Georgine Lamvu, MD, MPH prepared useful Practice Aids pertaining to the diagnosis and management of endometriosis and uterine fibroids for this CME activity titled "Current and Emerging Therapies for Endometriosis and Uterine Fibroids: What Do You Need to Know?" For the full presentation, monograph, complete CME information, and to apply for credit, please visit us at https://bit.ly/3cH0J2A. CME credit will be available until August 2, 2021.

1. Uterine Fibroids: Management Strategies
and Recommended Treatments1,2
PRACTICE AID
Access the activity, “Current and Emerging Therapies for Endometriosis and Uterine Fibroids:
What Do You Need to Know?,” at PeerView.com/ZYV40
Treatment Algorithm for Women With Uterine Fibroids
Uterine fibroids diagnosed
Asymptomatic
Clinical surveillance Premenopause
Preserving fertility or
uterus not a priority
Preserve uterusPreserve fertility
Symptomatic
Postmenopause
Possible investigations
Endometrial biopsy
Imaging
Surgical therapies
Myomectomy
or
Hysterectomy with
or without bilateral
salpingo-oophorectomy
Surgical therapies
UAE
MRgFUS
Myomectomy
Hysterectomy with
or without bilateral
salpingo-oophorectomy
Medical therapies
1L
NSAIDs
Oral contraceptives
LNG-IUD
Tranexamic acid
2L
GnRH agonist
GnRH antagonist
Investigational/
limited use
SPRMs/SERMs
Surgical therapy
Myomectomy
Medical therapies
1L LNG-IUD
2L
GnRH agonist
GnRH antagonist
Investigational/
limited use
SPRMs/SERMs
Surgical therapy
UAE
MRgFUS
Myomectomy

2. Uterine Fibroids: Management Strategies
and Recommended Treatments1,2
PRACTICE AID
Access the activity, “Current and Emerging Therapies for Endometriosis and Uterine Fibroids:
What Do You Need to Know?,” at PeerView.com/ZYV40
1L Medical
Therapy
Description Advantages Disadvantages
Fertility
Preserved?
NSAIDs
• Anti-inflammatories and
prostaglandin inhibitors
• Reduce pain and blood loss from fibroids
• Do not decrease fibroid volume
• Gastrointestinal AEs
Yes
Oral
contraceptives
• Treats abnormal uterine
bleeding likely by
stabilization of endometrium
• Reduces blood loss from fibroids
• Ease of conversion to alternative therapy
• Do not decrease fibroid volume
Yes, if discontinued
after resolution
of symptoms
LNG-IUD
• Treats abnormal uterine
bleeding likely by
stabilization of endometrium
• Most effective for reducing blood loss
• Decreases fibroid volume
• Irregular uterine bleeding
• Increased risk of device expulsion
Yes, if discontinued
after resolution
of symptoms
Tranexamic acid • Antifibrinolytic therapy
• Reduces blood loss from fibroids
• Ease of conversion to alternate therapy
• Does not decrease fibroid volume
• Medical contraindications
Yes
2L Medical
Therapy
Description Advantages Disadvantages
Fertility
Preserved?
GnRH agonists
• Preoperative treatment
to decrease tumor size
or in women approaching
menopause
• Decreases blood loss, operative time, and
recovery time
• Long-term treatment associated
with higher cost, menopausal
symptoms, and bone loss
• Increased recurrence risk with
myomectomy
Depends on
subsequent
procedure
GnRH
antagonists3,4,a
• Binds competitively to
progesterone receptor
• Reduce blood loss, dysmenorrhea, and
fibroid size
• Initial increase in bleeding
• Vasomotor symptoms
• Bone density loss
Depends on
subsequent
procedure
Investigational/
Limited Use
Description Advantages Disadvantages
Fertility
Preserved?
SPRMs
• Preoperative treatment
to decrease tumor size
or in women approaching
menopause
• Decreases blood loss, operative time, and
recovery time
• Not associated with hypoestrogenic AEs
• Headache, breast tenderness,
PAEC
• Increased recurrence risk with
myomectomy
Depends on
subsequent
procedure
Current and Investigational Management Strategies for Women With Uterine Fibroids

