Lei Om Yo Mas

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THE MANAGEMENTOF UTERINE

LEIOMYOMAS

Dr .Ashraf FoudaEgypt - Damietta General Hospital

[email protected]. mail :


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S.O.G.C.

(Society ofObstetricians

& Gynecologists ofCanada)CLINICAL PRACTICE GUIDELINES

SOURCE:

May 2003


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The majority of fibroidsare asymptomatic and

will not requireintervention or further

investigations.


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For the symptomaticfibroid, hysterectomyoffers a definitive solution.

However, it is not thepreferred solution for

women who wish topreserve their uterus.


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The predicted benefitsof alternative therapies

must be carefullyweighed against the

possible risks of thesetherapies.


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In the properly selectedwoman with

symptomatic fibroids,

the result from the selectedtreatment should be an

improvement inthe quality of life.


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INTRODUCTION

Uterine leiomyomas are themost common gynaecological

tumours andare present in 30% of

women of reproductive age.


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Treatment of women withuterine leiomyomas must be

individualized, based on:1. Symptoms,2. Size and

3. Rate of growth of the uterus,and4. The womans desire for fertility.

INTRODUCTION


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The majority of uterineleiomyomas are asymptomaticand will not require therapy.

However,75% of

hysterectomies are performedfor menorrhagia with fibroids.

INTRODUCTION


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In the last decade, severalnew conservative therapieshave been introduced, butthere remains a paucity of

randomized controlled trialsevaluating these therapies.

INTRODUCTION


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Women should consider

these options with theunderstanding that

high levels of evidenceare not yet available.

INTRODUCTION


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CLINICAL FEATURES

The vast majority of leiomyomasare asymptomatic.

The most common symptom of

uterine leiomyoma isabnormal uterine bleeding.

In published series ofmyomectomies , 30% of womensuffered from menorrhagia.


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The mechanism of fibroid-associatedmenorrhagia is unknown.

1. Vascular defects,

2. Submucous tumours, and

3. Impaired endometrial hemostasis have been offered as possible

explanations.

CLINICAL FEATURES


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Pelvic pain is rare with fibroids andit usually signifies degeneration,torsion, or, possibly, associatedadenomyosis.

Pelvic pressure,

bowel dysfunction, and

bladder symptoms such as urinaryfrequency and urgency

may be present.

CLINICAL FEATURES


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Urinary symptoms should

be investigated prior tosurgical management offibroids to exclude other

possible causes.

CLINICAL FEATURES


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In the postmenopausal

woman presenting withpain and fibroids,

leiomyosarcoma shouldbe considered.

CLINICAL FEATURES


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EVALUATION

Clinical examination is

accurate with a uterine size of12 weeks(correlating with a uterine

weight of approximately300 g) or larger.


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Ultrasonography

is helpful to assess theadnexa if these cannot

be palpated separatelywith confidence.

EVALUATION


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Although reliable inmeasuring growth,routine ultrasound

is not recommended

as it rarely affectsclinical management.

EVALUATION


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In women with large fibroids,diagnostic imaging will

occasionally demonstratehydronephrosis, the clinicalsignificance of which is unknown.

Complete ureteric obstructionis extremely rare.

EVALUATION


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In women who present with

abnormal uterine bleeding,it is important to excludeunderlying endometrial

pathology.

EVALUATION


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MEDICALMANAGEMENT

Treatment should be

tailored to the needs of thewoman presenting with

uterine fibroids and gearedto alleviating the symptoms.


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There is no evidence that

low-dose oral contraceptivescause benign fibroids togrow, thus uterine fibroids

are not a contraindicationto their use.

MEDICALMANAGEMENT


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Fibroids may be expected to shrinkby up to 50% of their initial volumewithin 3 months of therapy.

GnRH agonist treatment should berestricted to a 3- to 6-monthinterval, following which regrowthof fibroids usually occurs within12 weeks.

(GnRH) agonists


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GnRH agonists are

indicated preoperativelyto shrink fibroids and to

reduce menstrual relatedanemia.

MEDICALMANAGEMENT


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Tranexamic acid may reducemenorrhagia associated withfibroids.

Progestins may be associatedwith fibroid growth.

