Uterine myomas revisited

The present study was planned to review the pathophysiology of uterine myomas and emphasize the principles of logical management on the basis of literature review and synthesis of the author's experience. The growth of uterine myomas, the most common solid pelvic tumors in women, is related to genetic predisposition, hormonal influences and growth factors. The treatment options include pharmacologic, surgical and radiographic interventions. Most asymptomatic myomas can be followed serially for progressive growth or development of symptoms. The various diagnostic and therapeutic advancements available today permit higher management flexibility with safe options, which must be tailored to the individual patients requirement.     

The clinical relevance of hysteroscopic polypectomy in premenopausal women with abnormal uterine bleeding

This study assessed the efficacy of hysteroscopic polyp removal in the management of abnormal uterine bleeding (AUB) of premenopausal patients. The monthly menstrual blood loss, measured semi-objectively by the pictorial blood loss assessment chart (PBAC) and patients satisfaction were recorded prospectively preoperatively and postoperatively. Twenty-one patients were included. Median monthly PBAC-score before treatment was 288 (range 142–670) and 6 months after polyp removal 155 (range 39–560). It was concluded that hysteroscopic polyp removal in premenopausal women with AUB reduces the monthly blood loss significantly and has a high satisfaction rate on the short term.     

Endometrial thickness screening in premenopausal women with abnormal uterine bleeding

AIM: To assess the role of measuring endometrial thickness by transvaginal ultrasonography (TVS) as a screening tool for abnormal uterine bleeding triage in premenopausal women. METHODS: Between November 2002 and October 2004, endometrial thickness was measured by TVS in 111 premenopausal women with non-cyclic abnormal uterine bleeding before dilatation and curettage. RESULTS: Of the 111 women, 31 (27.9%) had an abnormal endometrium (hyperplasia 13.5%, polyps 5.4%, submucous myoma 5.4%, and adenocarcinoma 3.6%). An endometrial thickness of 8 mm showed optimal sensitivity and specificity (83.9% and 58.8%, respectively) and 90.4% negative predictive value (NPV) for an abnormal endometrium. When submucous myoma was excluded, the sensitivity, specificity, and NPV were 80%, 53.8%, and 89.6%, respectively. CONCLUSION: Endometrial thickness of 8 mm or less is less likely to be associated with malignant pathologies in premenopausal uterine bleeding.     

Laparoscopic subtotal hysterectomy using the plasma kinetic and lap loop systems: an alternative approach in the surgical management of women with uterine fibroids

OBJECTIVE: To evaluate the safety and applicability of laparoscopic subtotal hysterectomy (LSH) using the plasma kinetic (PK) and lap loop systems as an alternative surgical approach in the management of uterine fibroids in women who have completed their families. STUDY DESIGN: Sixty-two consecutive LSH were performed during this prospective study from March 2003 to March 2005 at Princess Royal University Hospital, Kent, UK. RESULTS: All study patients had menorrhagia resistant to at least one form of therapy, with a mean duration of symptoms of 3.5 years. In addition, four patients had previous myomectomy. The mean number of fibroids removed was 2.7. The mean weight of the uterus was 141.9 g. The mean operative time was 46.8 min, and the mean blood loss was 126.6 mL. The overall perioperative complication rate was 4.8% with no visceral injury, or return to theatre. At follow-up, all patients were satisfied with surgery. CONCLUSION: The study describes the first application of the PK and Lap Loop systems in LSH for the surgical management of uterine fibroids in women in whom fertility is not an issue, and its findings suggest that this minimally invasive technique is a safe, and valid alternative. Larger adequately-powered studies are however still required.     

Selective uterine artery embolization in the management of uterine myomas

OBJECTIVE: To evaluate the effectiveness of uterine artery embolization in women with uterine myomas in terms of the clinical results for the relief of related symptoms. DESIGN: A pilot study on 26 women affected by uterine single myoma. SETTING: Tertiary level care in an university hospital. PATIENT(S): Twenty-six patients, aged 32 to 54 years, suffering of menorrhagia, pelvic pain, and abdominal mass for single myoma, intramural localization. INTERVENTION(S): Selective uterine artery embolization performed under peridural anesthesia. MAIN OUTCOME MEASURE(S): We measured the x-ray dose to which patients were exposed. Color power Doppler ultrasound examinations were performed during the follow-up evaluations at 1 to 6 months and 1 year after the procedure. RESULT(S): Uterine artery embolization was successfully performed in 100% of cases. The mean fluoroscopy time was of 20 minutes during the procedure. The mean dose of x-ray absorbed by the ovary was estimated at 18.7 cGy and the mean dose of x-ray absorbed by the skin was 126.7 cGy. A reduction of myoma volume of 55% was found at 6 months' ultrasound examination and 75% at the 1-year examination. CONCLUSION(S): Patients are well satisfied and have short recovery times with this procedure. Uterine artery embolization may be a valid alternative to traditional surgery.     

Uterine fibroids affect pregnancy outcome in women over 30 years old: role of other risk factors

Objective: To evaluate the pregnancy outcome in women >30 years old with uterine fibroids also considering other possible concomitant risk factors. Methods: A multicentric, observational and retrospective study was conducted. All women were asked to complete a questionnaire while they were in hospital and the outcome of pregnancy was investigated. Results: Women with uterine fibroids before pregnancy were more frequently >35 years old and in their clinical history before pregnancy showed more pelvic pain, polliachiuria, previous pelvic surgery, hypermenorrhea and dysmenorrhea, than control women (p < 0.0001). During pregnancy patients with uterine fibroids showed significantly more threatened preterm birth (PTB) and PTB, weight gain, hyperemesis, gestational hypertension and post-partum bleeding and showed more often requirement for emergency cesarean section (p < 0.0001). The multivariate logistic regression model used for evaluating the effect of clinical parameters on outcome of pregnancy showed that age >35 years, pelvic pain, work, weight gain, hyperemesis, threatened miscarriage and threatened PTB were significantly correlated with unfavorable pregnancy outcome , independently of the presence of uterine fibroids (p < 0.0001). Conclusions: The present study confirming a more frequent negative pregnancy outcome in presence of uterine fibroids, showed that other risk factors may affect pregnancy and delivery outcome in women aging >30 years old.     

