What are the recommended conservative management options for a reproductive‑age woman with small (<5 cm) uterine fibroids and mild symptoms who wishes to preserve fertility and avoid surgery?

Conservative Management for Uterine Fibroids

For reproductive-age women with small (<5 cm) uterine fibroids and mild symptoms who wish to preserve fertility, first-line medical management with a levonorgestrel-releasing intrauterine system or combined oral contraceptives is recommended, with tranexamic acid as the preferred non-hormonal alternative. 1, 2

Initial Medical Management Algorithm

First-Line Hormonal Options

• Levonorgestrel-releasing intrauterine system (LNG-IUS) is the most effective hormonal option for controlling heavy menstrual bleeding associated with fibroids, particularly for women not actively attempting conception 2, 3
• Combined oral contraceptive pills effectively reduce bleeding symptoms and are appropriate for women with symptomatic fibroids who are not currently trying to conceive 4, 2
• NSAIDs reduce both bleeding and pain symptoms and can be used alone or in combination with hormonal therapy 4, 2

First-Line Non-Hormonal Option

• Tranexamic acid is the best non-hormonal alternative, significantly reducing menstrual blood loss without affecting fertility potential 4, 2
• This agent is particularly valuable for women who cannot tolerate or prefer to avoid hormonal therapy 5

Second-Line Medical Management

When First-Line Therapy Fails

• GnRH antagonists (elagolix, linzagolix, relugolix) with hormone add-back therapy reduce fibroid volume by 18-30% and control bleeding symptoms 4, 2
• GnRH agonists (leuprolide acetate) are effective at reducing tumor volume and bleeding but should be reserved for second-line treatment due to hypoestrogenic effects 4
• Add-back therapy with low-dose estrogen-progestin is mandatory when using GnRH agonists or antagonists for more than 3-6 months to prevent bone density loss and mitigate hypoestrogenic symptoms (hot flushes, headaches, hypertension) 4, 5

Selective Progesterone Receptor Modulators

• Ulipristal acetate reduces both bleeding and bulk symptoms and can be administered intermittently long-term, allowing for menstruation during medication breaks 4, 6
• This agent is particularly useful for women with pressure symptoms in addition to bleeding 2

Critical Management Considerations

Fertility Preservation

• All medical therapies suppress fertility during active treatment; discontinuation is required before attempting conception 2
• Asymptomatic fibroids require no intervention regardless of size or location, even in women desiring pregnancy 2
• Medical management does not improve fertility outcomes in women with non-cavity-distorting fibroids 5

Preoperative Optimization

• Correct anemia before any elective surgical procedure using GnRH agonists/antagonists or selective progesterone receptor modulators plus concurrent iron supplementation 2, 7
• Short courses (3-6 months) of GnRH therapy can shrink fibroids and facilitate surgical resection if conservative surgery becomes necessary 5

Common Pitfalls and Caveats

Symptom Recurrence

• High rates of symptom recurrence occur after discontinuation of medical therapy, particularly with GnRH agonists and antagonists 5
• This necessitates ongoing treatment or transition to definitive therapy in many cases 5

Bone Health Monitoring

• Prolonged GnRH agonist use without add-back therapy causes significant bone density loss 5
• Always prescribe concurrent low-dose estrogen-progestin when treatment extends beyond 3-6 months 5

Inappropriate Use

• Do not use medical management for asymptomatic fibroids in women attempting conception, as these agents suppress fertility without improving pregnancy outcomes 5, 2
• Endometrial ablation is contraindicated in women desiring future fertility due to elevated risk of ectopic pregnancy, preterm delivery, and stillbirth 4

When to Escalate Beyond Conservative Management

• Failure of medical therapy to control bleeding symptoms after 3-6 months of appropriate treatment 2
• Development of severe anemia despite medical management 5
• Progression of bulk symptoms (pelvic pressure, urinary frequency, constipation) causing significant quality of life impairment 2
• Documented cavity distortion by submucosal or intramural fibroids in women actively pursuing pregnancy 5