Hysterectomy has been the traditional therapy offered to women with uterine fibroids, increasingly women are interested in less invasive therapy. Women with minimal fibroid symptomatology are advised to consider “watchful waiting” or monitoring that can include periodic clinical examination, imaging, and journaling of their symptoms. The frequency of office visits and testing should be based on clinical symptoms. Nonoperative management and alternative to hysterectomy procedures such as uterine fibroid embolization (UFE) and endometrial ablation options are only for women who do not desire future fertility but request uterine sparing procedures. Medical therapy including hormonal therapy, levonorgestrel intrauterine device, tranexamic acid, NSAIDs, and GnRH agonist therapy are well suited for women who wish to retain their fertility.

However, quality-of-life (QOL) indicators must be considered in women with uterine fibroids and clinicians inquire about them as they may help to determine whether nonoperative management, watchful waiting, or surgical intervention is needed. The patient should be queried about QOL-related factors including:

A recent survey of 968 reproductive-aged women noted:

Nonextirpative uterine surgery should be considered for all women who desire pregnancy. Women of the African diaspora have the highest prevalence and burden of fibroid-related disease.

Uterine fibroid embolization (UFE) is a minimally invasive outpatient procedure performed by an interventional radiologist for the treatment of symptomatic uterine fibroids in women who do not desire fertility yet desire uterine preservation. Treatment is performed under conscious sedation and does not require an abdominal incision. Embolization results in ischemic infarction of the leiomyomata and decreased vascularity. Normal myometrium is spared.

Within 4 to 6 months the uterine fibroid diminishes in size, the fibroids undergo hyaline degeneration, and the volume and size of the uterus decrease. Shrinkage may continue up to 1 year after UFE. Among women with >90% fibroid infarction, there is more symptom relief and fewer subsequent treatments than in women with a lower infarction rate.

Magnetic resonance-guided focused ultrasound (MRgFUS) is a noninvasive outpatient treatment option for symptomatic uterine fibroids. It was approved by the FDA in 2004 for the treatment of uterine fibroids. Its labeling includes use for women who desire pregnancy. MRgFUS is an outpatient procedure that takes 2 to 4 hours and is performed under conscious sedation without an abdominal incision.

The objective of MRgFUS is to deliver focused high-energy ultrasound waves into the fibroid causing thermal coagulation of targeted tissue. With the patient lying prone, the ultrasound waves are focused by lenses or reflectors and pass through the skin and nontarget tissue and delivers sonications (heat) to targeted fibroids. It has been compared to the principle of focusing the sun’s rays with a magnifying glass to burn a hole in a piece of paper.

Preprocedural magnetic resonance imaging (MRI) is required to determine suitable candidates for MRgFUS. Fibroids most amenable to MRgFUS treatment are those that are homogeneous and hyperintense (dark) on T2-weighted images. They should also enhance because degenerated/infarcted fibroids have lost their blood supply and will not respond to treatment.

Contraindications to MRgFUS include:

Risks are very low but reports of skin burns to the abdomen, damage to structures near the fibroid, nerve stimulation causing temporary back or leg pain, and DVT.

Reported outcomes of MRgFUS include:

Tranexamic acid is an oral, nonhormonal, antifibrinolytic medical therapy used only during menstruation in women with symptomatic fibroids–related ovulatory heavy menstrual bleeding. Women with heavy menstrual periods reportedly have high fibrinolytic activity due to increased endometrial levels of plasmin and plasminogen activators. Tranexamic acid works by reversibly blocking lysine binding sites on plasminogen, thus preventing plasmin from interacting with lysine residues on the fibrin polymer, causing subsequent fibrin degradation.

Tranexamic acid has been available for more than 40 years in clinical practice and often is prescribed as an over-the-counter therapy in many countries. In the United States, it requires a prescription. The recommended dose is: tranexamic acid 650 mg, take two tablets by mouth every 8 hours, to commence with the onset of menstrual bleeding for a maximum of 5 days. Its onset of action is rapid but requires every 8 hours dosing due to short half-life. Eliminated through the kidneys, it has a half-life of 2 to 3 hours.

Tranexamic acid reduces menstrual blood loss (MBL) by 26% to 60%. Numerous studies demonstrate that it is an effective treatment of heavy ovulatory menstrual bleeding in women with uterine fibroids; has low side-effect profile, favorable safety profile, and is well tolerated by patients.

Thromboembolic events have not been reported with oral treatment regimens for the treatment of heavy menstrual bleeding. When compared to placebo, NSAIDs, or oral cyclical luteal phase progesterone, tranexamic acid significantly improved QOL. Levonorgestrel-releasing intrauterine system reduced mean blood loss more than tranexamic acid in clinical trials. Tranexamic acid should not be prescribed to women with prior history of embolic disease, active thromboembolism, intrinsic risk for thrombosis, or currently using hormonal therapy.

Gonadotropin-releasing (GnRH) analogs (Lupron [TAP Pharmaceutical Products, Inc. Lake Forest, IL] may be considered for
short-term use in women with symptomatic uterine fibroids and as adjunct to surgical therapy. GnRH agonists decrease uterine size and myoma volume by decreasing levels of estrogen and progesterone to menopausal values. They induce myoma degeneration, cause hyaline degeneration, decrease in the size of leiomyoma cells, reduce extracellular matrix, and decrease blood flow to the uterus. When used for short duration (<6 months), most women become temporally amenorrheic, have improvement in hemoglobin, and notice a decrease in uterine size by 40% to 60%.

GnRH analogs are often beneficial to women 50 years old or older. GnRH therapy given for 6 months will stop menstruation with improvement in bulk symptoms and cessation of menstruation. After 6 months of therapy, GnRH is stopped and the patient monitored for transition into natural menopause. If symptoms recur and patient has not entered menopause, then another 6 months of GnRH therapy instituted. Quite often these patients will enter natural menopause and not require surgical intervention and avoid surgery if menopause occurs shortly after completion of therapy.

Ulipristal is not currently available in this country; however, clinical trials are underway. Promising research in Europe has demonstrated the benefits of Ulipristal. Ulipristal is a synthetic steroid derived from 19-norprogesterone. It is a selective progesterone receptor modulator that binds to progesterone receptors. It exerts antiproliferative, pro-apoptotic, and antifibrotic action on leiomyoma cells. The binding and antagonist potency with glucocorticoid receptors is reduced compared to mifepristone.