Fibroids are innocuous estrogen dependent benign tumours occurring in the uterus. Also known as leiomyomata, the incidence of fibrids seems to be higher than before, probably due to the advent of ultrasonography. The newer concepts in the management of fibroids are detailed below:

Indication for hysterectomy in fibroids: To get a broad idea of the current international practice regarding hysterectomy, the practise guidelines given in the ‘Medscape women’s health’ is quoted below.

Uterine Leiomyoma : Guidelines for hysterectomy: (24)

   A.Documented growth is > 6 cm per year (any age patient)

   B.Postmenopausal patient with uterus > 12 week size (fibroid size

     documented by ultrasound, CT or MRI)

     or fibroid with documented growth rate > 2 cm/year

  C.Patients age 30 years to menopause who do not wish further children or

    BSO with one of the following:

  1.Documented fibroid > 20 week size with or without symptoms

  2.Documented fibroid 12-20 week size and one of the following:

  a.Documented submucous fibroid (D&C or hysteroscopy) with

     persistent bleeding,   unresponsive to medical therapy, or

  b.Urinary retention, frequency or incontinence or difficulty evacuating

     stool and myomectomy is not feasible, or

  c.Uterine bleeding for more than 8-10 days in the last 2 cycles or last 40

     days, and Hgb < 10 (or transfusion within the last 6 months), or

  d.At least 6 months of moderate to severe pelvic pain, interfering with

    daily activity and myomectomy is not feasible.

  3.Fibroid < 12 week size and one of the following:

  a.Documented submucous fibroid (D&C or hysteroscopy) with

     persistent bleeding, unresponsive to medical therapy, or

  b.Uterine bleeding for more than 8-10 days in the last 2 cycles or last

     40 days, and Hgb < 10 (or transfusion within the last 6 months).

 While these guidelines may help one in being more confident in leaving alone a few fibroids which one may otherwise have removed, sometimes it may be necessary to do a hysterectomy taking into consideration the clinical and social conditions of that particular patient.

Myomectomy in fibroids: In a woman with fibroids, who wants to preserve her uterus,myomectomy is the only option.. Myomectomy through a laparotomy incision is the preferred route for the ordinary surgeon.  A tourniquet tied around the uterine artery at the time of surgery will limit the blood loss to a minimum. There have  been reports of uterine rupture in pregnancies following laparoscopic myomectomy where large defects have been endosutured(27).  There is also an isolated report of a rupture uterus during pregnancy following myomectomy where a subserous fibroid was removed laparoscopically(28).  The uterus can be palpated at laparotomy.this  allows the surgeon to feel for deep seated myomas. Due to the lack of tactile sense, these could be missed at laparoscopy(27). Myomectomy with endosuturing is safe in the hands of an experienced endoscopic surgeon. Otherwise myomectomy by laparotomy would be better. Single submucous fibroids should be handled by hysteroscopic myomectomy.

Myomectomy in infertile women: The impact of leiomyomata on reproduction is not  clear due to the paucity of well controlled studies.(15). Intracavitary and large submucosal leiomyomata are most likely causally related to infertility. . Removal of submucosal and large intramural leiomyomata has been associated with improved outcome in infertile women undergoing assisted reproductive technologies such as in vitro fertilization(8). If the clinical problem is repeated miscarriage,preterm labor, or intrauterine growth restriction or the leiomyomata are large,preconceptional removal of intramural leiomyomata may be appropriate. All patients with myomas should be educated about specific risks during pregnancy, including miscarriage, pelvic pain,premature labor, and postpartum hemorrhage. In the absence of other causes of infertility or after the unsuccessful treatment of other infertility factors, it is reasonable to suggest myomectomy as an option. Most patients can be treated without surgery. There is ultrasonographic evidence of recurrence in 25% to 51% of patients, and as many as 10% require a second major operative procedure (9). According to one study(29), most  recurrences occur10-30 months following original surgery. Myomectomy removes only the fibroids, the genetic predisposition for the formation of fibroids remaining intact.

Asymptomatic fibroids: Fibroids regress after menopause and should be left alone if asymptomatic.  Hormone replacement therapy with estrogen can be given in indicated cases even if fibroids are present as the estrogen content in hormone replacement therapy is too small to cause any change in the size of fibroids(17). However there are a lot of options like Alendronate phytoestrogens, etc which could also be considered in place of estrogen in menopausal women requiring estrogen replacement therapy.

