How should uterine leiomyoma (fibroids) be managed based on the patient's age, desire for future fertility, symptom severity, and size or location of the lesions?

Management of Uterine Leiomyomas

For symptomatic uterine fibroids, begin with medical management using levonorgestrel IUD or oral contraceptives for bleeding symptoms, reserve surgery for failed medical therapy or bulk symptoms, and tailor definitive treatment based on fertility desires—hysteroscopic myomectomy for submucosal fibroids in women seeking pregnancy, uterine artery embolization for those wanting uterus preservation, and hysterectomy for completed childbearing. 1

Initial Assessment and Classification

Document three critical fibroid characteristics before treatment planning:

• Location relative to uterine cavity: Submucosal fibroids (protruding into cavity) cause heavy menstrual bleeding through endometrial surface disruption, cavity enlargement, and impaired endometrial blood supply 2
• Cavity distortion status: Intramural fibroids distorting the cavity reduce implantation rates to 6% versus 16% without distortion 1
• Size and number: These determine surgical approach feasibility and predict treatment outcomes 1

Use transvaginal ultrasound as first-line imaging, which achieves 90% sensitivity and 98% specificity for submucosal fibroids and reliably identifies cavity distortion 2. Combined transabdominal and transvaginal ultrasound yields 90-99% sensitivity for detecting fibroids overall 2.

Medical Management Algorithm

First-Line Therapy for Heavy Menstrual Bleeding

Start with hormonal options that directly reduce bleeding:

• Levonorgestrel IUD: Preferred initial treatment, effectively reduces bleeding symptoms 1, 3
• Oral contraceptive pills: Alternative first-line option with comparable efficacy 1

Second-Line for Hormonal Contraindications

• Tranexamic acid: Effective nonhormonal alternative when hormonal therapy is contraindicated or not tolerated 1

Third-Line for Refractory Symptoms or Preoperative Optimization

• GnRH agonists (leuprolide) or oral GnRH antagonists: Reduce both bleeding and tumor volume, particularly useful for short courses before surgery to decrease fibroid size 1
• Add-back therapy with low-dose estrogen-progestin: Mitigates hypoestrogenic symptoms and bone density loss with prolonged GnRH use 1, 4
• Selective progesterone receptor modulators: Effective for both bleeding and bulk symptoms, can be administered intermittently long-term 1, 3

Critical warning: High rates of symptom recurrence occur after discontinuing medical therapy, particularly with GnRH agonists/antagonists 1. Bone density loss requires add-back therapy with prolonged GnRH agonist use beyond 3-6 months 1.

Surgical Management Based on Fertility Desires

For Women Seeking Future Pregnancy

Hysteroscopic myomectomy is first-line conservative surgery for symptomatic submucosal fibroids, achieving 85% pregnancy rates and 65% live birth rates 1, 2. This transcervical, transvaginal approach is specifically indicated for intracavitary fibroids 2.

Do NOT perform myomectomy for intramural fibroids without cavity distortion—evidence shows no fertility benefit and adds unnecessary surgical risk 1. Subserosal fibroids do not impair fertility and removal is not routinely indicated 1.

For intramural fibroids WITH cavity distortion or submucosal components: Laparoscopic or open myomectomy via anterior uterine incision is advised before attempting conception or assisted reproduction 1. However, less than half of patients trying to conceive achieve pregnancy, and of these, less than half result in live births 1.

Operative risks to counsel patients about: Uterine perforation, need for blood transfusion, bowel or bladder injury, and possible adverse effects on subsequent pregnancy outcomes 1. When morcellation is necessary, inform patients about the rare risk of spreading unexpected malignancy 3.

Preoperative optimization:

• Correct anemia before elective surgery using selective progesterone receptor modulators or GnRH analogues 3
• Use vasopressin, bupivacaine with epinephrine, misoprostol, peri-cervical tourniquet, or gelatin-thrombin matrix to reduce blood loss 3

For Women NOT Seeking Future Pregnancy

Hysterectomy provides definitive treatment with approximately 90% patient satisfaction at 2 years, eliminates all fibroid-related symptoms including coexistent adenomyosis, and removes recurrence risk 4, 1. Approximately 150,000-200,000 hysterectomies are performed annually in the United States for fibroids 4, 1.

