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PubMed2006

New uterine-preserving therapies raise questions about interdisciplinary management and the role of surgery for symptomatic fibroids.

Mounting evidence to support the safety and effectiveness of new uterine-preserving fibroid therapies is raising questions not only about changing indications for surgery but also about gynecologists' role in therapies offered by other specialists. New collaborative relationships are needed to provide the best possible treatment; without them, those lag times of 10-15 years often cited as the time it takes for advances in clinical research to diffuse into clinical practice will be even longer for women with symptomatic fibroids.

Cooperative Behavior↗
PubMed2006

[Uterine embolization for submucous fibroid: a bad alternative to surgery?].

A case of septic expulsion of a leiomyoma is reported 18 weeks after uterine artery embolisation (UAE). The patient underwent UAE for a symptomatic sub-mucous leiomyoma (type 2) of 5 cm. She was feverish and presented pelvic pain and purulent vaginal discharges. Vaginal examination revealed a necrotic mass prolapsed through the cervix that was carefully twisted out. Histopathologic examination showed extensive necrosis of the myomatous tissue. Microbiologic cultures showed heavy growth of Escherichia coli. Such findings challenge the interest and the safety of UAE for sub-mucous fibroids. Our case report stresses that uterine artery embolisation for submucous fibroids does not constitute, because of its risks, an alternative to conventional surgical treatment represented mainly by hysteroscopic resection.

Embolization, Therapeutic↗
PubMed1990

Neodymium: YAG laser hysteroscopy in large submucous fibroids.

The preoperative use of a potent, subcutaneously injected gonadotropin-releasing hormone agonist (GnRH-a) was evaluated in a series of 60 women with large submucosal fibroids. Myomectomy by hysteroscopy and Nd:YAG laser was easily performed. In 12 cases, the largest portion of the myoma was not inside the uterine cavity and myomectomy was carried by a two-step hysteroscopy. In women who wished to become pregnant, a pregnancy rate of 66% was achieved. Advantages of preoperative use of a GnRH-a are (1) the significant decrease of the fibroid size, (2) a lower fluid absorption, and (3) the restoration of a normal hemoglobin concentration.

Adult↗
PubMed2001

Uterine artery embolization in a 10-week cervical pregnancy with coexisting fibroids.

A 36-year-old woman, gravid 3, para 1, abortus 1, was admitted to our department at 10 weeks and 4 days of gestation with the diagnosis of cervical pregnancy and multiple uterine fibroids. After admission she underwent angiographic embolization of bilateral uterine arteries followed by intraamniotic 70-mg methotrexate injection. Despite being given a second dose of methotrexate injection 1 week later, the gestational sac did not resolve spontaneously, thus vacuum evacuation and curettage of the cervical canal was required on the 15th day of embolization. The patient was discharged in good condition. She had no complaints by post-operative at month 11, except amenorrhea. Her uterine fibroids markedly decreased in size after the procedure. As a result, embolization of uterine arteries provided surgical evacuation of cervical pregnancy with minimal hemorrhage, and the patient's potential fertility was preserved, but a long-term amenorrhea was observed.

Abortifacient Agents, Nonsteroidal↗
PubMed2001

Uterine fibroids.

Uterine leiomyomas (fibroids or myomas), benign tumours of the human uterus, are the single most common indication for hysterectomy. They are clinically apparent in up to 25% of women and cause significant morbidity, including prolonged or heavy menstrual bleeding, pelvic pressure or pain, and, in rare cases, reproductive dysfunction. Thus, both the economic cost and the effect on quality of life are substantial. Surgery has been the mainstay of fibroid treatment, and various minimally invasive procedures have been developed in addition to hysterectomy and abdominal myomectomy. Formation of new leiomyomas after these conservative therapies remains a substantial problem. Although medications that manipulate concentrations of steroid hormones are effective, side-effects limit long-term use. A better approach may be manipulation of the steroid-hormone environment with specific hormone antagonists. There has been little evidence-based evaluation of therapy. New research into the basic biology of these neoplasms may add new treatment options for the future as the role of growth factors and genetic mutations in these tumours are better understood.

