The management options for uterine fibroid tumors have expanded greatly in the past 20 years. As Dr. Evans discusses in this issue of American Family Physician,1 there are few randomized trials to help generate level A evidence for appropriate counseling. Because of this lack of data, physicians defer to the lowest level of evidence: expert opinion and personal experience. This is probably why there is so much variation in treatment throughout the country. When considering these treatment choices, patients often must juggle expectations of treatment outcomes, quality of life, and preservation of fertility. Therefore, there is no best treatment plan.
Following the dictum of primum non nocere (“First, do no harm”), medical therapy is always the first-line option in management of symptomatic fibroid tumors. However, the use of hormonal therapies, including oral contraceptive pills, progesterones, and gonadotropin-releasing hormone agonists, has had conflicting results for some aspects of fibroid-related bleeding. In patients with symptoms persisting for more than three months, it is reasonable to try other therapies because further improvement is unlikely.
When considering other noninvasive treatment options, such as uterine artery embolization, it is important to carefully select your patients. There now are long-term follow-up data from the Fibroid Registry for Outcomes Data that may give patients some idea of treatment expectations. The overall success rate of uterine artery embolization is similar to that associated with the alternative treatment of myomectomy.2 Size and location of the tumor are important factors to consider when choosing a treatment. Submucosal fibroid tumors have a higher likelihood of necrosing and passing into the uterine cavity, which requires further surgical intervention (i.e., hysteroscopy or abdominal surgery), thus defeating the purpose of embolization. Fibroids larger than the equivalent of 20 weeks' gestational age, adenomyosis, and pedunculated subserosal fibroid tumors confer a higher chance of treatment failure and, if symptomatic, are best treated with other surgical options.
Another area of controversy is performing uterine artery embolization in patients who still desire fertility. Although there are more outcome-oriented case series for this treatment than for others, there are still insufficient data to recommend uterine artery embolization as a treatment option. This procedure is still considered investigational by the American College of Obstetricians and Gynecologists.3
Localizing submucosal fibroid tumors is best accomplished with magnetic resonance imaging; however, sonohysterography is more cost-effective. Fibroid tumors can then be classified as type 1, 2, or 3, depending on the extent of intracavitary involvement. This classification is useful in counseling about the likelihood of successful hysteroscopic resection. Patients with type 2 or 3 tumors are more likely to have incomplete resection or require a staged removal. If this risk is unacceptable to the patient, she may choose another treatment option.
Definitive surgery with hysterectomy improves most patients' symptoms with minimal effects on sexual function. Although supracervical hysterectomy has been suggested as a preferred option to total hysterectomy, removal of the cervix has been advocated because of purported benefits to sexual function, fewer operative complications, lower risk of future prolapse, and lower rates of postoperative morbidity and urinary dysfunction. However, a recent large randomized trial comparing the two types of hysterectomies did not show any benefit with either procedure in regards to these outcomes.4 Although limited conclusions can be drawn from the results of this study, it remains an ongoing debate whether to remove the cervix in hysterectomies for benign disease.
Options for hysterectomy include vaginal, abdominal, laparoscopy-assisted vaginal, laparoscopy-assisted supracervical, and complete laparoscopic hysterectomy. The approach recommended depends on many factors, such as size, concurrent ovarian pathology, prior surgeries, descent of uterus, and, most importantly, the expertise of the surgeon. Studies comparing all three approaches (i.e., vaginal, abdominal, and laparoscopic) suggest that the safest and most cost-effective approach is vaginal hysterectomy.5 This procedure is the most dependent on the expertise of the physician. Because residency training programs are now confined to 80-hour work weeks, and because less-invasive options are available, the rate of vaginal hysterectomies will continue to decline. Compared with abdominal hysterectomy, laparoscopy-assisted vaginal hysterectomy is marginally cost-effective and has faster recovery time, but it has slightly higher operative morbidity.5,6
The most difficult question about the treatment of fibroid tumors may be how to treat asymptomatic patients who are considering pregnancy. Although there are associated complications of pregnancy, including spontaneous abortions, preterm labor, growth restriction, and possible infertility if the tumor is blocking the fallopian tubes or impinging on the uterine cavity, most women do not experience any problems. The literature in infertile couples undergoing in vitro fertilization treatments suggests some improvement in implantation rates when fibroid tumors of a specific size and location are removed. However, it is difficult and possibly harmful to apply these data to a patient without infertility or a history of obstetric problems. Myomectomy can lead to hysterectomy, recurrence, adhesions, and tubal occlusion, all of which would have a negative impact on pregnancy rates.
Until there are better randomized trials comparing treatment options, physicians must carefully counsel patients and consider associated symptoms, individual expectations, and quality of life. In-depth counseling on the evidence for a specific treatment (or lack thereof) is an important consideration in the management of uterine fibroid tumors.