Management

Majority of fibroids are asymptomatic and require no treatment (1).

Fibroids (>3cm) which causes symptoms such as abnormal uterine bleeding, bulk effects etc may be require medical, surgical or a combination of both treatment methods.

Treatment option for patients with fibroids depends on the necessity of preserving fertility or the uterus or both.

• available treatment options include: expectant, medical, radiological, uterine preserving surgery, and hysterectomy

Expectant management can be considered in premenopausal women.

• shrinkage of fibroids with relieving of symptoms is seen with menopause in majority of women (2)

A number of medications are used to treat the symptoms of fibroids:

• for women with AUB
  • NSAIDs and antifibrinolytic agent e.g – tranexamic acid, mefenamic acid
  • levonorgestrol releasing intrauterine device
    • spontaneous expulsion of the IUD is more frequent in patients with submucosal fibroids.
  • selective progesterone receptor modulators e.g. - ulipristal acetate
    • used for short term in preparation for surgery (three months) and long term intermittent use (≥12 months) where surgery can be avoided
  • mifepristone
  • gonadotrophin releasing hormone agonists
    • often used temporarily, before surgery, to shrink fibroids
    • only effective while treatment is ongoing, and symptoms generally recur on stopping treatment.
  • progestins
  • danazol
    • rarely used due to the side effects
  • oral contraceptives
    • uterine fibroids are not a contraindication for the use of oral contraceptives
    • may also prevent development of uterine fibroids
• for women with bulk symptoms associated with fibroids
  • selective progesterone receptor modulators
  • gonadotropin-releasing hormone analogues

Surgical options include:

• myomectomy
  • removal of fibroid alone
  • indicated when future childbearing is desired
  • can be done through laparotomy, laparoscopy or hysteroscopy
  • is associated with higher risk of blood loss and greater operative time than with hysterectomy
• hysterectomy
  • removal of fibroid + uterus
  • indicated in women who have completed their family, and in patients over 40 years of age
• uterine artery embolization
  • used as an alternative to myomectomy
  • decreases fibroid size and menstrual blood loss; conserves uterus
  • higher rate of early re-intervention compared with surgery

Surgical intervention is indicated if:

• there is heavy or prolonged bleeding
• the tumour is large, even if asymptomatic; in young women, it will continue to grow; following the menopause, it may undergo complications
• there is urinary symptoms
• the tumour has undergone torsion
• the tumour threatens to obstruct labour

However, red degeneration is not an indication for surgery.

Medical treatments, using danazol or a GnRH agonist, may be employed to reduce the size of the fibroid, or to reduce blood loss during surgery.

More details regarding medical and surgical treatments are provided in the linked item

Reference:

1. Lumsden MA et al. Fibroids: diagnosis and management. BMJ. 2015;351:h4887
2. Vilos GA et al.The management of uterine leiomyomas. J Obstet Gynaecol Can. 2015;37(2):157-81.
3. Alexander-Sefre F. Clinical Review: Uterine fibroids. GPonlline 2012