Uterine fibroids predominantly occur in the late middle age, affecting approximately 20% to 25% of women before menopause. The management of uterine fibroids in perimenopausal women requires comprehensive evaluation based on the location, size, severity of symptoms, and presence of complications. Generally, the following therapeutic approaches are available.
1. Observation and Follow-Up
For perimenopausal women approaching menopause with slow-growing fibroids and a uterus smaller than 12 weeks’ gestational size, no active treatment is necessary if there is no menorrhagia or compressive symptoms. Follow-up examinations every 3 to 6 months are recommended, with the expectation that fibroids will shrink after menopause. Following menopause, reduced estrogen secretion deprives fibroids of hormonal stimulation, leading to gradual regression. However, women with fibroids often experience delayed menopause; surgical intervention should be considered if fibroids continue to enlarge or new symptoms develop during surveillance.
2. Western Medical Therapy
Pharmacological treatment is effective in alleviating clinical symptoms. Estrogen therapy may be used for women with menorrhagia, small fibroids, and excluded endometrial pathology. Androgens induce contraction of the myometrium and vascular smooth muscle, antagonize estrogen, and cause endometrial atrophy to reduce menstrual blood loss. Commonly used androgens include methyltestosterone 5 mg orally once or twice daily, and testosterone propionate 25 mg intramuscularly two to three times weekly, with a monthly dosage limit of 250 mg to avoid virilization. Additional hemostatic agents such as Yunnan Baiyao, etamsylate, tranexamic acid, and vitamin K also help reduce bleeding.
3. Traditional Herbal Therapy
Herbal medicine yields satisfactory outcomes for uterine fibroids, particularly in relieving menorrhagia and abdominal pain. In clinical practice, a customized formula has been administered to over 60 patients, resulting in significant symptom improvement in most cases after three months of treatment, with nearly half of the patients showing notable reduction in fibroid volume. The prescription is processed into water pills, administered at 9 g twice daily, discontinued during menstruation, with one month as a treatment course.
4. Minimally Invasive Therapy: High-Intensity Focused Ultrasound (HIFU) Ablation
High-intensity focused ultrasound (HIFU) ablation, also known as focused ultrasound surgery, is a non-invasive, outpatient-friendly treatment that has become a first-line minimally invasive option for perimenopausal uterine fibroids.
HIFU works by focusing extracorporeal ultrasound waves precisely into fibroid tissue, generating localized high temperatures to induce coagulative necrosis and targeted destruction of fibroid cells, while preserving normal myometrium and surrounding pelvic organs. It requires no surgical incisions, no anesthesia or only mild sedation, and is associated with minimal bleeding, rapid recovery, and preservation of uterine integrity.
Indications for HIFU ablation include:
- Symptomatic fibroids causing menorrhagia, pelvic pressure, or pain
- Fibroid size ranging from 2 cm to 10 cm
- Desire to avoid surgery or preserve the uterus
- Poor surgical candidates due to advanced age or comorbidities
Advantages for menopausal women:
- Non-invasive, no scarring, and short recovery time
- Effective in reducing bleeding and pressure symptoms
- Avoids surgical risks such as infection or anesthesia complications
- Compatible with concurrent observation for menopausal fibroid regression
5. Surgical Treatment
Surgical intervention is indicated in the following scenarios:
- Uterine enlargement equivalent to 12 or more weeks of gestation, even in asymptomatic patients
- Refractory menorrhagia leading to anemia unresponsive to conservative treatment
- Compressive symptoms including urinary frequency, dysuria, constipation, or pelvic pain
- Fibroids located in the cervix, broad ligament, or submucosal region
- Rapid fibroid growth within a short period
Surgical approaches are individualized. Vaginal myomectomy is feasible for prolapsed submucosal fibroids, while hysteroscopic myomectomy is available for non-prolapsed lesions. Endometrial ablation may induce artificial amenorrhea for menorrhagia caused by intramural fibroids. Total hysterectomy is the most common procedure for other fibroid types; subtotal hysterectomy may be performed in patients with poor general health or technical limitations. Oophorectomy is typically performed bilaterally in postmenopausal women or those over 50 years of age. Hysterectomy is a safe procedure with low complication rates and rapid recovery, and is generally recommended for infertile perimenopausal women, who usually do not undergo open myomectomy.