Uterine fibroids: Which treatment?

Uterinefibroids, also called uterine leiomyomata, are benign tumors that originate from the smooth muscle walls of the uterus and may be single but usually occur in clusters. They are most common in women of African descent and in women who have not borne children, and they are most often identified in women aged 30–45 years.1 New tumors rarely originate after menopause, and existing ones usually regress at that time but do not disappear. The symptoms are quite variable and depend largely on the location and size of the tumor. Fibroids can cause excessive uterine (menstrual) bleeding and pain, as well as a sensation of pressure in the uterus, and may contribute to infertility by interfering with egg implantation or by compressing the opening of the fallopian tubes so that the sperms are prevented from reaching the egg. The diagnosis is tentatively made by pelvic examination and confirmed by ultrasound or a noninvasive surgical procedure (hysteroscopy). Small asymptomatic fibroids need not be treated; the larger ones may be treated by hormone therapy, by surgical removal of the tumors (myomectomy), or by total or partial removal of the uterus (hysterectomy).

Until very recently, myomectomy enjoyed the near monopoly as the preferred treatment modality in women who desire to preserve their uterus in the presence of symptomatic uterine fibroids.2 Even when the size and/or the number of fibroids appear to render the uterus unsalvageable, most women would still rather have their uteri preserved especially since advances in assisted reproductive techniques offer fertility prospects for women in their reproductive years to bear a child if the uterus is still intact. Moreover, the presence of uterus carries a symbolic meaning to many women who associate it with femininity and can experience diminished self-esteem if it is removed. It is not surprising, therefore, that most women would rather choose myomectomy as an alternative to hysterectomy.

It is observed that leiomyoma has ovarian steroid dependency, and that both estrogen and progesterone receptors3 are expressed more in number in fibroids when compared with the myometrium.4 The implication is that any agent/drug that is capable of blocking the effects of these hormones would exert inhibitory effect on the growth of leiomyomata. This observation has the potential to revolutionalize none operative management of leiomyomata in the near future, and make less attractive abdominal myomectomy for large uterine fibroids which can be technically challenging and carries the risks of haemorrhage, anemia, wound sepsis, pelvic adhesions and uterine rupture in subsequent pregnancies.56 Further studies to determine any serious side effects of such therapy, especially following its prolonged use, are encouraged.