Management of Large Uterine Fibroids

Initial Medical Management

The American College of Radiology recommends correcting anemia with iron supplementation while simultaneously initiating medical therapy to control bleeding and reduce fibroid size in patients with large uterine fibroids 1, 2
GnRH antagonists, such as relugolix, elagolix, or linzagolix, are effective for reducing both bleeding symptoms and fibroid volume, making them appropriate first-line options for patients with large uterine fibroids 2
Combination treatment with low doses of estrogen and progestin can be used to mitigate hypoestrogenic side effects in patients taking GnRH antagonists 2

The American College of Radiology recommends performing appropriate imaging, such as ultrasound or MRI, to characterize fibroid location, size, and number in patients with large uterine fibroids 1
The American College of Obstetricians and Gynecologists suggests that if the uterine cavity is restored to normal after medical treatment, patients may attempt natural or assisted conception without surgery 3
If the cavity remains distorted after medical therapy, surgical intervention may eventually be necessary for fertility optimization, according to the American College of Obstetricians and Gynecologists 3

Uterine Artery Embolization (UAE) can be considered if medical management fails, with an average decrease in uterine fibroid size of >50% at 5 years, and reported live birth rates of approximately 50% 4
MR-Guided Focused Ultrasound (MRgFUS) is another non-surgical option that uses high-intensity ultrasound waves to thermally ablate fibroids, with significant improvement in quality of life and decrease in fibroid diameter (18%) compared to placebo 4

The American College of Radiology notes that ulipristal acetate is effective for reducing both bleeding and bulk symptoms, but reports of hepatotoxicity are a barrier to its approval in the United States 2

The American College of Radiology and the American College of Obstetricians and Gynecologists suggest that hysteroscopic myomectomy for submucosal fibroids or laparoscopic/open myomectomy for intramural or subserosal fibroids may eventually need to be reconsidered if the uterine cavity remains significantly distorted, compromising fertility potential 1, 3, 5

The American College of Radiology recommends that endometrial thickening of 1.67 cm requires immediate evaluation with endometrial biopsy to rule out endometrial hyperplasia or malignancy, especially with concurrent uterine fibroids 6, 7
Endometrial biopsy should be the priority before addressing fibroid management, as endometrial pathology could significantly impact treatment decisions 7
The American College of Radiology suggests that management should be guided by the presence and severity of symptoms, such as heavy menstrual bleeding, pelvic pressure, and pain, as well as impact on quality of life and fertility desires 6, 8, 9
The size, number, and location of fibroids should also be considered in treatment decisions, with multiple solid masses with increasing size being a significant factor 6, 7

Myomectomy is the preferred surgical approach for women desiring fertility preservation, with hysteroscopic myomectomy for submucosal fibroids and laparoscopic or open myomectomy for intramural or subserosal fibroids 6, 9, 10, 11
Medical management, including NSAIDs, estrogen-progestin oral contraceptives, and GnRH agonists or antagonists, can be used as a temporary measure or to reduce fibroid size before surgery, but may suppress fertility during treatment 8, 9, 12
For women not desiring fertility, hysterectomy provides definitive treatment and permanent cure for symptomatic fibroids, while uterine artery embolization (UAE) and MR-guided focused ultrasound (MRgFUS) are less invasive alternatives 7, 13, 12

Endometrial thickening must be addressed before or concurrently with fibroid treatment, and perimenopausal women may be candidates for short-term medical management while awaiting natural regression of fibroids during menopause 7, 14
The American College of Obstetricians and Gynecologists recommends that women with increasing size of fibroids noted on ultrasound should be monitored closely, as rapid growth can occasionally indicate malignant transformation, although this is rare 14