Uterine fibroids (also known as leiomyomas or myomas) are the most common form of benign uterine tumors. Clinical presentations
include abnormal bleeding, pelvic masses, pelvic pain, infertility, bulk symptoms and obstetric complications.
Almost a third of women with leiomyomas will request treatment due to symptoms. Current management strategies mainly involve
surgical interventions, but the choice of treatment is guided by patient’s age and desire to preserve fertility or avoid ‘radical’ surgery such as hysterectomy. The management of uterine fibroids also depends on the number, size and location of the fibroids. Other surgical and
non-surgical approaches include myomectomy by hysteroscopy, myomectomy by laparotomy or laparoscopy, uterine artery embolization
and interventions performed under radiologic or ultrasound guidance to induce thermal ablation of the uterine fibroids.
There are only a few randomized trials comparing various therapies for fibroids. Further investigations are required as there is a lack of
concrete evidence of effectiveness and areas of uncertainty surrounding correct management according to symptoms. The economic
impact of uterine fibroid management is significant and it is imperative that new treatments be developed to provide alternatives to surgical
intervention.
There is growing evidence of the crucial role of progesterone pathways in the pathophysiology of uterine fibroids due to the use of
selective progesterone receptor modulators (SPRMs) such as ulipristal acetate (UPA). The efficacy of long-term intermittent use of UPA
was recently demonstrated by randomized controlled studies.
The need for alternatives to surgical intervention is very real, especially for women seeking to preserve their fertility. These options now
exist, with SPRMs which are proven to treat fibroid symptoms effectively. Gynecologists now have new tools in their armamentarium,
opening up novel strategies for the management of uterine fibroids.
Diagnosis
Pelvic examination
Examination of the pelvis may reveal an enlarged uterus or mass. If
fibroids are suspected and a woman reports heavy menstrual
bleeding, a hemoglobin evaluation will allow detection of iron deficiency
anemia.
Ultrasonography
An ultrasound is the gold standard test for uterine fibroids. Its widespread
availability enables easy and inexpensive confirmation in
almost all instances. Moreover, ultrasonography after infusion of
saline into the uterine cavity can delineate submucous myomas and
indicate the proximity of intramural myomas to the endometrial cavity
(Seshadri et al., 2015). The advent of 3D imaging technology has
seen 3D ultrasound establishes itself as a useful tool for the investigation
of myometrial pathology due to its ability to reconstruct the
coronal plane of the uterus (Andreotti and Fleischer, 2014; Wong
et al., 2015).
Hysteroscopy
A hysteroscopy may be required to differentiate intracavitary myomas
and large endometrial polyps (Bettocchi et al., 2003; Di
Spiezio Sardo et al., 2010; Parazzini et al., 2015). Hysteroscopy is
usually performed in an outpatient setting and does not require
any anesthesia (Bettocchi et al., 2003). Ultrasonography with saline
infusion and diagnostic hysteroscopy should be considered more as
complementary examinations when hysteroscopic myomectomy is
indicated. Of course, in case of irregular bleeding or if the patient
has risk factors for endometrial hyperplasia (obesity, chronic anovulation),
hysteroscopy may be combined with an endometrial
biopsy.
Magnetic Resonance Imaging
MRI can provide information on the number of fibroids, their size,
vascularization, relationship with the endometrial cavity and serosal
surface, and boundaries with normal myometrium . It should
nevertheless be stressed that like ultrasonography, MRI cannot
diagnose malignancy with any certainty (Lumsden et al., 2015;
Stewart, 2015). While MRI findings can suggest a diagnosis of sarcoma,
there is currently no form of preoperative testing which can
definitively rule it out (Lin et al., 2015). Possibly in the future, new
types of imaging will improve the accuracy of detecting sarcoma,which remains a very infrequent condition (1/1500 in women aged
<40 years and 1/1100 in women aged 40–44) (Wright et al., 2014).
Novel approaches and algorithms,
with a special emphasis on infertility
There is a clear need for alternatives to surgery, even the less invasive
endoscopic techniques, especially when fertility preservation is
the goal (Donnez et al., 2014a,b; Donnez et al. 2015b). There is no
doubt that surgery remains indicated in some instances, but we must
now establish whether SPRMs (UPA) allow less invasive surgery or
even complete avoidance of surgery. On the other hand, it is clear
that long-term intermittent use of UPA will change our approach to
the management of uterine fibroids.
To address the question of which therapy to adopt, it is crucial to
consider key factors determining the management of uterine fibroids:
patient age, severity of symptoms (pain, bleeding and infertility), wish
to preserve the uterus and/or fertility, localization of fibroids according
to FIGO classification and myoma volume. The approaches
described below are according to the FIGO classification (Munro
et al., 2011).
Type 0 myomas
If type 0 myomas are present, cutting the pedicle by hysteroscopy is
indicated .
Type 1 myomas
In the majority of cases, hysteroscopic myomectomy for type 1 myomas
is relatively straightforward for experienced surgeons, especially
in case of type 1 myomas less than 3 cm in size (Fig. 8). If a fibroid is
of type 1 but larger than 3 cm, or if the patient presents with anemia,
pre-hysteroscopic medical therapy (SPRMs or GnRH agonist) is indicated.
Medical therapy may be given in one or two courses of three
months. In the vast majority of cases, type 1 myomas respond to this
preoperative therapy and regress in size, enabling an easier hysteroscopic
approach in better conditions (recovery of hemoglobin). It
should be pointed out that in some cases, myomas regress so much
that surgery may be avoided.
Type 2 or type 2–5 myomas (single or multiple) distorting the
uterine cavity
Young infertile women of reproductive age and wishing to conceive. In
case of type 2 myomas, medical therapy (SPRMs) can be proposed
(Fig. 9). Myomas often respond to this preoperative therapy
and regress in size. This reduction also allows a hysteroscopic
approach that can be planned after the first menstrual bleed
(Donnez et al., 2014a,b). In some cases (if myomas regress so
much that they no longer distort the uterine cavity), surgery may
not be required. If myomas are multiple (≥2) or of different types
(type 2–5), as is frequently observed, medical therapy (SPRMs)
can be given in two courses of three months, as described in clinical
trials with UPA (Donnez et al., 2014a,b; Donnez et al., 2015a,
b). After these two courses of three months, there are three possible
outcomes.
The most positive outcome would be that myoma regression is very
significant (>50% decrease in volume). The uterine cavity is no longer
distorted and the patient can try to conceive naturally or undergo
assisted reproductive techniques, if indicated. A first series of pregnancies
after UPA treatment was recently described, demonstrating that
in some cases, surgical treatment is not required and patients can conceive
and deliver healthy offspring (Luyckx et al., 2014). Other
case reports have also been published (Monleon et al., 2014). In our
series of pregnancies, patients were able to have unprotected sexual
intercours or to start with ovarian stimulation after the second menstrual
bleed (Luyckx et al., 2014). For those having to undergo IVF, a
vaginal ultrasound was performed on day 3 of the second menstrual bleed to assess the absence of a thick endometrium. The second
outcome would be that myoma regression is significant (≥25% but
<50%). However, in some instances, if the uterine cavity remains
distorted or if the myoma remains large due to great volume at
baseline, the indication for surgery stands. In this case, medical
treatment may allow surgery to be performed by a laparoscopic
approach once the hemoglobin level is normalized, avoiding
laparotomy.
