Slideshow: Uterine Fibroids Guidelines

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    Approximately 70% of women have uterine fibroids by the time they reach menopause, and a fourth of women with uterine fibroids are symptomatic. This slideshow features the American College of Obstetricians and Gynecologists’ clinical management guidelines on the diagnosis and treatment of symptomatic uterine leiomyomas.

    Because of a lack of sufficient comparative evidence, these recommendations are based on symptoms instead of clinical preference.



    Committee on Practice Bulletins – Gynecology. Management of symptomatic uterine leiomyomas. Obstet Gynecol. 2021;137;e100-15.

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    Reductions in leiomyoma size and size of the uterus, decreased AUB-L and dysmenorrhea, and improvement in quality of life are associated with treatment with GnRH agonists.

    GnRH agonists are not recommended to be used longer than 6 months without add-back therapy and 12 months with add back-therapy because of the risk of long-term hypoestrogenic adverse events.

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    The use of UAE is associated with significant reductions in leiomyoma and uterine volume. These reductions may be maintained for up to 5 years. Increased incidence of amenorrhea, improvement in bleeding scores, and a decrease in heavy menstrual bleeding have also been reported.

    However, the number of individuals who undergo UAE and require surgical reintervention may be 2 to 5 times higher than the number of individuals who were initially treated with hysterectomy or myomectomy.

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    Hysterectomy in individuals with symptomatic uterine fibroids has been associated with improvements in hemoglobin at 24 months, quality of life at 2 years following surgery, and total or substantial improvement in pressure symptoms.

    Compared with abdominal hysterectomy, vaginal hysterectomy was associated with a faster return to normal life and increased quality of life. Compared with laparoscopic hysterectomy, vaginal hysterectomy had shorter operating times and hospital stays.

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    Elagolix with add-back therapy is currently approved by the US Food and Drug Administration (FDA) for managing heavy menstrual bleeding associated with uterine fibroids. A second oral GnRH antagonist, relugolix, with hormonal add-back therapy is currently being reviewed by the FDA.

    A 52-mg LNG-IUD may be used to reduce menstrual bleeding. However, rates of IUD expulsion are higher among patients with uterine fibroids who are being treated with an LNG-IUD than those without uterine fibroids.

    According to limited data, a statistically significant decrease in AUB-L following the use of tranexamic acid may occur. 

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    Laparoscopic radiofrequency ablation, a minimally invasive treatment option, is the most studied radiofrequency ablation approach. However, the data is still limited and patients should be counseled about the lack of data on reproductive outcomes.

    Myomectomy, a surgical management option, has been associated with increased quality of life in patients with uterine fibroids. The myomectomy technique used for each patient should be the most minimally invasive approach when possible.

    For patients who do not desire uterine preservation, future childbearing, or to retain their uterus, hysterectomy is the recommended surgical management option for AUB-L and bulk symptoms.

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    While a 52-mg LNG-IUD may provide a larger reduction in menstrual blood loss, combined hormonal contraceptives have been determined as a reasonable option by extrapolation. Limited data exists to support the effectiveness of combined hormonal contraceptives in reducing menstrual blood loss.

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    Patients with expectant management of uterine leiomyomas may not have any clinically meaningful changes at 1-year of follow-up.

    If active management or pregnancy are desired, or if symptoms increase, patients should reassess their management with their health care provider.

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    To learn more about uterine fibroids, visit our Resource Center.



    Committee on Practice Bulletins – Gynecology. Management of symptomatic uterine leiomyomas. Obstet Gynecol. 2021;137;e100-15.