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Fibroid2
Fibroid2
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Fibroid2

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  • 1. Rajesh Varma MA PhD MRCOG Consultant Obstetrician and Gynaecologist Guy’s and St.Thomas’ NHS Foundation Trust 1415-1515: Tue 25th November 2008 Hot Topics in Clinical Practice Postgraduate Centre, Gassiot House, St.Thomas’ Hospital 1
  • 2. Fibroids Benign, but have 0.2% risk of malignant transformation Occur in 10% of HMB Recurrence risk after myomectomy (10% at 5 years) May undergo degeneration (hyaline, fatty, Red during pregnancy) May become acutely painful (torsion, haemorrhage, sepsis, degeneration) 2
  • 3. Wamsteker K et al. Transcervical hysteroscopic resection of submucous fibroids for abnormal uterine bleeding: results regarding the degree of intramural extension. Obstet Gynecol 1993; 82(5):736-740. 3
  • 4. Do all women with fibroids need treatment? 1. Asymptomatic 2. Abnormal Uterine Bleeding (AUB) Menorrhagia, anaemia Pelvic pressure effects (renal tract-ureter, bladder) Pelvic Pain 3. Improve fertility (reduce risk of miscarriage) 4
  • 5. 5
  • 6. Myomectomy and AUB Removal of the intracavity component of the submucous fibroid improves AUB (70-80% improvement) (Level II evidence) Parker WH. Uterine myomas: management. Fertil Steril. 2007 Aug;88(2):255-71. 2007 Jul 20. Varma R et al. Hysteroscopic myomectomy for menorrhagia using Versascope™ bipolar system: efficacy and prognostic factors at a minimum of one year follow up. In Press 2008, EJOG. Paradox: Post operative adhesions may cause pain and infertility 6
  • 7. Klatsky PC et al. Fibroids and reproductive outcomes: a systematic literature review from conception to delivery. Am J Obstet Gynecol. 2008 Apr;198(4):357-66. ASRM. Myomas and reproductive function. Fertility and Sterility, Volume 90, Issue 5, Supplement 1, November 2008, Pages S125-S130 Pritts EA et al. Fibroids and infertility: an updated systematic review of the evidence. Fertil Steril. 2008 Mar 11 Removal of the intracavity component of the submucous fibroid improves fertility (RR 1.72; 95% CI 1.13-2.58) Subserosal fibroids do not affect fertility outcome Intramural fibroids appear to decrease fertility, but the results of therapy are unclear. (Level II evidence) Myomectomy and Fertility 7
  • 8. NICE (Jan 2007) HMB 8
  • 9. MEDICAL THERAPIES FIBROID SIZE AUB FERTILITY NSAIDs No effect fibroid size Decrease 30% No effect COC No data Decrease 20-30% Contraceptive GNRHa * (3m-6m) Decrease 30% Decrease uterine volume by 35% Decrease >80% Contraceptive Progestins LARC LNG-IUS Mirena (uterine cavity<12cm) Decrease 30% Decrease uterine volume by 35% Decrease>60% Breakthrough bleeding systemic side effects Contraceptive 9
  • 10. GnRHa Side effects Experienced by 95% Hot flushes; vaginal dryness; frontal headaches 10% women stop treatment due to side effects Osteopenia: >6m use Prevented with add-back (tibilone, raloxifene) Suitable women? 1. 3-4 m prior to myomectomy (hysteroscopic, abdominal) or hysterectomy (anaemia, transfusion, avoid midline entry) (concern: recurrence of small myomas & surgical dissection) 2. Late perimenopause as “short-term” treatment (+/- add-back) 10
  • 11. NEW MEDICAL THERAPIES (UNDER TRIAL) FIBROID SIZE AUB FERTILITY GnRH antagonist Ganirelix (sc daily/6m) Decrease 30-40% Decrease Contraceptive Mifepristone (5mg daily/6m) Decrease 40% Decrease uterine size 40% Decrease (risk of endometrial hyperplasia) Contraceptive SPRM Asoprisnil (10mg daily/6m) Decrease Decrease Contraceptive Aromatase Inhibitors Decrease Decrease Contraceptive 11
  • 12. Fibroids >3cm size Fertility preserved Contraceptive Fertility is potentially retained 12
  • 13. Abdominal Myomectomy >80% improvement in AUB Very low conversion rate to hysterectomy Comparable risk to hysterectomy (organ damage, transfusion) Correct pre-operative anaemia (EPO, GnRHa) Tourniquet Transverse uterine incisions (parallel to arcuate vessels) Anti-adhesion : limit number of uterine incisions, anti- adhesion barrier, drainage Re-treatment rates after myomectomy over 5-10 years (symptom +/-fibroid recurrence): 10% single myomectomy vs. 25% multiple myomectomy 13
  • 14. Abdominal Myomectomy 14
  • 15. Value of adhesion prevention ? 15
  • 16. Hysteroscopic Myomectomy Versapoint®Resectoscope 16
  • 17. Hysteroscopic myomectomy Fibroid size Intracavity fibroid 90-100% AUB Decrease >80% Fertility Increase 40-60% Secondary treatment (2yr 10%; 5yr 30%) Complication rate 1-2% Uterine perforation Sepsis; intrauterine adhesions Haemorrhage Hyponatraemic fluid overload Additional treatment May be combined with endometrial resection or ablation-improved effect on AUB 17
