Uterine Leiomyomas, Current Concepts: Pathogenesis, Impact on Reproductive Health, and Medical, Procedural, and Surgical Management

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Leiomyoma Growth and Development

To understand medical therapy of leiomyomas requires some understanding of the myriad genetic factors and growth and steroid hormones that potentially influence leiomyoma development and growth. Unfortunately, estrogens have been perceived by many as the key, and even only stimulators of myoma growth, largely because the volume of a leiomyoma typically decreases following menopause. On the surface, this process seems to be simply related to hypoestrogenemia, even though the endocrinologic

Abnormal Uterine Bleeding

The mechanisms involved in leiomyoma-associated AUB are only beginning to be understood. First, leiomyomas themselves are typically and strikingly solid and relatively avascular, so bleeding from the myoma itself is probably rare. On the other hand, the myoma may be surrounded by a relatively rich vasculature. When hysteroscopy demonstrates submucous leiomyomas (Lsm) in women with heavy menstrual bleeding (HMB), in most instances the tumors are covered by endometrium, whereas in others

Diagnosing and Characterizing Leiomyomas

Because uterine leiomyomas are highly prevalent and frequently asymptomatic, it is important to both obtain a detailed and structured history and undertake a careful evaluation of the uterus before concluding that leiomyomas are contributing to the clinical problem. Just because there are symptoms and leiomyomas, the two are not necessarily related in a cause-effect fashion.

The diagnosis of leiomyomas is generally accomplished with one or a combination of hysteroscopy and radiologic techniques

Expectant Management of Leiomyomas

The process of watchful waiting is an option for most women with leiomyomas; however, counseling is difficult, in part because of variability in the natural course of any group or collection of tumors. The Fibroid Growth Study followed 262 leiomyomas in 72 women using sequential MRI scans over a period of 12 months. The median growth rate was 9%, but serially measured volume varied from an 89% reduction to a 138% increase.40 Tumors in the same women grew at different rates, and whereas growth

Medical Management of Leiomyomas

The use of medical therapy has expanded due to new information about the factors that affect myoma growth, the availability of new therapeutic agents, and a more reasoned understanding of the relationship of leiomyomas to symptoms. However, it is unlikely that these agents will have much of a role for women with infertility and AUB-Lsm because reduction (not elimination) of the structural distortion of the cavity is unlikely to result in improved fertility or pregnancy performance.

Myomectomy

In 1845, Atlee65 first reported removal of leiomyomas via laparotomy, traditionally called abdominal myomectomy. The principles of contemporary abdominal myomectomy were established by Bonney,66 with his publication of 20 years of experience and amplified by his 1946 report of 806 cases. The low morbidity and mortality were remarkable, with only 2 deaths in the last 400 cases (overall mortality of 1.1%).

Like many surgical procedures that were introduced in the 19th and 20th centuries, abdominal

Summary

Leiomyomas are such common tumors of the uterus that at least two-thirds of women will have at least one by the age of 50. Despite this high incidence, we know relatively little about their cause, growth and development, and contribution to the genesis of reproductive disorders. The prevalence of lesions puts women with associated but unrelated symptoms at risk for unnecessary and/or unsuccessful interventions, especially if they have not been carefully evaluated and counseled. Indeed, because

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    Disclosures: Consultant for Aegea Inc, Bayer Healthcare, Boston Scientific, Ethicon Endosurgery, Ethicon Women's Health and Urology, Gynesonics Inc, Idoman Teoranta, Karl Storz Endoscopy Americas.

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