Options for the treatment of AUB caused by fibroids
There are many options for the treatment of AUB caused by fibroids, including surgical, hormonal, and nonhormonal therapies. Women with bothersome fibroids strongly prefer to be involved in the decision-making process and select the treatment plan that is best for their situation.3 The patient’s preferences can be explored by discussing the main benefits and common complications and side effects of each treatment option.
Surgical options for the treatment of AUB caused by fibroids include, but are not limited to, hysterectomy (laparoscopic, vaginal, or laparotomy), myomectomy (hysteroscopic, laparoscopic, or laparotomy), uterine artery embolization, focused ultrasound surgery, radiofrequency ablation, cryomyolysis, endometrial ablation, and occlusion of the uterine arteries.4 The FIGO classification system provides a consensus nomenclature for describing fibroid location (see FIGURE 2).5 The selection of a treatment option is greatly influenced by the location of the fibroids in the uterus.6 Most experts recommend hysteroscopic myomectomy to treat Type 0 and Type 1 fibroids causing AUB.6 For Type 2 fibroids, hysteroscopic myomectomy, if technically feasible, is associated with a high rate of resolution of AUB with minimal complications. Hormonal treatment of Type 0 and Type 1 fibroids may result in red degeneration of the fibroid with significant menorrhagia.7,8 In my practice, I generally advise patients that hysteroscopic myomectomy is the first-line treatment option for Types 0, 1, and 2 fibroids causing AUB.
The FDA has approved the hormonal options of relugolix combination therapy (Myfembree)2 and elagolix combination therapy (Oriahnn)9,10 for the treatment of AUB associated with fibroids. Of note, elagolix combination therapy contains the same daily dose of estradiol (1 mg) and norethindrone acetate (0.5 mg) as relugolix combination therapy. Relugolix and elagolix combination therapy for fibroids are good options for women who have FIGO Type 2 to 5 fibroids and who prefer a nonsurgical option. If GnRH antagonist combination therapy results in a meaningful reduction in AUB, treatment can be continued for up to 2 years. If the patient reports an insufficient decrease in AUB, an alternative surgical, hormonal, or nonhormonal option can be offered.
Other hormonal treatments that may reduce AUB due to fibroids include combination estrogen-progestin contraceptives,11 the levonorgestrel-releasing intrauterine device (LNG-IUD),12 progestins, and leuprolide.13 Leuprolide plus iron therapy is approved by the FDA for improving red blood cell concentration prior to surgery in women with fibroids, AUB, and anemia.14 The Mirena LNG-IUD is FDA approved for the treatment of heavy menstrual bleeding among women who choose to use an IUD for contraception.15 However, a recent systematic review and meta-analysis concluded that because of very low-quality evidence it was difficult to assess the efficacy of the LNG-IUD and progestins for the treatment of fibroids.16 Tranexamic acid is a nonhormonal option, FDA approved for the treatment of cyclic heavy management of AUB caused by fibroids, and may be an option for women who are near menopause.
New hormonal treatment adds options for women
Fibroids are the most common pelvic tumor of women. Women with fibroids often present for clinical care due to AUB, pelvic pain, and/or lower abdominal discomfort. For women with symptomatic fibroids it may be difficult to effectively complete employment-related tasks and home responsibilities. In one study, women with symptomatic fibroids reported that their symptoms negatively impacted approximately 20 hours per month of employment-related work and 12 hours per month of home responsibilities, reducing productivity in both settings.19 Relugolix combination therapy adds another important option for the hormonal treatment of the problems caused by these prevalent and bothersome tumors, improving health and the quality of contributions at work and home. ●