The reduction in uterine size following treatment with the progesterone-blocking drug mifepristone is similar to that found with GnRH-a (94). A prospective, randomized, controlled trial of mifepristone treatment found a 48% decrease in mean uterine volume after 6 months (95). Mifepristone blocks progesterone, and the unopposed exposure of the endometrium to estrogen may lead to endometrial hyperplasia. A systematic review found endometrial hyperplasia in 10 of 36 (28%) women screened with endometrial biopsies (96).
The levonorgestrel-releasing intrauterine system (LNG-IUS) may be reasonable treatment for selected women with fibroid-associated menorrhagia. In women with fibroids, uterine size no larger than 12 weeks, and a normal uterine cavity, LNG-IUS substantially reduces menstrual bleeding (97). Twenty-two of 26 (85%) women with documented fibroid-related menorrhagia returned to normal bleeding within 3 months. By 12 months, 27 of 67 (40%) women had amenorrhea and 66 women had hemoglobin levels above 12 g/dL.
One study examined 32 women with at least one fibroid less than 5 cm in diameter and less than 50% of the tumor volume projecting into the endometrial cavity (type II) who had insertion of an LNG-IUS (98). After 12 months, mean estimated blood loss, measured by pictorial blood loss assessment, decreased from 392 to 37 mL with an associated increase in hemoglobin levels. There was no change in uterine volume over the course of the study. Some studies show that LNG-IUS expulsion rates are higher in women with fibroids than in women without fibroids (99).
A nonrandomized, nonblinded study compared fibroid growth in 37 women treated with Chinese medicine, body therapy, and guided imagery to 37 controls treated with nonsteroidal anti-inﬂammatory medications, progestins, or oral contraceptive pills (100). After 6 months, sonographic evaluation demonstrated that fibroids stopped growing or shrank in 22 of 37 (59%) women treated with Chinese medicine compared to 3 of 37 (8%) controls. Although symptoms responded equally well in both groups, satisfaction was higher in the Chinese medicine group. Participants actively sought alternative therapy, however, and assessment of satisfaction may reﬂect selection bias.
An uncontrolled study reported treatment of 110 women with fibroids smaller than 10 cm with the Chinese herbal medicine kuei-chih-fu-ling-wan for at least 12 weeks (101). Clinical and sonographic evaluation found complete resolution of fibroids in 19% of women, a decrease in size in 43%, no change in 34%, and an increase in 4%. Menorrhagia improved in 60 of 63 (95%) of women and dysmenorrhea improved in 48 of 51 (94%). Fifteen of the 110 (14%) women chose to have a hysterectomy during the 4 years of the study.
Surgical treatment options currently include abdominal myomectomy, laparoscopic myomectomy, hysteroscopic myomectomy, endometrial ablation, and abdominal, vaginal, or laparoscopic hysterectomy.
Serious medical conditions, such as severe anemia or ureteral obstruction, often need to be addressed surgically. Pain from fibroid degeneration is usually successfully treated with analgesics until symptoms resolve, but if severe the patient may opt for surgery. Torsion of a pedunculated subserosal fibroid may produce acute pain that requires surgical intervention. Surgical intervention may be indicated in women with fibroids associated with menorrhagia, pelvic pain or pressure, urinary frequency, or incontinence that compromises quality of life (102).