Contemporary management of fibroids

More women are delaying child-bearing such that gynaecologists can no longer resort as frequently to definitive treatments, such as a hysterectomy, in the management of uterine fibroids. A review of newer conservative medical, radiological and surgical therapies and minimal access approaches to the organ-preserving myomectomy operation are discussed.

Data from published literature describing newer modalities of treatment and reviewing updated information of the impact of fibroids and myomectomy on fertility potential were collated.

Medical treatments serve to retard the growth of fibroids temporarily and have short-term success in the amelioration of symptoms. Uterine artery embolisation is a novel non-surgical approach to debulking of uterine fibroids and the relieve of symptoms. Hysterectomy is a treatment choice that is curative. Laparoscopic hysterectomy carries a 3% risk of major complications compared to 1% via a laparotomy. Laparoscopic myomectomy is a viable alternative to open myomectomy but due diligence must be exercised in ensuring meticulous and secure myomectomy defect repair. The risk of uterine dehiscence has been reported to be about 0.5% which is comparable to that in traditional open myomectomy which has been somewhat understated. Hysteroscopic resection of submucous fibroids is very efficacious and preserves reproductive potential. This procedure and myomectomy of intramural fibroids associated with intracavitary distortion are clearly indicated as these types of fibroids have been implicated as a cause of infertility and pregnancy loss at least 2 to 3 times higher than controls. This relationship prevailed in patients undergoing assisted reproduction.

The management of uterine fibroids has undergone a revolution in the past few decades with better understanding of its impact on fertility and technical advances in endoscopy and radiologic embolisation techniques and also pharmaceutical alternatives such as gonadotrophin-releasing hormone agonist and progesterone intrauterine contraceptive devices. Advances in molecular biology may provide an opportunity to manipulate receptors and cellular biology in order to arrest tumourigenesis altogether.