Table III.

Current medical, radiological and surgical management options for uterine leiomyoma.

	Name	Function	Limitations	Source
Medical management	Non-steroidal anti-inflammatory agents [NSAIDs]	Improves dysmenorrhea and menorrhagia; works by inhibiting cyclooxygenase enzyme involved in the inflammatory process	May cause gastrointestinal [GI] bleeding and ulcers	(Vane and Botting, 1998)
	Selective progesterone receptor modulators [SPRMs]	Reduces bleeding, pain, fibroid volume; not associated with the adverse symptoms of a hypoestrogenic state; works by inhibiting cell proliferation and inducing apoptosis	May cause liver damage; may cause progesterone receptor modulator-associated endometrial changes	(Donnez and Dolmans, 2016)
	Gonadotropin releasing hormone [GnRH] agonist	Reduces heavy menstrual bleeding, uterine volume and fibroid volume; works by desensitizing the GnRH receptor producing a hypogonadotropic state and thereby reducing secretion of estradiol and progesterone	Short-term use may cause adverse symptoms associated with a hypoestrogenic state; long-term use may result in reduced bone mineral density and cause histological changes in uterine leiomyoma	(Lethaby et al., 2001; Donnez and Dolmans, 2016)
	GnRH antagonist	Provides faster symptom relief than GnRH agonists, reduces tumor volume and uterine size; works by competitively binding to GnRH receptor	Compared to GnRH agonists, GnRH antagonists are more expensive and require daily injections due to their short half life	(Lethaby et al., 2001; Giuliani et al., 2020)
	Combined estrogen-progesterone contraceptives	Reduces menorrhagia	Has no effect on decreasing tumor volume	(Marret et al., 2012)
	Tranexamic acid	Improves abnormal uterine bleeding and symptoms by acting as an antifibrinolytic agent	May produce GI and musculoskeletal symptoms	(De La Cruz and Buchanan, 2017)
	Progestogen-only	Progestogen: a synthetic progesterone hormone that may be administered orally or through injections; reduces menorrhagia	Progestogen-associated histopathological changes may lead to misdiagnosis of leiomyosarcoma or smooth muscle tumor of uncertain malignant potential; risk of IUS expulsion; overall lack of high-quality evidence assessing its efficacy; mixed study results regarding the influence on uterine and tumor volume	(Senol et al., 2015; Sohn et al., 2018; Donnez, 2020; Sangkomkamhang et al., 2020)
		Progestogen-releasing intrauterine system [IUS]: reduces menorrhagia; the device is placed inside the uterus and works by secreting progestogen to suppress endometrial lining and therefore reduce blood flow
Interventional Radiology	Uterine Artery Embolization [UAE]	Provides symptom relief and reduces tumor volume; works by limiting blood supply to the tumor and inducing ischemic necrosis	Risk of infection; may compromise blood supply to ovaries or other organs; increased likelihood of reintervention within 2 to 5 years after initial procedure; may impact fertility; post embolization syndrome	(Gupta et al., 2014; Zupi et al., 2016)
	Magnetic resonance-guided high-intensity focused ultrasound [MRgHIFU]	Significant symptom relief and tumor shrinkage for at least 12 months; works via using a magnetic resonance imaging [MRI] device to monitor thermal ablation using ultrasonic energy to cause coagulative necrosis within fibroid tissue	May cause abdominal pain, abdominal edema, vaginal discharge, skin burn, and damage to surrounding tissue; inclusion criteria is met by only a portion of patients; can compromise fertility; higher cost due to reinterventions and the need of an MRI device; procedure time is longer compared to USgHIFU	(Gorny et al., 2011; Zupi et al., 2016; Wang et al., 2018)
	Ultrasound guided-high intensity focused ultrasound [USgHIFU]	Significant symptom relief and tumor shrinkage; works by using a diagnostic ultrasound device to locate the target region to induce thermal ablation using ultrasonic energy and result in coagulative necrosis within the tissue	May cause vaginal bleeding, increased vaginal discharge, abdominal pain and edema, sciatic nerve damage, sacral injury, skin burns, and small bowel perforations. The lack of real time temperature mapping (which is present in MRgHIFU) limits feedback to adjust sonication power and energy and may result in incomplete or excessive ablation; risk for local reoccurrence and reintervention; can compromise fertility	(Wang et al., 2018; Liu et al., 2021b; Marinova et al., 2021)
	Cryomyolysis	Reduces tumor volume, bleeding, pelvic pain, and urinary frequency; works by limiting primary blood supply to the tumor via cryoablation	May impact fertility; exclusion criteria limits women who can undergo this treatment; lack of histological examination of fibroids	(Zupi et al., 2016)
	Radiofrequency thermal ablation (Acessa)	Reduces tumor volume and provides symptom relief; works by using a thin needle to target the tumors via radiofrequency heat, causing coagulative necrosis and reabsorption of the tumor by surrounding myometrium	May result in skin burns; Possibility of reoccurrence and reintervention; limited long term data for pregnancy and pregnancy outcomes	(Lee and Yu, 2016)
Surgical Management	Myomectomy	Gold standard for women of reproductive age to preserve fertility and the uterus; surgical excision of fibroid via open (incision in the lower abdomen; used if fibroids are large, numerous, or deeply embedded in the uterus) or through the following minimally invasive approach procedures: Laparoscopic: The surgeon uses instruments and a lighted scope with a camera (laparoscope) to visualize and extract fibroids through small incisions in the pelvic region that provide access to the abdominal cavity Robotic: Surgeon sits at a console and guides robotic instruments to extract the fibroid; similar to laparoscopic approach except this method allows for greater dexterity, precise movements, and the ability to remove fibroids which are less accessible Hysteroscopic: used to treat smaller fibroids that grow in the uterine cavity; the surgeon inserts a small telescope (hysteroscope) into the vagina and cervix to visualize and extract the fibroid	Risk of hemorrhage; possibility of being converted to hysterectomy; risk of uterine rupture; possible scarring which can affect fertility; likelihood of reintervention within 5 to 10 years due to fibroid reoccurrence	(De La Cruz and Buchanan, 2017; Flyckt et al., 2017; Piecak and Milart, 2017)
	Hysterectomy	Definitive cure for fibroids; surgical procedure to remove the uterus via open or minimally invasive approach	Fertility is not preserved; vaginal cuff cellulitis; risk of infection; infected pelvic hematoma or abscess; venous thromboembolic complications	(Clarke-Pearson and Geller, 2013; De La Cruz and Buchanan, 2017)