Literature

Clinical Pearls & Morning Reports

Posted by Carla Rothaus, MD

Published November 6, 2024

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What surgical or other interventional alternatives to hysterectomy are available for women needing treatment for fibroids?

Uterine fibroids are the leading indication for hysterectomy. Read the NEJM Clinical Practice Article here.

Clinical Pearls

Q: How are uterine fibroids classified?

A: In 2011, the International Federation of Gynecology and Obstetrics published a fibroid classification system to better describe the location of fibroids in relation to the uterine cavity and the serosal surface, beyond the historical terms of submucosal, intramural, and subserosal, thus enabling clearer communication and treatment planning. Types range from 0 to 8, with lower numbers indicating fibroids closer to the endometrium.

Q: Are fibroids more common in Black persons or in White persons?

A: The incidence of fibroids increases with age until menopause and is higher among Black persons than among White persons. Black persons have earlier onset of fibroids, a higher cumulative risk of symptoms, and a greater disease burden overall than non-Black persons.

Morning Report Questions

Q: How do oral gonadotropin releasing hormone (GnRH) antagonist combinations contribute to the management of fibroids?

A: The introduction of oral GnRH antagonist combinations to fibroid care has been a major treatment advance. Data from clinical trials show that oral GnRH antagonist combinations effectively decrease heavy menstrual bleeding (by 50 to 75%), pain (by 40 to 50%), and bulk-related symptoms with modest volume reduction (decrease in uterine volume, approximately 10%), with low levels of side effects (with hot flashes, headaches, and nausea occurring in <20% of participants). The efficacy of oral GnRH antagonist combination therapy is independent of the extent of fibroid disease (size, number, or location of fibroids), the presence of concomitant adenomyosis, or other factors that limit surgical therapies. Oral GnRH antagonist combinations are currently approved in the United States for 24 months of use and in the European Union for an unlimited duration of treatment. However, these drugs have not been shown to provide contraception, which is a limitation for long-term use in many persons.

Q: What surgical or other interventional alternatives to hysterectomy are available for women needing treatment for fibroids?

A: Numerous procedures have been developed to reduce bleeding and fibroid size and improve quality of life without hysterectomy. The procedure with the most evidence of efficacy is uterine-artery embolization, which uses a minimally invasive interventional catheterization, guided radiologically, to release embolic particles directly into both uterine arteries; this process causes ischemic infarction of the fibroids and subsequent decreases in bleeding, pain, and bulk-related symptoms. Uterine-artery embolization is widely available. Procedures that shrink individual fibroids with the use of energy to create coagulative necrosis include focused ultrasound ablation (with the use of MRI or ultrasound guidance) and radiofrequency ablation (with the use of laparoscopic or transcervical ultrasound guidance). These interventions reduce heavy menstrual bleeding and bulk-related symptoms. However, unlike uterine artery embolization, in which all fibroids can be treated concurrently, these therapies require the individual targeting of each fibroid, and they are not as readily available. Myomectomy, or the surgical removal of fibroids, remains an option for many persons, although it is most often used in persons who are actively seeking pregnancy or in those with very large fibroids.

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