Uterine fibroids cause clinical symptoms such as increased menstrual flow, abnormal uterine bleeding, infertility, and abdominal pain due to fibroid compression and degeneration. For a long time, the combination of various minimally invasive surgical options and traditional treatment methods has greatly improved the clinical outcome of fibroid treatment. The standardized treatment of uterine fibroids is of great significance to better grasp the indications of various treatment methods, improve the clinical treatment effect, and realize the humanistic and individualized treatment mode.
Uterine fibroids are solid tumors that occur in the body and neck of the uterus. They have become a very common disease in gynecological clinics due to their high incidence and the large number of people affected. The clinical symptoms caused by fibroids, such as increased menstrual flow, abnormal uterine bleeding, infertility and abdominal pain due to fibroid compression and degeneration, have greatly affected the physical and mental health and quality of life of many patients. For a long time, new procedures and methods for the treatment of uterine fibroids have been introduced, and the treatment pathways have developed from traditional transabdominal and transvaginal to hysteroscopic and laparoscopic, and various types of minimally invasive interventions and new use of original drugs, showing a “diversified” trend in clinical practice. The combination of various minimally invasive surgeries and traditional treatment methods has greatly improved the clinical outcome of myoma treatment while changing the limitations and shortcomings of the previous single treatment mode. In the face of the “blossoming” of clinical treatment, it is significant to discuss the standardized treatment of uterine fibroids to better grasp the indications of various treatment methods, improve the clinical treatment effect, and realize the humanistic and individualized treatment mode.
1. Emphasize the principle of standardization of surgical treatment
As with other solid tumors, surgery plays a pivotal role in the treatment of uterine fibroids. Surgery is the main choice for the treatment of uterine fibroids as it can eliminate the fibroids or remove the uterus and quickly relieve the clinical symptoms produced by the fibroids. In recent years, with the popularization of minimally invasive surgery, surgical treatment via hysteroscopic, laparoscopic and transvaginal routes are widely used for the surgical treatment of fibroids, especially hysterectomy in a minimally invasive environment, with the advantages of less trauma and faster recovery. Exactly how to choose the surgical method for uterine fibroids treatment, which truly reflects the concept of minimally invasive treatment, cures the disease while maximizing the protection of organ function and reducing damage to the human body, deserves further discussion.
1.1 It is not necessary to remove organs to treat fibroids
Since the 1950s, hysterectomy has been widely used as a routine surgical treatment for uterine fibroids. In the United States, 40% of the 600,000 hysterectomies performed each year are due to fibroids; in China, where the population base is much larger than in the United States, there are about 2.8 million total hysterectomies each year, more than half of which are due to fibroids. Removal of the uterus is equivalent to stopping the growth of fibroids at the source, eliminating the worry of future recurrence and malignancy, which is known as the “radical” treatment of fibroids. However, the loss of the uterus, a unique female organ, brings physiological and psychological trauma to the patient as well, especially in today’s world of higher quality of life requirements. In recent years, the role of the uterus for women is not only “to nurture the fetus and reproduce”, but also to maintain the anatomical function of the female pelvic floor and to prevent pelvic organ bulging. Clinical studies have shown that removal of the uterus, bulging of the posterior vaginal wall and excessive decline of the pelvic floor can cause defecation disorders in women; disconnection of the uterine ligaments and destruction of the parametrial tissues can lead to impaired innervation of the bladder and rectum and may alter the overall structure and physiology of the pelvic floor. Hysterectomy may cause a decrease in the blood supply to the ovaries, which in turn may affect ovarian function. The uterus has an endocrine role. The endometrium secretes prostaglandins, prolactin, as well as insulin-like growth factor, epithelial growth factor, and many other substances; at the same time, the endometrium is rich in estrogen and progesterone receptors, which play a major role in achieving endocrine regulation of the hypothalamic-pituitary-ovarian-uterine system. The role of uterine nerve transmission in maintaining the female sexual reflex arc is of concern; and the psycho-spiritual impact of hysterectomy on women and the risk of surgical damage to the vesicoureter cannot be ignored. In view of this, the choice of hysterectomy for uterine fibroids should be weighed against the advantages and disadvantages of organ preservation and clear indications. Suitable options for hysterectomy: rapid growth of perimenopausal fibroids and suspected malignancy. Myomas continue to grow after menopause. Malignant fibroids. Patients with multiple myomas without fertility requirements, large size and causing relevant clinical symptoms, and cancer-phobic patients requiring resection.
