A Case of a Prolapsed Fibroid in a 12-Year-Old Girl

BackgroundUterine fibroids are a common cause of abnormal uterine bleeding in adult women, but are extremely rare in the adolescent years.CaseA 12-year-old nulliparous girl presented with abnormal uterine bleeding and was found to have a prolapsing submucosal fibroid. The fibroid and her symptoms were successfully removed using an Endosnare.Summary and ConclusionThe most common cause of abnormal uterine bleeding in adolescent bleeding is due to anovulation. Though rare, fibroids should remain on the differential as the cause of abnormal uterine bleeding in the adolescent population, particularly if symptoms persist despite initial therapy. Fibroids can be managed successfully with minimally invasive techniques.     

Uterine fibroids and their treatment

Uterine fibroids are the most common benign disease of women. They occur in women under 30 years of 20-30% for women over 30 years in 50%. The most frequent indication for hysterectomy, uterine fibroids are just. Symptoms of uterine fibroids are various forms of pelvic pain and trouble from the oppression of the surrounding organs, irregular uterine bleeding and fertility disorders resulting from the inability to conceive or recurrent pregnancy loss. Problems of surgical treatment of fibroids applies not only to symptomatic patients who wish to preserve the uterus, but also women who have uterine fibroids negatively affect their reproduction. Treatment of uterine fibroids include monitoring, administration of medications and surgical techniques that preserve either the uterus or not. In recent years the conservatives have extended performance of minimally invasive surgery, which is a common feature of the endoscopic approach, or uterine fibroid devascularization. Gynecologist surgeon must be familiar with the history of the patient and based on history and examination to consider which procedure is best for the patient.     

Uterine artery occlusion: what is the evidence?

Symptomatic uterine fibroids are a relatively common gynecologic condition. In the past, fibroids were exclusively treated by myomectomy and/or hysterectomy. With the advent of uterine artery embolization or uterine artery occlusion, there now exist minimally invasive approaches to fibroid therapy especially for women in whom surgery is contraindicated or for those who wish to retain their uterus and possibly fertility. Fertility and pregnancy outcomes after these minimally invasive therapies are currently being evaluated.     

Modern management of uterine fibroids

Uterine fibroids are the most common tumor of the reproductive tract in women of reproductive age. Although they are benign tumors that are often asymptomatic, uterine fibroids may cause debilitating symptoms in many women, such as abnormal uterine bleeding, abdominal pain, increased abdominal girth, urinary frequency, constipation, pregnancy loss, dyspareunia, and in some cases infertility. Several approaches are available for the treatment of uterine fibroids. These include pharmacologic options, such as hormonal therapies and gonadotropin-releasing hormone agonists; surgical approaches, such as hysterectomy, myomectomy, myolysis, laparoscopic uterine artery occlusion, magnetic resonance imaging-guided focused ultrasound surgery, and uterine artery embolization. The choice of approach may be dictated by factors such as the patient's desire to become pregnant in the future, the importance of uterine preservation, symptom severity, and tumor characteristics. New treatment options for uterine fibroids would be minimally invasive, have long-term data demonstrating efficacy and safety, have minimal or no incidence of fibroid recurrence, be easy to perform, preserve fertility, and be cost effective. New treatment approaches are under investigation, with the goals of being effective, safe, and less invasive.     

Endoscopic management of uterine fibroids

Uterine fibroids are the most common benign tumours of the uterus. Management depends on the symptoms, location and size of the fibroids, and the patient's desire to conceive. Surgical management of uterine fibroids has changed from laparotomy to minimally invasive surgery. Uterine fibroids are usually asymptomatic and do not require treatment. Laparoscopic myomectomy is the best treatment option for symptomatic women with uterine fibroids who wish to maintain their fertility. The authors' criteria for laparoscopic myomectomy are a fibroid of <15 cm in size, and no more than three fibroids with a size of 5 cm. Compared with laparotomy, laparoscopic myomectomy has the advantages of small incisions, short hospital stay, less postoperative pain, rapid recovery and good assessment of other abdominal organs. Due to the concern of decreased ovarian reserve, uterine artery embolization is not advisable for these women. In addition, it is associated with high risks of miscarriages, preterm delivery and postpartum bleeding. Laparoscopic myolysis causes severe adhesion formation. Women with submucous fibroids receive myomectomy by hysteroscopy. For women who have completed their family, laparoscopic hysterectomy could be performed. Most fibroids can be managed endoscopically either by laparoscopy or hysteroscopy. Surgeon expertise, especially laparoscopic suturing, is crucial. Laparoscopic myomectomy is still the best treatment option for symptomatic women with uterine fibroids who wish to maintain their fertility. Hysteroscopic myomectomy is an established surgical procedure for women with excessive uterine bleeding, infertility or repeated miscarriages.     

