Hysterectomy vs levonorgestrel inter-uterine device Hysterectomy was the most cost-effective treatment Progesterone receptor modulators for the treatment of uterine fibroids Progesterone receptor modulators (ulipristal acetate or mifepristone) were also identified as a potential new treatment by members of the Guideline Development group (GDG) Pre-surgical medical treatment of uterine fibroids (progesterone receptor modulaters and gonadotrophin releasing hormone analogues) The new evidence may favour ulipristal acetate over gonadotrophin releasing hormone analogue for some, but not all outcomes as a pre-treatment for uterine fibroids before myomectomy

1. Current practices in
management of Fibroid
By Indraneel Jadhav
MBBS, DGO, DNB
Consultant Gynecologist and IVF
Indira IVF, Kolhapur
Indraneel Jadhav

2. Medical management
 Pharmaceutical treatment should be considered in
 Fibroids less than 3 cm in diameter
 Causing no distortion of the uterine cavity
NICE Guideline January 2007
Indraneel Jadhav

3. Tranexamic acid
 Indications
 While investigations and definitive treatment are
being organised.
 Stopped if no improvement within 3 menstrual cycles
Dosage : 1 g tid up to 4 days (max – 4g/day)
Contraindications : Active thromboembolic disease,
severe renal failure, and hypersensitivity
Caution : concomitant use of hormonal oral
contraceptives : risk of thrombotic events
Indraneel Jadhav

4. Non-Steroidal
Anti-Inflammatory Drugs
 Inhibit prostaglandin synthesis and decreases menstrual
blood loss
 Reduces blood loss by 20–40% and more in those with
excessive bleeding
 Ibuprofen (400 mg, 3 times daily) and mefenamic acid
(500 mg 3 times daily) have been studied
 Added advantage of providing relief from dysmenorrhea

5. Levonorgestrel-releasing intrauterine
system (LNG-IUS)
 Indications
 Non-submucosal fibroids (undistorted uterine cavity)
 Uterine size of less than 12 weeks
 Effects: 94% decrease blood loss over 3 months
 Caution : Advised of anticipated changes in the bleeding
pattern: persevere for at least 6 cycles to see the benefits
of the treatment.
Indraneel Jadhav

6. Combined oral contraceptives (COCs)
Appears to be ineffective
No evidence that low-dose contraceptives cause the
growth of uterine fibroid tumors
Further evaluation needed.
Indraneel Jadhav

7. Gonadotrophin-releasing hormone
analogues
 Temporizing measures
• peri-menopausal women
• pre-operatively
 Shrinkage directly proportional to the percentage of cells
that are estrogen receptor positive
 No long-term standalone therapy : Rapid rebound
growth on cessation
 Dosage : Leuprolide acetate– 3.75 mg Depot Suspension
once a month
 ‘Add-back' therapy is recommended. (If to be used for
more than 6 months )
Indraneel Jadhav

8. Selective estrogen receptor modulators
(SERMs)
 Hypothesis: Any molecule that blocks estrogen activity
has potential therapeautic effect on fibroid
 Tamoxifen : Not been investigated in RCTs: Endometrial
hyperplastic effect .
 Raloxifene : Shrinkage of uterine fibroids in
postmenopausal women
 Daily 60 mg doses of raloxifene over a 2-year
period exhibited no change in leiomyoma size
(Fertil Steril. 2007 Dec;88(6):1637-44)
Indraneel Jadhav

9. Selective progesterone receptor
modulators (SPRMs)
 Stimulates growth :
 Up regulating epidermal growth factor (EGF)
 Down regulating tumour necrosis factor-alpha
expression
 Inhibits growth :
 Downregulating insulin-like growth factor-1 (IGF-1)
expression
 Mifepristone : 5 or 10 mg per day for 1 year
 Ulipristal acetate: 5-10mg/day for 13 weeks
 Longer than 3 months:PRM-associated endometrial
changes (PAEC) :Cystic glandular dilation
Indraneel Jadhav

10. Selective progesterone receptor
modulators (SPRMs)
Indraneel Jadhav

11. Aromatase inhibitors
Indraneel Jadhav
 Inhibits peripheral conversion of androgen to estrogens
 Regimens recommended:
 2.5 mg per day of letrozole
 1 mg per day of anastrozole.
 Bone loss with prolonged use
 Aromatase inhibitor (letrozole) Vs gonadotropin-
releasing hormone agonist (triptorelin) :
Rapid onset of action of Aromatase Inhibitors in addition to the
avoidance of the flare-ups

12. Other hormonal agents
Indraneel Jadhav
 Somatostatin analogs : Lanreotide : Insulin growth factor
IGF-I/IGF-II receptors
 Long-term use :Decreased life expectancy :accelerated
heart disease , gallstone formation.
 Gestrinone : Anti-estrogen receptor and Anti-
progesterone receptor properties
 Long-term use : mild androgenicity, weight gain,
seborrhea, acne, hirsutism, and occasional hoarseness
 Vitamin D
 Epigallocatechin gallate (EGCG) – green tea extract

13. Minimally invasive techniques
Uterine artery embolization (UAE)
 Principle : limiting blood supply to the myomas
(infarction) ⇒ their volume may be reduced ⇒ Normal
myometrium recovers.
 Minimally invasive procedure ⇒ shortened hospital stay
 Complications
1) