Therapeutic management of uterine fibroid tumors: updated French guidelines

Service de gynécologie, Centre Hospitalier Régional Universitaire de Tours, Hôpital Bretonneau, 2 boulevard Tonnelé, 37044 Tours, France.
European journal of obstetrics, gynecology, and reproductive biology (Impact Factor: 1.63). 08/2012; 165(2). DOI: 10.1016/j.ejogrb.2012.07.030
Source: PubMed

ABSTRACT The medical management of symptomatic non-submucosal uterine fibroid tumors (leiomyomas or myomas) is based on the treatment of abnormal uterine bleeding by any of the following: progestogens, a levonorgestrel-releasing intrauterine device, tranexamic acid, nonsteroidal anti-inflammatory drugs, or GnRH analogs. Selective progesterone receptor modulators are currently being evaluated and have recently been approved for fibroid treatment. Neither combined estrogen-progestogen contraception nor hormone treatment of the menopause is contraindicated in women with fibroids. When pregnancy is desired, whether or not infertility is being treated by assisted reproductive technology, hysteroscopic resection in one or two separate procedures of submucosal fibroids less than 4cm in length is recommended, regardless of whether they are symptomatic. Interstitial, also known as intramural, fibroids have a negative effect on fertility but treating them does not improve fertility. Myomectomy is therefore indicated only for symptomatic fibroids; depending on their size and number, and may be performed by laparoscopy or laparotomy. Physicians must explain to women the potential consequences of myomas and myomectomy on future pregnancy. For perimenopausal women who have been informed of the alternatives and the risks, hysterectomy is the most effective treatment for symptomatic fibroids and is associated with a high rate of patient satisfaction. When possible, the vaginal or laparoscopic routes should be preferred to laparotomy for hysterectomies for fibroids considered typical on imaging. Because uterine artery embolization is an effective treatment with low long-term morbidity, it is an option for symptomatic fibroids in women who do not want to become pregnant, and a validated alternative to myomectomy and hysterectomy that must be offered to patients. Myolysis is under assessment, and research on its use is recommended. Isolated laparoscopic ligation of the uterine arteries is a potential alternative to uterine artery embolization; it also complements myomectomy by reducing intraoperative bleeding. It is possible to use second-generation techniques of endometrial ablation to treat submucosal fibroids in women whose families are complete. Subtotal hysterectomy is a possible alternative to total hysterectomy for fibroid treatment, given that by laparotomy the former has a lower complication rate than the latter, while by laparoscopy, these rates are the same. In each case, the patient is informed about the benefit and risk associated with each therapeutic option.

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    ABSTRACT: Objective: The principal objective of this study was to use contrast-enhanced ultrasonography to describe the characteristics of fibroid microvascularization before and after embolization. Study design: Forty women had contrast-enhanced ultrasonography with Sonovue(R) injections before uterine artery embolization, the day afterwards, and at 6-12 months afterwards. An MRI was also performed before and after the procedure. Results: Two thirds of the fibroids took up the contrast product before the myometrium did, and 45.8% were vascularized along the peripheral rim of the fibroid, compared with 41.6% with a principal pedicle and from the center in three (12.6%). After embolization at day one (D1), the myometrium was fully enhanced, that is, perfusion of the myometrium was plainly visible, in 25 cases (69.4%; n = 36), partially enhanced in eight (22.2%), and totally avascular in three (8.4%). Analysis of the failures according to imaging criteria the day after embolization (D1) showed failure in seven women, with partial enhancement for six, and total for one. In the imaging at 6 months (M6), contrast ultrasonography showed failure for three women, with enhancement of the largest fibroid. This enhancement was total in two cases and partial (40%) in one. There were five failures according to MRI at M6, with partial enhancement. Only two of these failures were simultaneously failures according to the contrast-enhanced ultrasonography. There were five clinical failures, two consistent with the imaging at 6 months and four predictable on D1. Conclusion: Contrast-enhanced ultrasonography is feasible and useful to understand fibroid vascularization and for monitoring embolization; its correlation with MRI is good, its concordance less so.
    European Journal of Obstetrics & Gynecology and Reproductive Biology 08/2014; 181C:104-110. DOI:10.1016/j.ejogrb.2014.07.030 · 1.63 Impact Factor
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    ABSTRACT: Uterine leiomyomas, commonly called fibroids, are the leading indication for hysterectomy in the United States. Incidence increases with age from menarche to perimenopause. Regardless of their generally benign neoplastic character, uterine fibroids are responsible for significant morbidity in a large proportion of women of reproductive age. As uterine leiomyomas generally regress after menopause, the general attitude when women are approaching perimenopausal age is to avoid treatment and wait for menopause and a spontaneous resolution. When it is decided that treatment is needed, the choice for peri- and postmenopausal women is often hysterectomy. In the present paper we point out aspects of leiomyoma management that are unique to the perimenopausal period, and address future directions in care. We conclude that the management of uterine leiomyomas should not be overlooked in the perimenopausal period merely on the grounds that the pathology and symptoms are unlikely to persist after the menopause; on the other hand, opting for a quick resolution with total surgical removal of the uterus, as seen at present in many cases, should be avoided. Studies on the impact of therapy for fibroids should be performed not exclusively with premenopausal women but also with perimenopausal and postmenopausal women, both users and non-users of hormone replacement therapy.
    Maturitas 04/2014; 78(3). DOI:10.1016/j.maturitas.2014.04.011 · 2.86 Impact Factor
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    ABSTRACT: Abstract Objective: This review provides an overview of therapeutic options, with a specific focus on the emerging role of medical options for UF management. Research Design and Methods: PubMed, Google Scholar, and Cochrane Systematic Reviews were searched for articles published between 1980 and 2013. Relevant articles were identified using the following terms: "uterine fibroids," "leiomyoma," "heavy menstrual bleeding," and "menorrhagia." The reference lists of articles identified were also searched for other relevant publications. Results: Because of the largely benign nature of UFs, the most conservative options that minimize morbidity/risk and optimize outcomes should be considered. Watchful waiting, or no immediate intervention combined with regular follow-up, is an appropriate option for the majority of UF patients who experience no symptoms. For women with symptomatic UFs, the optimal treatment should restore quality of life through rapid relief of UF signs and symptoms, reduce tumor size for a sustained period, and maintain or improve fertility. Invasive surgical treatments, such as hysterectomy, have historically been the mainstay of UF treatment. Less invasive surgical & interventional techniques, such as myomectomy, uterine artery embolization, endometrial ablation, and myolysis provide alternatives to hysterectomy. Until recently, medical management of UFs was characterized by short-term treatments and therapies that provided symptomatic control. In addition to controlling abnormal uterine bleeding, newer medical therapies, including the recently Health Canada-approved ulipristal acetate, act directly to shrink the tumor. Although no agent is currently approved for such use, emerging evidence suggests the potential for long-term medical management of UFs. Conclusions: The advent of novel medical therapies may diminish the long-held reliance on more invasive surgical UF treatment options.
    Current Medical Research and Opinion 11/2014; 31(1):1-23. DOI:10.1185/03007995.2014.982246 · 2.37 Impact Factor

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