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PubMed2003

[Uterine fibroids--therapy from the point of view of the gynaecologist].

Uterine fibroids are the most common benign tumour affecting the female reproductive tract, 20% of all women older than 35 years are afflicted. Patients with fibroids tend to be asymptomatic, but fibroids may lead to meno-, metrorrhagia, hyper- and dysmenorrhoea and urination and defecation problems. If the fibroids do not cause any clinical symptoms and if there is no suspicion of a malignant tumor, there is no need for therapeutic intervention. Otherwise, besides the medical management with gestagenes and GnRH (gonadotropin-releasing hormone) analog, surgery represents the classical treatment. Hysterectomy is the common approach for women with completed family planning. For women who wish to conserve their fertility enucleation of the fibroids can be considered. These surgical procedures can be performed endoscopically or abdominally. Uterine artery embolisation, a radiological intervention, is less invasive and represents an interesting therapeutic alternative.

Adult↗
PubMedDate not supplied

Uterine fibroids: targeted embolization, an update on technique.

Uterine fibroid embolization has become an attractive alternative therapy for symptomatic uterine fibroids. Since its introduction, the applied embolization technique has undergone several refinements. Complete fibroid devascularization to block uterine arteries was the initial goal. Thereafter, more sophisticated techniques for targeted embolization of the fibroid to preserve cervical and vaginal branches and ovarian anastomosis were being performed by more and more interventionists. In addition, the use of calibrated embolic agents has become more and more popular. In this article we provide an update on the modern uterine fibroid, targeted embolization technique, including a summary of catheterization-related problems, flaws, and tricks.

Embolization, Therapeutic↗
PubMedDate not supplied

Laparoscopic ultrasound-guided radiofrequency ablation of uterine fibroids.

Four patients with symptomatic uterine fibroids measuring less than 6 cm underwent laparoscopic ultrasound-guided radiofrequency ablation (RFA) using multiprobe-array electrodes. Follow-up of the treated fibroids was performed with gadolinium-enhanced magnetic resonance imaging (MRI) and patients' symptoms were assessed by telephone interviews. The procedure was initially technically successful in 3 of the 4 patients and MRI studies at 1 month demonstrated complete fibroid ablation. Symptom improvement, including a decrease in menstrual bleeding and pain, was achieved in 2 patients at 3 months. At 7 months, 1 of these 2 patients experienced symptom worsening which correlated with recurrent fibroid on MRI. The third, initially technically successfully treated patient did not experience any symptom relief after the procedure and was ultimately diagnosed with adenomyosis. Our preliminary results suggest that RFA is a technically feasible treatment for symptomatic uterine fibroids in appropriately selected patients.

Adult↗
PubMed1992

The response of uterine fibroids to GnRH-agonist treatment can be predicted in most cases after one month.

Twenty-seven patients with uterine fibroids were treated for 3 months with the GnRH-agonist goserelin prior to surgical myomectomy. Ovarian function was suppressed reliably in all patients. After three applications, 15 fibroids were reduced in volume by more than 50%, and one complete remission was achieved. Seven patients showed a decrease of 10-50% in volume. However, in 5 cases there was no significant reduction. Analysing the time course of the fibroid reduction, the response can be predicted in most cases as early as four weeks after the first injection. Retrospective statistical analysis showed that a 50% reduction in fibroid size due to GnRH treatment is preceded by a 35% reduction after 4 weeks in 81% of cases, and after 8 weeks in all cases. Only 2 of 12 fibroids, which showed a smaller response (less than 50%) to GnRH therapy, were reduced by more than 35% after 4 and 8 weeks. In most cases it seems to be possible to estimate the individual response to GnRH-application after the first injection, so that it is possible to stop therapy in non-responding patients.

Buserelin↗
PubMed2005

A large inflammatory fibroid polyp of the colon treated by endoclip-assisted endoscopic polypectomy: A case report.

