Elsevier

Fertility and Sterility

Volume 88, Issue 2, August 2007, Pages 255-271
Fertility and Sterility

Modern trend
Uterine myomas: management

https://doi.org/10.1016/j.fertnstert.2007.06.044Get rights and content

Objective

To review the currently available literature regarding the current management alternatives available to women with uterine myomas.

Design

Literature review of 198 articles pertaining to uterine myomas.

Result(s)

Many advances have been made in the management of uterine myomas. Watchful waiting; medical therapy; hysteroscopic myomectomy; endometrial ablation; laparoscopic myomectomy; abdominal myomectomy; abdominal, vaginal, and laparoscopic hysterectomy; uterine artery embolization; uterine artery occlusion; and focused ultrasound are now available.

Conclusion(s)

Many options are now available to women with uterine myomas. The presently available literature regarding the treatment of myomas is summarized.

Section snippets

Watchful waiting

There is no evidence that failure to treat myomas results in harm, except in women who have severe anemia from myoma-related menorrhagia or who have hydronephrosis caused by obstruction of at least one ureter by an enlarged, myomatous uterus. Predicting future myoma growth or onset of new symptoms is not possible (5). Studies of myoma treatments have found no significant change in uterine size or myoma volume over 6–12 months of follow-up in placebo arms (6, 7). A nonrandomized study of women

Non-Steroidal Anti-Inflammatory Drugs

Nonsteroidal anti-inflammatory drugs have not been shown to be effective in women with myomas. A placebo-controlled, double-blind study of 25 women with menorrhagia, 11 of whom also had myomas, found a 36% decrease in blood loss among women with idiopathic menorrhagia but no decrease in women with myomas. No other studies have examined this treatment (10).

Gonadotropin-Releasing Hormone

Gonadotropin-releasing hormone agonists (GnRH-a) have been shown to decrease uterine volume, myoma volume, and bleeding. However, the

Surgical treatment options

Surgical treatment options currently include abdominal myomectomy; laparoscopic myomectomy; hysteroscopic myomectomy; endometrial ablation; and abdominal, vaginal, and laparoscopic hysterectomy.

Abdominal myomectomy long has been used as a conservative treatment for uterine myomas, and much of the literature predates the use of randomized controlled trials. Myomectomy has been stated to relieve symptoms in 80% of women (1). But there is scant literature documenting the efficacy of abdominal

New appearance of myomas

Although new myomas may grow after myomectomy, most women will not require additional treatment. If the first surgery is performed in the presence of a single myoma, only 11% of women will have subsequent surgery. If multiple myomas are removed during the initial surgery, only 26% will have subsequent surgery (mean follow-up, 7.6 y) (104). Individual myomas, once removed, do not grow back. Myomas detected after myomectomy, often referred to as recurrence, either are the result of persistence of

Uterine artery embolization

Uterine artery embolization appears to be an effective treatment for selected women with uterine myomas. Presently, the effects of UAE on premature ovarian failure, fertility, and pregnancy are unclear. Therefore, many interventional radiologists advise against the procedure for women considering future fertility. Appropriate candidates for UAE include women who have symptoms severe enough to warrant hysterectomy or myomectomy. Although very rare, complications of UAE may necessitate

Considerations for management of uterine myomas

A woman’s individual circumstance, including myoma-related symptoms and their effect on quality of life, desire (or not) to preserve fertility, and her desires regarding care should be considered before recommending therapy. Multiple treatment options often exist, and on the basis of this review, the following points may be considered.

For an asymptomatic woman who desires fertility, evaluation of the uterine cavity with saline infusion sonography, hysteroscopy, or MRI provides useful

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