1.2 Pay attention to the protection of function when “removing tumors
As with other benign tumors, it is reasonable to request organ preservation while treating fibroids, especially for young patients with fertility requirements; even for older patients without fertility requirements, it is understandable that they do not want to remove the uterus. It can be said that there are almost no contraindications to myomectomy, unless the fibroid is malignant; it can also be said that there is no myomectomy that cannot be completed, unless it is not a fibroid. This summarizes the indications for surgery: all patients with fibroids who have fertility requirements. Patients with fibroids who wish to preserve the uterus. To rule out myoma malignancy, etc.
While preserving the uterus, the main focus of myomectomy is the preservation of uterine function, including anatomical morphology and physiological function, especially in young, non-childbearing patients. The incision design should be appropriately far away from the root of the fibroid so that the myometrium and endometrium can be restored to their original position after removal of the fibroid. Type II and interstitial myoma, with a wide base, can be removed by cutting the mucosa and muscle layer covered by the myoma with needle-like electrodes to avoid the destruction of the electrodes; during surgery, the myoma can be “loosened” from the envelope with the help of hysteroscopic pressure and irrigation medium, and the tumor can be removed after protruding into the uterine cavity. It is important to emphasize that for hysteroscopic surgery, the cutting depth of the buried interstitial fibroids should reach the level of the uterine wall, and the remaining fibroids should be removed after the contraction of the uterus to the uterine cavity, not by “digging” the fibroids into the uterine wall with the action of electrodes to avoid hemorrhage and uterine perforation. When removing interstitial fibroids, the suture alignment of the tumor cavity is the key to reducing the risk of rupture of the pregnant uterus, regardless of the surgical method, the suture must emphasize the accurate closure of the invasive surface; laparoscopic surgery for tumor cavity bleeding should be minimized by electrocoagulation to avoid local tissue necrosis resulting in muscle wall defects. For multiple myoma resection, the alignment of the cavity and suture hemostasis are extremely important to ensure the functional recovery of the uterus and need to be given high priority during surgery.
1.3 Trade-offs in the choice of procedure
The choice of surgical procedure for the treatment of fibroids, whether myomectomy or hysterectomy, is one of the components of surgical standardization. The choice of laparoscopic (including laparoscopic-assisted negative surgery, laparoscopic total hysterectomy, etc.), transcatheter, or transabdominal surgery for hysterectomy that meets the indications needs to be analyzed and weighed from both patient and surgeon levels: first, the suitability of the patient’s condition for the chosen procedure, in other words, whether the chosen procedure can minimize surgical injury; second, the extent of the surgeon’s mastery of the chosen procedure and The second is the degree of mastery and experience of the surgeon. In today’s development of minimally invasive surgical treatment, laparoscopic and transvaginal hysterectomy is certainly in line with the principle of minimally invasive surgery, but due to the influence of the volume of the uterus and the degree of pelvic lesions (serious adhesions), the surgeon needs to have skillful surgical skills and rich clinical experience. The “novelty” of the procedure may lead to a “mega-invasive” outcome. In the same way, the choice of surgical procedure for uterine fibroid removal should not be “losing sight of the other”. For all types of submucosal fibroids, cervical canal fibroids and some interstitial fibroids, hysteroscopic surgery through the natural channel is regarded as a model of minimally invasive surgery; for interstitial fibroids and subplasma fibroids including those in the broad ligament, laparoscopic surgery should be the first choice; for fibroids in the isthmus, neck and body of prolapsed uterus, the choice of transvaginal surgery is also a reasonable way to remove them; of course, these considerations are not enough. It is not enough for the operator to choose open surgery if the lesion is complex and difficult to perform, especially if it is a wise choice to timely transit open abdomen or small incision assistance during the surgery.
2, objective evaluation of interventional indications and problems faced
Interventional treatment (Interventionaltreatment) is a minimally invasive treatment method for localized treatment of lesions through blood vessels or skin under the guidance of imaging equipment. Uterine fibroids are the most commonly used diseases in the field of gynecology. Interventional treatment is aimed at reducing or eliminating fibroids and relieving clinical symptoms by blocking the blood vessels of the tumor or ablating and destroying the tumor. Interventional treatments for fibroids include uterine artery embolization (UAE), HighIntensity Focused UltrasoundAblation (HIFUA) and radiofrequency ablation. To a certain extent, interventional treatment has avoided invasive surgery, curbed the growth of leiomyoma and its clinical symptoms, and achieved certain clinical efficacy. However, there are still more problems: can we achieve satisfactory treatment effect for larger myomas? How to reduce the residual and recurrence of multiple myomas? What are the long-term effects on ovarian function? (4) The risk of uterine rupture in second pregnancy and the risk of myoma malignancy, etc.
