What are the treatment options for a significant size uterine myoma (leiomyoma)?

Treatment Options for Significant Size Uterine Myoma

Hysterectomy is the most effective and definitive treatment for symptomatic uterine fibroids with high satisfaction rates exceeding 90%, especially for significant size myomas where symptom elimination and zero recurrence risk are priorities. 1

Medical Management Options

• GnRH agonists effectively reduce fibroid volume by approximately 35% and improve hemoglobin levels, but cause significant hypoestrogenic side effects limiting their long-term use 2, 1
• Add-back therapy with GnRH agonists can mitigate the hypoestrogenic side effects while maintaining therapeutic efficacy for longer-term management 1
• Mifepristone (a partial progesterone agonist) has shown promising initial results for symptom control, though more long-term studies are needed 2
• Tranexamic acid may help reduce menorrhagia associated with fibroids but can cause adverse effects such as pelvic pain and fever 2

Surgical Management Options

• Hysterectomy remains the "gold standard" treatment with elimination of presenting symptoms and virtually zero recurrence risk 2

  • Can be performed via abdominal, vaginal, laparoscopic, or laparoscopically assisted approaches depending on fibroid size and location 2
  • Satisfaction rates following hysterectomy exceed 90%, though reproductive potential is eliminated 2

• Myomectomy is appropriate for women who wish to preserve fertility or their uterus 1

  • Recurrence rate ranges from 23% to 33% using either abdominal or laparoscopic approaches 2
  • Associated with 2% major complication and 9% minor complication rates in large multicenter studies 2
  • Patients with multiple fibroids tend to recur more frequently 2

Minimally Invasive Interventional Treatments

• Uterine Artery Embolization (UAE) is an effective alternative to surgery 2

  • Technical success rate exceeds 95% in experienced hands 2
  • Results in 40-50% decrease in uterine volume and symptom control in approximately 80% of patients 2
  • Shorter procedural and recovery times with fewer adverse events compared to myomectomy 2
  • Higher reintervention rates (36%) compared to myomectomy (5%), especially for fibroids >5cm 2

• MR-guided high-intensity focused ultrasound (MRgFUS) is a non-invasive option for focal leiomyomas 2

  • Use is restricted to patients with fewer than six leiomyomas or leiomyoma volume <900 cm³ 2
  • Achieves nearly 50% volume reduction at 1 year, though viable cells remain present in 26% of specimens 2
  • Limited long-term efficacy data available 2

• Myolysis techniques (laparoscopic approach using Nd:YAG laser, bipolar needles, monopolar cautery, or cryotherapy) 2

  • Can reduce fibroid volume by 40-80% with a simple, brief laparoscopic procedure 2
  • Long-term recurrence risk is unknown 2

Important Clinical Considerations

• Treatment selection should be based on:

  • Fibroid characteristics (number, size, location) 3
  • Patient's age and desire for future fertility 1
  • Symptom severity (abnormal bleeding, pelvic pain/pressure, compression symptoms) 1

• Fertility considerations:

  • UAE should not be considered first-line for women seeking pregnancy due to increased risk of miscarriage (35%), cesarean sections (66%), and postpartum hemorrhage (13.9%) 2
  • Myomectomy should be offered as first therapeutic choice for women planning future pregnancy 2
  • Women should wait 2-3 months after myomectomy before attempting pregnancy to allow proper healing 1

• Procedural risks:

  • UAE complications include temporary fever in 40% of patients and extreme pain in up to 20% 2
  • When morcellation is necessary during myomectomy, patients should be informed about the rare risk of spreading occult malignancy 4
  • Hysterectomy carries risks of minor complications and occasionally major morbidity 2