Abdominal Pain↗
PubMed1984

Inflammatory fibroid polyp of the rectum.

A case of inflammatory fibroid polyp of the rectum in an 8 years old boy is reported. This lesion is not infrequently found in the gastro-intestinal tract, is very rare in childhood and has never been reported in the rectum. The pathogenetical hypothesis that fibroid represents a dynamic response to recurrent small injuries with possible different histological patterns is prospected.

Child↗
PubMed2001

Therapeutic failure of uterine fibroid embolization caused by underlying leiomyosarcoma.

The authors describe an unusual case in which continued growth of uterine fibroids in a postmenopausal patient after polyvinyl alcohol embolization therapy prompted hysterectomy, which revealed an underlying leiomyosarcoma. The surgery was nearly fatal as a result of venous bleeding, and parasitization of blood from adjacent bowel by the tumor was noted. The difficulty of preoperative diagnosis of leiomyosarcoma and the need for diligent follow-up after uterine fibroid embolization are discussed.

Embolization, Therapeutic↗
PubMed1998

Experience with collaborative management of symptomatic fibroids by gynecology and interventional radiology.

Objective: The purpose of this paper is to review the initial collaborative experience of a gynecologist and an interventional radiologist in the utilization of embolotherapy in the management of symptomatic uterine myomas.Methods: One hundred five consecutive subjects treated by embolotherapy were selected for review. All patients derived from a single gynecologic practice and were evaluated by the same examiner, using standardized criteria. Embolotherapy was carried out in all subjects by the same interventional radiologist using 500-700 µm polyvinyl alcohol particles injected bilaterally into the uterine arteries utilizing uniform technique and endpoints.Results: Size reduction of 20-85% confirmed by follow-up ultrasound was achieved. Ninety percent of patients noted improvement in their overall symptoms. Eighty percent of patients were able to resume normal activity 4 days after therapy, the remainder of 20% within 2 weeks. One patient subsequently underwent hysterectomy. At 1-year follow-up, changes in size and menorrhagia persisted.Conclusion: The collaborative treatment of fibroids by gynecologists and interventional radiologists appears to offer an effective alternative to women with symptomatic uterine fibroids.

Journal Article↗
PubMed1996

Extraperitoneal Laparoscopic Hysterectomy for Fibroid Uteri

The feasibility of dividing the uterine arteries laparoscopically using the extraperitoneal technique for laparoscopic hysterectomy to remove large (&gte;500 g) fibroid uteri was assessed in a retrospective review. Over 9 months, 24 women underwent extraperitoneal laparoscopic hysterectomy for a fibroid uterus. Additional procedures were performed in five patients: one colposuspension, one pelvic lymphadenectomy, and three pelvic and aortic lymphadenectomies. In 14 cases the uterus weighed 500 g or more (mean 847 g), 5 weighed 0.7 to 1.0 kg, and 3 weighed 1 kg or more. One patient had pelvic and another had pelvic plus aortic lymphadenectomy in addition to hysterectomy. Two (14%) women required transfusion. Twenty-five (89%) of 28 uterine arteries were divided laparoscopically; both arteries in 12 patients, one artery in 1 patient, and neither artery in 1. None of the women in whom both uterine arteries were divided required transfusion, whereas both in whom one or both arteries were divided vaginally did. In most patients undergoing a laparoscopic hysterectomy by the extraperitoneal technique, both uterine arteries can be divided laparoscopically, and the procedure seems to reduce blood loss.

Journal Article↗
PubMed1996

Fertility Outcome after Outpatient Hysteroscopic Removal of Endometrial Polyps and Submucous Fibroids

