Uterine Fibroids (Leiomyoma)
NICE guideline NG88 Heavy menstrual bleeding: assessment and management. Last updated: May 2021
NICE CKS Fibroids. Last revised Apr 2023.
The intervention section has been re-structured and improved for clarity.
Date: 13/02/26
Guidelines
Approach
Primary care management is suitable if:
- Fibroid <3 cm, and
- Not distorting uterine cavity
Refer to secondary care if any of the following:
- Fibroid ≥3cm
- Suspected submucosal fibroid
- Severe symptoms (inc. compressive symptoms)
- Suspected fertility issues associated with fibroids
Primary Care Management
This is essentially the same as the primary care management of heavy menstrual bleeding outlined in the Heavy Menstrual Bleeding (HMB) article.
Choice of management is largely determined by whether the patient is planning to conceive (at the moment or in the near future).
Patient NOT Planning to Conceive
1st line: levonorgestrel intrauterine system (LNG-IUS)
2nd line (either):
- Non-hormonal options: NSAIDs / tranexamic acid
- Hormonal options: COCP / cyclical oral progestogen (norethisterone)
Key contraindications to LNG-IUS:
- History / current cancer (breast / cervical / endometrial)
- Unexplained, uninvestigated vaginal bleeding (due to possible endometrial cancer)
- Distorted uterine cavity (e.g. due to submucosal fibroids, intrauterine adhesions, large endometrial polyps, congenital uterine anomalies – typically seen on ultrasound / other imaging)
- Current PID
It is important to not mix up the copper IUD and LNG-IUS
- Copper IUD can worsen or cause HMB
- LNG-IUS often causes oligomenorrhoea / amenorrhoea, thus used to treat HMB
Patient IS Planning to Conceive
Only non-hormonal treatment is appropriate:
- Tranexamic acid, or
- Other NSAIDs
Secondary Care Management
Primary care management should also be considered and continued if effective.
Medical Therapy
Consider short-term GnRH agonist (e.g. leuprolide, nafarelin, goserelin) therapy:
- Prior to interventional therapy if the fibroids are causing an enlarged/distorted uterus (to shrink the fibroids), OR
- In women approaching the menopause
GnRH is the only medical option that can significantly shrink fibroid size. However, this effect is only transient, with fibroids generally regrowing to their original size after treatment is discontinued.
They are therefore useful as bridging therapy to surgery/interventions OR as short-term therapy in women approaching menopause where symptoms tend to improve thereafter.
GnRH agonists are only used short-term due to their prominent hypoestrogenic side effects with prolonged therapy (>3-6 months) which include:
- Bone mineral density loss (→ osteoporosis)
- Vasomotor symptoms (e.g. hot flushes, night sweats)
Interventional Options
NICE states that pharmacological treatments for ≥3cm fibroids have limited effectiveness. Therefore ≥ 3cm is generally considered the cut-off for considering interventional management.
Pre-procedural ultrasound (+/- MRI) should be offered before uterine artery embolisation and myomectomy.
Interventional options include: [Ref]
| Intervention / procedure | Indications / rationale |
|---|---|
| Hysteroscopic removal | Submucosal fibroids |
| Endometrial ablation |
NOT to be performed if fertility is desired |
| Uterine artery embolisation |
NOT to be performed if fertility is desired |
| Myomectomy | 1st line to improve fertility
|
| Hysterectomy | Definitive management – eliminates symptoms completely
Usually indicated if
NOT to be performed if fertility is desired |
If interventional options are not appropriate / failed → consider ulipristal acetate
- For intermittent treatment of moderate to severe symptoms
- Note that ulipristal acetate is rarely associated with serious liver injury (hence, its limited use in fibroid management)
Do not offer dilatation and curettage as a treatment option for HMB.
References