Uterine fibroid management: from the present to the future.

Jacques Donnez,Marie-Madeleine Dolmans

doi:10.1093/humupd/dmw023

Abstract

Uterine fibroids (also known as leiomyomas or myomas) are the most common form of benign uterine tumors. Clinical presentations include abnormal bleeding, pelvic masses, pelvic pain, infertility, bulk symptoms and obstetric complications.Almost a third of women with leiomyomas will request treatment due to symptoms. Current management strategies mainly involve surgical interventions, but the choice of treatment is guided by patient's age and desire to preserve fertility or avoid ‘radical’ surgery such as hysterectomy. The management of uterine fibroids also depends on the number, size and location of the fibroids. Other surgical and non-surgical approaches include myomectomy by hysteroscopy, myomectomy by laparotomy or laparoscopy, uterine artery embolization and interventions performed under radiologic or ultrasound guidance to induce thermal ablation of the uterine fibroids.There are only a few randomized trials comparing various therapies for fibroids. Further investigations are required as there is a lack of concrete evidence of effectiveness and areas of uncertainty surrounding correct management according to symptoms. The economic impact of uterine fibroid management is significant and it is imperative that new treatments be developed to provide alternatives to surgical intervention.There is growing evidence of the crucial role of progesterone pathways in the pathophysiology of uterine fibroids due to the use of selective progesterone receptor modulators (SPRMs) such as ulipristal acetate (UPA). The efficacy of long-term intermittent use of UPA was recently demonstrated by randomized controlled studies.The need for alternatives to surgical intervention is very real, especially for women seeking to preserve their fertility. These options now exist, with SPRMs which are proven to treat fibroid symptoms effectively. Gynecologists now have new tools in their armamentarium, opening up novel strategies for the management of uterine fibroids.

Highlights

Uterine fibroids are the most common form of benign uterine tumors (Stewart, 2001; Donnez and Jadoul, 2002; Bulun, 2013; Islam et al, 2013; Drayer and Catherino, 2015). They are monoclonal tumors of uterine smooth muscle, originating from the myometrium (Kim and Sefton, 2012; Bulun, 2013; Islam et al, 2013). They are composed of large amounts of extracellular matrix (ECM) containing collagen, fibronectin and proteoglycans (Parker, 2007; Sankaran and Manyonda, 2008; Kim and Safton, 2012)
Leiomyomas occur in 50–60% of women, rising to 70% by the age of 50 (Baird et al, 2003), and, in 30% of cases, cause morbidity due to abnormal uterine bleeding and pelvic pressure (Donnez and Jadoul, 2002; Donnez et al, 2014a,b)
Several non-controlled studies have suggested that myomectomy yields a decrease in the miscarriage rate in women with myomas distorting the uterine cavity (Saravelos et al, 2011; Bernardi et al, 2014; Parazzini et al, 2015).In a review of prospective and retrospective studies, Donnez and Jadoul reported a pooled pregnancy rate of 49% in patients who underwent laparoscopic myomectomy (Donnez and Jadoul, 2002)

Summary

Introduction

Uterine fibroids ( known as leiomyomas or myomas) are the most common form of benign uterine tumors (Stewart, 2001; Donnez and Jadoul, 2002; Bulun, 2013; Islam et al, 2013; Drayer and Catherino, 2015). Benefits include a resolution of preoperative anemia (Donnez et al, 1989; Lethaby et al, 2001; Stamatellos and Bontis, 2007; Doherty et al, 2014); a decrease in fibroid size (Donnez et al, 1989; Lethaby et al, 2001); a reduction of endometrial thickness and vascularization with subsequently improved visibility and reduced fluid absorption (Donnez and Jadoul, 2002; Metwally et al, 2011; Doherty et al, 2014) and the possibility of surgical scheduling (Donnez et al, 1990; Donnez and Jadoul, 2002; Pritts, 2001; Pritts et al, 2009) This preoperative treatment is associated with post-injection endometrial bleeding due to the flare-up effect. Future clinical trials should focus on prevention strategies, such as preventing occurrence in women genetically predisposed to this condition, and avoiding recurrence after surgery in women at high risk (i.e. those of a young age or with a family history) (Fig. 14)

Conclusion

Findings

Conflicts of interest