Fibroids in pregnancy: A fibroid diagnosed during pregnancy should be managed expectantly.  There is an increased chance of red degeneration of fibroid which may lead to pain and tenderness on palpation.  These symptoms should be managed symptomatically with rest and analgesics.  During second and third trimester the fibroid flattens out along the walls of the uterus and are usually less symptomatic.  The patient should be given a warning of increased chance of abortion or premature delivery.  During labour, unless there is obstruction to the passages, there is no indication for LSCS.  In case an LSCS has to be done,the classical teaching is not to touch a fibroid during the surgery, but a few workers have tried myomectomy succesfully at LSCS using a tourniquet around the uterine arteries to reduce blood loss

GnRh Agonist treatment in fibroids: Gonadotropin releasing hormone agonists(GnRH agonists) are agents which increase the production of gonadotropins(FSH & LH) . this inhibits production of estrogen, creating a state of pseudomenopause.  The fibroids shrink while on treatment and come back to the original size once the administration is stopped.  The analogues can thus temporarily reduce the size of the fibroids. 

Dose: Inj Goserline acetate 3.5mg subcut. Every month.After 3 months the size of the fibroid  will reduce by 40-50%.  Inj.triptorelin 3.73mg every 4 weeks.

Indication: To buy time till the actual surgery is undertaken, meanwhile treating anaemia, or some medical condition. It can also be used to reduce the size of the fibroids so that an abdominal surgery could be converted to a vaginal,laparoscopic or hysteroscopic procedure(19).

Disadvantage: If a myomectomy is contemplated after GnRh agonist therapy, the margins of the tumour gets obscured, thus increasing the chances  of leaving behind some fibroid, leading to recurrence.  The therapy is costly, each injection costing around Rs.6000.

Uterine artery embolisation: Uterine artery embolisation is the latest nonsurgical treatment for the treatment of fibroids.  It can be done only in centres with facilities for angiographic studies.  The uterine artery is cannulated via the right femoral artery under fluoroscopic control and obstructive particles, usually polyvinyl alcohol are injected into the uterine artery.  Then the cannula is steered into the aorta and from there into the left uterine artery which is also cannulated and obstructive particles injected.  The blood supply to the fibroids is thus curtailed. They undergo degeneration.  The advantage is that all the fibroids can be treated simultaneously and the procedure can be completed under sedation. The disadvantage is that while the fibroids are undergoing degeneration, the patient may get severe pain, sometimes necessitating hospitalisation . Though thousands of uterine artery embolisation have been done there are few reports regarding the procedure in literature. The results so far have been encouraging. 

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Bookmark URL: /das/journal/view/N/11433496?ja=199931&PAGE=1.html&ANCHOR=top&source=MI

Section III: This section describes procedures which the author has learnt through her own practice which may be found useful in clinical practice.

1.Vaginal myomectomy is a feasible procedure.

 If laparoscopic myomectomy is contemplated in multiple fibroids, it is helpful to take the uterus out through a colpotomy incision after the procedure so one can feel the uterus properly and ensure that no intramural fibroids are missed. The disadvantage is the delay in getting back to sexual life.This is important for patients whose husbands stay with them only for 2-3 months yearly or 2 yearly.

2.Thermal ablation in patients with fibroids:

Thermal ablation is successful in treating dysfunctional uterine bleeding even if the patient has fibroids, provided she has no dysmenorrhoea.The author has done thermal ablation in 7 patients with fibroids, where hormonal imbalance and not fibroids were found to be the cause of menstrual irregularity.,5 of them were successful. These included patients in whom there were multiple fibroids. However, rate of failure may be higher in patients with fibroids.

3. Vaginal hysterectomy in postmenopausal women with fibroids:

When fibroids occur in postmenopausal women, specially after 55 years, vaginal hysterectomy becomes difficult as the ligaments and the uterus itself is very soft.In such cases abdominal hysterectomy may be the only option. The author has been routinely doing vaginal hysterectomy for patients with 16wks size uterus, but on attempting to do vaginal hysterectomy for 2 women around 60 years, one with a16 wks uterus and another with a 12 wk size uterus, it was found that after the mackenrodt’s ligaments are secured, they start tearing off while the uterus is pulled.

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