MEDICALMANAGEMENT


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Danazol has been associated witha reduction in volume of the

fibroid in the order of20% to25%.

Although the long-term responseto danazol is poor, it may offer anadvantage in reducing

menorrhagia.

MEDICALMANAGEMENT


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SURGICALMANAGEMENT


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HYSTERECTOMY

The only indications forhysterectomy in a woman with

completely asymptomatic fibroidsare:

1. Rapidly enlarging fibroids or,

2. When enlarging fibroids raiseconcerns ofleiomyosarcoma(after menopause).


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A recent study showed noincrease in perioperative

complications in womenwith a uterus

greater than 12 weeks sizecompared to smaller uteri.

HYSTERECTOMY


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Hysterectomy need not berecommended as aprophylaxis againstincreased operative

morbidity associated withfuture growth.

HYSTERECTOMY


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When considering hysterectomyfor menorrhagia attributed to

fibroids, other causes should beruled out.

Endometrial biopsy should beconsidered, to excludeendometrial lesions.

HYSTERECTOMY


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Leiomyomas rarely cause

pelvic pain, and therefore,if pain is a major symptom,

other causes should beexcluded.

HYSTERECTOMY


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Hysterectomy is not

expected to offer a cure forsymptoms ofincontinencein the presence of uterine

fibroids.

HYSTERECTOMY


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CONSERVATIVE

SURGICALTHERAPIES


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Although myomectomy allowspreservation of the uterus,

available data suggest a:1. Higher risk of blood loss and

2. Greater operative timewith myomectomy than withhysterectomy.

MYOMECTOMYTHROUGH

AL

APAROTOMY

INCISION


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The risk ofureteric injury may bedecreased with myomectomy.

There is a 15% recurrence rate forfibroids and

10% of women undergoing amyomectomy will eventually requirehysterectomy within 5 to 10 years.

MYOMECTOMYTHROUGHA LAPAROTOMYINCISION


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Women should be counselledabout the risks of requiring a

hysterectomy at the time of aplanned myomectomy.

This would be dependent on theintra-operative findings and thecourse of the surgery.

MYOMECTOMYTHROUGHA LAPAROTOMYINCISION


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LAPAROSCOPICMYOMECTOMY

For several pelvic disorders,gynaecologists have

resorted to minimal accesssurgery in an effort to:

1. Reduce hospital stay and2. Improve recovery time.


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Myomas may be removed bya laparoscopic approach.

The challenges of this surgeryrest with the surgeons ability to

1. Remove the mass through a

small abdominal incision and to2. Reconstruct the uterus.



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A few case series have beenpublished including more than500 women with fibroids ranging

from 1 cm to 17 cm.When compared to a laparotomy,

the laparoscopic approach appears totake longer but is associated with aquicker recovery.



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Concerns have been raisedregarding the ability to

suture the uterus with anadequate multilayer closure

laparoscopically.



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Uterine rupture during asubsequent pregnancy has been

reported.The risk ofrecurrent myomas may

be higher after a laparoscopicapproach, with a 33% recurrencerisk at27 months.



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In one case-control series there werefewer postoperative adhesions in

women who had undergonemyomectomy laparoscopically,but adhesion formation after

laparoscopic myomectomy has stillbeen reported to occur in

60% of cases.



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The choice of surgical approachis largely dependent on surgical

expertise.Morcellators have permitted

removal of larger myomas,but there is a danger ofinjuryto surrounding organs.



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In a review of availablerecommendations, most suggest

a laparotomy for:1. Fibroids exceeding 5 cm to 8 cm,

2. Multiple myomas, or3. When deep intramural

leiomyomas are present.



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Laparoscopic-assisted myomectomypresents an opportunity to enucleate themyoma partially by laparoscopy, deliver

the tumour through a small abdominalincision, then close the uterine defect

through this laparotomy.

Long-term outcomes of these newapproaches are lacking.



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Hysteroscopic myomectomyis feasible and very effective,

and it should be considered inwomen with

1. Symptomatic intracavitary or

2. Submucous narrow-basedintrauterine myomas.

HYSTEROSCOPICMYOMECTOMY


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Indications include :

1.Infertility,2.Repeated pregnancy losses,and

3.Abnormal uterine bleeding.



