Stewart, E. A., & Laughlin-Tommaso, S. K. (2024). Uterine Fibroids. N Engl J Med. https://doi.org/10.1056/NEJMcp2309623
Stewart EA, Laughlin-Tommaso SK. Uterine Fibroids. N Engl J Med. 2024. doi:10.1056/NEJMcp2309623
Stewart, Elizabeth A., and Shannon K. Laughlin-Tommaso. "Uterine Fibroids." N Engl J Med, 2024.
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RRM Academy Synopsis
Uterine fibroid symptoms can ease with drugs and uterine-sparing care
Medicines and procedures that keep the uterus can relieve fibroid symptoms, says a 2024 clinical practice review. The authors say these options should be used more widely. They cite observational studies that tie hysterectomy to higher risks of heart and blood vessel disease, anxiety, depression, and death.
Key Findings
Across a lifetime, fibroids affect 70 to 80% of people with a uterus, and up to 50% of those with fibroids have symptoms.
In trials, oral gonadotropin-releasing hormone (GnRH) antagonist combinations lowered heavy menstrual bleeding by 50 to 75% and pain by 40 to 50%. Hot flushes, headaches, and nausea occurred in <20% of participants.
Within 5 years after myomectomy, new fibroids developed in approximately 50% of persons. Reintervention percentages generally ranged up to 33%, with follow-up of up to 5 years after treatment.
In a recent study of commercially insured patients, nearly 60% of those undergoing hysterectomy for fibroids had not previously received a conservative treatment.
After hysterectomy at 35 or younger, coronary artery disease risk was 2.5 times and congestive heart failure risk 4.6 times that of women without it, over a median follow-up of 22 years.
Interpretation
This review sums up trials and cohort studies, then gives the authors' own recommendations. The authors call the evidence for contraceptive hormones, the first step in most plans, low in quality. Drugs like ibuprofen and tranexamic acid have more evidence for heavy periods with no known cause, where trials have typically left out people with large or submucosal fibroids. Data from randomized trials that compare all the minimally invasive procedures are limited. The authors say longer-term follow-up studies of reintervention have not been done. The hysterectomy findings come from observational studies. The authors say causality cannot be confirmed.
RRM Context
The authors say fibroid symptoms may overlap with those of ovulation problems and adenomyosis. The drug they recommend for the opening case is a suppressive pill. One ingredient lowers ovarian hormone production, and the pill is approved for 24 months of use in the United States. Restorative reproductive medicine starts by asking why the bleeding is heavy. For fertility, most guidelines suggest taking fibroids out by surgery.
Our editorial summary of this paper, not the article's abstract.