Treatment

Management should be based on shared decision-making and tailored to the patient's symptoms and desire for fertility and/or uterine preservation.

• Asymptomatic or mild symptoms: expectant management

• Symptomatic leiomyoma

  • Fertility desired: pharmacotherapy or myomectomy

  • Fertility not desired

    • Uterine preservation desired: nonsurgical interventional therapy

    • Uterine preservation not desired (definitive treatment): hysterectomy

Leiomyomas tend to regress after menopause; expectant management or pharmacotherapy as a bridge to menopause is recommended for most perimenopausal patients.

Indications

• Asymptomatic or minimally symptomatic patients

• Perimenopausal patients

Management

• Monitor reported symptoms for any worsening at annual well-woman exams.

• Typically, no active treatment is required.

• Surveillance imaging is not routinely required. [14]

• Recommend follow-up if symptoms change or pregnancy is planned.

• Medications can either be used long-term for symptom control or temporarily as a bridge until a more definitive modality can be performed.

• Pharmacotherapy should be selected based on the patient's symptoms.

• There is currently insufficient evidence to recommend one agent over other for first-line therapy.

Recommended in patients with symptomatic leiomyoma who desire uterine preservation and/or want to avoid surgery.

Uterine artery embolization (UAE)

• A minimally invasive percutaneous radiologic procedure in which an embolic agent (e.g., polyvinyl alcohol) is injected into the uterine arteries that supply the leiomyoma, causing it to shrink

• Significantly reduces leiomyoma size and bleeding

• Complications [4][18]

  • Postembolization syndrome

    • Common complication of transarterial embolization

    • Clinical features: fever, pelvic pain, nausea, and vomiting < 72 hours of UAE in the absence of infection

    • Typically self-limited

  • Thromboembolic events (e.g., pulmonary embolism, uterine ischemia and necrosis)

  • Bleeding/blood-tinged vaginal discharge : typically self-limited

  • Endometritis

  • Treatment failure

• Unknown effects on fertility : Counsel patients who wish to conceive about the possible effects of UAE on fertility.

Radiofrequency ablation (RFA) [

• Ultrasound-guided targeted coagulative necrosis of leiomyoma

• A significant decrease in leiomyoma size and symptoms have been noted in studies.

• Low risk of further surgical intervention

• Unknown effects on fertility

Myomectomy

A uterus-preserving surgical option for the removal of leiomyomas

• Indications

  • Patients with symptomatic leiomyomas who wish to preserve fertility

• Approach

  • Hysteroscopic myomectomy is preferred for submucosal leiomyomas.

  • Laparoscopic myomectomy may be preferred for subserosal and most intramural leiomyomas.

• Recurrence rate: ∼ 25% within 40 months

Hysterectomy

• Indications

  • Patients seeking definitive treatment who do not desire fertility and/or have had an insufficient response to alternative treatments

  • Suspected leiomyosarcoma

• Approach : vaginal, abdominal, or laparoscopic

Patients often receive GnRH agonists or antagonists prior to surgery to reduce leiomyoma size, which may allow less invasive procedures to be performed.

• Infertility

• Iron deficiency anemia (due to heavy menstrual bleeding)

• Fibroid torsion

• Thromboembolism

• Very rare: malignant transformation to uterine leiomyosarcoma