Guideline No. 461: The Management of Uterine Fibroids

Abstract

Objective

To provide clinicians with an understanding of the clinical significance of fibroids for individuals with uteruses and provide evidence-based guidance on currently available treatment options.

Target Population

This clinical practice guidelines seeks to improve the lives of individuals with uterine fibroids and fibroid-associated menstrual bleeding or pressure symptoms. Fertility considerations are not discussed in detail, as they are described in the SOGC’s Clinical Practice Guideline on The Management of Uterine Fibroids in Women with Otherwise Unexpected Infertility guideline.¹

Options

This guideline reviews the available medical and surgical management options available for treatment of fibroid-related symptoms. Alternate procedural options, such as uterine artery embolization and energy-based treatment options are also reviewed.

Outcomes

This clinical practice guideline is intended to facilitate the decision-making process between patients and healthcare providers regarding the assessment and management of symptomatic uterine fibroids.

Benefits, Harms, and Costs

A majority of fibroid patients are asymptomatic and require no intervention. For patients with abnormal uterine bleeding, iron deficiency anemia, or pelvic pain or pressure symptoms, selected treatment should take into consideration fibroid characteristics and be directed towards patient symptoms and fertility goals. The cost of therapy to the healthcare system for individuals with fibroids must be interpreted in the context of the economic burden, lost productivity, and adverse impacts on quality of life that can be associated with untreated disease.

Evidence

This clinical practice guideline is an update of the SOGC’s Clinical Practice Guideline No. 318 on The Management of Uterine Leiomyomas.² Using relevant MeSH headings and keywords, published literature was retrieved through searches of PubMed and Cochrane Systematic Reviews the date of last search in February 2013 to January 2025. Grey literature was identified through searching the websites of health technology assessment and health technology–related agencies, clinical practice guideline collections, and national and international medical specialty societies.

Validation Methods

A national panel of patient partners were gathered to provide feedback and perspective on the recommendations and summary statements for this guideline. Patient partners were purposefully selected to ensure representation of Canadian geographic region, racial representation, and fibroid-related symptom and treatment received.

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations).

Intended Audience

Health care providers involved in the assessment and management of individuals with uterine fibroids.

Tweetable Abstract

Uterine fibroids are very common and can cause uterine bleeding and pressure symptoms. There should be a low threshold for investigation of such symptoms, as a variety of treatment options are available.

SUMMARY STATEMENTS

• 1.
  Uterine fibroids are common, benign tumors of the uterus that will occur in a majority of females over their lifetime. (high)
• 2.
  The presence of uterine fibroids can lead to a variety of clinical challenges, with abnormal uterine bleeding and bulk symptoms being the most common presentations. (high)
• 3.
  Uterine fibroids can be associated with a variety of adverse reproductive and pregnancy outcomes, and additional surveillance may be required in pregnancy. (moderate)
• 4.
  Uterine fibroids have considerable social and economic impact in Canada and worldwide due to high prevalence and associated symptoms. (high)
• 5.
  The FIGO leiomyoma subclassification system describes the location of the fibroid(s) within the uterus, which is used to correlate with patient symptoms and determine treatment options. (high)
• 6.
  Management options for uterine fibroids are selected based on patient symptoms, age, personal preferences, fertility goals, number, size, location of fibroids, availability of treatment options, and the experience of the clinician. (high)
• 7.
  Treatment is generally not required for asymptomatic fibroids. (moderate)
• 8.
  Surgical planning for uterine fibroids is based on physical examination, as well as fibroid size, fibroid number, and FIGO classification. (high)
• 9.
  Access to specific therapies for uterine fibroids may be limited by sociodemographic factors, and ongoing work is needed to ensure equitable access for all patients. (moderate)