子宫肌瘤子宫动脉栓塞术后妊娠情况及影响因素分析

目的:探讨子宫肌瘤患者行子宫动脉栓塞术(UAE)后的妊娠结局,以及肌瘤位置对妊娠率和结局的影响。方法:对行子宫动脉栓塞术的84例有生育要求和497例无生育要求的子宫肌瘤患者进行随访,了解其术后妊娠和产科并发症的发生情况。结果:(1)截止2011年4月,本研究中有50例患者60次妊娠。其中有妊娠要求组共30例39次妊娠,无妊娠要求组共20例21次妊娠。(2)有妊娠要求组妊娠结局为分娩26次(自然分娩9次,剖宫产17次),人工流产4次,自然流产5次,异位妊娠1次,宫内死胎3次(同1人);无妊娠要求组均行人工流产;(2)分娩的26例患者中,发现产科并发症7例26.92%(7/26),其中子痫前期1例3.85%(1/26)、胎盘前置状态1例3.85%(1/26)、早产4例15.38%(4/26)、中央性前置胎盘1例3.85%(1/26);(4)有妊娠要求的单发性肌瘤组(黏膜下、肌壁间、浆膜下、不明)和多发性肌瘤组的妊娠率分别为25.00%、59.09%、62.50%、14.29%和27.58%;单发浆膜下肌瘤组无产科并发症发生,黏膜下子宫肌瘤患者的产科并发症发生率高达75%。结论:子宫肌瘤患者在UAE后可正常妊娠,但自然流产率、胎盘异常等的发生率明显增高,特别是黏膜下和多发性子宫肌瘤患者。     

Uterine leiomyomas, current concepts: pathogenesis, impact on reproductive health, and medical, procedural, and surgical management

Leiomyomas are such common tumors of the uterus that at least two-thirds of women will have at least one by the age of 50. Despite this high incidence, we know relatively little about their cause, growth and development, and contribution to the genesis of reproductive disorders. The prevalence of lesions puts women with associated butun related symptoms at risk for unnecessary and/or unsuccessful interventions,especially if they have not been carefully evaluated and counseled. Indeed, because the majority of leiomyomas do not cause symptoms, when a woman presents with AUB, infertility, pelvic pain, or vague abdominal complaints, it is possible if not likely that the cause of the problem exists elsewhere. The other overwhelming impression that can be gleaned is this: when leiomyomas are the cause of the symptoms,particularly in women desiring to preserve fertility, the tumors have already and frequently induced irreparable harm, a circumstance that cries out for a strategy of early detection and interventions designed to minimize morbidity.Fortunately, because of the efforts of a few, we are just beginning to understand the potential molecular mechanisms by which leiomyomas may contribute to reproductive tract symptoms such as AUB, infertility, and pregnancy loss, work that may contribute to the development of more specific medical therapeutic techniques and strategies. The use of increasingly precise and accessible imaging for diagnosis,combined with the application of customized intrauterine drug-releasing systems or minimally invasive and highly accurate targeted ablative technologies that minimize collateral damage, may provide women the opportunity to avoid the mutilating,painful, expensive, and frequently unsuccessful surgical interventions of today that are applied to end-stage disease.For the present, clinicians should evaluate any woman with reproductive tract symptoms and leiomyomas carefully and with skepticism, ensuring that they have done all that is necessary to determine if the lesion or lesions are related to the problem. If leiomyomas are the suspected or known cause, clinicians must also be prepared to offer or otherwise provide access to the complete spectrum of care that the patient deserves, regardless of the limitations of the clinician’s training, experience,or institutional environment. Such an approach will limit the number of unnecessary and ineffective interventions and, it is hoped, minimize morbidity while optimizing quality of life for affected women.     

An analysis of fluid loss during transcervical resection of submucous myomas

Objective: To determine the contribution of several variables to fluid loss during transcervical resection of submucous myomas.Design: An observational study using multiple linear regression analyses.Setting: A university-affiliated training hospital and a university department of clinical epidemiology and biostatistics.Patient(s): Patients with submucous myomas.Intervention(s): Transcervical resection of submucous myomas and monitoring of fluid loss.Main Outcome Measure(s): Patient age, uterine enlargement, treatment with GnRH analogues or 8-ornithine-vasopressin, type of anesthesia, number of myomas, intramural extension of the myoma (type of myoma), and operating time were tested as variables.Result(s): Only intramural extension of the myoma and operating time were obviously related to fluid loss. For the other variables, such a relation was weak at best. The relation between fluid loss and operating time was not modified by any of the other variables.Conclusion(s): Because fluid loss is an important limiting factor in the transcervical resection of submucous myomas, special attention should be paid to reduction of the operating time and preoperative assessment of the intramural extension of the myoma to guide appropriate patient selection.     

Intraoperative ultrasound in reconstructive surgery for multiple uterine myomas

In this paper, we describe a case of successful surgical treatment of multiple uterine myomas in an open reconstructive operation with intraoperative ultrasound (IOUS) guidance. Eight nodules were removed during myomectomy. Three of them, the smallest nonpalpable tumors, were detected only by IOUS examination. The patient had remained asymptomatic and free of recurrence at follow-up 27 months postoperatively. Future studies in a larger number of series are needed before any final conclusions are reached about the effectiveness of IOUS during reproductive gynecologic procedures.