Myoma coagulation (myolysis)

Myoma coagulation or myolysis by way of the laparoscope or hysteroscope is a valuable addition to the armamentarium of treatments for a problem that remains pervasive among women: uterine leiomyomata. Likewise, surgical techniques include the use of the Nd:YAG laser as well as the bipolar needle. The addition of myolysis to earlier uterine-sparing endometrial ablation or resection markedly improves the success rate of these minimally invasive alternatives to hysterectomy. Myoma coagulation when combined with endometrial ablation among women with symptomatic fibroids and bleeding also reduces all subsequent surgery rates compared with endometrial ablation alone. The continued goal for therapy of fibroids and debilitating menorrhagia must take into consideration the needs and desires of the patient in terms of her lifestyle (e.g., days lost from work because of symptoms) and childbearing plans. Hysterectomy continues to be costly in billions of dollars spent annually as well as in the more fundamental terms of morbidity and mortality when compared with the less invasive alternatives of myomectomy, ablation, and myolysis.     

Embolization of uterine arteries for uterine fibroids: state-of-the-art

Embolization of uterine arteries for fibroids is a modern minimally invasive method for treatment of uterine fibroids. Results from published data show a substantial short-term uterine reduction, an improvement in menorrhagias, and a reduction in fibroid related pain. Hospital stay and recovery are shortened compared with hysterectomy. One randomised comparative trial EAU vs hysterectomy has showed a reduction in hospital stay length and in the rate of major complications, but an increased rate of minor complications. Pregnancies and uneventful deliveries have been reported after uterine arteries embolization. Rare but severe complications have been described. Embolization of uterine arteries can be considered as a safe alternative to hysterectomy or myomectomy in selected cases. It cannot be a routine method for treating fibroids with women of childbearing age.     

Ulipristal acetate for the management of acute heavy menstrual bleeding without fibroids

Heavy menstrual bleeding is a common condition among women of childbearing age. Although hysterectomy was the usual approach in acute cases in the past, other minimally invasive therapies or pharmacological alternatives, such as the levonorgestrel intrauterine device have shown to be highly effective. This case report presents the case of a pluripathological patient with acute heavy menstrual bleeding and severe anemia, who was successfully managed with ulipristal acetate, a selective progesterone receptor modulator. Bleeding control was achieved in 6?d without side effects, avoiding the need for surgery. This report suggests that ulipristal acetate could be useful in the treatment of acute uterine bleeding even in a structurally normal uterus without fibroids.     

超声引导下射频消融治疗子宫肌瘤的研究进展

子宫肌瘤又称平滑肌瘤或肌瘤,是女性生殖器官最常见的良性肿瘤,由平滑肌和结缔组织组成,常见于30～50岁妇女,发病率约20%。子宫肌瘤的治疗包括保守治疗及手术治疗,其中射频消融（RFA）是一种微创治疗手段,目前已应用于多种疾病,在治疗妇科良性疾病方面的价值也得到了充分的认可。理想的RFA是运用热能以微创的方式、不损伤邻近正常组织的前提下,使靶组织遭受到彻底的破坏。现从作用机制、超声造影技术的临床应用、疗效评价、对生育功能的影响、安全性和有效性、影响因素等方面对RFA治疗子宫肌瘤进行简要概述。     

射频消融治疗子宫肌瘤的临床应用

随着近年来医疗水平的提高及妇科常规体检的普及,子宫肌瘤发病率居高不下。目前子宫肌瘤的治疗有多种方法,其中射频消融是一种临床显著有效的微创治疗手段。其通过破坏肌瘤组织缩小肌瘤体积,同时不伤害其他组织及器官,作为一种简便、安全、有效的治疗方式正逐渐受到临床医生的认可。现从原理、适应证及禁忌证、术中麻醉及手术方法、并发症及其处理、疗效评价、术后病理变化及实用性等方面对射频消融治疗子宫肌瘤作一简要概述。     