We assessed the value of hysteroscopic removal of polyps and submucous fibroids from women requesting fertility treatment. Between December 1991 and June 1995 we recruited 146 women (age 28-44 yrs) with such lesions who were undergoing investigations for in vitro fertilization (IVF). In most of them, intrauterine pathology was not the sole cause of subfertility. In all women the lesions were diagnosed by hysterosalpingography or vaginal ultrasound examination with fluid instillation and subsequent hysteroscopy. In 122 patients the lesion was removed hysteroscopically with the resectoscope under light sedation in an outpatient setting. No complications occurred during or after surgery. The remaining 24 patients with polyps smaller than 2 cm underwent IVF treatment directly. In the 122 women who proceeded to treatment, further diagnostic office hysteroscopy was also performed. Group A consisted of 82 women with up to three polyps (65 <2 cm, 17 >2 cm); group B, 40 women with up to five fibroids smaller than 4 cm; and group C, 24 women with ultrasound diagnosis of polyps smaller than 2 cm for whom no treatment was carried out. In groups A and B the diagnosis was confirmed histologically. All these women subsequently underwent IVF. In group A (<2 cm polyps) the pregnancy rate was 28% per embryo transfer, and in the rest of group A (>2 cm) it was 40%. In group B the pregnancy rate was 46% and in group C 35%. We think that polyps less than 2 cm diameter do not require removal before IVF and do not affect the outcome of the subsequent pregnancy.

Journal Article↗
PubMed1998

Cryomyolysis, a new procedure for the conservative treatment of uterine fibroids.

Conservative surgical options for uterine myomata traditionally were abdominal myomectomy, laparoscopic myomectomy, and, more recently, myolysis. Each of these procedures has distinct advantages, but also apparent disadvantages. We attempted to introduce an additional option for conservative surgical treatment of fibroids by freezing the structures, a procedure termed cryomyolysis. In this pilot study, 14 women were pretreated with a gonadotropin-releasing hormone (GnRH) agonist for a minimum of 2 months preoperatively to minimize uterine and myoma size. Cryomyolysis was performed and the GnRH agonist was discontinued. Magnetic resonance imaging scans were performed in 10 of the 14 women after GnRH agonist treatment but before surgery, and 4 months postoperatively. Total uterine volume ranged from 41.3 to 1134.8 ml preoperatively, and 49.5 to 1320 ml postoperatively (mean increase 22% after discontinuation of GnRH agonist). Normal uterine volume ranged from 35.6 to 548.7 ml preoperatively and 45.1 to 729.6 ml postoperatively (mean increase 40%); however, myoma volume showed a mean decrease of 6% (range -87-28%). Analysis of only frozen myomata revealed a mean volume decrease of 10%. Cryomyolysis maintains at or slightly reduces these lesions to post-GnRH agonist size, and all other uterine tissue returns to pretreatment size. We believe cryomyolysis may be an effective conservative surgical approach to uterine fibroids.

Adult↗
PubMed1997

Diagnostic efficacy of compressed digitized real-time sonography of uterine fibroids.

RATIONALE AND OBJECTIVES: The authors investigated the diagnostic efficacy of compression of real-time ultrasound (US) examinations. METHODS: Low- and high-compression recordings (9:1 and 15:1, respectively) of examinations were generated by using Joint Photographic Experts Group algorithms. Seven radiologists used a five-level response scale to answer questions about the presence, number, and location of focal fibroid tumors in 67 randomly sorted uterine examinations. The images were viewed after no, low, and high compression. Results were evaluated by using multipatient, multireader receiver operating characteristic jack-knife analysis. RESULTS: Given the reduction in the US digital video rates from 74 Mbit/sec for uncompressed images to 8 Mbit/sec for low compression and 4.7 Mbit/sec for high compression, there were no statistically significant differences in accuracy between the compression schemes. Confidence intervals suggested that the sample size was adequate. CONCLUSION: Compressed images with compression ratios of 9:1 and 15:1 were diagnostically equivalent to uncompressed images of uterine fibroid tumors.

Female↗
PubMed2004

The effects of hysterectomy on sexual arousal in women with a history of benign uterine fibroids.

Research indicates hysterectomy surgery may adversely affect the pelvic autonomic nerves and autonomic mechanisms are integral to the sexual arousal response in women. This study explored the possibility that women who undergo hysterectomy may experience an impaired vasocongestive response to erotic stimulation. Thirty-two women with a history of benign uterine fibroids who had ( n = 15) or had not ( n = 17) undergone hysterectomy participated in two experimental sessions in which self-report and physiological (vaginal pulse amplitude; VPA) sexual responses were recorded during an erotic film presentation. In one of the sessions, the women exercised on a treadmill for 20 min prior to viewing the erotic films as a means inducing autonomic arousal. Exercise significantly increased VPA but not subjective sexual responses in both groups of women. VPA responses were marginally higher among the fibroid than hysterectomy group in the no-exercise condition. The hypothesis that physiological sexual arousal may be impaired with hysterectomy surgery was only partially supported.

