Management of uterine fibroids

Abstract

Uterine fibroids are the most common tumors of the female reproductive tract. It is estimated that the incidence of fibroids by age 35 reaches 40% for Caucasian women and 60% for African American women (Baird and Dunson 2003). Most women with fibroids are asymptomatic; however, symptomatic fibroids remain the most common indication for hysterectomy. In 2010, approximately 196,735 hysterectomies were performed for fibroids in the United States (Wright et al., Obstet Gynecol 122(2 Pt 1):233-241, 2013). The location of fibroids in the uterus will often determine the type and severity of symptoms a woman will experience. The most common presenting symptoms include infertility, heavy menstrual bleeding, bladder pressure, and pelvic pressure. A thorough history and physical examination along with appropriate imaging can help the clinician tailor the treatment options to improve a patient's symptoms. As such, the management of fibroids is highly variable. Expectant management of fibroids is a reasonable option for women who are asymptomatic or not bothered by their symptoms. Medical management can be used for patients desiring to avoid surgery or in preparation for surgery. The surgical management of symptomatic fibroids is broad and includes endometrial ablation, laparoscopic cryomyolysis, laparoscopic uterine artery occlusion, laparoscopic radiofrequency volumetric thermal ablation (LRVTA), myomectomy (abdominal, laparoscopic, or hysteroscopic), and hysterectomy. Radiology-based management options include uterine artery embolization (UAE) and MRI-guided focused ultrasound. Both the UAE and the MRI-guided focused ultrasound require consultation with radiologists. Despite treatment options available, it is important for the clinician to recognize that not all fibroids require intervention. Counseling patients that fibroids do not have oncogenic potential may also help reassure them and guide their decision-making. Expectant management of fibroids in a stable woman is often an acceptable choice.