Uterine Fibroids: Treatment Options

Non-Surgical (Medical) Options for Fibroids

Hormonal and Non-Hormonal Medications

Combined estrogen-progestin contraceptives: These come in the form of a pill, patch, or ring, and known as traditional "OCPs." They are usually the first line approach, as can be used long-term, are well-tolerated, are relatively inexpensive, and provide contraception and additional benefits including decreasing the risk of ovarian and endometrial cancers.

Progestins: Options include high dose oral progestins (norethindrone acetate or medroxyprogesterone acetate most commonly),  a progestin injection ("Depo provera," administered every 6 months), the etonorgestrel arm implant ("Nexplanon"), or the levonorgestrel intrauterine device (IUD).  However, there is compelling evidence that the progesterone IUD results in a greater decrease in menstrual blood loss as compared to oral or other routes of administration.  

One factor to note with progestins compared to OCPs is that while CHCs maintain a regular menses, continuous progestins can suppress periods completely (ie amenorrhea) or result in irregular bleeding. While this does not have negative long-term consequences (owing to its mechanism), it may be bothersome for some. 

Gonadotropin-releasing hormone (Gn-RH) agonists and antagonists: These drugs block the production of ovarian-stimulating hormones, lowering estrogen levels. Since fibroids are estrogen responsive, this results in reduction of menstrual bleeding, and notably, some reduction in fibroid size. Because these drugs create an artificial menopause, one often experiences menopausal side effects such as hot flashes, sleep issues, and vaginal dryness. Some of the newer oral options mitigate this by including a low dose of estrogen and progestin added back within the medication.

There are currently two oral Gn-RH agonists on the market that are FDA approved for fibroid related heavy menstrual bleeding: Myfembree (relugolix-estradiol-norethindrone) and Orianhh (elagolix-estradiol-norethindrone). These medications have been found to result in a 50% reduction in menstrual blood loss, and can even improve bulk symptoms. However, due to limited data at this point they are both only approved for up to 24 months of use, and are not approved to be used as a contraceptive. 

Tranexamic acid ("Lysteda"): This is a non-hormonal medication that works to slow down the breakdown of blood clots. In turn, slows down bleeding, and in this case can be used to reduce fibroid related bleeding. It is only taken during your period, rather than the entire month, and is non-hormonal; this makes it a good option for those who prefer to avoid contraception or a daily medication! 

Uterine-sparing Surgical Options for Fibroids

Myomectomy

Essentially a myomectomy is a procedure where the fibroids are surgically removed from the uterus, and the uterine tissue is repaired. There are three ways to perform this procedure. 

Hysteroscopic myomectomy: this is the least invasive option. With this approach, the surgeon enters the uterine cavity via the vagina/cervix with a small camera. When inside the uterus, they are able to remove the fibroids that line the endometrium, known as submucosal fibroids (see diagram below). Any intramural or subserosal fibroids cannot be accessed with this approach. For this reason, this procedure is good for you if you want a quick and simple procedure with very little recovery, and you have submucosal fibroids resulting in bleeding. If you have larger intramural or subserosal fibroids causing bulk symptoms, unfortunately this won't help. 

Laparoscopic myomectomy: this where the surgeon enters the abdomen with a camera, and performs the surgery through small cuts. This is also a same day procedure and allows for a smooth recovery. 

Abdominal myomectomy: this is the traditional way this procedure is performed, through a large incision. If the fibroids are numerous or very large, a laparoscopic approach is not feasible, and large cut has to be made. With this approach, you would stay in the hospital for at least one night, and the recovery is longer than the above two. 

When performing a myomectomy, very small fibroids may not be visible and may be left behind. The growth of these fibroids is what contributes to the recurrence risk. In general, the rate of reoperation (ie sympoms returning and needing another surgery for fibroids) after 8 years is about 16%. The risk of recurrence is higher is one has multiple fibroids at time of surgery or if younger than 36 years old. 

As above, if someone desires future pregnancy, a myomectomy is the only recommended surgical option. You need to discuss the risks with your provider. 

Uterine Artery or Uterine Fibroid Embolization 

This procedure is generally recommended for pre-menopausal people who have symptomatic fibroids (bleeding or bulky) and wish to retain their uterus but do not intend for future pregnancy. This procedure is performed by an interventional radiologist, rather than a gynecologist. The doctor inserts a catheter (a small tube) into a blood vessel and under image guidance, the catheter makes it way to the uterine blood vessels, which are then embolized. By blocking the blood supply to the fibroids, they shrink in size and symptoms improve. The procedure is done under sedation (rather than general anesthesia) and you go home the same day. 

Outcomes of this procedure are generally favorable. In a large study, 70-90% of patients reported improvement or resolution in their heavy menstrual bleeding symptoms, and 80-90% reported improvement in their pain or bulk symptoms. The recurrence rate is worth noting however - after 5 years about 27% of patients end up needing a subsequent hysterectomy for failure or recurrence of symptoms.