3. Uterine Fibroids: Management Strategies
and Recommended Treatments1,2
a
FDA approved in combination with estradiol and norethindrone acetate for management of heavy menstrual bleeding associated with uterine fibroids in premenopausal women (up to 24 months).
1L: first line; 2L: second line; AEs: adverse events; GnRH: gonadotropin-releasing hormone; LNG-IUD: levonorgestrel-releasing intrauterine device; MRgFUS: magnetic resonance–guided focused ultrasound surgery; NSAIDs: nonsteroidal anti-inflammatory drugs;
PAEC: progesterone receptor modulator–associated endometrial changes; SPRMs: selective progesterone receptor modulators; UAE: uterine artery embolization.
1. Vilos GA et al. J Obstet Gynaecol Can. 2015;37:157-178. 2. De La Cruz MSD, Buchanan EM. Am Fam Physician. 2017;95:100-107. 3. Schlaff WD et al. N Engl J Med. 2020;382:328-340. 4. Singh SS et al. Am J Obstet Gynecol. 2018;218:563-572.e1.
PRACTICE AID
Access the activity, “Current and Emerging Therapies for Endometriosis and Uterine Fibroids:
What Do You Need to Know?,” at PeerView.com/ZYV40
Surgical
Therapy
Description Advantages Disadvantages
Fertility
Preserved?
Hysterectomy
• Surgical removal of
uterus (transabdominally,
transvaginally,
or laparoscopically)
• Definitive treatment for when preserving
fertility not a priority
• Transvaginal and laparoscopic approach
associated with decreased pain, blood
loss, and recovery time compared with
transabdominal surgery
• Transabdominal surgery risks
(infection, pain, fever, increased
blood loss, and recovery time)
• Morcellation with laparoscopic
approach increases risk of
iatrogenic dissemination of tissue
No
MRgFUS
• In situ destruction using
high-intensity ultrasound
waves
• Noninvasive approach
• Shorter recovery time with modest
symptom improvement
• Heavy menses
• Pain from sciatic nerve irritation
• Higher reintervention rate
Unknown
Myomectomy
• Surgical or endoscopic
excision of tumors
• Resolution of symptoms with preservation
of fertility
• Recurrence rate of 15%-30% at
5 years, depending on size and
extent of tumors
Yes
UAE
• Interventional radiologic
procedure to occlude
uterine arteries
• Minimally invasive
• Avoids surgery
• Short hospitalization
• Recurrence rate 17% at 30
months
• Postembolization syndrome
Unknown
Current and Investigational Management Strategies for Women With Uterine Fibroids (Cont'd)

4. Clinical Diagnosis of Endometriosis1
a
Alternative diagnosis indicated by symptoms on the right side of the figure may coexist with endometriosis and does not rule out endometriosis.
IBS: irritable bowel syndrome; NSAIDs: nonsteroidal anti-inflammatory drugs.
1. Agarwal SK et al. Am J Obstet Gynecol. 2019;220:354.e1-354.e12.
PRACTICE AID
Access the activity, “Current and Emerging Therapies for Endometriosis and Uterine Fibroids:
What Do You Need to Know?,” at PeerView.com/ZYV40
ConsistentWithEndometriosis
ConsiderOtherDiagnosisinAdditiontoEndometriosisa
Step 1: Evaluate Presence of Symptoms
Step 2: Review Patient History
Step 3: Perform a Physical Examination
Step 4: Perform/Order Imaging
• Persistent and/or worsening cyclic or constant pelvic pain
• Dysmenorrhea
• Deep dyspareunia
• Cyclic dyschezia
• Cyclic dysuria
• Cyclic catamenial symptoms located in other systems
(eg, lung, skin)
• Infertility
• Dysmenorrhea in adolescence; current chronic pelvic pain
• Previous laparoscopy with diagnosis
• Dysmenorrhea unresponsive to NSAIDs
• Positive family history
• Nodules in cul-de-sac
• Retroverted uterus
• Mass consistent with endometriosis
• Obvious endometrioma that is external (seen on speculum or
on skin)
• Endometrioma on ultrasound
• Presence of soft markers (eg, sliding sign)
• Nodules and masses
• Severe pain, amenorrhea, or cramping without menstruation in
adolescent could indicate a reproductive tract anomaly
• Severe noncyclic constipation and diarrhea suggest IBS
• Painful voiding or flank pain could suggest urinary tract stones
• Urinary symptoms (eg, hematuria, frequent urination) could
indicate interstitial cystitis/painful bladder symptoms
• Absence of menses or other obstructive conditions in adolescence
• History of pain directly associated with surgery (eg, postoperative
nerve entrapment or injury, bowel adhesions)
• Pelvic floor spasms
• Severe allodynia along pelvic floor/vulva or elsewhere
• Masses not consistent with endometriosis (eg, fibroids)
• Adenomyosis and fibroids (although these
may be present with endometriosis)