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    Macy

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    - Management of symptomatic uterine fibroids includes nonsurgical approaches like medications, but surgery is considered when medical management fails. - Laparoscopic myomectomy is becoming more accepted for treating fibroids in selected patients but more research is still needed, while hysteroscopic resection is standard for submucosal fibroids. - Imaging like ultrasound and MRI can help identify and characterize fibroids prior to deciding on treatment.

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    Macy

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    - Management of symptomatic uterine fibroids includes nonsurgical approaches like medications, but surgery is considered when medical management fails. - Laparoscopic myomectomy is becoming more accepted for treating fibroids in selected patients but more research is still needed, while hysteroscopic resection is standard for submucosal fibroids. - Imaging like ultrasound and MRI can help identify and characterize fibroids prior to deciding on treatment.

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    - Management of symptomatic uterine fibroids includes nonsurgical approaches like medications, but surgery is considered when medical management fails. - Laparoscopic myomectomy is becoming more accepted for treating fibroids in selected patients but more research is still needed, while hysteroscopic resection is standard for submucosal fibroids. - Imaging like ultrasound and MRI can help identify and characterize fibroids prior to deciding on treatment.

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    Download as DOCX, PDF, TXT or read online from Scribd
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    Macy

    Uploaded by

    Macy Calibod
    - Management of symptomatic uterine fibroids includes nonsurgical approaches like medications, but surgery is considered when medical management fails. - Laparoscopic myomectomy is becoming more accepted for treating fibroids in selected patients but more research is still needed, while hysteroscopic resection is standard for submucosal fibroids. - Imaging like ultrasound and MRI can help identify and characterize fibroids prior to deciding on treatment.

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    c 

    
     c   

    Management of symptomatic uterine fibroids includes a number of nonsurgical approaches. Of


    note, treatment is usually strictly for patient comfort, and withholding treatment is reasonable in
    patients with no symptoms or with mild, well-tolerated symptoms. While medical treatment does
    not currently allow a permanent cure for fibroids, therapy with nonsteroidal anti-inflammatory
    drugs, oral contraceptive pills, progestins, androgens, and gonadotropin-releasing hormone
    (GnRH) analogs is often attempted.21 In a 2007 Cochrane review evaluating the effectiveness of
    SERMs in treating fibroids, evidence was insufficient to show any improvement in fibroid size
    or clinical symptoms.22

    In a review by the Agency for Health Care Research and Quality, the use of preoperative GnRH
    agonist was shown to decrease uterine size and increase hemoglobin. They comment about the
    "lack of high-quality evidence supporting the effectiveness of most interventions for
    symptomatic fibroids."23

    No randomized trials compare medical management with surgery.

    In general, surgery is reserved for people in whom medical management has failed. Despite the
    lack of good randomized evidence for the use of nonsteroidal anti-inflammatory drugs and oral
    contraceptive pills, these seem to be appropriate options for properly selected women without
    contraindications. Many women with fibroids, particularly those who have fibroids that are
    compounding dysfunctional bleeding, can be treated successfully with a combination of
    nonsteroidal anti-inflammatory drugs, birth control pills, or cyclic progestins. A short course is
    reasonable for patients with fibroids before committing to surgery because some patients can be
    treated successfully with medical management. Most studies of medical management are short,
    from 3 months to 1 year, and long-term success remains uncertain.

    Patients who are treated expectantly are usually examined more frequently than once a year. If
    the myomas are large and extend laterally, consideration can be given to performing periodic
    ultrasonographic studies to monitor for the development of hydronephrosis or the rare occurrence
    of ureteral obstruction.

    pp

    
     
      
    
     
    
     
      
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    h      Fellow, Reproductive Endocrinology and Infertility,
    Washington University School of Medicine
         ! Professor of Obstetrics and Gynecology, Tufts University
    School of Medicine; Program Director, Tufts University Affiliated Hospitals OB/GYN
    Residency Program; Chair, Tufts University Health Sciences Campus Institutional Review
    Board; "! "   Assistant Professor, Department of Obstetrics and
    Gynecology, Tufts University School of Medicine; Associate Division Chief of General
    Obstetrics and Gynecology, Director of Center for Abnormal Uterine Bleeding, Department of
    Obstetrics and Gynecology, Tufts Medical Center
    Contributor Information and Disclosures

    Updated: Aug 6, 2008

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    c 
    
     c   

    Management of symptomatic uterine fibroids includes a number of nonsurgical approaches. Of


    note, treatment is usually strictly for patient comfort, and withholding treatment is reasonable in
    patients with no symptoms or with mild, well-tolerated symptoms. While medical treatment does
    not currently allow a permanent cure for fibroids, therapy with nonsteroidal anti-inflammatory
    drugs, oral contraceptive pills, progestins, androgens, and gonadotropin-releasing hormone
    (GnRH) analogs is often attempted.21 In a 2007 Cochrane review evaluating the effectiveness of
    SERMs in treating fibroids, evidence was insufficient to show any improvement in fibroid size
    or clinical symptoms.22
    In a review by the Agency for Health Care Research and Quality, the use of preoperative GnRH
    agonist was shown to decrease uterine size and increase hemoglobin. They comment about the
    "lack of high-quality evidence supporting the effectiveness of most interventions for
    symptomatic fibroids."23

    No randomized trials compare medical management with surgery.

