Dr. Cátia Paixão Martins

Gynecology and Obstetrics Service

Medical treatment of uterine fibroids

HPA Magazine 24 // 2025

Although fibroids are very prevalent and affect a significant percentage of women until the end of their reproductive life, in the vast majority of cases, they are completely asymptomatic. In other words, they are not associated with any type of symptom and are identified accidentally during a routine consultation or gynaecological ultrasound.
In these situations, it is not necessary to institute any type of medical intervention; it is only recommended to maintain clinical surveillance during gynaecology consultations since fibroids can continue to develop until menopause.

So, which women need treatment?
Any woman who presents signs or symptoms that affect her health or interfere with her quality of life.
Many patients will present symptoms, including abnormal uterine bleeding, symptoms of pelvic pressure or volume, fertility problems, and/or pain that justify treatment. These patients have a variety of therapeutic options available to treat their symptoms, which will always be indicated on a case-by-case basis. The woman's preference and shared decision-making with her physician are used to create the most effective strategy until symptoms are adequately controlled.
Medical treatment is usually the first option for controlling symptoms associated with uterine fibroids. We have increasingly effective drugs with fewer side effects that can allow us to preserve the uterus and its anatomy, i.e., avoid surgery. However, there are important limitations; these drugs only act to reduce symptoms, usually by suppressing menstruation, with very variable efficacy among patients, and they are not able to reduce uterine volume persistently.

So, what types of drugs are available?
We can consider two types of medical strategies: non-hormonal treatments and hormonal therapy, with different mechanisms of action.
Non-hormonal treatments interfere with the inflammatory mechanisms and phenomena of altered vascularization that are associated with fibroids; they act non-specifically and, therefore, are also not very effective. They are normally used as a complement or when there is a contraindication to hormonal treatment. This group includes anti-inflammatories, widely used to control pain associated with menstruation, and the group of antifibrinolytics, a type of medication that enhances coagulation, with the aim of reducing the volume and duration of abnormal uterine bleeding.
Hormonal therapy is based on modulating the response of fibroids to hormones in the female reproductive cycle by suppressing menstruation.
Hormonal contraceptives are indicated as the first choice in the treatment of pain and abnormal uterine bleeding associated with fibroids, in women who do not want to become pregnant. At the ovarian level, these medications block ovulation (and thus guarantee contraception) and at the uterine level, they induce controlled uterine shedding (so-called withdrawal bleeding), of a smaller quantity and with less associated pain.
Oral pills, the vaginal ring, the hormonal implant, and the transdermal patch have this underlying mechanism, and any of them can be effective; the choice between them will depend on the profile and preference of each woman.
The intrauterine device (IUD) with levonorgestrel is also part of the hormonal contraceptives; it acts essentially in the uterus and can be a very effective option with reduced side effects. Hormonal contraceptives are usually well accepted by women, with good clinical tolerance and can combine several beneficial effects in addition to contraception, namely, increased quality of life, treatment of hormonal changes, reduction of iron deficiency anaemia, and reduction of the risk of uterine cancer and ovarian cancer.
When hormonal contraceptives fail to control symptoms or in urgent situations, in which a more effective and rapid blockade of the hormonal axis is needed, we resort to another group of hormonal treatments: GnRH agonists or antagonists.
 GnRH is a hormone produced in the brain, responsible for the regularity of the menstrual cycle. When its release is interrupted by this type of medication (GnRH agonists or antagonists), there is a central and complete blockage of the hormonal axis, and the woman's ovarian function is completely suppressed. In other words, there is a sudden drop in oestrogen and progesterone, simulating a state of menopause. In this way, these medications can act very quickly to control bleeding and even reduce the size of fibroids; however, when the medication is stopped, the symptoms return, and the fibroids return to their previous size.

But if these drugs are so effective, why do we have to stop taking them?
These medications usually immediately induce very pronounced, abrupt menopause symptoms that interfere with the woman's quality of life and lead to her abandoning therapy. In the long term, there are more serious health repercussions, such as the risk of osteoporosis and cardiovascular events, which make prolonged use of this type of medication impossible. Their indication remains only for controlling urgent situations or optimizing a future surgical intervention.
A group of medications that combine GnRH antagonists with oestrogens and progesterone was recently approved, with the aim of achieving the effectiveness of this type of medication without side effects, the so-called “menopause-like” treatment. They are a safe alternative to hormonal contraceptives, which can be continued for a long time, but their use must be discussed individually with the patient.
In short, medical treatment of symptoms associated with uterine fibroids is always instituted on an individual basis. It is very important to understand that we are treating women and not fibroids. Treatment should always be discussed with the doctor and take into account the characteristics of each patient. Hormonal contraceptives are usually the first line of treatment for pain and uterine bleeding associated with fibroids in women who do not want to become pregnant and can have multiple benefits for women's health. Nowadays, we have increasingly effective medications and, with a combination of strategies, it may be possible to preserve the uterus and avoid surgery.