There are various treatment modalities for uterine fibroids. Conservative management is appropriate where asymptomatic fibroids are detected incidentally. It may be necessary to establish the rate of growth of the fibroids by repeated clinical examination or ultrasound after a 6-12 month interval. The main types of medical treatment for heavy menstrual bleeding (tranexamic acid, mefenamic acid, combined oral contraceptive pill) tend to be ineffective.

Gonadotrophin-releasing hormone (GnRH) agonists offers the only effective medical treatment. Unfortunately, while very effective in shrinking fibroids, when ovarian function returns, the fibroids regrow to their previous dimension. Mifepristone (an antiprogesterone) has been shown to be effective in shrinking fibroids at a low dose, but is currently unavailable for use as it causes endometrial hyperplasia. The optimal dose, duration of treatment and long term effects have yet to be established.

The choice of surgical treatment is determined by the presenting complaint and the patient’s aspirations for menstrual function and fertility. Menorrhagia associated with a submucous fibroid or fibroid polyp should be treated by hysteroscopic removal. Where a bulky fibroid uterus causes pressure symptoms, the options are myomectomy with uterine conservation, or hysterectomy (surgical removal of the uterus). Myomectomy is the preferred option where preservation of fertility is required. Hysterectomy and myomectomy can be facilitated by GnRH agonist pretreatment over a 3 month period to reduce the bulk and vascularity of the fibroids. Useful benefits of the approach are to enable a suprapubic (low transverse) rather than a midline abdominal incision, or to facilitate vaginal rather than abdominal hysterectomy, both of which are conducive to more rapid recovery and fewer postoperative complications. GnRH agonist pretreatment can obscure tissue planes around the fibroid making surgery more difficult but, on the positive side, blood loss and the likely need for transfusion is reduced.

Uterine artery embolization (UAE) is a newer technique performed by interventional radiologists. It involves embolization of both uterine arteries under radiological guidance with a small incision in the femoral artery performed under local anaesthesia. The current evidence indicates that the overall shrinkage of fibroids and reduction in menstrual blood loss is around 50%, although long term follow-up data beyond 18-24 months are not available. Following UAE, patients usually requires admission overnight because of pain following arterial occlusion requiring opiate analgesia. Complications include fever, infection, fibroid expulsion and potential ovarian failure. Women wishing to retain their fertility should be counseled carefully before undergoing UAE as the effects are not known, although there have been pregnancies reported in the literature.

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