NICE vs RCOG: Management of Uterine Fibroids (2025)

NICE vs RCOG: Management of Uterine Fibroids (2025)

Uterine fibroids (leiomyomas) are a common clinical presentation in gynaecological practice. In the UK, two key bodies provide guidance for their management: the National Institute for Health and Care Excellence (NICE) and the Royal College of Obstetricians and Gynaecologists (RCOG). While complementary, these guidelines have distinct purposes and nuances. This comparison aims to delineate the approaches of NICE NG88 (updated 2023) and the RCOG Green-top Guideline No. 42 (currently under review but the prevailing RCOG standard) to aid clinicians in evidence-based decision-making.

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Diagnosis and Assessment

Both guidelines agree on the central role of ultrasound as the first-line diagnostic imaging tool. However, their focus and recommendations for further assessment differ.

NICE NG88 Approach

• Primary Aim: To confirm the diagnosis and assess suitability for uterine-preserving treatments, particularly uterine artery embolisation (UAE) and other minimally invasive procedures.
• Key Recommendation: Magnetic Resonance Imaging (MRI) is recommended if ultrasound is inconclusive or before undertaking UAE to map vascularity, precisely locate fibroids (e.g., submucosal vs. subserosal), and exclude other pathology.
• Practical Takeaway: NICE has a lower threshold for recommending MRI, especially when interventional radiological treatments are being considered.

RCOG Guideline Approach

• Primary Aim: To establish a diagnosis and guide overall management, including surgical planning.
• Key Recommendation: Supports ultrasound as the cornerstone. Recommends MRI for complex cases, such as when malignancy is suspected, or for precise surgical planning (e.g., for myomectomy where fibroid number/location is uncertain on ultrasound).
• Practical Takeaway: RCOG typically reserves MRI for more complex diagnostic dilemmas or pre-surgical mapping, rather than as a routine pre-procedure step for all interventional treatments.

Key Difference: NICE is more proactive in recommending pre-procedural MRI for UAE, reflecting its focus on ensuring procedural appropriateness and safety. RCOG's stance on MRI is more traditionally conservative, prioritising it for diagnostic uncertainty or complex surgical planning.

Medical and Interventional Treatment

Both guidelines cover the spectrum of medical and interventional treatments, but with differing emphasis on newer pharmacological agents and the hierarchy of treatment options.

Medical Management

• NICE: Strongly emphasises the use of tranexamic acid and non-steroidal anti-inflammatory drugs (NSAIDs) for heavy menstrual bleeding (HMB). It also includes ulipristal acetate (UPA) but with important caveats due to the recognised risk of rare serious liver injury, recommending it only for women in whom surgical procedures are not suitable or have failed, with strict liver function monitoring.
• RCOG: Also recommends tranexamic acid and NSAIDs. Its guidance on UPA predates the full safety restrictions, so clinicians must refer to the latest MHRA advice for current prescribing protocols. RCOG provides detailed guidance on GnRH analogues, often used pre-operatively to reduce fibroid size and correct anaemia.

Interventional and Surgical Management

• Uterine Artery Embolisation (UAE): NICE places UAE much more prominently, positioning it as a key treatment option for women who wish to avoid surgery, following a full discussion of risks and benefits. RCOG also recognises UAE but traditionally presents it as an alternative to hysterectomy or myomectomy, with perhaps less emphasis on its front-line status.
• Myomectomy: Both guidelines support myomectomy for women wishing to preserve fertility or the uterus. RCOG offers more detailed surgical guidance on approaches (laparoscopic, hysteroscopic, open).
• Hysterectomy: Considered a definitive treatment for symptomatic women who have completed their family by both bodies. NICE stresses the importance of proper consent, including discussion of UAE as an alternative.
• High-Intensity Focused Ultrasound (HIFU): NICE has a specific interventional procedure guideline supporting its use with special arrangements for clinical governance and audit. RCOG mentions it as an emerging technology but with less procedural detail.

Key Difference: NICE's treatment pathway is notable for its strong integration of UAE as a mainstream option, closely aligned with surgical treatments. RCOG's pathway, while inclusive of UAE, reflects a more surgically-oriented tradition.

