SUMMARY:

Uterine leiomyomas are the most common solid neoplasm in women and occur in at least 70% of the population. Although leiomyomas are the most common indication for hysterectomy, there are many other management options, especially for patients who desire future childbearing or uterine preservation. This Practice Bulletin summary provides evidence based recommendation for medical, procedure, and surgical management of symptomatic leiomyomas

KEY POINTS:

Symptoms

• Prolonged or heavy menstrual bleeding
• Anemia
• Bulk symptoms such as pelvic pressure, urinary frequency, constipation
• Differences in race have been noted, with Black women experiencing clinically significant disease at an earlier age with larger uteri at diagnosis
  • Differences due to systemic racism and social determinants of health

Classification of Fibroids

Classification is based on FIGO system

• Submucosal fibroids
  • Type 0 is pedunculated intracavitary
  • Type 1 is less than 50% intramural
  • Type 2 is more than 50% intramural
  • Type 3 contacts the endometrium but 100% intramural
• “Other” fibroids
  • Type 4 is intramural
  • Type 5 is subserosal with more than 50% intramural
  • Type 6 is subserosal with less than 50% intramural
  • Type 7 is pedunculated subserosal
  • Type 8 is “other” but requires specification, i.e. cervical, parasitic

Diagnosis

• Transvaginal ultrasound is used as a screening test
• Sonohysterography can be used to identify and distinguish between type 0, type 1, and type 2 leiomyomas
• Hysteroscopy can be used to distinguish between type 2 and type 3 leiomyomas
• MRI
  • Can be used to distinguish between type 4 and 5 leiomyomas
  • Can aid with surgical planning, as well as determine vascularity and degeneration

Medical Management

• Expectant management can be considered in asymptomatic patients who do not desire intervention
• GnRH agonists (e.g., leuprolide) can be used for both bleeding symptoms and bulk symptoms as short term treatment of leiomyomas, or as a bridge to further treatment
  • These can facilitate the use of a minimally invasive surgical route, and are associated with an increased in preoperative hemoglobin level in patients
  • GnRH agonist use is typically limited to 6 months without add back therapy, and 12 months with add back therapy
  • Cessation of agonist leads to regrowth of fibroids within 6 to 9 months
  • Add-back therapy dosage typically 0.625 mg oral conjugated estrogen and norethindrone acetate 2.5 to 5.0 mg daily
• A 52 mg LNG-IUD can be used for the treatment of AUB-L, although there is a higher rate of expulsion
• Tranexamic acid can be used for the treatment of AUB-L
  • Dose (based on RCT cited in the guideline): 1.3 g per dose (two tablets, 650 mg each) three times daily at least 6 hours apart for up to 5 days per cycle over the course of six menstrual cycles
  • Begin treatment at the onset of heavy menstrual bleeding
  • Maximum daily dose used in study: 3.9 g
• Oral GnRH antagonists (elagolix or relugolix) can be used for treatment of AUB-L for up to 2 years | FDA limit of 24 month regimen due to risk for bone loss which may not be reversible | Add back therapy offsets hypoestrogenic effects, such as hot flashes, increased serum lipids, or bone mineral density loss
  • Elagolix: 1 capsule (elagolix 300 mg, estradiol 1 mg, norethindrone acetate 0.5 mg) in the morning and 1 capsule (elagolix 300 mg) in the evening
  • Relugolix: 1 Fixed-dose combination tablet (relugolix 40 mg, estradiol 1 mg and norethindrone acetate 0.5 mg) once daily
• Combined and progestin only hormonal contraceptives can be considered for treatment of AUB-L, although there is limited data to support this
• Selective progesterone receptor modulators (mifepristone and ulipristal acetate) have some short-term benefits but are not approved in the US with daily use limited in Europe due to rare but serious liver injury

Surgical Management

• Uterine artery embolization (UAE) can be used for treatment of leiomyomas in patients who desire uterine preservation
  • These patients should be counseled about the limited data regarding future pregnancy outcomes
  • 2 to 5 years post-procedure, satisfaction rates are similar among UAE, myomectomy, and hysterectomy but post-UAE rates of re-intervention and further surgical intervention are 2 to 5 times higher (range from 15 to 38%)
  • Lower risk of blood transfusion, 1 to 2% rate of major complications, and higher rate of minor complications at 21 to 64%
• Laparoscopic radiofrequency ablation can be used as a minimally invasive treatment option for symptomatic leiomyomas for patients who desire uterine preservation however widespread access to techniques are limited
  • These patients should be counseled about the limited data regarding future pregnancy outcomes
  • Decreases uterine fibroid size up to 50 to 75% | Low rates of complications, both minor and major | No data on effect of uterine bleeding
• Endometrial ablation has insufficient evidence for use in AUB-L

Definitive Surgical Management

• Myomectomy allows fibroid removal in patients desiring their uterus
  • Risks include rate of recurrence (25% by 40 months) and procedural risks including blood transfusion (0 to 5%)
  • Re-intervention rate approximately 10 to 12% regardless of route of myomectomy (abdominal, robotic, laparoscopic)
  • Hysteroscopic myomectomy for Type 0, 1 and 2 fibroids have high efficacy with low risk of complications (1 to 3%) and low re-intervention rates (7% at 60 months)
• Hysterectomy is the definitive surgical management option for treatment of leiomyoma in patients who do not desire future childbearing or uterine preservation
  • Similar rates of complications between myomectomy and hysterectomy
  • The most minimally invasive route should be performed, with the vaginal approach being preferred
• If a patient desires uterine preservation or future pregnancy, myomectomy is recommended. If possible, a minimally invasive approach is preferred

Learn More – Primary Sources

ACOG Practice Bulletin 228 – Management of Symptomatic Uterine Leiomyomas

Tranexamic Acid Treatment for Heavy Menstrual Bleeding: A Randomized Controlled Trial

Management of Uterine Fibroids After the Withdrawal of Fibristal

Related ObG Topics:

RCT Results: Does Relugolix Combined with Estradiol and Progestin Reduce Fibroid-Associated Heavy Menstrual Bleeding?

Intervention Comparison for the Treatment of Uterine Fibroids

Does Elagolix Reduce Heavy Menstrual Bleeding Associated with Uterine Fibroids?

What Uterine-Sparing Treatment for Fibroids Has the Best Outcomes?

High-Intensity Ultrasound for Fibroids – What are the Pregnancy Outcomes?

How does TXA Measure Up as a Treatment for Menorrhagia?