Management of Uterine Fibroids: A Focus on Uterine-sparing Interventional Techniques

Abstract

Uterine fibroids occur in approximately 50% of women over the age of 40 years, and an estimated 50% of those are symptomatic. Menorrhagia is the most common symptom and the primary indication for treatment, although bulk symptoms often occur and can be treated. Pharmacotherapy is typically inadequate unless it can be expected to successfully bridge to menopause or allow for a less-invasive intervention. However, hormonal therapies have risks. Hysterectomy is still the most commonly performed procedure for symptomatic fibroids and has the lowest rate of reintervention (compared with myomectomy or uterine artery embolization [UAE]), but rates of more serious complications are higher and patient satisfaction and ability to return to normal activities may also be less favorable. Myomectomy is not necessarily less morbid than hysterectomy and may have a greater failure rate than UAE. Techniques and devices vary with little standardization, and operator experience is crucial to success. The largest studies of UAE show very low rates of serious complications and rapid recovery. UAE significantly improves symptoms related to uterine fibroids in 85%-90% of patients. Herein, this article will discuss the nature of fibroids and their diagnosis, pharmacotherapy, surgical treatment, and nonsurgical interventional treatment, including UAE and magnetic resonance-guided focused ultrasound. (©) RSNA, 2016.

European Society of Urogenital Radiology (ESUR) Guidelines: MR Imaging of Leiomyomas

“…Persistent vaginal discharge may indicate a necrotic remnant or, rarely, expulsion and transvaginal sloughing of a necrotic leiomyoma may occur [4, 49]. …”

Impact of pelvic magnetic resonance imaging findings in the indication of uterine artery embolization in the treatment of myoma

“…In the present study, adenomyosis was associated with fibroids in 43/263 (16.35%) cases. The diagnosis of adenomyosis associated with fibroids is important for counseling women that the results of uterine-artery embolization, as well as the resolution of symptoms, may not be as long-lasting compared with the results obtained when the diagnosis is fibroid alone [15]. Of the 43 patients in the present study who were diagnosed with adenomyosis by MRI, only one did not have symptoms.…”

Abnormal uterine bleeding: managing endometrial dysfunction and leiomyomas

“…In this procedure, the end arterioles supplying a leiomyoma are blocked, causing necrosis, while vascular anastomoses ensure adequate supply to the normal myometrium. UAE is a uterine‐sparing procedure that may be offered to symptomatic patients wanting to retain their uterus, and has been shown to be highly effective at treating leiomyoma symptoms, with up to 90% initial improvement 27 , 45 , 46 . Moreover, a recent systematic review showed shorter procedure time and hospital stay with reduced blood loss and need for transfusion when compared with both myomectomy and hysterectomy 45 …”

“…Fertility concerns associated with UAE include non‐target embolisation of the ovary, endometrial deterioration from poor perfusion and abnormal placental implantation 49 , 50 . Pregnancy concerns include intrauterine growth restriction, malpresentation, pre‐term labour, uterine rupture, post‐partum haemorrhage and increased risk of caesarean delivery 46 , 50 , 51 . While live births have been reported after the procedure, the evidence regarding the impact of UAE on fertility is poor.…”

“…Low‐level data from subgroup analyses of small studies suggest slightly improved outcomes with myomectomy (ie, lower rates of miscarriage and higher rates of live births) 45 . However, the quality of the evidence is low, with insufficient comparison between the two procedures to assess fertility outcomes, but it appears that UAE does not increase the risk of radiation‐associated cancer or radiation‐related infertility 46 , 50 …”