Management of Uterine Myomas: A Critical Update
Androutsopoulos G*, Decavalas G
Department of Obstetrics and Gynaecology, University of Patras, Medical School, Rion, Greece.
Lecturer, Department of Obstetrics and Gynecology,
University of Patras, Medical School,
Rion 26504, Greece
Received: June 03, 2014; Published: July, 22,2014
Citation: Androutsopoulos G, Decavalas G. (2014). Management of Uterine Myomas: A Critical Update, Int J Translation Community Dis, 02(01), 01-03. doi: dx.doi.org/10.19070/2333-8385-140003e
Copyright: Androutsopoulos G © 2014. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited.
Uterine myomas are benign, fibromuscular tumors.[1-3] They consist of clonal expansions of a single myometrial cell with various amounts of fibrous tissue.[1,2] They originate from smooth muscle cells of the uterus. However, in some cases they originate from smooth muscle cells of uterine blood vessels. Estrogen and progesterone appear to play a key role in the pathogenesis of uterine myomas.[1,2].
They diagnosed in 20%-40% of women during reproductive age. [1,3] Their incidence increase during reproductive age and decline in menopause.[1,2] Most patients with uterine myomas are asymptomatic. However uterine myomas can cause various symptoms: abnormal uterine bleeding, pelvic pain, pressure complaints, infertility and pregnancy-related complications.[2-4]
The management of patients with uterine myomas remains controversial. There are various treatment protocols that use: medical treatment (GnRH analogues), radiological intervention (focused ultrasound surgery, uterine artery embolization) or surgical intervention (myomectomy, hysterectomy).,[5-13] Recent advances in the nonsurgical management of uterine myomas have shown promising results simplifying or eliminating the need for surgical intervention in carefully selected patients.[5,7,9].
Stand-alone treatment with GnRH analogues results in temporary relief of symptoms. However, GnRH analogues are expensive and have significant side-effects (bone demineralization, menopausal symptoms). Moreover, uterine myomas return to their initial size within a few months of discontinuation of the treatment.,[6-8], It is obvious that GnRH analogues cannot be used as stand-alone treatment.[5,7,8]
However, preoperative treatment with GnRH analogues for 3 to 4 months: improves hematocrit levels and reduces myomas size,total uterine volume and intraoperative blood loss.[3,6,8] This is very important especially in patients with large uterine myomas and/or anemia.
Certainly, preoperative use of GnRH analogues makes myomectomy technically easier and less time consuming.[6,8,11] However, in some cases uterine myomas become softer with less distinct surgical planes.[4,8,11] That cause technical difficulties and increase intraoperative bleeding.[4,8] 11 Also there is increased risk of recurrence, as small uterine myomas recognized with difficulty during operation.[5,6,8]
Other agents with various degrees of success are: GnRH antagonists, selective estrogen receptor modulators (SERMs), aromatase inhibitors, selective progesterone receptor modulators (mifepristone, asnoprisinil), cabergoline, danazol and gestrinone.[4,8]
Magnetic resonance imaging-guided focused ultrasound surgery (MRgFUS) is a hybrid technique that combines the anatomic detail and thermal monitoring capabilities of magnetic resonance imaging (MRI) with the therapeutic potential of focused ultrasound (FUS).[15,16] More specifically, it uses high intensity ultrasound waves directed into a focal volume of uterine myoma. [4,15,17] The ultrasound energy penetrates soft tissue and produces well defined regions of protein denaturation, irreversible cell damage and coagulative necrosis.[4,15,17]
MRgFUS is a safe and effective technique and most patients are able to return to their normal activities in 1 day.[15,18,19] Pregnancy is possible in patients treated with MRgFUS. However, they need careful ultrasound evaluation of placental site and placental status to ensure appropriate care.
Uterine artery embolization (UAE) is a minimal invasive technique that use transcutaneous femoral artery approach, to block uterine blood supply. During procedure, we usually use polyvinyl alcohol particles of trisacryl gelatin microspheres.[4,21] Embolization causes irreversible ischemia and leads to necrosis and shrinkage of uterine myomas.[9,22]
UAE is a safe and effective technique for appropriately selected women who wish to preserve their uterus.[4,21,23,24] It substantially improves symptoms and quality of life in the majority of patients.[4,21,23] Moreover, UAE results in shorter hospital stay and quicker return to normal activities.
Although pregnancy is possible in patients treated with UAE, there is increased risk of obstetric complications (miscarriage, abnormal placentation, preterm labor, malpresentation and postpartum hemorrhage).[25-27]
Myomectomy remains the treatment of choice, in women who desire future fertility or wish uterine preservation.[4,7,11,28] The aim of myomectomy is to remove all visible uterine myomas and reconstruct uterine defects properly.[4,28] Rarely intraoperative complications, may lead to an unanticipated hysterectomy.
Laparotomic myomectomy is a safe and effective approach for the treatment of uterine myomas. However, it is associated with significant morbidity including excessive blood loss, infection and postoperative adhesions.[3,12,29,30]
Laparoscopic myomectomy is an alternative approach for the treatment of uterine myomas.[4,12] It is associated with fewer complications, shortened hospital stay and less disability.[4,10,12] However, it is a tedious operation especially in intramural uterine myomas and requires skills in suturing.[4,31,32] Also, many gynecologists are not skilled laparoscopists to perform laparoscopic myomectomy and uterine repair.
Mini laparotomic myomectomy is an alternative to laparoscopic myomectomy for the treatment of uterine myomas.[5,13,33,34] Compared with laparoscopic myomectomy, it is technically easier.[5,13] It is associated with fewer complications, shortened hospital stay and less disability.[5,13] [35-39] Surgical technique is basically the same as in classical laparotomic myomectomy.[5,13,35]
Hysteroscopic myomectomy is a safe and effective approach for the treatment of submucosal uterine myomas.[3,4] It is associated with fewer complications and shortened hospital stay.[4,5]
Hysterectomy is the treatment of choice, in symptomatic perimenopausal women with multiple uterine myomas and completed childbearing.[3,5,28] It is associated with various complications.
It is obvious that nonsurgical management of uterine myomas has shown promising results simplifying or eliminating the need for surgical intervention in carefully selected patients. However, it is inappropriate for infertile women and for women wanting to preserve future childbearing capability.[5,7] For those women myomectomy remains the treatment of choice.[5,7,11]
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