Uterine Fibroids: Treatment

Most uterine fibroids are asymptomatic and need not be treated. Intervention depends upon a number of factors, including age (women approaching menopause may not require therapy as fibroids typically regress spontaneously), fertility concerns, and the location and size of the fibroids.

Surgery

Surgical interventions are generally the most effective therapy for fibroids.

Myomectomy, via hysteroscopy, laparoscopy, or laparotomy, preserves childbearing potential but is at least as difficult for the surgeon and patient as hysterectomy. Hysteroscopy is best for submucosal fibroids. Laparotomy may be indicated for large or multiple fibroids.

Hysterectomy is a definitive treatment that offers clear symptomatic improvement in approximately 90% of fibroid patients who undergo it. The primary indication for hysterectomy is uncontrollable bleeding.

Other options for women who do not desire pregnancy include endometrial ablation via hysteroscopic myomectomy, cryotherapy, uterine artery embolization, or magnetic resonance–guided ultrasonic ablation.

Pharmacologic Interventions

Oral contraceptives or progestins (norethindrone acetate, levonorgestrel–containing intrauterine device) are the simplest treatments for abnormal bleeding associated with fibroids. These treatments can be continued until menopause in women who are not interested in pregnancy.

Gonadotropin–releasing hormone (GnRH) analogs (eg, leuprolide) can shrink fibroids prior to surgical removal. Symptoms will sometimes return with discontinuation of the therapy. GnRH analogs are generally not recommended for long–term medical management due to cost.

GnRH antagonists, mifepristone, asoprisnil, and androgens are under investigation for future use in treating fibroids.

Acute pain can be treated with nonsteroidal anti–inflammatory drugs (NSAIDs).

COX–2 inhibitors appear to benefit postmenopausal women,⁵ but further trials are needed to establish their effect for premenopausal women. However, potential cardiac and other risks of COX–2 inhibitors must be considered.