Special Situations: Fertility and Pregnancy

This is an area of significant divergence in focus and recommendation strength.

• NICE: Is cautious regarding fibroids and fertility. It states that there is insufficient evidence to recommend myomectomy for improving fertility outcomes in women with fibroids unless the uterine cavity is distorted. The emphasis is on individualised assessment and referral to a specialist.
• RCOG: Provides much more comprehensive guidance. It discusses the impact of fibroid location (submucosal fibroids having the strongest association with reduced fertility) and offers more definitive support for hysteroscopic myomectomy to improve fertility outcomes in such cases. It also includes detailed advice on the management of fibroids in pregnancy, including risks of red degeneration and management strategies.

Key Difference: For clinicians managing women with fibroids and fertility concerns, the RCOG guideline is the more detailed and practical resource. NICE defers more to specialist opinion due to a perceived lack of high-grade evidence.

Practical Clinical Flow: A Synthesis

A pragmatic UK clinical pathway synthesising both guidelines would be:

1. Presentation & Diagnosis: History, examination, FBC for anaemia. First-line imaging with pelvic ultrasound.
2. MRI Indication: Consider MRI if: ultrasound is inconclusive (per RCOG/NICE); UAE is a serious consideration (per NICE); complex fibroids for surgical planning (per RCOG); or malignancy is suspected.
3. Treatment Discussion: Offer all suitable options based on symptoms, fibroid characteristics, and patient preference (fertility desires, desire for uterine preservation). Crucially, as per NICE, ensure the discussion includes tranexamic acid/NSAIDs, UPA (with safety counselling), UAE, myomectomy, and hysterectomy.
4. Fertility-Preserving Focus: For women seeking fertility, lean on RCOG's detailed guidance, particularly regarding the resection of submucosal fibroids. Referral to a specialist centre with expertise in reproductive surgery is often appropriate.
5. Definitive Treatment: For women with completed families, the choice between UAE (NICE-promoted) and hysterectomy (definitive) should be made after balanced counselling.

Frequently Asked Questions (FAQs) for Clinicians

1. Which guideline should I prioritise in daily practice?

They are not mutually exclusive. Use NICE NG88 as your core pathway for diagnosis and initial treatment discussions, as it represents a national standard. Consult the RCOG guideline for deeper detail on surgical techniques, fertility implications, and management in pregnancy.

2. Is MRI mandatory before referring a patient for UAE?

According to NICE, yes. It is a key recommendation to ensure appropriateness and safety. A referral for UAE without an MRI may be declined by interventional radiology departments adhering to NICE standards.

3. What is the current UK position on Ulipristal Acetate (UPA)?

Following MHRA safety updates, UPA is only recommended for intermittent treatment of moderate to severe symptoms in adult women of reproductive age for whom surgical procedures are not appropriate or have failed. It must not be used for long-term continuous treatment. Strict monthly LFT monitoring for the first two treatment courses is mandatory. Always check the latest MHRA website for updates.

4. How should I manage a woman with fibroids who wishes to conceive?

This is where RCOG guidance is essential. Assess fibroid location. Submucosal fibroids that distort the cavity should be considered for hysteroscopic resection. The management of intramural fibroids without cavity distortion is more controversial and should involve a specialist fertility multidisciplinary team (MDT).

5. Does NICE recommend HIFU for fibroids?

NICE states that HIFU can be used provided that standard arrangements for clinical governance, consent, and audit are in place. This means it is an option in specialised centres that can collect outcome data, but it is not yet a universally commissioned first-line treatment across the NHS.

Source Links

• NICE Guideline NG88 (Updated May 2023): Heavy menstrual bleeding: assessment and management. Note: Fibroid management is integrated within this broader guideline.
• RCOG Green-top Guideline No. 42 (Last updated 2014, under review): Management of women with symptomatic uterine fibroids. Despite its age, it remains a key reference until the new version is published. Always check the RCOG website for the status of the review.
• MHRA Safety Update on Ulipristal Acetate (Esmya^®): Latest MHRA advice.