Table 1.

Summary of traditional medical treatment for symptomatic uterine fibroids

Class of agent	Mechanism of action	Advantages	Disadvantages	General Comments
Combined estrogen-progestin agents	Thinning of the endometrial lining, constant hormonal milieu	Reduces AUB-L and pain. Provides contraception. Additional health benefits: ovarian cancer/uterine cancer protection, reduction of anemia Inexpensive, widely available	Not effective for bulk related symptoms Not suitable for patients who cannot take high-dose estrogen	Available in oral pills, vaginal ring, transdermal patch
Levonorgestrel-releasing-IUD	Induce endometrial decidualization and atrophy	Reduces AUB-L and pain Provides contraception Ideal for patients who cannot take estrogen	Not suitable for FIGO type 1–2 uterine fibroids due to risk of IUD expulsion. Procedure required for insertion. Expensive in most environments
Tranexamic acid	Prevent fibrin degradation	Reduces AUB-L Ideal for patients who cannot use hormonal agent. Only taken during menses on heavy days	Can only be used for up to 5 days a month	Given during heavy days of period at 1.3g dose three times daily
SPRM : ulipristal, mifepristone	Progesterone antagonism	Reduction in HMB and some volume reduction	Varied outcomes with pain Does not provide contraception. Rare cases of severe liver toxicity with ulipristal	Not available in the US for fibroid treatment
Parenteral GnRH agonists: goserelin, nafarelin, buserelin, leuprorelin	Interferes with pulsatile release of GnRH with reduced LH/FSH secretion, downregulation of GnRH receptor, and reversible hypogonadism	Reduce fibroid and uterine size and AUB-L. Used for 3–6 months before surgery to allow minimally invasive route for surgery, smaller incisions, improves preoperative anemia and perioperative outcomes	Initial flare effect Hypoestrogenic side effects Only short-term use: 6 months without ABT or 12 months with ABT Only in injectable forms Expensive Does not provide contraception	Available in 1- or 3-months depot
Oral GnRH antagonists: elagolix, relugolix, linzagolix	Competitive binding of the synthetic analog of endogenous GnRH to the receptors with reduced LH/FSH secretion, rapid HPO axis suppression, and reversible hypogonadism	Available in oral forms No initial flare effect. FDA and EU approved for 24 months of use for relugolix and elagolix when combined with 1 mg estradiol and 0.5 mg norethindrone acetate	Well tolerated with less hypoestrogenic side effects Expensive Does not provide contraception	Linzagolix is approved in the EU both with and without ABT.

Abbreviations: AUB-L, Abnormal uterine bleeding due to leiomyomas; LNG-IUD, levonorgestrel-releasing intrauterine device; SPRM, selective progesterone receptor modulator; GnRH, gonadotropin releasing hormone; LH, luteinizing hormone; FSH, follicle stimulating hormone; ABT, add-back therapy