Human Reproduction Update, Vol.6, No.6 pp.587, 2000
© European Society of Human Reproduction and Embryology 2000; all rights reserved
Mini symposium |
Management of leiomyomata
1 Service de Chirurgie Gynécologique (Pr. Dubuisson), Clinique Universitaire Baudelocque, CHU Cochin – Saint Vincent de Paul, 123 Bd Port-Royal, 75014 Paris, France
Abstract
Uterine myoma is the benign tumour with which the general public is most familiar. Indeed, because it is extremely frequent and has such an effect on women’s genital life, it is a subject of preoccupation for public health. Although there was little change in conservative management for over a century after Atlee described the first myomectomy by laparotomy in 1844 (reported in Brown et al., 1956), since the end of the 1970s several new techniques have been proposed as alternatives to myomectomy by laparotomy: hysteroscopic myomectomy, laparoscopic myomectomy, myolysis, uterine artery embolization, and treatment with gonadotrophin-releasing hormone (GnRH) agonists. Renewed interest is also being shown in abstention from therapy. These new approaches are the subject of considerable enthusiasm because they enable patients to be treated while keeping the constraints and sequelae of treatment to a minimum. These minimally invasive therapies are in line with the present attitude of ‘reduced therapy’ for the management of myoma. Integration of these new techniques into everyday practice does raise certain questions, however.
Firstly, many of the new techniques are still in the assessment stage, which poses the problem of their efficiency and side effects compared with myomectomy via laparotomy. Given that conservative treatment affects the whole reproductive life of the woman concerned, it is essential to have data on the long term results with these techniques, especially with respect to fertility, subsequent pelvic adhesions and the outcome of pregnancies after the treatment.
Secondly, these new techniques are not being spread evenly among the centres, which results in a different scheme of management depending on where the patients consult. Moreover certain techniques such as laparoscopic myomectomy or uterine artery embolization require skilled surgeons which raises the problem of training and regular practice. Another aspect concerns the need for specialized and expensive equipment for these new techniques (interventional radiology, laparoscopic surgery equipment). Altogether there is a very clear need to establish a ranking for the various approaches to conservative management of uterine leimyomata according to their cost, feasibility and facilities required.
The third point is that the new possibilities afforded by these minimally invasive techniques require the strategy for management and indications to be modified. The decision for surgery affects the long-term future of reproductive function, with potential beneficial effects (cure of symptoms, improvement in fertility) together with risks (adhesions, synechia, uterine scars, ‘iatrogenic hysterectomy’). At present the indications are founded on empirical reasoning and common sense (large myomata, deforming the cavity, etc) but the relationships between the anatomopathological characteristics of the myomata and the symptoms are still very vague, in particular with respect to infertility and pain. On the other hand, renewed interest in abstention from therapy requires a more thorough knowledge of the natural history of the disease, especially in the long term, in patients who have myomata but receive no treatment.
The prospects for the future of conservative management of uterine leimyomata will be governed inevitably by the contribution of fundamental research. Our understanding of the processes leading to tumorigenesis and growth of uterine myomata is still patchy. Recent epidemiological studies have identified some interesting leads, such as the protective role of tobacco, genetic, nutritional, and hormonal factors for which the physiopathology still needs to be clarified at molecular level. This type of research could modify profoundly the management of this pathology by allowing prevention or an early, non-invasive cure.