Minimally invasive management of uterine fibroids

PURPOSE OF REVIEW: Many minimally invasive techniques have recently been introduced for the management of uterine fibroids. The purpose of this review is to analyse recent data for techniques that are used to manage uterine fibroids. RECENT FINDINGS: Laparoscopic myomectomy has provided a minimally invasive alternative to laparotomy for intramural and subserous myomata. However, this technique is still the subject of debate. With good surgical experience, the risk of perioperative complications is comparable with conventional surgery. Laparoscopic myomectomy is associated with faster postoperative recovery, and could potentially reduce the risk of postoperative adhesions compared with laparotomy. Spontaneous uterine rupture, although uncommon after laparoscopic myomectomy, is still a concern. The risk of recurrence seems to be higher after laparoscopic myomectomy than after myomectomy performed by laparotomy. Uterine artery embolization is another new and attractive treatment for patients with symptomatic fibroids. Uterine artery embolization provides excellent relief for abnormal bleeding, pelvic pain, and bulk-related symptoms. Early reports show that uterine artery embolization is associated with normal reproductive and obstetric functions. This technique is associated with a shorter hospital stay and a rapid recovery time. SUMMARY: Laparoscopic myomectomy and uterine artery embolization are being performed more than ever. Current evidence proves the safety, reliability and reproducibility of both procedures. However, prospective randomized controlled trials comparing both procedures with conventional myomectomy are needed.     

Uterine artery embolisation for the treatment of symptomatic uterine fibroids: short-term results of work in progress

Bilateral uterine artery embolisation (UAE) was used to treat 11 women with symptomatic uterine fibroids. Uterine volume and dominant fibroid volume were assessed quantitatively by ultrasonography both before and at two and six months post procedure. Both uterine arteries were occluded effectively in all of the women, and the procedure was well tolerated, with hospital stays limited to 24-48 hours in all cases. An improvement of symptoms occurred in 10 of the 11 women. There were no significant complications. The mean percentage reductions in uterine volume and dominant fibroid volume at six months following the procedure were 45.32% and 56.34%, respectively. Bilateral uterine artery embolisation for the treatment of uterine fibroids is a minimally invasive technique with very good clinical results. This procedure may be considered as an alternative to hysterectomy, or myomectomy in properly selected cases.     

Pregnancy after transcervical radiofrequency ablation guided by intrauterine sonography: case report

Uterine fibroids are a prevalent disorder; with the exception of myomectomy, there are no treatments that are generally accepted as compatible with future fertility and fecundity. Radiofrequency ablation is a minimally invasive treatment modality for uterine fibroids that results in coagulative necrosis and fibroid volume reduction. There have been few reports of pregnancy after laparoscopic and transvaginal radiofrequency ablation of fibroids and no previous reports after a transcervical approach. We report the outcome of the first viable pregnancy after intrauterine sonography-guided radiofrequency ablation of a uterine fibroid.     

Medical management of uterine fibroids with medroxyprogesterone acetate (Depo Provera): a pilot study.

The aim of this study was to determine the effectiveness of medroxyprogesterone acetate (Depo Provera) in the treatment of menorrhagia attributed to uterine fibroids and to determine whether it reduces fibroid volume. Twenty premenopausal women with menorrhagia attributed to uterine fibroids received Depo Provera (150 mg/month) for 6 months. Control of bleeding was assessed by menstrual diary, haematologic parameters (Hb) and uterine and fibroid size measured sonargraphically. Following a period of 6 months after the initiation of Depo Provera, 30% became amenorrhoeic, 70% noticed improvement in their bleeding pattern and 15% had an increase in their haemoglobin levels. The mean uterine and fibroid volume was also reduced by 48% and 33%, respectively. Medical therapy with Depo Provera with symptomatic fibroids causes significant improvement in bleeding pattern as well as a reduction in fibroid volume.     

Fibroid embolisation: a technique not without significant complications

Uterine artery embolisation is a new minimally invasive technique used for the treatment of fibroids. Twenty-one women underwent bilateral uterine artery embolisation at our unit, and we assessed the efficacy, morbidity and patient satisfaction with the procedure. Mixed outcomes were found. Reduction in fibroid volume measured by magnetic resonance imaging was impressive, and the majority of women felt their symptoms had improved. One woman achieved a full term pregnancy following the procedure. However, the procedure involved a significant inpatient stay, analgesia requirement, and a slower recovery time than anticipated. One woman died following overwhelming sepsis occurring 10 days after the procedure. Further studies are required to assess the role this technique may play in the management of uterine fibroids.     

