Uterine leiomyomas: individualizing the approach to a heterogeneous condition.

Abstract

Uterine myomas (leiomyomas) are an important problem in women's health. Leiomyoma treatment has evolved significantly from the late 19th century when the Chairman's address to the American Medical Association's section on Obstetrics and Gynecology argued that myomectomy was “so dangerous and difficult as not to be thought of except in desperate conditions.”1 Although many alternatives to hysterectomy are widely used, hysterectomy remains the mainstay of treatment in the United States where approximately 200,000 hysterectomies for leiomyomas are performed annually2 with only a recent decline noted in hysterectomy use.3,4 In contrast, over the same timeframe, treatment of ectopic pregnancies and endometriosis has evolved from a time when every affected woman required major surgery to one in which minimally invasive surgical approaches and medical treatments predominate. Why does hysterectomy continue to dominate treatment for leiomyomas? A concrete impediment to innovation is the heterogeneity of disease in terms of size, location, growth trajectory, and symptomatology of leiomyomas. Symptomatic leiomyomas range from sizes small enough to not be palpable or visible by ultrasonography to ones large enough to distort a woman's abdominal contour mimicking pregnancy. Having a single therapy such as hysterectomy obviates the complicated decision-making brought on by a disease with many presentations. Myomas are a common phenotype representing many genotypes and somatic mutations leading to different symptoms and growth patterns; this makes recommendations for treatment more complex and individual. An analogous situation would be if Crohn's disease, ulcerative colitis, and celiac disease were not individually characterized so that all gastrointestinal disease seemed to have an unpredictable course. Our goal as leiomyoma researchers is to understand the biology of this diversity and provide evidence to guide individualized treatment for the future.