The medical management of symptomatic non-submucosal
uterine fibroid tumors (
leiomyomas or
myomas) is based on the treatment of abnormal
uterine bleeding by any of the following:
progestogens, a
levonorgestrel-releasing
intrauterine device,
tranexamic acid, nonsteroidal anti-inflammatory drugs, or
GnRH analogs. Selective
progesterone receptor modulators are currently being evaluated and have recently been approved for
fibroid treatment. Neither combined
estrogen-
progestogen contraception nor
hormone treatment of the menopause is contraindicated in women with
fibroids. When pregnancy is desired, whether or not
infertility is being treated by assisted reproductive technology, hysteroscopic resection in one or two separate procedures of submucosal
fibroids less than 4 cm in length is recommended, regardless of whether they are symptomatic. Interstitial, also known as intramural,
fibroids have a negative effect on fertility but treating them does not improve fertility.
Myomectomy is therefore indicated only for symptomatic
fibroids; depending on their size and number, and may be performed by laparoscopy or
laparotomy. Physicians must explain to women the potential consequences of
myomas and
myomectomy on future pregnancy. For perimenopausal women who have been informed of the alternatives and the risks,
hysterectomy is the most effective treatment for symptomatic
fibroids and is associated with a high rate of patient satisfaction. When possible, the vaginal or laparoscopic routes should be preferred to
laparotomy for
hysterectomies for
fibroids considered typical on imaging. Because
uterine artery embolization is an effective treatment with low long-term morbidity, it is an option for symptomatic
fibroids in women who do not want to become pregnant, and a validated alternative to
myomectomy and
hysterectomy that must be offered to patients. Myolysis is under assessment, and research on its use is recommended. Isolated laparoscopic
ligation of the uterine arteries is a potential alternative to
uterine artery embolization; it also complements
myomectomy by reducing intraoperative
bleeding. It is possible to use second-generation techniques of
endometrial ablation to treat submucosal
fibroids in women whose families are complete. Subtotal
hysterectomy is a possible alternative to total
hysterectomy for
fibroid treatment, given that by
laparotomy the former has a lower complication rate than the latter, while by laparoscopy, these rates are the same. In each case, the patient is informed about the benefit and risk associated with each therapeutic option.