Perform hysterectomy by the least invasive approach possible 3. However, reserve this for failed medical therapy or when less invasive options are unsuitable, as hysterectomy carries higher complication rates, longer hospitalization, and long-term risks including cardiovascular disease, osteoporosis, and dementia 1.

Minimally Invasive Interventional Options

Uterine Artery Embolization (UAE)

UAE is effective for properly selected patients who wish to preserve their uterus but have not improved with medical treatment 1, 5.

Outcomes data:

• Immediate symptom control: 73-98% for both bleeding and bulk symptoms 1, 5
• Sustained relief at 5 years: 72-73% 4, 1, 5
• Mean fibroid volume reduction at 3 months: 42-53% 1, 5
• Uterine volume reduction: 35% 5

Compared to hysterectomy: UAE has lower complication rates (<3% major complications), shorter hospitalization, and comparable quality-of-life outcomes at 2-5 years 1, 5. However, re-intervention is more common—28% by 5 years and 35% by 10 years 1.

Patient selection considerations:

• Age matters: Women under 40 have 23% treatment failure at 10 years due to collateral vessel recruitment from ovarian arteries 4, 5
• Location matters: Anterior wall fibroids respond best; cervical fibroids have high failure rates 4, 5
• Amenorrhea risk: 20% in women over 45 years versus 2-3% in women under 45 4, 5
• Readmission for pain: Approximately 10% 5

For pedunculated subserosal fibroids: Previous concerns about stalk necrosis and fibroid detachment have not been validated in larger studies; symptom improvement is similar to non-pedunculated fibroids 4.

For adenomyosis with fibroids: UAE shows 65-82% long-term symptomatic relief (median follow-up 27.9 months), with more recent studies reporting 73-88% symptom control 4.

Repeat UAE is effective for recurrent symptoms and does not preclude other therapies if unsuccessful 4, 5.

Insufficient evidence for UAE in asymptomatic patients desiring pregnancy; ongoing controversy exists regarding its use in this population 1.

MR-Guided Focused Ultrasound (MRgFUS)

MRgFUS uses high-intensity ultrasound for thermal ablation without incisional tissue damage 4, 1. Quality-of-life improvements and re-intervention rates at 5 years are similar to laparoscopic myomectomy 1.

Fertility data is limited: Registry data shows 54 pregnancies in 51 women, with 41% resulting in live births, 28% in spontaneous abortions, 93% term delivery rate among those who delivered, but 43% had associated complications 4.

Long-term durability data are currently lacking 1.

Laparoscopic Uterine Artery Occlusion (LUAO)

LUAO decreases heavy menstrual bleeding and fibroid diameter with lower postprocedural complications and rehospitalizations compared to UAE 1. However, this is less established than UAE.

Special Population Considerations

Reproductive-Age Women

For asymptomatic fibroids, no intervention is warranted—interventions should be limited to those with symptomatic reproductive dysfunction 1. Avoid endometrial ablation due to high risk of pregnancy complications 1.

For symptomatic fibroids with anemia despite medical therapy, escalate to interventional or surgical options 1.

Perimenopausal and Postmenopausal Women

Fibroid-associated symptoms are greatest leading up to menopause and typically decline postmenopausally, making expectant management particularly appropriate 1. Asymptomatic fibroids require no intervention; reassure patients there is no evidence to substantiate major concern about malignancy 3.

Leiomyosarcoma risk is extremely rare (less than 1 in 1000), and fibroids do not increase the risk of malignant uterine disease 6.

Common Pitfalls to Avoid

• Do not perform myomectomy on non-cavity-distorting intramural fibroids in infertile women—no fertility benefit exists 1
• Do not use UAE as first-line in women under 40 without counseling about higher failure rates 4, 5
• Do not forget add-back therapy with prolonged GnRH agonist use to prevent bone density loss 1
• Do not assume all fibroids cause infertility—subserosal fibroids do not impair fertility 1
• Do not overlook anemia correction before elective surgery 3
• Do not use endometrial ablation in women desiring future fertility 1