Management of leiomyomata

Uterine myoma is the benign tumour with which the general publicis most familiar. Indeed, because it is extremely frequent andhas such an effect on women’s genital life, it is a subjectof preoccupation for public health. Although there was littlechange in conservative management for over a century after Atleedescribed the first myomectomy by laparotomy in 1844 (reportedin Brown et al., 1956), since the end of the 1970s several newtechniques have been proposed as alternatives to myomectomyby laparotomy: hysteroscopic myomectomy, laparoscopic myomectomy,myolysis, uterine artery embolization, and treatment with gonadotrophin-releasinghormone (GnRH) agonists. Renewed interest is also being shownin abstention from therapy. These new approaches are the subjectof considerable enthusiasm because they enable patients to betreated while keeping the constraints and sequelae of treatmentto a minimum. These minimally invasive therapies are in linewith the present attitude of ‘reduced therapy’ forthe management of myoma. Integration of these new techniquesinto everyday practice does raise certain questions, however. Firstly, many of the new techniques are still in the assessmentstage, which poses the problem of their efficiency and sideeffects compared with myomectomy via laparotomy. Given thatconservative treatment affects the whole reproductive life ofthe woman concerned, it is essential to have data on the longterm results with these techniques, especially with respectto fertility, subsequent pelvic adhesions and the outcome ofpregnancies after the treatment. Secondly, these new techniques are not being spread evenly amongthe centres, which results in a different scheme of managementdepending on where the patients consult. Moreover certain techniquessuch as laparoscopic myomectomy or uterine artery embolizationrequire skilled surgeons which raises the problem of trainingand regular practice. Another aspect concerns the need for specializedand expensive equipment for these new techniques (interventionalradiology, laparoscopic surgery equipment). Altogether thereis a very clear need to establish a ranking for the variousapproaches to conservative management of uterine leimyomataaccording to their cost, feasibility and facilities required. The third point is that the new possibilities afforded by theseminimally invasive techniques require the strategy for managementand indications to be modified. The decision for surgery affectsthe long-term future of reproductive function, with potentialbeneficial effects (cure of symptoms, improvement in fertility)together with risks (adhesions, synechia, uterine scars, ‘iatrogenichysterectomy’). At present the indications are foundedon empirical reasoning and common sense (large myomata, deformingthe cavity, etc) but the relationships between the anatomopathologicalcharacteristics of the myomata and the symptoms are still veryvague, in particular with respect to infertility and pain. Onthe other hand, renewed interest in abstention from therapyrequires a more thorough knowledge of the natural history ofthe disease, especially in the long term, in patients who havemyomata but receive no treatment. The prospects for the future of conservative management of uterineleimyomata will be governed inevitably by the contribution offundamental research. Our understanding of the processes leadingto tumorigenesis and growth of uterine myomata is still patchy.Recent epidemiological studies have identified some interestingleads, such as the protective role of tobacco, genetic, nutritional,and hormonal factors for which the physiopathology still needsto be clarified at molecular level. This type of research couldmodify profoundly the management of this pathology by allowingprevention or an early, non-invasive cure.