Inflammatory fibroid polyp is a rare benign polypoid lesion of the gastrointestinal tract. Histologically, inflammatory fibroid polyp is characterised by an admixture of numerous small vessels, fibroblasts and oedematous connective tissue, accompanied by marked inflammatory infiltration by eosinophils. A 40-year-old man visited our hospital for the purpose of colorectal screening due to a positive faecal occult blood test. A pedunculated and reddish polyp was found endoscopically in the ascending colon. The polyp was large but was resected endoscopically without any problems. Histologically, the abnormal tissue of the polyp was located in the submucosal and mucosal layer. Proliferation of spindle cells and infiltration of inflammatory cells, such as plasma cells and eosinophils, were observed. Immunohistochemically, the spindle cells were positive for CD34, which was localised in the cytoplasm. These cells were also positive for S100 protein but were negative for c-kit and muscle markers. These findings are compatible with the histological diagnosis of inflammatory fibroid polyp. The surgical margin of the polyp was free of the tumour. Inflammatory fibroid polyp is more commonly found in the stomach or small intestine, and rarely in the colon, and therefore our case is a rare example of large and pedunculated colonic inflammatory fibroid polyp, which was treated successfully by endoscopic polypectomy.

Adult↗
PubMed2005

Treatment of uterine fibroids by embolization--advantages, disadvantages, and pitfalls.

Uterine fibroids are the most common benign tumors of the female genital tract. Apart from vaginal or abdominal hysterectomy, which has been in use for more than 100 years, the more recently established techniques of laparoscopy and hysteroscopy provide two additional treatment approaches. In cases of symptomatic uterine fibroids, the most widely accepted alternative to surgery is the catheter-supported embolization of uterine arteries (uterine artery embolization, UAE). All patients who wish to be treated by UAE because of symptomatic fibroids should be presented to both gynecologists and radiologists. To the best of our knowledge, there are no interdisciplinary guidelines for UAE. Therefore, it would be very helpful if gynecologists and radiologists could reach an agreement for both indications and treatment strategies. However, there is no defined "gold standard" for fibroid therapy at all. In this respect, the therapeutic approach should be influenced less by the preference of the (potential) surgeon, and more by factors like size, localization, and number of fibroids. In addition, symptoms, ethnicity, and the wish to have children should be considered. Cooperation between radiologists and gynecologists is absolutely necessary, not only for the choice of the optimal treatment and care of patients, but also for the development of useful guidelines and future studies. UAE may be a therapeutic approach for selected patients. In these special cases, embolization is a safe and practical alternative to the established treatment options.

Adolescent↗
PubMed2004

[Uterine fibroids. Embolization: state-of-the-art].

Uterine artery embolization is a radiological procedure consisting in occluding the perifibroid arterial plexus to induce fibroid ischemia. To date, with more than 50,000 women treated worldwide, embolization seems to be a valuable alternative to hysterectomy and multiple myomectomies particularly in women with severe menorrhagia. Embolization should ideally be performed in case of intramural or submucosal uterine fibroids. It must be preferrably realized in case of multiple fibroids, be they intramural or submucosal (when hysteroscopic resection is not feasible). Complication rates are low if large calibrated microspheres are used to perform embolization and if pedunculated subserosal fibroids are excluded. In case of associated adenomyosis clinical recurrence seems more frequent. The role of embolization as an alternative to a single myomectomy, particularly in young women desiring future pregnancy remains a matter of debate and should be evaluated with clinical randomized trials. Pluridisciplinary management of women is the key to a widespread acceptance of uterine artery embolization in the management of uterine fibroids.

Adult↗
PubMed2005

Uterine artery ligation for management of uterine fibroids.

OBJECTIVE: To determine the efficacy of uterine artery ligation by the vaginal route for the management of symptomatic uterine fibroids. A pilot study had suggested that the procedure was effective. METHODS: After bilateral uterine artery ligation, ultrasonic measurements of uterine and fibroid volumes were determined at 6 and 12 months in 21 women (age, 31-49 years) with symptomatic fibroids. The severity of symptoms was assessed preoperatively and postoperatively. RESULTS: Mean uterine and fibroid volumes were significantly reduced at 6 and 12 months. A consistent pattern of decreased duration of menstrual blood flow was recorded. All participants who completed follow-up expressed satisfaction with treatment outcome. CONCLUSION: The procedure was found to be a safe, inexpensive, and effective therapeutic option for the treatment of symptomatic uterine fibroids.

Adult↗
PubMed2001

Laparoscopic bipolar coagulation of uterine vessels: a new method for treating symptomatic fibroids.