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The pregnancy rate inwomen undergoing

in vitro fertilization (IVF)may be reduced whenmyomas are submucosal or

when they distort the uterinecavity.



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Recently,

Electrosurgical loop electrodes using

bipolar technology, as well asVaporizing electrodes using both

monopolar and bipolar technology,

have been described as newtechnologies to facilitate hysteroscopic

myomectomy.


S OSCO C O C O


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Pretreatment with a GnRH analogue for3 months prior to myomectomy :

1. May increase the preoperative

hemoglobin and hematocrit in womenwith anemia and

2. May result in shrinkage of the fibroid and

3. Decrease of uterine blood flow andendometrial cavity size, as well as

4. Thinning of the endometrium.



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Hysteroscopic

myomectomy has beenassociated with

significant complications.




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1. Intraoperative bleeding may lead toan emergency hysterectomy.

2. Electrical burns to the genital tract,

and bowel have been reported.

3. Hyponatremia, Blindness, Coma, andDeath from excessive irrigant fluidabsorption have also been reported.



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Prolonged surgical proceduresrequire careful monitoring of

irrigant fluid balance.Surgeons should be realistic abouttheir expertise and ability to resect

multiple and large intrauterinemyomas.



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Data describing thefertility and pregnancy outcomes

following hysteroscopicmyomectomy are limited,but results appear to be similar

to those following laparoscopicand abdominal myomectomies.


LAPAROSCOPICMYOLYSIS


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Myolysis refers to theprocedure of delivering

energy to myomas in anattempt to desiccate themdirectly or disrupt their

blood supply


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Myomata deprived of theirblood supply would

presumably shrink orcompletely degenerate as they

receive less :

nutrients, sex hormones, andgrowth factors.


OSCO C O S S


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Laparoscopic myomacoagulation was first

explored as an alternativeto myomectomy or

hysterectomy in the late1980s.



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The indications for myolysisinclude symptomatic myomas

requiring surgical treatment for:1. Abnormal uterine bleeding and

2. Pelvic pain and3. Pressure to adjacent organs.



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Women may be consideredcandidates for myolysis if they

1. Have fewer than four myomas of5 cm or

2. If their largest myoma measuresless than 10 cm in diameter.


LAPAROSCOPIC MYOLYSIS


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Other concomitant pelvic surgerycan be carried out at the same

time , such as:1. Adhesiolysis,

2. Excision of endometriosis, or3. Adnexal surgery,



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As a rule, concomitanthysteroscopic endometrial

ablation or resectionis recommended to further assist

in the management ofmenorrhagia and can beperformed at the end oflaparoscopic myolysis.



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Complications consisting of

1. Pelvic infection,

2. Bacteremia, and

3. Bleeding

have been reported in less than1% of cases.




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In general, 3 months ofGnRH agonistpretreatment reduces the total uterinemyoma volume by approximately 35% to50%.

Following myoma coagulation, the totaluterine myoma volume is reduced by an

additional 30% for a total reduction ofapproximately 80%, appearing to bepermanent.



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Repeat diagnostic laparoscopy

in a limited number of womenhas demonstrated variousdegrees ofadhesion formation

over the coagulated myomas.




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The integrity and tensile strengthof the uterine wall has not been

determined following laparoscopicmyolysis, and it is recommendedthatpregnancy should not be

undertaken by women who haveundergone myolysis.




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Although some women whounderwent the procedure haveconceived and have uneventfullydelivered by Caesarean section,

The fertility and pregnancy

outcomes after laparoscopicmyolysis remain unknown.



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Three cases of uterine rupture duringthe third trimester of pregnancy,

one with catastrophic results for thefetus, have been reported.

Thus, myolysis can be considered

only after a woman expressescertainty she desires no furtherchildren.


SELECTIVE UTERINE ARTERY


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SELECTIVEUTERINE ARTERY

OCCLUSION

Selective uterine artery occlusion is aglobal treatmentalternative to

hysterectomy for women withsymptomatic uterine fibroids,

in whom other medical and surgical

treatments arecontraindicated, refused, or

ineffective.