RECOMMENDATIONS

• 1.
  In patients presenting with fibroid symptoms, there should be a low threshold for investigation. (conditional, high)
• 2.
  Ultrasound should be offered as first line imaging for fibroids, while MRI can provide additional information for complex cases and surgical planning. (strong, high)
• 3.
  Structured reporting templates that incorporate the FIGO leiomyoma subclassification system for US and MRI can help standardize communication between care providers. (strong, high)
• 4.
  Patients presenting with fibroids and abnormal uterine bleeding (AUB) remain at risk of other causes of AUB. Thorough assessment that includes endometrial biopsy and cervical cancer screening should be considered based on risk factors. (strong, high)
• 5.
  Fibroid patients with abnormal uterine bleeding may be offered menstrual suppression with oral contraceptives, progestins (including the levonorgestrel intrauterine system), gonadotropin-releasing hormone agonists, gonadotropin-releasing hormone antagonists, and danazol. (strong, high)
• 6.
  Tranexamic acid may be offered to patients with fibroids to specifically reduce heavy menstrual bleeding. (strong, high)
• 7.
  Patients with fibroids and bulk symptoms may be offered gonadotropin-releasing hormone agonists or antagonists. Long term use of these agents may be limited by hypoestrogenic effects, though this may be mitigated by add-back hormone replacement therapy. (strong, high)
• 8.
  Definitive treatment for uterine fibroids is hysterectomy. (strong, high)
• 9.
  Patients with asymptomatic fibroids should be reassured that there is no evidence that hysterectomy is indicated for prevention of malignancy. (strong, high)
• 10.
  In symptomatic patients wishing to preserve their fertility and/or their uterus, myomectomy may be offered. (conditional, moderate)
• 11.
  Patients with cavity-distorting fibroids may be offered myomectomy to optimize fertility and pregnancy outcomes. For patients with non-cavitary-distorting fibroids, it is unclear whether fertility is improved and perinatal risks are reduced with myomectomy. (conditional, moderate)
• 12.
  Patients considering myomectomy should be counselled that abdominal and laparoscopic myomectomy generally carries more surgical risk than hysterectomy. (conditional, moderate)
• 13.
  Consideration should be given to the least invasive approach to surgery to optimize surgical outcomes and facilitate patient recovery. (conditional, high)
• 14.
  The patient should be counselled regarding the risks and complications of morcellation when this is being considered for tissue extraction. (strong, high)
• 15.
  Anemia should be corrected with iron supplementation and consideration of menstrual suppression prior to elective surgery. (strong, high)
• 16.
  Preoperative treatment with GnRH agonists is effective in correcting anemia, reducing fibroid size, and reducing intra-operative bleeding. (strong, high)
• 17.
  Intraoperative medical adjuncts to reduce surgical blood loss in myomectomy patients include misoprostol, vasopressin, epinephrine, and tranexamic acid. Mechanical strategies include uterine artery occlusion, peri-cervical tourniquet, and use of barbed suture. Which adjuncts are superior and whether there are additive effects of multiple adjuncts remains unclear. (strong, moderate)
• 18.
  Myomectomy patients should be counselled about the potential pregnancy risks including uterine rupture, placenta accreta spectrum, and preterm birth. (strong, moderate)
• 19.
  For laparoscopic and abdominal myomectomy, closure of the myometrium in multiple layers and minimizing the use of electrosurgery may help prevent uterine rupture. (conditional, low)
• 20.
  Uterine artery embolization may be offered as a minimally invasive technique that can reduce fibroid symptoms in patients wishing to preserve their uterus. (conditional, moderate)
• 21.
  Patients should be aware that uterine artery embolization may be associated with decreased fertility, higher miscarriage rate, and adverse pregnancy outcomes, and is not advised in patients wishing for future fertility. (conditional, moderate)
• 22.
  Radiofrequency ablation (RFA) may be offered as an option in the management of symptomatic uterine fibroids with comparable outcomes to myomectomy, with potential for decreased surgical bleeding and faster recovery. (conditional, moderate)
• 23.
  High Intensity Focused Ultrasound (HIFU) may be offered as a minimally invasive treatment option for uterine fibroids, but it is not widely available in Canada. (conditional, moderate)
• 24.
  Patients should be aware that there is insufficient evidence at present to comment on reproductive and pregnancy outcomes RFA or HIFU. (conditional, moderate)