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: 1.7). 08/2012; 165(2). DOI: 10.1016/j.ejogrb.2012.07.030
Source: PubMed


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.

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Available from: Guillaume Legendre
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    ABSTRACT: Uterine fibroids are one of the most common pathologies of the female reproductive system, which may cause abnormal, heavy bleeding and pelvic pain. These ailments often prompt women to consult their gynecologists. Pharmacotherapeutic options in uterine fibroids are limited. The studies conducted so far have assessed the efficacy of progestogens, levonorgestrel-releasing intrauterine systems, antifibrinolytic agents, nonsteroid anti-inflammatory drugs, GnRH analogues and Selective Progesterone Receptor Modulators (SPRMs) in the treatment of fibroid symptoms. Few agents available on the market have been approved for symptomatic treatment of uterine fibroids; these include GnRH analogues and, recently, ulipristal acetate (SPRM). The treatment with GnRH analogues as a alternative to surgery, proved unsatisfactory. Treatment duration cannot exceed 6 months due to rapid demineralization of bones associated with decreased estrogen levels. Once GnRH ana- logues are discontinued, fibroids start growing again, almost reaching their baseline size, while most women experience the recurrence of symptoms. Ulipristal acetate may prove a true therapeutic alternative to such technically complicated procedures as laparoscopic myomectomy or uterine artery embolization. The sustainable therapeutic effect and favorable safety profile are important characteristics of ulipristal acetate distinguishing it from other drugs. The results of studies conducted to date demonstrate that after treatment termination, surgery has been abandoned in about half of patients. Follow-up of patients who discontinued ulipristal acetate showed sustained improvement in bleeding control, pain and quality of life. Myomectomy is only indicated in symptomatic uterine fibroids, depending on their size and number; it may be an endoscopic procedure or it may require laparotomy. The choice of treatment method and scope of therapy should take into account not only clinical symptoms but also expectations of women who wish to maintain their fertility and femininity, which is related to the fact of having their uterus intact.
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    ABSTRACT: Purpose. The problem of fertility after Myomectomy is very essential to establish the success of the quality of life of women planning pregnancy. The risk for a patient with myomas is infertility, late abortion, threatened preterm delivery and preterm birth; whereas for a patient with previous myomectomy it is uterine rupture or sterility; the former happens when the layers suture of uterus is not well supported, the latter when the fallopian tubes are damaged because of surgery. The aim is to show a fertility case after an exceptional multiple Myomectomy (37 myomas). Methods. A conservative surgical approach, consisting of laparotomy for the treatment of a great number of myomas, in a 35-year-old non-pregnant woman with a history of previous sterility, metrorrhagia and dysmenorrhea. Myomas were of various size: from 1 to 6 cm and they involved anterior, posterior wall and fundus; 3 were submucosal, 10 interstizial and the remaining ones were subserous. Results. All the myomas weighted 3.190 g. Postoperative course was regular and 13 months after operation, the patients obtained a successful pregnancy with cesarean section at the 39th week. The baby weighted 3.750 g and was born healthy. During caesarean, uterine walls were well supported with no areas of weakness. Conclusions. This case report involves the issue of fertility, when myomas alter both uterine cavity and walls. A skillful operation, after a complete mapping of the fibroids, allows the patient to solve metrorrhagia, pain and sterility too.
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    ABSTRACT: PURPOSE: To retrospectively evaluate the ability of magnetic resonance imaging (MRI) to differentiate malignant from benign myometrial tumours. METHODS: Fifty-one women underwent MRI before surgery for evaluation of a solitary myometrial tumour. At histopathology, there were 25 uncertain or malignant mesenchymal tumours and 26 benign leiomyomas. Conventional morphological MRI criteria were recorded in addition to b 1,000 signal intensity and apparent diffusion coefficient (ADC). Odds ratios (OR) were calculated for each criterion. A multivariate analysis was performed to construct an interpretation model. RESULTS: The significant criteria for prediction of malignancy were high b 1,000 signal intensity (OR = +∞), intermediate T2-weighted signal intensity (OR = +∞), mean ADC (OR = 25.1), patient age (OR = 20.1), intra-tumoral haemorrhage (OR = 21.35), endometrial thickening (OR = 11), T2-weighted signal heterogeneity (OR = 10.2), menopausal status (OR = 9.7), heterogeneous enhancement (OR = 8) and non-myometrial origin on MRI (OR = 4.9). In the recursive partitioning model, using b 1,000 signal intensity, T2 signal intensity, mean ADC, and patient age, the model correctly classified benign and malignant tumours in 47 of the 51 cases (92.4 %). CONCLUSION: We have developed an interpretation model usable in routine practice for myometrial tumours discovered at MRI including T2 signal, b 1,000 signal and ADC measurement. KEY POINTS : • MRI is widely used to differentiate benign from malignant myometrial tumours. • By combining T2-weighted, b 1,000 and ADC features, MRI is 92.4 % accurate. • DWI may limit misdiagnoses of uterine sarcoma as benign leiomyoma. • Patient age is important when considering a solitary myometrial tumour.
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