An update on the management of uterine fibroids: personalized medicine or guidelines?

During the last decades relevant advances have been made in understanding the pathophysiology of uterine fibroids (UFs) and their formation from smooth muscle cells by the stimulation of hormonal and genetic pathways. Although 50–75% of UFs are considered to be non-clinically relevant when non-asymptomatic, the main clinical symptoms and signs of UFs are abnormal uterine bleeding (AUB), pelvic pain and/or bulk symptoms and reproductive failure. The first diagnostic tool recommended is transvaginal ultrasound (TVUS), usually providing a clear and straightforward diagnosis. In order to standardize the description of TVUS findings and to facilitate guidelines to provide clearer and targeted recommendations, different UF reporting systems are being used, such as the Morphological Uterus Sonographic Assessment criteria, the FIGO Classification and the STEPW/Lasmar Classification. In specific cases other complementary imaging techniques may be required. Depending on the presentation of symptoms, their severity, and the clinical context of each patient, different options may be proposed and individualized. Since many UFs are asymptomatic, in these cases no medical or surgical intervention would be necessary. In symptomatic UFs physicians should individualize the treatment considering other factors beyond the UF type or morphology. Tranexamic acid, levonorgestrel intrauterine devices, selective progesterone receptor modulators, oral contraceptives, GnRH antagonist +/− addback therapy and surgical procedures, are among the different therapeutic options that clinicians should discuss with the patient. Nevertheless, the heterogeneity of UFs intrinsic stem cells may directly affect the response to targeted treatments, making a variable response to treatments plausible for each UF.