    In general, surgery is reserved for people in whom medical management has failed. Despite the
    lack of good randomized evidence for the use of nonsteroidal anti-inflammatory drugs and oral
    contraceptive pills, these seem to be appropriate options for properly selected women without
    contraindications. Many women with fibroids, particularly those who have fibroids that are
    compounding dysfunctional bleeding, can be treated successfully with a combination of
    nonsteroidal anti-inflammatory drugs, birth control pills, or cyclic progestins. A short course is
    reasonable for patients with fibroids before committing to surgery because some patients can be
    treated successfully with medical management. Most studies of medical management are short,
    from 3 months to 1 year, and long-term success remains uncertain.

    Patients who are treated expectantly are usually examined more frequently than once a year. If
    the myomas are large and extend laterally, consideration can be given to performing periodic
    ultrasonographic studies to monitor for the development of hydronephrosis or the rare occurrence
    of ureteral obstruction.

     
     c   

    A number of surgical therapies are available for the management of myomas, including
    hysterectomy, abdominal myomectomy, laparoscopic myomectomy, and hysteroscopic
    myomectomy. Myomas are most commonly treated with total abdominal hysterectomy. The
    following sections focus on conservative surgery for leiomyomas. The traditional procedure is
    abdominal myomectomy, although laparoscopic myomectomy is an acceptable option for
    experienced laparoscopic surgeons.

    Myomectomy can be performed laparoscopically under certain conditions. Development of this


    procedure was driven by the desire to create a minimally invasive approach that would obviate a
    major abdominal laparotomy. Numerous published series document the feasibility of
    laparoscopic myomectomy.24,25,26,27

    The most recent American College of Obstetricians and Gynecologists Practice Bulletin suggests
    that it "may be a safe and effective option for women with a small number of moderately sized
    uterine leiomyomas who do not desire future fertility. Further studies are necessary to evaluate
    the safety of this procedure for women planning pregnancy."28 However, a review of
    randomized studies and clinical series concluded that laparoscopic myomectomy is feasible in
    well-selected individuals and, with meticulous closure of the myometrium, is safe in women
    considering pregnancy in the future.29 A randomized control trial revealed similar cumulative
    pregnancy and live birth rates in women with unexplained infertility following laparoscopic
    versus abdominal myomectomy.30 Laparoscopic myomectomy is gradually becoming a more
    acceptable treatment for myomas.
    A third technique, hysteroscopic resection, can also be used selectively for myomas impinging
    on the endometrial cavity that are thought to contribute to abnormal bleeding or infertility. Over
    the last 30 years, hysteroscopic resection of fibroids has become the standard for conservative
    treatment for submucosal fibroids. With the recent improvements in smaller scopes, continuous
    flow monitoring systems, and operative resecting tools the procedure has become safer and less
    invasive and, in many cases, can be performed with minimal anesthesia and cervical
    dilation. Proper patient selection and correct surgical technique are essential for optimizing
    operative success and reducing risk of complications.31

    Women with submucosal fibroids often have symptoms related to menorrhagia or infertility.
    Most women have significant reduction in bleeding after undergoing hysteroscopic
    resection. Improved fertility is also seen after removal of submucosal fibroids, although the
    mechanism is not fully understood.32

    =  

    ap Ultrasonography: Uterine leiomyoma can usually be detected on pelvic examination. If


    any doubt remains or if the uterine enlargement must be confirmed or differentiated from
    a pelvic mass, ultrasonography is very useful. Leiomyomas can also be detected with CT
    scanning or MRI, but, in general, these tests are more expensive and do not help visualize
    the uterus as well as ultrasonography does. Fortunately, uterine leiomyosarcomas are
    rare; imaging study findings are not usually helpful for differentiating them from the far
    more common leiomyoma; confirmation requires a tissue diagnosis.
    ap HSG or sonohysterography: In the evaluation of the endometrial cavity, if a strong
    possibility exists that myomas are present within the endometrial cavity, perform HSG or
    sonohysterography. This allows the preoperative detection of myomas that may be more
    amenable to hysteroscopic resection and may thereby preclude the need to enter the
    endometrial cavity during an abdominal procedure.
    ap MRI: Myomectomy is possible only for myomas; therefore, one must reasonably believe
    that the uterine enlargement is from leiomyoma and not from adenomyosis. The presence
    of myomas can usually be confirmed based on ultrasonography or physical examination
    findings by the characteristic irregularities of a uterus with multiple fibroids. If any doubt
    remains, MRI has been found useful in differentiating leiomyoma from adenomyosis.19,20

     
    # 
     

    ap Endometrial biopsy: Myomectomy is not an acceptable option if the patient has an


    endometrial malignancy. An endometrial biopsy should be performed prior to performing
    myomectomy in any patient older than 35 years who has a history of irregular bleeding.

    
    #  
    Despite a long history of using myomectomy and extensive literature on this procedure, data are
    actually poor because of 2 important issues related to outcome. In particular, both the recurrence
    rate and the impact on fertility have been poorly studied.
    p

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