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Uterine Fibroids (leiomyoma)

NICE guideline NG88 Heavy menstrual bleeding: assessment and management. Last updated: May 2021 NICE CKS Fibroids. Last revised Apr 2023.

Guidelines

Primary care management is suitable if:
  • Fibroid <3 cm, and
  • Not distorting uterine cavity

Refer to secondary care if any of the following:
  • Fibroid ≥3cm
  • Suspected submucosal fibroid
  • Severe symptoms
  • Suspected fertility issues associated with fibroids 

This is essentially the pharmacological management of heavy menstrual bleeding.


1st line: levonorgestrel intrauterine system (LNG-IUS) - progestogen containing hormonal IUS

2nd line:
  • Non-hormonal options: NSAIDs / tranexamic acid
  • Hormonal options: COCP / cylical oral progestogens (e.g. norethisterone)
 
 

If the patient is planning to conceive, offer non-hormonal options.

The above management should also be considered and continued if effective. 
Consider GnRH antagonist (e.g. linzagolix, relugolix) in:
  • Moderate to severe symptoms of uterine fibroids
  • Pretreatment before hysterectomy and myomectomy if fibroids are causing an enlarged / distorted uterus to reduce risk of bleeding

Interventional options:
  • If submucosal fibroids → consider hysteroscopic removal
  • Uterine artery embolisation
  • Surgical treatment
    • Endometrial ablation
    • Myomectomy
    • Hysterectomy 

If interventional options not appropriate / failed → consider ulipristal acetate
  • For intermittent treatment of moderate to severe symptoms
  • Note that ulipristal acetate is associated with serious liver injury 
 

If fibroids are associated with fertility issues → consider uterine artery embolisation or myomectomy.

NICE states that pharmacological treatments for >3cm fibroids have limited effectiveness; therefore >3cm is generally considered the cut-off for interventional management.

Myomectomy vs hysterectomy

  • Myomectomy: preservation / improvement of fertility but higher risk of adhesions and recurrence
  • Hysterectomy: definitive management for fibroids but loss of fertility

References

Author: Adams Lau
Reviewer:
Last Edited: 13/04/25