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Fibroids have been treatedeffectively by laparoscopic

occlusion at the origin of theuterine arteries using vascular

clips or bipolarelectrocoagulation.

SELECTIVEUTERINE ARTERYOCCLUSION



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Since the uterine arteries are locatedless than 2 cm away from the vaginal

lateral fornices,transvaginal uterine occlusionby surgery or colour Doppler-directed

ultrasonic probe appears feasible andseveral approaches are currentlyundergoing investigation.


OCCLUSION



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The most popular approach to uterineartery occlusion is selective uterine

artery catheterization andembolization.

Eligible women include those with

symptomatic fibroids who wish toavoid surgical therapy.


OCCLUSION



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Before undergoing uterine arteryembolization, all women should be

counselled that this procedure is1. Less than 10 years old, and

2. Its long-term effects and durability,

including fertility and pregnancyoutcomes, are not yet known.


OCCLUSION



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Preoperative evaluation should include:

1. A thorough history,

2. Physical and pelvic examination,3. Complete blood count (CBC),

4. Electrolytes, and

5. Renal function tests and

6. Coagulation profile.

SELECTIVEUTERINE ARTERYOCCLUSION



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Routine cervical cytology andendometrial sampling should be

performedUterine artery embolization is

performed in a medical imaging

suite by interventional radiologistsusing aseptic sterile techniques.


OCCLUSION

PERIOPERATIVE RISKS AND COMPLICATIONS


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PERIOPERATIVERISKS AND COMPLICATIONS

Perioperative risks and complications include:

1. Infection,2. Bleeding, and

3. Hematomas at the femoral artery puncture

site,4. Allergic or anaphylactic reactions to the

iodinated contrast dye, and

5.Incomplete uterine artery occlusion as well as6. Misembolization of non-target organs.

Such complications occur inapproximately 1% to 2% of procedures.


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POSTUTERINE ARTERY

OCCLUSIONSIDEEFFECTS ANDCOMPLICATIONS

Early or Acute Abdominal Pelvic Pain


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Virtually all womenexperience some degree of

acute pain, often requiringhospitalization with intensivepain management protocols

and monitoring.




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No correlation has been establishedbetween:

1. Uterine size,

2. Myoma number or size,

3. Duration of procedure,

4. Quantity of polyvinyl alcohol (PVA)particles used, or

5. Clinical outcome of the treatment.




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The pain is thought to be dueto nonspecific ischemia of the

uterus and fibroids,and responds to pain control

including opiates and

nonsteroidal anti-inflammatorydrugs (NSAIDs).


Post embolization Syndrome


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Up to 40% of women experience a :1. Diffuse abdominal pain,

2. Generalized malaise,

3. Anorexia,

4. Nausea, vomiting,

5. Low-grade fever, and6. Leukocytosis.


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The syndrome is self-limiting andusually

resolves within 48 hours to 2 weekswith conservative and supportivetherapy, consisting of intravenous

fluids and adequate pain control,including NSAIDs.


Infection


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InfectionThe incidence offebrile morbidity and

sepsis following embolizationhas beenreported tobe between1.0% and 1.8%.

The infections have includedpyometria with endomyometritis, bilateralchronicsalpingitis, tubo-ovarianabscess,

and infected myomas.The mostfrequentpathogenisolated has

beenEscherichia coli.

Infection


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Some women haveresponded to antibiotic

therapy but others haverequired prolonged

hospitalization, intensivetherapy, and hysterectomy.

Infection


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Prophylactic antibioticshave not been shown to be

effective and their useshould be reserved for

women at higher risk ofinfection.

Infection

Persistent or Chronic Pain


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PersistentorChronicPain

In5% to10% of women, the painpersists formore than2 weeks.

Persistentpaininthe absence ofinfection

orpain lasting longerthan2 to3 monthsmay require surgical intervention.

Hysterectomy forpostembolizationpain

hasbeenreported inup to2% of womenwithin6 monthsofthe embolization.

Ovarian Dysfunction


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OvarianDysfunction

Transientand permanentsymptomsindicative of

ovarianfailure have beenreported byup to10%

ofwomenafteruterinearteryembolization.


