Treatment Options for Symptomatic Uterine Fibroids

Medical Management Options

The American College of Radiology recommends NSAIDs and estrogen-progestin oral contraceptive pills as first-line medical treatments for reducing bleeding symptoms associated with uterine fibroids 1, 2
Progestin-containing intrauterine devices (IUDs) effectively reduce bleeding symptoms and should be considered for long-term management of fibroid-related bleeding 1, 2
Tranexamic acid is an effective nonhormonal alternative that can reduce bleeding symptoms in patients with fibroids who cannot use hormonal options 1, 2
GnRH agonists and oral GnRH antagonists are effective second-line options that both reduce bleeding symptoms and significantly reduce fibroid volume by 18-30% 1, 3, 2
Combination treatment with low doses of estrogen and progestin (add-back therapy) mitigates the side effects of GnRH modulators and is FDA-approved for fibroid-related heavy menstrual bleeding 1, 4

Laparoscopic myomectomy is associated with shorter hospital stays and faster return to usual activities compared to open myomectomy 1
Both laparoscopic and open myomectomy procedures are associated with improved quality of life for up to 10 years 1
Hysteroscopic myomectomy is the procedure of choice for pedunculated submucosal fibroids <5 cm, offering shorter hospitalization and faster recovery compared to other approaches 2

Uterine Artery Embolization (UAE) is effective for patients with fibroids who desire uterus-preserving therapy, improving symptom scores and quality of life for up to 7 years 1, 3, 2
UAE demonstrates greater reduction in fibroid diameter (53%) compared to laparoscopic uterine artery occlusion (39%) 1, 3
MR-guided Focused Ultrasound (MRgFUS) can be considered, though it has a higher reintervention rate (30%) compared to UAE (13%) 3, 2

For mild symptoms with desire for future fertility, the American College of Radiology recommends starting with NSAIDs and/or tranexamic acid for acute bleeding episodes, and considering hormonal contraceptives or levonorgestrel IUD for ongoing management 1, 3, 2
For moderate-severe symptoms with desire for future fertility, consider short-term GnRH modulators with add-back therapy to reduce fibroid size, and hysteroscopic myomectomy for submucosal fibroids <5cm 1, 3, 2, 4

The American College of Radiology suggests that relugolix functions as a second-line medical therapy, positioned after first-line options but before surgical or interventional procedures, for patients with uterine fibroids 5, 6, 7

The American College of Radiology notes that fertility is actively suppressed during relugolix treatment, although it is chosen by patients interested in uterus-preserving therapy or future fertility preservation 5, 7
The American College of Radiology states that relugolix should be reserved as second-line treatment after failure of or contraindications to hormonal contraceptives, IUDs, or tranexamic acid 5, 6, 7

The American College of Radiology compares relugolix to surgical options, noting that while hysterectomy provides definitive resolution and UAE shows fibroid diameter reduction, relugolix offers a non-invasive option for patients desiring uterus preservation or avoiding procedural risks 6

The American College of Radiology suggests that when to transition to definitive therapy, such as surgical options or UAE, should be considered if symptoms recur rapidly after discontinuation of relugolix or if the patient desires permanent resolution 6