Treatment of Uterine Leiomyomas

TREATMENT

Most patients with uterine myomas do not require (surgical or medical) treatment. Treatment is generally first directedtoward the symptoms caused by the myomas. If this approach fails (or there are other indications present), sur-gical or other extirpative procedures may be considered.

For example, if a patient presents with menstrual aber-rations that are attributable to the myomas, with bleeding that is not heavy enough to cause her significant hygiene or lifestyle problems—and the bleeding is also not contribut-ing to iron-deficiency anemia—reassurance and observation may be all that are necessary. Further uterine growth may be assessed by repeat pelvic examinations or serial pelvic ultrasonography.

An attempt may be made to minimize uterine bleed-ing by using intermittent progestin supplementation and/or prostaglandin synthetase inhibitors, which decrease the amount of secondary dysmenorrhea and amount of menstrual flow. If significant endometrial cavity distortion is caused by intramural or submucous myomas, hormonal supplementation may be ineffective. If effective, this con-servative approach can potentially be used until the time of menopause.

Of the surgical options available, myomectomy is war-ranted in patients who desire to retain childbearing poten-tial or whose fertility is compromised by the myomas, creating significant intracavitary distortion. Indications for amyomectomy include a rapidly enlarging pelvic mass, persistent bleeding, pain or pressure, or enlargement of an asymptomatic myoma to more than 8 cm in a woman who has not completed childbearing. Contraindications to myomectomy includepregnancy, advanced adnexal disease, malignancy, and the situation where enucleation of the myomas would com-pletely compromise the function of the uterus. Potential complications of myomectomy include excessive intra-operative blood loss; postoperative hemorrhage, infection, and pelvic adhesions; and even the need for emergent hys-terectomy. Within 20 years of a myomectomy procedure, 1 in 4 women has a hysterectomy, the majority for recur-rent leiomyomas.

Although hysterectomy is commonly performed for uterine myomas, it should be considered as definitive treatment only in symptomatic women who have com-pleted childbearing. Indications should be specific and well-documented (Box 44.1). 

Box 44.1

Criteria for Hysterectomy for Leiomyomata*

Indication

Leiomyomata

Confirmation of indication (1, 2, or 3)

1. Asymptomatic leiomyomata of such size that they are palpable abdominally and are a con-cern to the patient

2. Excessive uterine bleeding evidenced by either of the following:

a. Profuse bleeding with flooding or clots, or repetitive periods lasting >8 days

b. Anemia caused by acute or chronic blood loss

3. Pelvic discomfort caused by myomata (a, b, or c):

a. Acute and severe

b. Chronic lower abdominal or low back pressure

c. Bladder pressure with urinary frequency not caused by urinary tract infection

Actions Before Procedure

·              Confirm no cervical malignancy

·              Eliminate anovulation and other causes of abnormal bleeding

·              When abnormal bleeding is present, confirm no endometrial malignancy

·              Assess surgical risk from anemia and need for treatment

·              Consider patient’s medical and psychological risks concerning hysterectomy

Contraindications

·              Desire to maintain fertility, in which case, myomectomy should be considered

·              Asymptomatic leiomyomata of 12 weeks’ ges-tation determined by physical examination or ultrasound examination 

Modified from the American College of Obstetricians and Gyne-cologists. Quality Assessment and Improvement in Obstetrics and Gynecology. Washington, DC: American College of Obstetricians and Gynecologists; 1994

Depending on the size of the fibroids and the skill of the surgeon, both myomec-tomy and hysterectomy can potentially be performed via laparoscopy. The ultimate decision whether to perform a hysterectomy should include an assessment of the patient’s future reproductive plans as well as careful assessment of clinical factors, including the amount and timing of bleed-ing, the degree of enlargement of the tumors, and the asso-ciated disability for the individual patient. Uterine myomas alone do not necessarily warrant hysterectomy.

In addition to surgery, pharmacologic inhibition of estrogen secretion has been used to treat fibroids. This is particularly applicable in the perimenopausal years when women are more likely anovulatory, with relatively more endogenous estrogen. Pharmacologic removal of the ovar-ian estrogen source can be achieved by suppression of the hypothalamic-pituitary-ovarian axis through the use of gonadotropin-releasing hormone agonists (GnRHanalogs), which can reduce fibroid size by as much as 40%to 60%. This treatment is commonly used before a planned hys-terectomy to reduce blood loss as well as the difficulty of the pro-cedure. It can also be used as a temporizing medical therapy until natural menopause occurs. Therapy is generally limitedto 6 months of drug treatment.

In patients with an adequate endogenous estrogen source, this treatment does not permanently reduce the size of uterine myomas, as withdrawal of the medication predictably results in regrowth of the myomas. Although less successful, other pharmacologic agents such as dana-zol have also been used as medical treatment for myomasby reducing endogenous production of ovarian estrogen.

Other therapeutic modalities have been introduced, although their efficacy is yet to be demonstrated. Included in these are myolysis (via direct procedures or by the deliv-ery of external radio or ultrasonic energy) and uterine artery embolization (UAE). The safety and efficacy of UAE have been studied to the point that it is now considered a viable alternative to hysterectomy and myomectomy for selected patients. The procedure involves selective uterine artery catheterization with embolization using polyvinyl alcohol particles, which creates acute infarction of the target myomas. For maximal efficacy, bilateral uterine artery cannulation and embolization is necessary. In assessing outcomes data, the three most common symptoms of myomas—bleeding, pressure, and pain—are ameliorated in over 85% of patients. Acute postembolization pain that requires hospitalization occurs in approximately 10% to 15% of patients. Other complications include delayed infection and/or passage of necrotic fibroids through the cervix up to 30 days after the procedure. UAE is currently notrecommended as a procedure to consider in patients who desire future childbearing.MRI-guided focused ultrasound surgery is a newapproach used to treat myomata. A focused ultrasound unitdelivers sufficient ultrasound energy to a targeted point to raise the temperature to approximately 70°C. This results in coagulative necrosis and a decrease in myoma size. Treatment is associated with minimal pain and appears to improve self-reported bleeding patterns and quality of life.