Clinical Management of Leiomyoma

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Key points

  • Uterine leiomyoma, benign monoclonal tumors, afflict an estimated 60% of reproductive-aged women, with higher rates among African American women.

  • Leiomyomas are associated with significant medical costs, impaired fertility potential, obstetric complications, and gynecologic morbidity.

  • Currently, the effective clinical management of leiomyoma is limited by the fact that hysterectomy is the only cure.

  • New methods of diagnosis, medical and surgical treatments, as well as interventional radiology and

Pathophysiology

In this section, the pathophysiology of leiomyoma, including molecular mechanisms and genetics, is discussed. In examining the gross appearance of leiomyoma as well as the molecular structure, it has become clear that these benign tumors are composed of altered collagen fibrils, resulting in an altered extracellular matrix (ECM) compared with adjacent myometrium. The distorted ECM is thought to contribute to the increased rigidity of leiomyoma compared with normal myometrium. This understanding

Diagnosis and assessment

In this section, the diagnosis and assessment of leiomyoma, including clinical symptoms and the role of imaging, are discussed.

Most women with uterine fibroids are asymptomatic25, 26; however, women can experience abnormal uterine bleeding (AUB), pelvic pain, bulk symptoms, reproductive dysfunction, sexual dysfunction, and urologic complications. It has been estimated that approximately 20% to 50% of patients with uterine leiomyoma experience symptoms credited to the presence of myomas.27, 28

Fibroids medical therapy

Currently, hysterectomy is the only cure for fibroids, which underscores the need for identification of effective nonsurgical medical treatments, with high efficacy, and a desirable side-effect profile. This section reviews the use of medical treatments, both as adjuvant therapy and as primary therapy. The discussion focuses on gonadotrophin-releasing hormone (GnRH) analogues, selective progesterone receptor (SPRM) modulators, and aromatase inhibitors (AI). The use of levonorgestrel-containing

Uterine artery embolization

Uterine artery embolization (UAE) is a widely accepted, nonsurgical technique used to treat symptomatic uterine fibroids. This technique has been endorsed by the American College of Obstetricians and Gynecologists as safe and effective for women with uterine fibroids who are appropriately selected.76 UAE is ideal for women with symptomatic uterine fibroids who have medical management, are poor surgical candidates, wish to avoid surgery, or wish to retain their uterus.

Women seeking UAE most

Magnetic resonance–guided focused ultrasound surgery

In 2004, the FDA approved the first magnetic resonance--guided focused ultrasound surgery (MRgFUS) device as a noninvasive thermal ablation therapy for uterine fibroids. The technology uses MRI guidance to map and monitor high-intensity ultrasound-focused ablation of fibroid tumors. The goal of therapy is to achieve an increase in temperature within the fibroid leading to coagulation necrosis while avoiding patient discomfort and damage to surrounding structures (eg, bowel, bladder,

Surgical therapies

For women who desire surgery, the most important considerations are size and location (Fig. 1) of the fibroids and fertility potential. Although hysterectomy is the only cure, myomectomy is the only viable surgical option for women who want to maintain an option for future pregnancies. This section reviews surgical options, with a focus on patient selection and outcomes.

Patients who elect conservative surgery should be apprised of their risk of recurrence and likelihood of eventual

Laparoscopic and robotic myomectomy

For appropriate candidates, laparoscopic myomectomy offers the advantage of lower blood loss, more rapid return to normal activities, shorter hospital stays, and a more cosmetically acceptable scar. A large multicenter trial and other clinical investigations have reported uterine rupture after laparoscopic myomectomy, and it has been recommended that women with fibroids greater than 5 cm multiple myomas and deep intramural myomas consider abdominal myomectomy.93 Although there are many

Abdominal myomectomy

Abdominal myomectomy is the preferred surgical option when hysteroscopy or laparoscopy is not an option, or the patient has another indication for laparotomy (Fig. 2). Other recommendations based on earlier studies suggested that women with more than 3 to 4 fibroids or total uterine size greater than 9 cm consider abdominal myomectomy. The increasing experience of surgeons and the advent of robotic technology have made it possible for women with larger uteri to avoid laparotomy. In a recent

Hysterectomy

For women who desire definitive therapy, there are several options, which include vaginal hysterectomy, total laparoscopic hysterectomy (TLH), laparoscopic-assisted vaginal hysterectomy (LAVH), and laparotomy. Like myomectomy, the surgical route is determined by size and location of the fibroids, surgeon experience, and patient preference. In a recent randomized comparison of vaginal hysterectomy in Europe, TLH and LAVH for leiomyoma, the study found vaginal hysterectomy was the faster

Outcomes

Rates of mortality for fibroid surgery are low, and the risk of serious complications is small. Surgical site infection rates vary from 1% to 11%, but most of these are superficial infections. Although rates of deep vein thromboses are high among surgical patients who do not receive prophylaxis, the risk of fatal pulmonary embolism is less than 1%. The risk of postoperative bleeding that requires transfusion is 2% after abdominal hysterectomy, but transfusion rates vary from 2% to 28% with

Summary

Although hysterectomy remains the only cure for fibroids, there are several exciting candidates for medical therapies in the treatment of fibroids. Vitamin D, epigallocatechin gallate (EGCG), or green tea extract, compounds that increase retinoic acid and dietary supplements such as curcumin, all appear to have potential as nonsurgical therapies.

There is evidence to suggest that vitamin D inhibits growth, induces apoptosis in human leiomyoma cell cultures, and may act as an antifibrotic factor.

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