Uterine fibroids are the most common benign uterine tumors. Increasing age (premenopausal) and ethnic differences are currently considered to be the main risk factors for fibroids. Studies have confirmed that the incidence of fibroids is 7 times higher in black than in white people and that symptoms are more severe. In addition, environmental factors and genetic mutations are also associated with the formation of fibroids.
Diagnosis
1. Ultrasonography is preferred for patients who present with an enlarged uterus, pelvic mass or increased menstrual flow. Routine blood and thyroid function tests are also required.
2. Magnetic resonance imaging (MRI) with gadolinium contrast can provide information to the endometrial and plasma surfaces about the degenerating myoma, between the myoma and the endometrial and plasma surfaces, and determine whether the uterus should be preserved.
3. In women with heavy menstrual flow, ultrasonography after saline input into the endometrial cavity can identify the extent of intraluminal myomas. (As defined by the FIGO classification system for uterine fibroids, the type of fibroid ranges from 0 to 8, with lower numbers indicating closer to the endometrium)
4. If the patient presents with irregular vaginal bleeding or has risk factors for endometrial hyperplasia (obesity, persistent anovulation or long-term estrogen therapy without progesterone), coagulation tests and endometrial biopsy may be performed selectively.
Treatment
In addition, the guidelines recommend that treatment of fibroids be determined by symptoms, while asymptomatic fibroids may be treated without treatment. Rapid growth of fibroids is not an indication for treatment.
1. Hysterectomy
Hysterectomy is the main treatment option for women who have had children and includes transabdominal, transvaginal and laparoscopic hysterectomy. Transvaginal hysterectomy is associated with fewer complications, but is limited by the size of the fibroids. However, some studies suggest that this surgical procedure has been overused.
Studies have shown that the use of endoscopy is associated with a decrease in morbidity. However, the application of power fractionation needs to be weighed against the pros and cons, as it may lead to further spread of undiagnosed cancer, such as causing peritoneal spread affecting the prognosis. Although this risk is controversial, the latest FDA guidance recommending restriction of total hysterectomy with power comminution in premenopausal women has illustrated its risk.
2. Treatment with preservation of the uterus
(1) Treatment of heavy menstrual flow
Drug treatment
For patients with the only symptom of heavy menstruation, tranexamic acid and levonorgestrel intrauterine device (Mannorrhea) have been shown to be effective treatment options. Taking tranexamic acid during heavy menstruation reduces menstrual flow with minimal side effects. Although it may theoretically cause thrombosis, no corresponding findings have been made in clinical studies. It should be noted that tranexamic acid should not be used in combination with oral contraceptives.
The levonorgestrel IUD (Mannoprotein) is effective in reducing menstrual bleeding and providing contraception; however, patients with submucosal fibroids have a higher rate of IUD dislodgement. In addition, there are data surface NSAIDs reduce dysmenorrhea and decrease menstrual flow, but are not as effective as the first two in reducing bleeding.
Surgical treatment
① Radiofrequency ablation: For those women who have had children, endometrial radiofrequency ablation with hysteroscopy combined with myomectomy is an option with similar recovery time as hysteroscopic myomectomy alone, but with better results.
It is important to note that contraception is required after ablation, as immediate pregnancy its may increase the risk of ectopic pregnancy, placental abnormalities or preterm delivery.
②Hysteroscopic myomectomy: For patients with submucosal fibroids causing bleeding, hysteroscopic myomectomy is the best treatment option. This procedure can be performed on an outpatient basis, has a faster recovery and increases the likelihood of clinical pregnancy, although there is no data to suggest that it is associated with an increase in birth rates.
(2) Treatment of compression symptoms
In women with symptoms of compression alone or with increased menstrual flow due to large fibroids, the main goal of treatment is to reduce the size of the fibroids.
Drug treatment
(1) Gonadotropin-releasing hormone agonists: Gonadotropin-releasing hormone agonists (GnRH-α) may cause amenorrhea and a reduction in the size of the uterus. Long-term use needs to be combined with steroid hormones to reduce menopausal symptoms and osteoporosis. Currently, it is mainly used for short-term use (2-6 months) before elective surgery or early onset of menopause, and can be combined with iron to reduce anemia before surgery.
② Progesterone modulating drugs: they can be used as alternative therapies, such as mifepristone and ulipristal acetate to reduce the size of fibroids and the corresponding symptoms. Ulipristal acetate can be used in the 3 months before surgery; there are no valid data on whether it increases the risk of endometrial abnormalities.
(iii) Other: aromatase inhibitors and androgenic steroid hormones have been shown to be effective in the treatment of uterine fibroids; clinical applications do not yet support their use.
Surgical treatment
(1) Myomectomy: Transabdominal or laparoscopic myomectomy can be used to treat one or more fibroids to eliminate symptoms and preserve fertility. The complications and postoperative recovery are similar to those of hysterectomy. Recent guidelines recommend the use of electrical fractionation for laparoscopic myomectomy. Although it may carry a risk of malignant spread, women considered for myomectomy tend to be younger and generally have a lower risk of smooth muscle sarcoma.
Most guidelines recommend myomectomy as the treatment of choice for women with fertility requirements, but only for symptomatic interstitial and subplasmalemmal fibroids. Transabdominal myomectomy carries a high risk of preserving fertility, with approximately 3-4% of patients being converted to hysterectomy or developing postoperative adhesions.
Treatment of asymptomatic interstitial fibroids is not recommended. Because interstitial fibroids themselves increase the risk of infertility and pregnancy complications, myomectomy does not reduce this risk. In addition, at least 25% of patients with fibroids
of patients may experience recurrence of fibroids.
(2) Uterine artery embolization: Uterine artery embolization is a minimally invasive interventional technique with rapid postoperative recovery for patients. Because most fibroids are supplied by the uterine artery, embolization will work on the entire uterus but will not determine which fibroids are treated.
Complications include mild fever, pain, and transvaginal discharge of the fibroids. Absolute contraindications include pregnancy, suspected malignancy, and active infection. It is important to note that embolization may affect ovarian function and subsequent pregnancy. However, it has been suggested that loss of ovarian function occurs mainly in women older than 45 years and has no effect on ovarian reserve 12-24 months after the procedure.
(3) Radiofrequency ablation: MRI-guided focused ultrasound procedure is used to treat uterine fibroids using ultrasound thermal ablation. The treatment modality has fewer side effects, but skin burns and reversible pelvic neuropathy may occur. Data on postoperative outcomes are still needed to support this. Recent FDA approval of laparoscopic myomectomy using a radiofrequency ablation device has shown less intraoperative bleeding and faster recovery. However, long-term data (including data related to subsequent pregnancies) are still needed to support this. Currently, both this method and focused ultrasound surgery are widely used in the United States.
Conclusions and Recommendations
Hysterectomy with preservation of the ovaries may be an option for patients without fertility requirements, and alternative treatment to hysterectomy may also be considered; the specific treatment plan depends on the presence or absence of symptoms, increased menstrual flow, and whether the patient has multiple and enlarged uteri; ultrasound-guided embolization or radiofrequency ablation is recommended if available. Although there are no comparative data on the various treatment modalities, it is generally accepted that embolization or radiofrequency ablation may lead to a rapid recovery and a reduced risk of complications compared to hysterectomy.
Frontier advances
Recent industry interest has focused on the effectiveness of embolization versus ultrasound procedures for uterine fibroids; subsequent reproductive outcomes and adjustment for effects based on clinical variables, including race; and prospective data comparing the long-term outcomes of various treatment approaches, including hysterectomy.