OBJECTIVE: To evaluate the effects of laparoscopic bipolar coagulation of uterine vessels in treating symptomatic fibroids. DESIGN: Prospective clinical study. SETTING: University-affiliated tertiary referral center. PATIENT(S): Eighty-seven women with symptomatic fibroids warranting surgical treatment and wanting to retain their uteri. INTERVENTION(S): Laparoscopic bipolar coagulation of uterine arteries and anastomotic sites of uterine arteries with ovarian arteries. MAIN OUTCOME MEASURE(S): Percentage reduction in the dominant fibroid size and clinical response evaluation. RESULT(S): Eighty-five (97.7%) of 87 patients underwent technically successful laparoscopic coagulation of uterine vessels without intraoperative complications. The mean follow-up time was 10.2 months. Symptomatic improvement was reported in 76 (89.4%) of 85 patients, including 18 (21.2%) with complete resolution of symptoms. Significant reductions in the dominant fibroid size (average, 76%) and the uterine volume (average, 46%) were sonographically demonstrated. Two patients conceived 4 and 9 months, respectively, after treatment. Three (3.5%) premenopausal women became postmenopausal postoperatively. CONCLUSION(S): Laparoscopic bipolar coagulation of uterine vessels appears to be a promising new method for treating fibroid-related menorrhagia and pelvic pain.

Adult↗
PubMed1995

Total and unbound cytosolic estrogen and progesterone receptors in myometrium and fibroid after gonadotropin-releasing hormone agonist treatment.

OBJECTIVE: To study the changes in bound and unbound cytosolic estrogen receptor (ER) and progesterone receptor (PR) in fibroid and myometrium after treatment with gonadotropin-releasing hormone agonists (GnRH-a). DESIGN: Prospective randomized study. SETTING: A tertiary institutional hospital. PATIENTS: Thirty premenopausal women with normal regular menstrual cycles and uterine fibroids. INTERVENTIONS: Patients were randomized to receive buserelin acetate for 3 months (n = 20) or no treatment (n = 10) before hysterectomy. MAIN OUTCOME MEASURES: Bound and unbound ER and PR. RESULTS: In nontreated women, values of unbound ER and PR in fibroid were higher than in myometrium. There were no differences in total receptors. The total and unbound ER in myometrium was higher in treated than in nontreated women. There were no differences in fibroid. CONCLUSIONS: The higher content of unbound hormone receptors in fibroid correlates with an exacerbation of the hormone dependence of this tissue compared with myometrium. The increase of total and unbound ER in myometrium after treatment suggests a higher level of synthesis or a lower level of degradation of receptors in this tissue.

Adult↗
PubMed1996

The effects of hormone replacement therapy on uterine fibroids in postmenopausal women.

OBJECTIVE: To evaluate and compare the effects of two different modalities of hormone replacement therapy (HRT) on the size of uterine fibroids. DESIGN: Randomized clinical study. SETTING: The Menopause Center of a public hospital. PATIENTS: Postmenopausal women with small asymptomatic uterine fibroids were selected. INTERVENTIONS: One group was treated with 50 micrograms transdermal E2 plus 5 mg medroxyprogesterone acetate (MPA) continuously, whereas the second group was given 0.625 mg conjugated equine estrogen plus 2.5 mg MPA continuously. MAIN OUTCOME MEASURE: The size of the uterine fibroids was measured before and after the first year of HRT. RESULTS: At the end of the first year on HRT, the size of the uterine fibroids was re-evaluated sonographically and no significant difference was found with the oral group, whereas there was a significant increase in the transdermal group. CONCLUSION: Hormone replacement therapy with 50 micrograms transdermal E2 plus 5 mg MPA increases the size of the uterine fibroids.

Antineoplastic Agents, Hormonal↗
PubMed2002

The effect on menstrual blood loss in women with uterine fibroids of a novel "frameless" intrauterine levonorgestrel-releasing drug delivery system: a pilot study.

