Current Practices for Treatment of Uterine Fibroids.

The treatment of uterine fibroids depends on symptoms of patients, size of the fibroid, desire for future pregnancy, and preference of the treating gynecologist. The present study was undertaken to compare treatment preferences in women desirous and nondesirous of pregnancy by an experienced gynecologist in symptomatic uterine fibroids. Newer medical or minimally invasive treatment modalities are increasingly being used for the treatment of fibroids. However, conventional surgical treatment such as myomectomy and hysterectomy are still preferred by gynecologists.

INTRODUCTION

Symptomatic fibroids need treatment and management differs with experience of gynecologist and patient's decidedness to save the uterus. The conservative management in the form of medical treatment with gonadotrophin-releasing hormone analogs (GnRHa), levonorgestrel intra-uterine device (LNG-IUS) and selective progesterone receptor modulators; and minimally invasive treatment options such as uterine artery embolization and ultrasound- or endoscopic-guided ablation procedures have become increasingly available for management of fibroids. The objective of this study was to understand management preferences for symptomatic fibroids in women desirous and nondesirous of pregnancy by an experienced gynecologist.

METHODS

A total of 106 gynecologists with clinical experience of >10 years were invited in May 2017 to participate in the survey. Ninety-four (88.7%) of gynecologist could submit their response on time. Seventy-four (74% of the participating gynecologists were working in the government sector and in teaching hospitals. More than one choice was allowed for every question. Descriptive analysis was used considering the size of fibroid and desire for the future pregnancy. The percentages were calculated for every preferred choice.

RESULTS

In women, nondesirous of pregnancy with larger size fibroid (>4 cm); hysterectomy was preferred choice by gynecologists (79.8%). Levonorgestrel intrauterine system device was preferred in 55.3% and myomectomy in 51.1% for smaller size fibroid (≤4 cm).

In women, desirous of pregnancy with larger size fibroid, myomectomy was preferred by all (100%) gynecologist. Gonadotrophin-releasing hormone agonists were preferred by 47.9% for smaller size fibroid. Detailed analysis of treatment practices is shown in Table 1.

Table 1

Comparison between women desirous of pregnancy and nondesirous of pregnancy with respect to size of larger fibroid: >1 choices were allowed for every option

DISCUSSION

Above results showed that invasive method such as hysterectomy and myomectomy are still preferred methods for the treatment of uterine fibroids as compared to medical treatment. Similar practices are also reported from gynecologists across the world, probably due to faster relief of symptoms.[1] Our survey reports that LNG-IUS in women nondesirous of pregnancy and GnRHa in women desirous of pregnancy is next preferred methods. However, these require multiple follow-up visits and more time is required to achieve symptom-free life. There are no reported long-term benefits of these treatments, and hence, these treatments can be considered to be short-term options.[2] In our survey, progesterone receptor modulators were less preferred by gynecologists (8.5%–20.2%) as compared to GnRha (20.2%–47.9%). This is due to the lack of enough evidence for its long-term use and price of the drug. Totally four progesterone receptor modulators, namely, mifepristone, asoprisnil, ulipristal acetate (UPA) and telapristone acetate are being used for the treatment of uterine fibroids. UPA (5–10 mg daily) has shown promising results in 12 weeks therapy with a significant reduction in the volume of uterine fibroid.[3] Other drugs of this group are less studied to produce evidence-based results. SPRM treatment has less estrogen deprivation and bone loss, and no rebound side effects; hence, may be considered for future use.[4] Recently, an internet survey of Belgian gynecologist has reported increasing use of SPRM followed by surgery (70%) and myomectomy was a preferred surgical method (79%).[5] To conclude, currently, surgical options are more practiced for the treatment of uterine fibroids as there is lack of enough evidence for the long-term use of medical treatment.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.