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Underlying factors leading to ovariandysfunction are unknown, but the

evidence indicates that women over theage of 45 are more likely to experiencepostembolization ovarian failure.

Ovarian failure is of greater consequencewhen preservation of fertility is desired.

Ovarian Dysfunction


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Transcervical Myoma Expulsion


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TranscervicalMyomaExpulsion

Following arteryembolization,spontaneousexpulsionofmyomasthrough the cervix hasbeenreported to

occurinapproximately5% to10% ofwomen.

60% of womenwith submucousmyomas,

confirmed byhysteroscopy, passedmyomasvaginally, following uterine arteryembolization.

Uterine Wall Integrity


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Uterine WallIntegrity

The physicalcharacteristics, integrity,and the histopathologic features ofthe uterine wallafteruterine artery

embolizationremainunknown.Uterine walldefects, uterine fistula,and one case of diffuse uterine

necrosis followinguterine arteryembolizationhave beenreported.


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Hysterectomy


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Hysterectomy

The numberof women whoproceed tohysterectomy

following uterine arteryembolization hasbeen used as

an indicator forthemeasurementoftreatment

failure.

H t t


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The rate of hysterectomy within6 months of embolization has

been reported to be 1% to 2%,and the indications have included

infection, persistent bleeding,

persistent pain, fibroid prolapse,and uterine malignancies.

Hysterectomy

Mortality


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Mortality

In the United Kingdom, onefatalitywas associated with

septicemia,And in Italy, one death wasattributed topulmonaryembolism

from aclotin the pelvic veinsfollowing uterine arteryembolization.

M t lit


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No fatality has been reportedfollowing the approximately 10 000

to 12 000 procedures performed inthe United States and Canada.

The combined mortality is

estimated to be approximately0.1 to 0.2 per 1000 procedures.

Mortality


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SPECIAL

CONSIDERATIONS

FIBROIDS AND INFERTILITY


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The impact of fibroids onfertility is controversial.

Fibroids probably accountfor only 2% to 3% of

infertility cases.



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After abdominal myomectomyfor fertility , a combined

pregnancy rate of57% in theprospective studies.




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The overall conception rate was61% when no other infertility

factors were identified.No randomized controlled trialsof myomectomy for infertilityhave been published.




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Only women whosemyomas had an intracavitary

componenthadlower pregnancy rates and

implantation rates than controls

and were the most appropriatecandidates for surgical intervention.




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Various theories have been advanced toexplain the potential subfertility effect of

fibroids:1. Dysfunctional uterine contractility,

2. Focal endometrial vascular disturbance,3. Endometrial inflammation,4. Secretion of vasoactive substances, or5. Enhanced endometrial androgen environment.

The published evidence suggeststhat submucous fibroids are more

likely to cause subfertility.



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Fibroids larger than 5 cm, and thoseclose to the cervix or tubal ostia, arealso thought to be more problematic.

In women undergoing IVF cycles ,submucous or intramural myomas,which distort the uterine cavity, havea negative impacton implantationand pregnancy rates.

FIBROIDS AND PREGNANCY


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In 4% to 5% of womenundergoing prenatal ultrasounds,uterine fibroids are detected.

An increasing number of womenare delaying pregnancy until their

late thirties, which is also the mostlikely time for fibroids to develop.



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Most of these fibroidsMost of these fibroids ((8080%)%)remain the same size or becomeremain the same size or become

smaller during the pregnancy.smaller during the pregnancy.There is conflicting evidence inThere is conflicting evidence in

the literature regarding thethe literature regarding the

impact of fibroids on pregnancy.impact of fibroids on pregnancy.



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If the placenta implants over or inclose proximity to a myoma, theremay be an increased risk of:

1. Miscarriage,2. Preterm labour,3.Abruption,4. Prelabour rupture of membranes, or5. Intrauterine growth restriction.




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Fibroids located in the loweruterine segment may increase

the likelihood of :1. Fetal malpresentation,

2. Caesarean section, and3. Postpartum hemorrhage.




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A large retrospective review ofultrasounds and medical records of12 708 pregnant women concluded

that:

1. Mode of delivery,2. Fetal growth, and3. Risk of prelabour rupture of

membraneswere generally unaffected by the

presence of fibroids.