OBJECTIVE: To evaluate the effect on menstrual blood loss, in women with uterine fibroids, of a novel "frameless" intrauterine drug delivery system (IUS), FibroPlant-levonorgestrel (LNG), releasing 14 microg of LNG per day. STUDY DESIGN: An open label, non-comparative ongoing pilot study. Fourteen insertions were performed in premenopausal women between 39 and 48 years of age for the treatment of menorrhagia. The effect on menstrual blood loss was evaluated using a simple visual assessment technique. Women were followed-up for at least 12 months (range 12-30 months). RESULTS: At the time of study analysis the total number of women-months was 283. All women, except one reported greatly reduced bleeding. In two women, the treatment failed although both reported reduced bleeding. One failure (patient no. 4) was due to the presence of a large endometrial polyp. This patient underwent hysterectomy. The other women (patient no. 1) had submucosal fibroids. She refused hysterectomy and is continuing treatment. In the other 12 patients, reduction of bleeding was appreciable after one month of treatment and tended to decrease further over the next months to stabilize afterwards. The mean bleeding score before treatment was 465 (185-960) and dropped to a mean score of 100 (range 5-300) after a minimum of 12 months of treatment which is highly statistically significant (P<0.001). In eight women, the bleeding reduced to very low scores. An effect on the size of the uterine fibroids could not be demonstrated. Significant spotting was rare after the first 3 months following insertion. Neither complications (e.g. infection, expulsion or perforation) nor pregnancies occurred. The FibroPlant-LNG IUS was well tolerated by all women involved in the study and no systemic hormonal side effects were reported. CONCLUSION: This study suggests that FibroPlant-LNG IUS is effective to significantly reduce the amount of menstrual blood loss in women with menorrhagia in the presence of intramural and subserosal fibroids and can avoid surgery. The strong endometrial suppression is the principal mechanism explaining the effect on menstrual blood loss of the IUS. The two failures probably explain that a successful treatment in women with endometrial abnormalities (e.g. polyps, submucous fibroids) is unlikely with the IUS. The low daily release rate of LNG from the FibroPlant-LNG IUS results in a low incidence of hormonal side effects. The simple design characteristics and revolutionary anchoring system account for minimizing the occurrence of complaints of pain and expulsion. The flexible fibrous delivery system adapts to cavities of every size even when severely distorted.

Adult↗
PubMed1998

Other medical management of uterine fibroids.

Several medicines are emerging with the potential to treat symptomatic uterine fibroids. Anti-progesterone compounds seem particularly promising. These drugs have been widely used for nearly 20 years and are known to be safe; medical politics have prevented their proper investigation for uterine fibroids. In particular, the value of mifepristone, 50 mg per day for 3 months, seems particularly promising. Further investigation is clearly warranted for this medicine. Several anti-oestrogen compounds have recently become available and may also be useful for the medical treatment of symptomatic uterine fibroids. This includes the possibility of the use of selective oestrogen receptor modulators as well as the prospect of the use of pure anti-oestrogens. On a longer time frame, inhibitors of angiogenesis may be useful. These medicines would act upon the blood supply to uterine fibroids. Physicians also have an obligation to investigate scientifically any promising naturopathic treatment that appears to have possible activity for symptomatic fibroids.

Androgens↗
PubMed2006

Ultrasonographic evaluation of the change in uterine fibroids induced by treatment with a GnRH analog.

OBJECTIVE: To investigate the change in volume of uterine fibroids after GnRH analog (GnRHa) treatment. MATERIALS AND METHODS: Twenty-five patients who had a uterine leiomyoma were included in this study. Four of them were lost to follow-up during the study, and a myomectomy was performed on the remaining subjects. All of these patients received two doses, 4 weeks apart, each of 3.75 mg leuprorelin acetate subcutaneously (Leuplin depot, a GnRHa) before the operation. The vascularization index (VI), flow index (FI), vascularization-flow index (VFI), pulsative index (PI), resistance index (RI), vascular patterns (histogram), blood flows, and sizes (volume and largest diameter) of each fibroid were measured with power Doppler by the same technician every month before the operation. In addition, the total blood loss and time required for each operation were also recorded. RESULTS: Results of this study showed that the volume of the uterus and the fibroids, but not the vascularity, including VI, FI, VFI, PI and RI, decreased significantly after two doses of GnRHa treatment. In addition, blood loss during the operation decreased significantly compared to an untreated group. CONCLUSION: We found that the volumes of the uterus and fibroids decreased significantly after treatment with two consecutive doses (given a month apart) of GnRHa. The 3D color Doppler including a histogram and blood flow parameters is another useful tool for fibroid evaluation.

Adult↗
PubMed1999

Initial results from uterine fibroid embolization for symptomatic leiomyomata.

