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Alternatives to Hysterectomy in the Management of Fibroids (Leiomyomas)

Uterine leiomyomas (also called fibroids) are the most common solid pelvic tumors in women and the leading indication for hysterectomy. Although most women with uterine leiomyomas are asymptomatic and can be followed without treatment.

Hysterectomy remains the most common treatment for leiomyomas because it is the only treatment that provides a cure and eliminates the possibility of recurrence. Many women seek an alternative to hysterectomy because they desire future childbearing or wish to retain their uteri even if they have completed childbearing. As alternatives to hysterectomy become increasingly available, the efficacies of these treatments and the risk of potential problems are important to delineate fibroid, fiboid, leiomyoma. The purpose of this bulletin is to review the literature about surgical alternatives to hysterectomy and to offer treatment recommendations.

Background

As benign neoplasms, uterine leiomyomas usually require treatment only when they cause symptoms. The two most common symptoms for which women seek treatment are abnormal uterine bleeding and pelvic pressure.

However, not all bleeding is caused by leiomyomas; therefore, other causes of abnormal bleeding should be ruled out. The most common kind of abnormal uterine bleeding associated with leiomyomas is menorrhagia. Often, menses last 7 days or more, frequently resulting in iron deficiency anemia. This heavy flow also may require frequent changes of sanitary protection, causing significant interruptions in a woman's work.

Uterine leiomyomas are clinically apparent in 25-50% of women (1), although studies in which careful pathologic examination of the uterus is carried out suggest the prevalence may be as high as 80% (2). The lack of a simple, inexpensive, and safe long-term medical treatment means that most symptomatic leiomyomas.

Leiomyomas range greatly in size. Both size and location can play a role in symptoms and potential treatments. Leiomyomas may be subserosal, submucosal, or intramural; however, some types may be combined, for example, largely intramural.

The pelvic and abdominal discomfort that women experience with leiomyomas often is referred to as pressure and often is analogous to the discomforts women experience during pregnancy due to the enlarging of the uterus. In addition to pelvic pressure, the leiomyomas may press on adjacent structures, leading to difficulty with urination or defecation or dyspareunia.

Surgical Alternatives to Hysterectomy

In choosing a surgical alternative to hysterectomy, both safety and efficacy need to be established for each procedure. It must be recognized that all surgical alternatives to hysterectomy allow the possibility for new leiomyomas to form, and preexisting leiomyomas that were too small to be detected or were intentionally not removed may exhibit significant growth.

Myomectomy

For women who desire future childbearing or who prefer to retain their uteri, myomectomy may be an option. Myomectomy removes only the visible and accessible leiomyomas, and the uterus is reconstructed.

Laparoscopic Myomectomy

Endoscopic myomectomy is now a treatment option for many women. Laparoscopic myomectomy minimizes the size of the abdominal incision, although it usually requires a minimum of three small incisions. Because the laparoscope usually is inserted.

Hysteroscopic Procedures

Hysteroscopic procedures are primarily efficacious for the control of leiomyoma-related bleeding and do not significantly reduce uterine size. Only if a leiomyoma is submucosal or has a submucosal component can it be removed through the vagina (ie, hysteroscopic myomectomy).

For women with primarily intramural leiomyomas or women who have simultaneous hysteroscopic myomectomies, destruction of the endometrium by endometrial ablation can decrease bleeding. Endometrial ablation can be performed for a variety.

Procedures Under Development

Several innovative options are being studied as possible alternative treatments for leiomyomas. Although all of these procedures may prove to be effective treatments for leiomyomas compared with current options, the number of patients treated.

Uterine artery embolization is a radiologic alternative to surgery that involves partial blockage of the uterine arteries and, thus, decreased blood flow to the leiomyomatous uterus. Several case series of embolizations have been reported, with 8-53 patients monitored for intervals of 3-20 months (3-5). These reports suggest that most patients have a significant decrease in bleeding symptoms, as well as a reduction in uterine size. However, uterine artery embolization may have serious consequences including infection, massive uterine bleeding, and uterine necrosis, requiring emergency surgery (6).

Abdominal Myomeetomy. Although early studies suggested the morbidity associated with myomectomy was increased compared with hysterectomy, more recent studies suggest that the risks of the two procedures are similar (12-14). However, women choosing myomectomy face the additional risks of recurrence of leiomyomas and the possibility of having to proceed with hysterectomy because of intraoperative complications.

There is less outcomes research available for myomectomy than there is for hysterectomy (15).

Laparoseopic Myomeetomy. There are a number of case series of laparoscopic myomectomies, the largest of them reporting on more than 200 patients covering a period in excess of 5 years (26-28). The two major concerns with laparoscopic myomectomy versus hysterectomy are the removal of large myomas through small abdominal incisions and the repair of the uterus. The introduction of more efficient morcellators has made the removal easier, although skilled operative technique is necessary because injury to other organs is possible. Although there are multiple techniques available for laparoscopic suturing.

Hysteroscopic Myomectomy. Several series of between 100 and 200 patients undergoing hysteroscopic myomec-tomies with good results have been published. In a series in which almost all patients were treated for menorrhagia, 16% of the submucosal resection group ultimately underwent a second surgery after a mean follow-up of 9 years.

Endometrial Ablation. Endometrial ablation appears to be an effective therapy for the control of menstrual bleeding in women with abnormal bleeding only. For leiomy-omas, one study suggested endometrial ablation had a failure rate of 40%.