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Large fibroids, defined asgreater than 20 cm

in diameter, were morelikely to cause

abruption and abdominalpain.




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Myomectomy should notbe performedin pregnant women because of theincreased risk of uncontrolledbleeding.

The exception may be symptomatic

subserous fibroids on a pedicle lessthan 5 cm thick, in which case the riskof hemorrhage may be reduced.


ACUTEBLEEDING


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Rarely, women withfibroids present with an

acute hemorrhage, whichcan become life-

threatening.

ACUTE BLEEDING


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High-dose estrogens may helpcause vasoconstriction and

stabilize the endometrium.

A dilatation and curettage may

help slow down the bleeding.

ACUTEBLEEDING

ACUTEBLEEDING


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If a submucous fibroidis found prolapsing

through the cervix,its removal will usuallystop the bleeding.

ACUTE BLEEDING


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Hysteroscopic resection ofan intracavitary submucous

fibroid that is bleeding is anoption, but may be

technically difficultdue to poor visualization.

ACUTEBLEEDING


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FIBROIDS IN MENOPAUSE


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FIBROIDSINMENOPAUSE

Fibroids will usuallyshrink to about

half their original sizeafter menopause.

Effect of HRT on fibroids int l


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Combined HRT, particularly usingtransdermal estrogen, can causemyoma growth, however, the myoma

growth did not cause any clinicalsymptoms in these women.

A recent prospective study confirmed

these findings in the first 2 years of HRTuse, but noted a decline in fibroid volumein the third year.

postmenopausal women.

FIBROIDS AND UTERINELEIOMYOSARCOMAS


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LEIOMYOSARCOMAS

Uterine sarcoma is a raregynaecologic malignancy, occurring in

1.7 per 100 000 women over the ageof20 years.

Sarcomas represent1.2% to 6% of all

uterine malignancies, withleiomyosarcomas representingapproximately 25% of these.

FIBROIDS AND UTERINE


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The mean age at diagnosisfor uterine leiomyosarcoma

has been reported to be

between 44 and 57 years.


LEIOMYOSARCOM

AS


LEIOMYOSARCOMAS


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In one series, 47% of womenwere between the ages of41 and

50 years.Women found to have aleiomyosarcoma have experiencedsymptoms for a median of2.7 months.

LEIOMYOSARCOMAS



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50% of the women had experiencedabnormal bleeding, more likely if the

lesion was submucous.Other symptoms in descending order

of frequency were pain, an enlarging

abdomen, or abnormal vaginaldischarge.

LEIOMYOSARCOMAS



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A uterine mass increasing in size in apostmenopausal woman suggests aleiomyosarcoma rather than a benign

leiomyoma.Also, leiomyosarcomas tend to be

present as a singular large uterinemass or to be confined to the largestof the multiple uterine masses.

LEIOMYOSARCOMAS



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The masses tend to be softer due totissue necrosis and internal cysticdegeneration and hemorrhage.

Leiomyosarcomas tend to be difficult toseparate from the surroundingmyometrium at attempted myomectomy

because of their invasive nature.Fewer than 1 in 10 leiomyosarcomas arise

within the cervix.

LEIOMYOSARCOMAS



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Preoperative diagnosis ofleiomyosarcoma is infrequent.

Cervical cytology, endometrialsampling, and ultrasound

(including colour Doppler) havenot been found to be reliable.

LEIOMYOSARCOMAS



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There is insufficient evidence to supportroutine biopsy of uterine fibroids.

Magnetic resonance imaging (MRI) ispromising in distinguishing betweenbenign and malignant smooth muscletumours.

An ill-defined margin of a uterine smoothmuscle tumour on MRI is more inkeeping with a malignant process.

LEIOMYOSARCOMAS



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There is currently no evidence tosubstantiate performing a

hysterectomy or myomectomy foran asymptomatic uterine

leiomyoma for the sole purpose of

alleviating the concern that it maybe malignant.

LEIOMYOSARCOMAS



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The clinical diagnosis of a rapidlygrowing leiomyoma prior tomenopause has not been shown to

predict uterine leiomyosarcoma in theabsence of any othersymptomatology,

And thus should not be used as thesole indication for myomectomy orhysterectomy.