PURPOSE: To evaluate the safety and short-term efficacy of uterine fibroid embolization (UFE) in patients with symptomatic uterine fibroids. MATERIALS AND METHODS: Bilateral UFE was performed in 61 patients with symptomatic uterine leiomyomata during a 16-month period. Imaging was performed before the procedure and at 3 months and 1 year after the procedure. Questionnaires were obtained at regular intervals after the procedure to assess patient outcome. RESULTS: All procedures but one were technically successful. Mean clinical follow-up was 8.7 months. Minor complications occurred in five patients during the follow-up period. All were treated without permanent sequelae. Menstrual bleeding was improved in 89%, with 81% of patients moderately to markedly improved. Pelvic pain and pressure was improved in 96% of patients, with moderate to marked improvement in 79%. At initial imaging follow-up (mean, 4.4 months postprocedure), median uterine volume decreased 34% (P = .0001) and the median dominant fibroid volume decreased 50% (P = .0001). Imaging at 1 year (mean, 12.3 months) after the procedure showed continued reduction with a median uterine volume reduction of 48% (P = .0002) and median dominant fibroid volume decrease of 78% (P = .0002). CONCLUSION: In the authors' initial clinical experience, UFE appears effective in controlling symptoms and substantially reducing fibroid volume with few complications.

Adult↗
PubMed1996

Cryomyolysis in the Conservative Treatment of Uterine Fibroids

Conservative surgical options for uterine fibroids are abdominal myomectomy, laparoscopic myomectomy, and, more recently, myolysis. Another option for the conservative surgical treatment of fibroids is freezing the structures. This procedure, cryomyolysis, can be performed rapidly by laparoscopic or hysteroscopic access. We performed a pilot study of 14 women with uterine fibroids. All were pretreated with a gonadotropin-releasing hormone (GnRH) agonist for 3 months to reduce uterine and myoma size. Cryomyolysis was performed in each, and the GnRH agonist was discontinued. Magnetic resonance imaging scans were performed in 10 of the 14 women after GnRH agonist treatment 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, for a mean increase of 22%. Normal uterine volume ranged from 35.6 to 548.7 ml preoperatively and 45.1 to 729.6 ml postoperatively, for a mean increase of 40%. Myoma volume showed a mean decrease of 6% (range 87-28%). Analysis of frozen fibroids revealed a mean volume decrease of 10%. We conclude that cryomyolysis is able to maintain (or slightly reduce) the uterine fibroid at its post-GnRH agonist size, whereas all other uterine tissues return to pretreatment size.

Journal Article↗
PubMed2005

Effect of inner myometrium fibroid on reproductive outcome after IVF.

To evaluate the influence of inner myometrium fibroids (myomas) on the outcome of IVF cycles, a retrospective agematched controlled study was performed at SISMeR Reproductive Medicine Unit. The study group included 129 IVF/intracytoplasmic sperm injection cycles in 75 patients with one or more intramural and/or submucosal fibroids, while the control group consisted of 129 cycles in 127 patients without fibroids. The two groups were similar for mean oestradiol concentration at human chorionic gonadotrophin administration (1205.16 +/- 874 versus 1395 +/- 821 pg/ml), mean number of transferred embryos (2.02 +/- 0.4 versus 2.14 +/- 0.6) and clinical pregnancy rate (34.9 versus 41.1%). Conversely, the implantation rate was significantly lower in the study group (18.0%) than in the control group (26.5%; chi(2) = 4.81, P < 0.05), whereas the rate of spontaneous abortion demonstrated an opposite trend (40 versus 18.9%; chi(2) = 4.34, P < 0.05). Further research should be aimed at classifying fibroids on the basis of their location, especially when they are positioned in the junctional zone of the myometrium. Whether this classification will be superior in predicting the impact of fibroids on the reproductive outcome should be elaborated in a large multicentric study.

Abortion, Spontaneous↗
PubMed2006

New treatments for uterine fibroids.

Since the introduction of uterine artery embolization as a minimally invasive treatment option for uterine fibroids, there has been a great deal of effort made toward developing other options for these patients. These options approach the problem differently, either with direct targeting of individual fibroids, organ-wide targeting of multiple fibroids, and systemic therapy to address the problem of fibroids using a hormonal approach. This review will focus on the different techniques and different philosophies that have been applied to the treatment of fibroids during the past decade.

Catheter Ablation↗