The modern management of uterine fibroids-related abnormal uterine bleeding

Uterine fibroids (UFs) are the most common female benign pelvic tumors, affecting over 60% of patients aged 30-44 years. UFs are asymptomatic in a large percentage of cases and may be identified incidentally by a transvaginal ultrasound or a magnetic resonance. However, in around 30% of cases UFs affect quality of life (QoL) and women’s health, being abnormal uterine bleeding (AUB) and heavy menstrual bleeding (HMB) the most common complaints, along with iron deficiency (ID) and ID anemia (IDA). Medical treatments used for UFs-related AUB include symptomatic agents, such as nonsteroidal anti-inflammatory drugs and tranexamic acid, and hormonal therapies, including combined oral contraceptives, gonadotropin-releasing hormone (GnRH) agonists or antagonists, levonorgestrel intrauterine systems, selective progesterone receptors modulators and aromatase inhibitors. Nevertheless, few drugs are approved specifically for UFs treatment and most of them manage the symptoms. Surgical options include fertility-sparing treatments, such as myomectomy, or non-conservative options, as hysterectomy, especially in perimenopausal women not responding to any treatment. Radiological interventions are also available: uterine artery embolization, high-intensity focused ultrasound or magnetic resonance-guided focused ultrasound, radiofrequency ablation. Furthermore, the management of ID and IDA, as a consequence of acute and chronic bleeding, should be taken into account by using iron replacement therapy both during medical treatment and before and after a surgical procedure. In case of symptomatic UFs, the location, size, multiple UFs or coexistent adenomyosis should guide the choice with a shared decision-making, considering long- and short-term treatment goals expected by the patient, including pregnancy desire or wish to preserve the uterus independently of reproductive goals.