Table 1.

Medical management of uterine fibroids

Treatment	Evidence-based recommendation
Oral contraceptives (estrogen/progestin)	Reduces HMB but does not inhibit fibroid growth or reduce fibroid volume [31, 40–42]
Tranexamic acid	Non-hormonal oral antifibrinolytic agent; reduces HMB but has no effect on fibroid size; widely available globally [31, 41, 42]
Non-steroidal anti-inflammatory drugs	Reduces HMB and pain, though less effectively than estrogen/progestin contraceptives, the levonorgestrel-releasing intrauterine system, or tranexamic acid [31, 41]
Oral or injectable progestins	Reduces HMB but data supporting effectiveness are limited [2, 41]
Levonorgestrel-releasing intrauterine system	Reduces HMB to a greater extent than oral contraceptives; may have limited benefits in women with high fibroid burden that distorts the uterine cavity due to risk off expulsion [31, 41, 42]
GnRH agonists	Reduces HMB, significantly reduces fibroid size, and improves hemoglobin levels; recommended in combination with low-dose estrogen/progestin add-back therapy to mitigate adverse effects and/or as pretreatment to reduce fibroid volume before surgery (3–6 months) [7, 31, 40–42, 53]
GnRH antagonists	Reduces HMB and fibroid volume; improves hemoglobin levels; recommended in combination with low-dose estrogen/progestin add-back therapy to mitigate adverse effects [31, 42]
Selective progesterone receptor modulators	Reduces HMB, pain, and fibroid volume and increases hemoglobin levels; recommendations suspended in 2020 due to safety concerns; long-term safety is under investigation [31, 42, 56, 57]
Aromatase inhibitors	Limited evidence to demonstrate reductions in HMB or fibroid size [31, 41]
Natural therapy (vitamin D, epigallocatechin gallate)	May inhibit fibroid growth; currently under clinical investigation and further evaluation is needed [31, 58, 59]

GnRH, gonadotropin-releasing hormone; HMB, heavy menstrual bleeding