LEIOMYOSARCOMAS



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In women for whomhysterectomy is warranted

because of significant signs andsymptoms, the incidence of

uterine leiomyosarcoma rangesbetween 0.3% and 0.7%.

LEIOMYOSARCOMAS



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The index of suspicion

for malignancy shouldincrease with age and a

past history of pelvicirradiation.

LEIOMYOSARCOMAS



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Women considering uterineconserving treatment, for

leiomyomata, should becounselled regarding the potentialrisk of leiomyosarcoma, as a delay

in diagnosis in those rareinstances may compromise

ultimate survival.

LEIOMYOSARCOMAS


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Intraoperative or

postoperative diagnosisof leiomyosarcoma

warrants an oncologicconsultation.

LEIOMYOSARCOMAS

Recommendations:


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Medical managementshould betailored to the needs of thewoman presenting with uterine

fibroids and to alleviating thesymptoms.

Cost and side effects of medical

therapies may limit their long-term use.

(III-C)

Recommendations


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In women who do not wish topreserve fertility and who have beencounselled regarding the alternatives

and risks, hysterectomy may beoffered as the definitive treatment forsymptomatic uterine fibroids and is

associated with a high level ofsatisfaction.

(II-A)

Recommendations


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Myomectomy is an option forwomen who wish to preserve

their uterus, but women shouldbe counselled regarding the

risk of requiring furtherintervention.

Recommendations

(II-B)

Recommendations


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Myomectomy is an option forwomen who wish to preserve

their uterus, but women shouldbe counselled regarding the

risk of requiring furtherintervention.

Recommendations

(II-B)

Recommendations


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It is important to monitorongoing fluid balance

carefully during hysteroscopicremoval of fibroids.

(I-B)

Recommendations

Recommendations:


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Laparoscopic myolysis may presentan alternative to myomectomy orhysterectomy for selected womenwith symptomatic intramural or

subserous fibroidswho wish to preserve their uterus but

do not desire future fertility.

(II-B)

Recommendations:

Recommendations:


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Uterine artery occlusionmay be offered as analternative to selected

women with symptomaticuterine fibroids who wish to

preserve their uterus.

(I-C)

Recommendations:


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Women choosing uterine artery occlusionfor the treatment of fibroids should becounselled regarding:

1. possible risks, and that2. long-term data regarding efficacy,

fecundity, pregnancy outcomes, and

patient satisfaction are lacking.

(III-C)

Recommendations:


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Recommendations:


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Concern of possible complicationsrelated to fibroids in pregnancy

is not an indication for

myomectomy, except in womenwho have experienced a previouspregnancy with complications

related to these fibroids.

(III-C)

Recommendations:


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Women who havefibroids detected in pregnancy may

require additional fetal surveillancewhen the placenta is implanted overor in close proximity to a fibroid.

(III-C)

Recommendations:

Recommendations:


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In women who present withacute hemorrhage related to uterine fibroids,

conservative managementconsisting of1. Estrogens,2. Hysteroscopy, or3. Dilatation and curettage

may be considered,

but hysterectomy may become necessary insome cases.

(III-C)

Recommendations

Recommendations:


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Hormone replacement therapy may

cause myoma growth in postmenopausalwomen, but it does not appear to causeclinical symptoms.

Postmenopausal bleeding and painin women with fibroids should beinvestigated in the same way as in

women without fibroids.

(II-B)

Recommendations:


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There is currently no evidence tosubstantiate performing a

hysterectomy for anasymptomatic leiomyoma for thepurpose of alleviating the concern

that it may be malignant.

(III-C)

CONCLUSION


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30% of women have uterine fibroidsand the majority of them will not

require intervention.For those women who present with

symptoms, the menu of options for

the treatment of uterine leiomyomasis expanding.

CONCLUSION


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These technologies are relativelynew and although many are

promising, they often lacklong-term data, which interferes

with our ability to present all risksand benefits with assurance.

CONCLUSION


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Ongoing research and datacollection will help us

assess the relative meritof newer options as the

technology continues toexpand.


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