter hospitalization compared to hysterectomy, with equivalent quality of life at 2-5 years 5, 4
• Higher reintervention rates: 28% at 5 years and 35% at 10 years require secondary procedures 5
• Amenorrhea risk: 2-3% if age <45 years; ~20% if age >45 years 1

MR-Guided Focused Ultrasound (MRgFUS):

• Uses high-intensity ultrasound for thermal ablation without incisional damage 1
• Quality of life and reintervention rates similar to laparoscopic myomectomy at 5 years 5
• Lacks long-term durability data compared to UAE 1

Special Clinical Scenarios

Concurrent Adenomyosis

• Medical management or UAE are preferred initial approaches over myomectomy alone, which does not effectively address adenomyosis 2, 4
• UAE provides 65-82% long-term symptomatic relief 2
• Hysterectomy is definitive if medical management fails 2

Preoperative Optimization

• Correct anemia before elective surgery using GnRH agonists/antagonists or SPRMs with concurrent iron supplementation 4, 3

Asymptomatic Fibroids

• No intervention required regardless of size or location 4, 3
• Follow-up imaging to document stability is advisable 6

Critical Warnings and Procedures to Avoid

Endometrial ablation:

• Do NOT offer to patients desiring future fertility—high risk of pregnancy complications including extrauterine pregnancy, preterm delivery, and stillbirth 1, 2, 4
• Requires counseling about pregnancy risks and need for reliable contraception 2, 4

UAE in patients actively seeking pregnancy:

• Myomectomy is superior for fertility preservation 2
• UAE carries elevated risks of miscarriage (up to 20%), cesarean sections, and postpartum hemorrhage in subsequent pregnancies 4

Laparoscopic power morcellation:

• Counsel patients that in rare cases fibroids may contain unexpected malignancy, and morcellation may spread cancer, worsening prognosis 3

Treatment Algorithm Summary

1. Confirm symptoms warrant intervention (heavy bleeding, anemia, bulk symptoms) 4
2. Document failure of medical management before proceeding to surgery/intervention 4
3. Assess fertility desires:
   • Fertility desired: Hysteroscopic myomectomy for submucosal fibroids; laparoscopic/open myomectomy for intramural with cavity distortion 1, 2
   • Fertility NOT desired: UAE for uterus preservation; hysterectomy for definitive treatment 2, 4
4. Optimize preoperatively: Correct anemia with GnRH agonists/SPRMs plus iron 4, 3