Adult↗
PubMed2003

Diagnostic value of sonohysterography in the evaluation of submucosal fibroids and endometrial polyps.

AIMS: To evaluate the diagnostic value of sonohysterography in the evaluation of submucosal fibroids and endometrial polyps. METHODS: Thirty-two women whose preliminary transvaginal ultrasound suggested endometrial abnormality underwent sonohysterography. The findings were then compared with histopathological results. RESULTS: The sonohysterographic diagnosis was fibroid in seven patients, endometrial polyp in 23 patients and simple hyperplasia in two patients. Histopathological findings confirmed our diagnosis in all except three patients with endometrial polyps, who had normal secretory endometrium. Sonohysterography was found to have a sensitivity of 100%, a positive predictive value of 90% and diagnostic accuracy of 90.6%. CONCLUSION: Sonohysterography is a useful, minimally invasive and accurate technique to evaluate the pathologies involving endometrium and uterine cavity.

Adult↗
PubMed2002

Cost effectiveness of pre-operative gonadotrophin releasing analogues for women with uterine fibroids undergoing hysterectomy or myomectomy.

OBJECTIVE: To conduct a cost effectiveness analysis of pre-operative gonadotrophin releasing hormone agonists (GnRHa) in women with uterine fibroids undergoing hysterectomy or myomectomy. DESIGN: A cost effectiveness analysis using the effectiveness data from a systematic review of GnRHa. SETTING: Secondary care. SAMPLE: Women with uterine fibroids undergoing hysterectomy or myomectomy and women volunteers. METHODS: Effectiveness data were used from a systematic review to construct a model and to calculate the cost per surgical outcome avoided. In order to evaluate the value women place on the outcome, a willingness to pay analysis of women volunteers was undertaken. MAIN OUTCOME MEASURES: (a) The cost of avoiding abdominal hysterectomy and the cost of avoiding a vertical incision at either hysterectomy or myomectomy; (b) The value that women place on avoiding abdominal hysterectomy and on avoiding a vertical incision at either hysterectomy or myomectomy. All costs are in NZ dollars. RESULTS: For hysterectomy, the additional cost of treatment with GnRHa was NZ$1190 per case. The cost of avoiding one abdominal procedure was NZ$4577 per case and the cost of avoiding one vertical incision was NZ$6263. For a myomectomy, the additional cost of treatment with GnRHa was NZ$1535 per case. The cost of avoiding one vertical incision was NZ$4651 per case. These costs exceeded the benefit women placed on the outcomes. CONCLUSION: Although the pre-operative use of GnRHa results in benefits which include less frequent abdominal incisions in the case of hysterectomy and less frequent vertical incisions in the case of myomectomy, the benefits do not justify the costs. This study highlights the importance of considering both the benefits and costs in health care decisions.

Cost-Benefit Analysis↗
PubMed2002

I. Uterine fibroid embolization: preprocedure assessment.

Increasing clinical experience with uterine fibroid embolization (UFE) has improved the ability of interventionalist radiologists to discern who is and who is not an appropriate candidate for this procedure. Initial evaluation should be directed at obtaining answers to the following key questions: (1) Does the patient have uterine fibroids that account for her symptoms and are they severe enough to require invasive treatment? (2) Does she desire future childbearing? (3) Are there any clinical indications or imaging signs of uterine malignancy? (4) Are there any medical or anatomic features that would favor a particular therapeutic modality? (5) What are her own preferences regarding treatment? Ultrasound and magnetic resonance imaging are vital elements to the assessment and planning of the appropriate course of action. Given the lack of prospective comparative trials between UFE and surgical treatment, recommendations are often highly influenced by patient preference.

Embolization, Therapeutic↗