Obstetric complications of fibroids

The effect of uterine fibroids on fecundity and pregnancy outcome is difficult to determine with any degree of accuracy; this is due, in large part, to the lack of adequate large clinical trials. In general, the literature tends to underestimate the prevalence of fibroids in pregnancy and overestimate the complications that are attributed to them. In contrast to popular opinion, most fibroids do not exhibit a significant change in volume during pregnancy, although those that do increase in size tend to do so primarily in the first trimester. Although most pregnancies are unaffected by the presence of uterine fibroids, large submucosal and retro-placental fibroids seem to impart a greater risk for complications, including pain (degeneration), vaginal bleeding, placental abruption, IUGR, and preterm labor and birth. Preconception myomectomy to improve reproductive outcome can be considered on an individual basis, but likely has a place only in women who have recurrent pregnancy loss, large submucosal fibroids, and no other identifiable cause for recurrent miscarriage. Antepartum myomectomy should be reserved for women who have subserosal or pedunculated fibroids and intractable fibroid pain that are unresponsive to medical therapy and who are in the first or second trimester of pregnancy. Myomectomy at the time of cesarean delivery is associated with significant morbidity (hemorrhage) and should be pursued with caution and only in select patients.     

Should we recommend hysterectomy more often to premenopausal and climacteric women?

In developed countries, women live on average over 30 years as postmenopausal. In the premenopausal and climacteric period, abnormal uterine bleeding and other symptoms may occur. In addition, endometrial cancer is the most common gynecological malignancy, and possible hormone replacement therapy is much more beneficial among women with prior hysterectomy. With this background and the recommended use of minimally invasive surgical techniques, we argue in favor of more liberal hysterectomy practice before and around the menopause. Many will disagree, because for many years we have argued to save the uterus, but considering pros and cons with the patient in focus, we discuss the topic and advertise for studies to support our view.     

Interstitial thermo-ablation under MRI guidance for the treatment of fibroids

Women with symptomatic uterine fibroids are increasingly seeking alternatives to open surgery. The combination of high resolution magnetic resonance imaging and the application of laser heat permit percutaneous treatment of fibroids under local anaesthetic. This article reviews the technique of interstitial thermo-ablation and other current minimally invasive therapies for symptomatic fibroids.     

Uterine Fibroids in the Setting of Infertility: When to Treat,How to Treat?

Purpose of Review

We aim to provide insight on the treatment of fibroids in the infertile patient. Specifically, we discuss which fibroids, based on size and location within the uterine wall, have the most impact on fertility outcomes. In addition, we demonstrate which methods are best for treatment of fibroids in the infertile patient, focusing on minimally invasive techniques.

Recent Findings

Current research demonstrates that, in addition to submucosal fibroids, also intramural fibroids can have a negative impact on fertility via molecular and mechanical disruption of the endometrium and of normal uterine peristalsis. Certain intramural fibroids should be considered for removal or treatment in the infertile patient, depending on size and patient history. We also provide a large body of evidence demonstrating the safety and clinical advantages of minimally invasive techniques, such as hysteroscopy, laparoscopy, and robot-assisted laparoscopy in the treatment of uterine fibroids.

Summary

All submucosal and many intramural fibroids interfere with uterine function. In the evaluation of the infertile patient, accurate fibroid mapping within the uterus is essential to identify those submucosal and intramural fibroids that are likely to have the most impact of fertility outcomes. The mainstay of treatment is surgery for those fibroids with the most detrimental impact. Nonsurgical alternatives such as magnetic resonance-guided focused ultrasound (MRgFUS) and radiofrequency volumetric thermal ablation (RFVTA) need further validation before their widespread adoption in infertile patients.

     

Long-term results of hysteroscopic myomectomy in 235 patients

OBJECTIVE: To assess the efficacy of transcervical resection of submucous fibroids according to type and size. MATERIALS AND METHODS: Retrospective follow-up of 235 women with submucous fibroids at outpatient hysteroscopy who underwent a hysteroscopic transcervical resection. The main indications were the abnormal uterine bleeding and fertility problems. Thirty-seven percent of patients had an associated endometrial ablation and 32% had a polyp resection. Fifty-one percent of women were menopausal. In cases of incomplete resection a repeat procedure was offered. RESULTS: Intra-operative complications were rare (2.6%) and there was no major complication. Eighty-four percent of cases were followed-up. The median follow-up was 40 months (range 18-66 months). The procedure was classed as a success in 94.4% of patients. Among the cases that were classed as a failure, four patients had a repeated hysteroscopic procedure, three patients had a subsequent hysterectomy and four patients presented with abnormal uterine bleeding at follow-up. CONCLUSION: The hysteroscopic transcervical resection of submucous fibroids is a safe and highly effective long-term therapy for carefully selected women presenting with abnormal uterine bleeding and fertility problems. It produces satisfactory long-term results with few complications.