Current Treatment for Symptomatic Uterine Fibroids: Available Evidence and Therapeutic Dilemmas

Leiomyomas, or uterine fibroids, are benign tumors of the smooth muscle of the uterus with origins in the myometrium. Many women experience uterine fibroids, with an estimated prevalence ranging from 20% to 80%. Symptomatic fibroids can have a profound effect on quality of life and typically include symptoms such as heavy menstrual bleeding, pelvic pain, lower back pain, abdominal bloating, urinary symptoms, sexual dysfunction, fertility issues, and anxiety and depression resulting from physical symptoms. Treatment options have become more advanced in recent years, and this article is a review designed to assess evidence and raise awareness surrounding novel, minimally invasive or medicinal alternative treatments to hysterectomy or abdominal myomectomy. The goal of this article was to provide clinical guidance and contribute knowledge to personalized care and decision-making for patients while also identifying gaps in current literature. Current treatments for symptomatic fibroids included in this review are uterine artery embolization, magnetic resonance-guided high-intensity focused ultrasound (MR-HIFU), laparoscopic radio-frequency ablation, transcervical radiofrequency ablation, ulipristal acetate intermittent treatment (four 12-week treatment regimens) and oral gonadotropin-releasing hormone receptor antagonists with add-back therapy. Uterine artery embolization includes blocking the blood supply to uterine fibroids and thus providing relief from symptoms as the fibroids shrink due to lack of blood flow. This is an inpatient hospital procedure done under local anesthesia with epidural or spinal anesthesia or intravenous pain medication postprocedure. Common side effects of this procedure include pain, nausea, groin hematoma, and fever, but most resolve within 24 to 72 hours. Studies comparing the effectiveness of uterine artery embolization and hysterectomy have shown that quality of life improvement is similar between the two, but hysterectomy is better in terms of controlling abnormal uterine bleeding. Comparisons to myomectomy have shown conflicting evidence in terms of quality of life improvement, with some showing myomectomy as superior and others showing uterine artery embolization as superior. There is little evidence surrounding fertility outcomes for uterine artery embolization, including pregnancy. MR-HIFU is a technique of thermal ablation that induces necrosis in uterine fibroids through a high-intensity ultrasound beam under MRI guidance. This is a noninvasive method with few side effects. Current treatments allow for 100% ablation of fibroids, and the procedure typically takes place over a 1-day admission to the hospital. There has been only 1 randomized controlled trial comparing MR-HIFU with a placebo, and an additional 3 have compared it to the standard of care. No study reported its effect on menstrual bleeding, but all reported improvement in quality of life at 12 weeks postintervention. Compared with placebo, however, this improvement was insignificant. Compared with uterine artery embolization, MR-HIFU was inferior in improving both symptom severity and quality of life. Laparoscopic radiofrequency ablation causes uterine fibroids to shrink by applying radiofrequency energy. This procedure is also a 1-day admission procedure, and recovery time is 1 to 2 weeks. Compared with myomectomy, this method showed some improvement in heavy menstrual bleeding and in quality of life; however, there was greater improvement associated with myomectomy. Symptom severity was improved with laparoscopic radiofrequency ablation compared with myomectomy. Transcervical radiofrequency ablation is another approach that applies radiofrequency energy using a cervical approach. This is a same-day procedure with a short recovery time of 3 to 4 days. Common side effects include fibroid soughing and cramping. Clinical trials showed significantly improved outcomes in quality of life, symptom severity, fibroid volume, and menstrual blood loss. Additional surgical intervention was also common. Ulipristal acetate and oral GnRH antagonists are pharmacological approaches. Ulipristal acetate reduces fibroid size through apoptosis and inhibition of cell proliferation, and additionally causes anovulation to control menstrual bleeding. Randomized controlled trials have shown a significant reduction in fibroid size and successful amenorrhea, but outcomes relating to reproduction have not been assessed. GnRH antagonists inhibit gonadotropin release and impact ovulation. Randomized controlled trials showed significant improvement in quality of life and symptom severity compared with baseline, without a significant reduction in fibroid volume compared with placebo. No studies have compared this treatment with embolization, hysterectomy, or myomectomy. Each of these options should be considered in the context of patient desires and symptom severity, as well as future reproductive plans. Future research should focus on comparing methods to find what is most effective as well as studying reproductive outcomes for each method.