  • 18. Hysteroscopic myomectomy: New developments Use of pre-operative GnRHa 3-4m Improved video instrumentation Bipolar resectoscopes: virtually eliminates risk of hyponatraeimc fluid overload syndrome Outpatient microhysteroscopy and Versapoint®- concept of One Stop See-and-Treat gynaecology clinic18
  • 19. 3.5mm diameter disposable outer sheath 19
  • 20. Video clip Outpatient fibroid resection 20
  • 21. New Interventional Technologies Treatment in women with fibroid-related symptoms and not desiring future fertility Uterine artery embolization (UAE) Magnetic resonance image-guided transcutaneous focused ultrasound for uterine fibroids (MRgFUS) Magnetic resonance (MR) image-guided percutaneous laser ablation of uterine fibroids Laparoscopic or transvaginal uterine artery occlusion Laparoscopic cryomyolysis 21
  • 22. Aims: New Interventional Technologies Improvement in AUB, fertility and & QoL Avoid risks of major surgery (e.g. quicker recovery) Safety (lower complication rate) Sustained benefit (low re-treatment rate) Cost-effective Insufficient evidence: RCTs with long term data are lacking22
  • 23. NICE (Oct 2004) Audit and review clinical outcomes of all patients having UAE. Data should be submitted to the British Society of Interventional Radiology registry (www.bsir.org). 23
  • 24. •Both uterine arteries are blocked by Interven. Radiol. •Contraindications :active genitourinary infection, genital tract malignancy •Relative contraindications:submucous myomas (check hysteroscopy prior to UAE), pedunculated myomas, recent GnRHa, previous UAE, postmenopausal status Uterine artery embolisation (UAE) 24
  • 25. UAE Fibroid size Reduced 30-50% AUB Improved (>80% satisfaction)- sustained over 5yr Fertility Reported case series: obstetric outcome uncertain Secondary treatment 20-30% within 5yr Complication rate 1-2w recovery back to work 10-15% persistent vaginal discharge 5% Post embolization syndrome (pain, fever, nausea, vomiting) 10-15% risk premature ovarian failure (especially>45y) 20% intra-abdominal adhesions <1% uterine necrosis/sepsis; death 1/10,000 •Gupta, JK et al. Uterine artery embolization for symptomatic uterine fibroids. Cochrane 2008. •G. Tropeano et al.Non-surgical management of uterine fibroids. Hum Reprod Update 2008;14(3): 259 – 274. •Agdi et al. Intraabdominal adhesions after uterine artery embolization. AJOG, Volume 199, Issue 5, November 2008, Pages 482.e1-482.e3 25
  • 26. NICE (Sept 2007) Audit and review clinical outcomes of all patients having MRgFUS. Data should be submitted to the British Society of Interventional Radiology registry (www.bsir.org). 26
  • 27. Hindley, J. et al. Am. J. Roentgenol. 2004;183:1713-1719 Woman lying on ExAblate 2000 (InSightec) focused ultrasound system ready to be placed into MRI unit MRI-guided focused ultrasound (MRgFUS) 27
  • 28. MRgFUS: outline of procedure Clear pathwayfrom the anterior abdominal wall to the fibroid without passingthrough the bladder or the bowel Shaved anteriorabdomen A urinary catheter is inserted Unsuitable for very large uteri (>24w) or fibroids (>10cm) IV analgesia and conscious sedation Maximumtreatment time of 3 hr ; recovery 1-2 days Thermal ablation of selected fibroid Real time MR Thermometry (aiming >55 degrees C) Gadolinium-enhanced MRI performed immediately after treatment 28
  • 29. Hindley, J. et al. Am. J. Roentgenol. 2004;183:1713-19 AFTER MRgFUS: Non-Perfused Volume (NPV) ratio calculated from the gadolinium-enhanced MRI performed immediately after treatment BEFORE 29
  • 30. MRgFUS Fibroid size 20% at 2yr AUB 60-70% Higher NPV corresponds to greater fibroid size reduction and symptom relief at 12-month Fertility Reported-mainly for single fibroid ablations Secondary treatment ? 30% Complication rate 10% (pain, vaginal discharge) •E. A. Stewart et al. Sustained Relief of Leiomyoma Symptoms by Using Focused Ultrasound Surgery. Obstet. Gynecol., August 1, 2007; 110(2): 279 - 287. •Z. M. Lenard et al. Uterine Leiomyomas: MR Imaging-guided Focused Ultrasound Surgery-- Imaging Predictors of Success. Radiology, Oct 1, 2008; 249(1): 187 – 194 •Rabinovici J et al. Pregnancy outcome after magnetic resonance–guided focused ultrasound surgery (MRgFUS) for conservative treatment of uterine fibroids. Fertility &Sterility, In Press, 200830
  • 31. Conclusions Multiple treatment options exist Advances in hysteroscopy New interventional technologies show early promise However, • Several unanswered questions • Urgent need for further research • Need for increased consumer input 31
  • 32. 32 CONSUMER WEBSITE UNDER DEVELOPMENT

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