2.1 High Intensity Focused Ultrasound Ablation (HIFUA) for uterine fibroids
Ultrasound ablation, also known as ultrasound ablation, is a medical imaging system guided by the convergence of ultrasound beams outside the body to form a high-energy focus on the target fibroid tissue in the body, to thermally ablate and “excise” the fibroid, forming coagulative necrosis to achieve the purpose of treatment. A two-center prospective clinical study reported a 91.7% improvement in symptom scores after ultrasound ablation of uterine fibroids and a 59.0% average reduction in fibroids 6 months after the procedure, with no serious adverse effects. A study on type I and type II submucosal fibroids showed a 90.1% reduction rate at 2 years after surgery, with significant improvement in fibroid-related symptoms and quality of life after treatment. Nevertheless, HIFUA is an emerging technology, and due to the lack of follow-up data on long-term treatment outcome in a large sample, the indications for HIFUA are mainly for patients who have completed childbirth, who do not want to undergo surgery for some reasons, and who wish to preserve their uterus, and whose tumors are <10 cm in diameter. HIFUA is not indicated in the following cases: family history of malignant tumors. Patients with rapid growth of fibroids in the short term. Fibroids >10 cm in diameter with pressure or uterine volume greater than 20 weeks of gestation. Severe vaginal bleeding. Those with ultrasound focus intended target area <1cm away from the skin. Patients with longitudinal scarring in the abdomen (as scarring can absorb a large amount of ultrasound, resulting in local overheating or even burning of the skin, affecting the treatment effect). It should be noted that the local coagulative necrosis of the myometrial wall caused by HIFUA treatment may reduce the elasticity of the pregnant myometrial wall and increase the risk of uterine rupture, which is usually selected for patients without fertility requirements. In recent years, this treatment has been attempted in patients with fertility requirements and successful pregnancies have been reported; however, surgical resection is still preferred in patients who have not yet had children.
2.2 Blocking blood supply UAE
The principle of UAE for uterine fibroids is to selectively block the blood vessels of the tumor through embolic agents, causing acute ischemia and necrosis of the tumor, which results in its reduction or even disappearance. In the literature, the symptom relief rates at 3 months, 6 months, 1 year and 2 years after UAE are 90%, 92%, 87% and 100%, respectively; the myoma volume reduction rates at 3 months and 2 years after surgery are 29% and 86%, respectively; most of the myoma blood supply disappears, and uterine blood flow and vascular resistance are not affected. The main contraindications for UAE treatment are the same as for HIFU, and other contraindications include severe contrast allergy, renal insufficiency and coagulation abnormalities. In addition, UAE may cause ovarian failure. Basal follicle stimulating hormone (FSH) and estrogen levels should be measured before and after treatment, and ovarian function should be closely monitored. Data on postoperative pregnancies show that there are more obstetric complications after UAE than myomectomy, especially preterm labor, spontaneous abortion, placental abnormalities and postpartum hemorrhage. Therefore, myomectomy is still recommended as the first choice for patients who wish to have children.
3. Further clarification of the role and significance of drug therapy
Although the exact pathogenesis of uterine fibroids is still unknown, clinical examples of fibroids that are highly prevalent in the reproductive age and shrink or even disappear after menopause have demonstrated the regulatory role of female hormones on the growth of fibroids. Attempts to inhibit the growth of leiomyosarcomas through sex hormones or their analogs have been made in clinical treatment for many years and have shown significant therapeutic effects. In summary, sex hormones or their analogues used clinically for the treatment of uterine fibroids mainly include the following categories: gonadotropin-releasing hormone agonists (GnRHa), commonly used preparations such as treprostinil, leuprolide, goserelin, etc. Androgen derivatives: Pregnant trienone (19 norethindrone derivatives), danazol (17A
ethynyltestosterone derivatives), etc. Progesterone receptor antagonists, mifepristone. Selective estrogen receptor modulator (SERM), triamcinolone acetonide. Androgenic drugs, methyltestosterone, testosterone propionate, etc. Although all of the above drugs are clinically used and have achieved some therapeutic efficacy, none of them, except for the GnRHa class, are listed in the instructions as indications for uterine fibroids. Only GnRHa is approved by FDA for the treatment of uterine fibroids to correct the symptoms of bleeding and anemia caused by uterine fibroids.
