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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















 

j
 

 



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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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