Managing Uterine Fibroids: Alternatives to Hysterectomy

William H. Parker, MD

Disclosures

July 20, 2012

In This Article

Medical Fibroid Therapies

Progesterone-Releasing Intrauterine Device

Some women with fibroid-associated heavy menstrual bleeding will benefit from treatment with the levonorgestrel-releasing intrauterine system (LNG-IUS).One study found that women with at least 1 fibroid smaller than 5 cm, with less than 50% of the fibroid in the endometrial cavity (type 2), had a 90% reduction in blood loss and an increase in hemoglobin levels 1 year after insertion of an LNG-IUS.[4]

Gonadotropin-Releasing Hormone Agonists

Gonadotropin-releasing hormone (GnRH) agonists have been shown to reduce uterine volume by 35% and bleeding in 95% of women.[5]However, 95% of women experience side effects, including hot flushes (78%), vaginal dryness (32%), and transient frontal headaches (55%).[6]Some women also experience arthralgia, myalgia, insomnia, edema, emotional lability, depression, or decreased libido.

In addition, the hypoestrogenic state induced by GnRH agonists can result in significant bone loss after 6 months of therapy.[7]Low doses of estrogen and progestins may be added while continuing treatment with GnRH agonists, but a study found no difference in bone loss between groups given estrogen/progestin and those treated with GnRH agonists alone over 6 years.[8]Of note, after discontinuation of therapy with GnRH agonists, menses returns in 4-8 weeks and uterine size returns to pretreatment levels within 4-6 months.

Women in late perimenopause with symptomatic uterine fibroids may consider short-term use of GnRH agonists. Thirty-one of 34 perimenopausal women treated with GnRH agonists for 6 months were able to avoid surgery.[9]

GnRH Antagonist

The immediate suppression of endogenous GnRH by daily subcutaneous injection of the GnRH antagonist ganirelix results in a 29% reduction in fibroid volume within 3 weeks.[10]Treatment, however, is accompanied by hypoestrogenic symptoms. When long-acting compounds are available, GnRH antagonists might be considered for medical treatment before surgery.

Progesterone-Mediated Medical Treatment

Ulipristal acetate, a selective progesterone-receptor modulator, was studied in 2 randomized, double-blind, phase 3 trials in women with uterine fibroids. More than 13 weeks of treatment with oral ulipristal acetate, 5 mg daily, controlled excessive uterine bleeding in at least 90% of patients and was shown to be noninferior to leuprolide acetate injected monthly over 3 months.[11]Uterine volume reduction was maintained for at least 6 months after discontinuation of treatment. The incidence of hot flushes was significantly lower than for women given leuprolide acetate.

Alternative Medicine Treatment

Most published studies of alternative medicine treatments have been nonrandomized, nonblinded, and small. A study reported that after 6 months of treatment with traditional Chinese medicine, ultrasonography showed that fibroids stopped growing or shrank in 59% of patients compared with 8% of controls.[12]In women with fibroids smaller than 10 cm that were treated with traditional Chinese medicine, heavy menstrual bleeding declined in 95% and dysmenorrhea improved in 94%.[13]

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