3.1 Reduction of the tumor, correction of anemia, and beneficial surgery
After entering the blood circulation, GnRHa can compete with pituitary GnRH receptors to inhibit the release of pituitary FSH and luteinizing hormone (LH), resulting in a lower estrogen and progesterone environment in the body, inhibiting the growth of fibroids and reducing the size of fibroids, thinning the endometrium and reducing the size of the uterus; at the same time, due to the inhibitory effect of GnRHa on the hypothalamic-pituitary-ovarian axis and the resulting caused by amenorrhea, it reduces menstrual bleeding, increases hemoglobin concentration and corrects anemia-related symptoms. Basic studies have shown that the use of GnRHa also causes a reduction in the diameter of the myxoma tumor vessels, an increase in the thickness of the vessel wall, and a thinning and degenerative change of the official lumen, resulting in a decrease in the blood supply to the tumor. The effectiveness and safety of GnRHa in the treatment of uterine fibroids have been widely reported in the literature. In general, the use of GnRHa for 3-6 months can reduce the volume of fibroids by 20%-77%; for giant fibroids with severe anemia, the use of GnRHa for 2-4 months can not only correct the anemia but also reduce the volume of fibroids, and reduce intraoperative bleeding and the difficulty of surgery. For minimally invasive surgery, the surgical access is performed through minimal trauma or the natural orifices of the body, and reducing the size of the fibroids will undoubtedly reduce the difficulty of the surgical operation, decrease the operating time and reduce the occurrence of surgical complications. In hysteroscopic myomectomy, the volume of fibroids is an important factor in determining the success or failure of the operation. Reducing the size of the fibroids can reduce the damage to the normal endometrium around the fibroids, making it possible to perform hysteroscopic stage I surgery for aphthous and interstitial fibroids; for laparoscopic surgery and transvaginal surgery, regardless of myomectomy and total hysterectomy, reducing the size of the fibroids and uterus is easier for surgical operation, suturing of the cavity, hemostasis and removal of the fibroids. The reduction in the size of fibroids and uterus facilitates surgical operation, cavity suturing, and removal of the fibroids, providing a guarantee for reducing complications and improving surgical safety.
3.2 Low estrogenicity, pros and cons, and time frame control
Although GnRHa drugs are effective in treatment, the function of the gonadal axis returns to normal 60-120 d (average 75 d) after discontinuation, and the uterus gradually increases in size and “rebounds” to its pre-drug level. In addition, the low “female” symptoms and bone calcium loss in the body caused by long-term use of GnRHa are one of the serious “drawbacks” of the treatment. Therefore, some scholars advocate that those who have been using GnRHa for more than 3 months should be treated with estrogen or estrogen-progestin combination with reverse addition to maintain estrogen levels at “window concentrations” (serum estradiol 109.8-164.7 pmol/L). Calcium supplements should also be given with reverse addition to improve perimenopausal symptoms and bone loss. However, for the treatment of uterine fibroids, there is a lack of reliable studies to confirm this. The therapeutic dose of GnRHa as recommended by the FDA is 3.75 mg per month and may be supplemented with iron but preferably for no more than 3 months of continuous use.
4.Understanding the implication and timing of expectant therapy
It is indisputable that not all fibroids are clinically harmful and not all of them can be detected early. This being the case, the coexistence of fibroids with the uterus and the body is objective and acceptable. Since there are many cases of fibroids found accidentally during health checkups or confirmed during pelvic and abdominal surgery, we cannot expect to “kill” all fibroids, but expectation is also an option when the location and size of fibroids do not pose a clinical risk. Expectant therapy for fibroids is a means of monitoring the development of fibroids through regular follow-up without any medical intervention. It is generally indicated for small and asymptomatic fibroids and is particularly suitable for patients in the perimenopausal period. The indications for expectant therapy for perimenopausal fibroids are those who are over 40-45 years of age, who are starting to show signs of menopause, who have small subplasma or interstitial fibroids, and who have no clinical symptoms. In addition, younger patients with fibroids smaller than 8 weeks of gestation and without significant symptoms or complications may also be treated with anticipatory therapy. Patients undergoing expectant therapy need to be followed up regularly, clinically and imaging-wise, every 3 to 6 months. In general, fibroids can gradually shrink after menopause, but active intervention should be performed for those with worsening symptoms, persistent enlargement of fibroids, or rapid growth with suspected malignancy.
Pregnancy has a certain role in promoting the growth of uterine fibroids, and the management of uterine fibroids combined with pregnancy needs to be decided according to the month of pregnancy and the type, size and location of the tumor, as well as complications, clinical manifestations and the age of the patient. When the fibroids, especially those in the body of the uterus, are less than 5-6 cm in diameter and asymptomatic, the majority of mothers can have a successful vaginal delivery and thus can be treated with expectant therapy. Surgical intervention is not necessary during pregnancy, regardless of the size or location of the fibroid, as long as it does not interfere with the continuation of the pregnancy. Even if red degeneration occurs, surgery is avoided if possible and palliative treatment is usually used. However, surgical intervention should be considered in case of subplasmalemmal myoma reversal, myoma compression of adjacent organs producing severe symptoms, or if the myoma is too large or embedded affecting the continuation of pregnancy.
In conclusion, uterine fibroids, like other diseases treatment, have one more option, one more means and one more problem. Emphasis on the principle of standardization, strict mastery of the indications and contraindications of various treatment methods, and clarification of their complications and management countermeasures are necessary to lock in safer and more reasonable treatment among many treatment options.