Implementing AHRQ Effective Health Care Reviews

Helping Clinicians Make Better Treatment Choices

Management of Uterine Fibroids

 

Am Fam Physician. 2019 Mar 1;99(5):330-333.

Author disclosure: No relevant financial affiliations.

Key Clinical Issue

What are the comparative effectiveness and harms of treatments for uterine fibroids, and what is the risk of finding unexpected leiomyosarcoma in women with fibroids?

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Strength of Evidence and Summary of Findings for Intervention Effects on Fibroid Volume, Fibroid-Related Bleeding, and Quality of Life

Intervention categoryKey outcomesStrength of evidenceKey findings

Expectant management (N = 514)

Change in fibroid size or uterine volume

○○○

Few women followed in 16 study arms, findings inconsistent, data inadequate to project course of watchful waiting (follow-up from three to 12 months)

Change in bleeding

○○○

As above

Quality of life

○○○

As above

Gonadotropin-releasing hormone agonist (N = 912)

Change in fibroid size and uterine volume

●●○

Consistent reductions in size or volume

Change in bleeding

●●○

Bleeding outcomes (e.g., menorrhagia, perceived blood loss, days of bleeding) consistently improved

Quality of life

●○○

Consistent improvements in arms reporting varied measures of quality of life

Mifepristone (N = 690)

Change in fibroid size or uterine volume

●●○

Consistent reductions in size or volume in study arms reporting these outcomes

Change in bleeding

●●○

Consistent improvements in bleeding outcomes (e.g., hemoglobin, amenorrhea, hypermenorrhea) in arms reporting these outcomes

Quality of life

●●○

Quality of life improved in study arms reporting varied measures of quality of life

Ulipristal (N = 1,095)

Change in fibroid size and uterine volume

●●○

Improvements in arms reporting these outcomes, with reductions generally maintained over six months of follow-up

Change in bleeding

●●○

Bleeding outcomes (e.g., amenorrhea, hemoglobin) consistently improved in study arms reporting these outcomes

Quality of life

●●○

Improvement in fibroid-related quality of life in study arms reporting varied measures of quality of life

Levonorgestrel-releasing intrauterine system (N = 30)

Change in bleeding

○○○

Limited data in one small study with high risk of bias

Estrogen receptor agents (raloxifene, tamoxifen; N = 117)

Change in fibroid size and uterine volume

●○○

Lack of effect on fibroid size with raloxifene

Change in bleeding

●○○

No changes in bleeding patterns or hemoglobin with raloxifene

Uterine artery embolization and occlusion (N = 1,376)

Change in fibroid size and uterine volume with uterine artery embolization

●●●

Consistent reduction in size in study arms reporting these outcomes, with two studies reporting continued effects for five years

Change in bleeding with uterine artery embolization

●●○

Improvements in bleeding outcomes (e.g., days of bleeding, hemoglobin, patient-rated bleeding) in study arms reporting these outcomes

Quality of life with uterine artery embolization

●●○

Improvements in study arms reporting varied measures of quality of life

Change in bleeding, fibroid size with uterine artery occlusion

○○○

Heterogeneity of intervention methods prohibits conclusions

High-intensity focused ultrasound for fibroid ablation (N = 264)

Change in fibroid size and uterine volume

●○○

Reduction in study arms reporting these outcomes

Radiofrequency fibroid ablation (N = 75)

Change in bleeding

○○○

Limited data available to assess outcome

Endometrial ablation (N = 96)

Change in bleeding

○○○

Limited data available to assess outcome

Myomectomy (N = 2,257)

Change in fibroid size and uterine volume

Not applicable, not measured

Not applicable, not measured

Change in bleeding

○○○

Few studies reported outcome; improvement in heavy bleeding noted in one study

Quality of life

●○○

Improvements in study arms reporting varied measures of quality of life

Hysterectomy (N = 1,116)

Change in fibroid size and uterine volume

Not applicable, not measured

Not applicable, not measured

Change in bleeding

Not applicable, not measured

Not applicable, not measured

Quality of life

●○○

Improvements in study arms reporting varied measures of quality of life


Strength of evidence scale

●●● High: High confidence that the evidence reflects the true effect. Further research is very unlikely to change the confidence in the estimate of effect.

●●○Moderate: Moderate confidence that the evidence reflects the true effect. Further research may change the confidence in the estimate of effect and may change the estimate.

●○○Low: Low confidence that the evidence reflects the true effect. Further research is likely to change the confidence in the estimate of effect and is likely to change the estimate.

○○○Insufficient: Evidence either is unavailable or does not permit a conclusion.

Adapted from the Agency for Healthcare Research and Quality, Effective Health Care Program. Management of uterine fibroids. Evidence summary. Rockville, Md.: Agency for Healthcare Research and Quality; D

Address correspondence to Tyler S. Rogers, MD, at tyler.s.rogers11.mil@mail.mil. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

show all references

1. Agency for Healthcare Research and Quality, Effective Health Care Program. Management of uterine fibroids. Evidence summary. Rockville, Md.: Agency for Healthcare Research and Quality; December 2017. https://effectivehealthcare.ahrq.gov/sites/default/files/evidence-summary-cer-195-uterine-fibroids-final_0.pdf. Accessed January 9, 2019....

2. Cardozo ER, Clark AD, Banks NK, Henne MB, Stegmann BJ, Segars JH. The estimated annual cost of uterine leiomyomata in the United States. Am J Obstet Gynecol. 2012;206(3):211.e1–9.

3. De La Cruz MS, Buchanan EM. Uterine fibroids: diagnosis and treatment. Am Fam Physician. 2017;95(2):100–107.

4. American College of Obstetricians and Gynecologists. ACOG practice bulletin. Alternatives to hysterectomy in the management of leiomyomas. Obstet Gynecol. 2008;112(2 pt 1):387–400.

5. American College of Obstetricians and Gynecologists. Practice advisory: management of uterine leiomyomas (fibroids). https://www.acog.org/Clinical-Guidance-and-Publications/Practice-Advisories/Practice-Advisory-Management-of-Uterine-Leiomyomas-Fibroids. Accessed August 11, 2018.

6. Hehenkamp WJ, Volkers NA, Birnie E, Reekers JA, Ankum WM. Pain and return to daily activities after uterine artery embolization and hysterectomy in the treatment of symptomatic uterine fibroids: results from the randomized EMMY trial. Cardiovasc Intervent Radiol. 2006;29(2):179–187.

The Agency for Healthcare Research and Quality (AHRQ) conducts the Effective Health Care Program as part of its mission to produce evidence to improve health care and to make sure the evidence is understood and used. A key clinical question based on the AHRQ Effective Health Care Program systematic review of the literature is presented, followed by an evidence-based answer based upon the review. AHRQ's summary is accompanied by an interpretation by an AFP author that will help guide clinicians in making treatment decisions. For the full review, clinician summary, and consumer summary, go to https://effectivehealthcare.ahrq.gov/topics/uterine-fibroids/research-2017.

This series is coordinated by Kenny Lin, MD, MPH, Deputy Editor.

A collection of Implementing AHRQ Effective Health Care Reviews published in AFP is available at https://www.aafp.org/afp/ahrq.

 

 

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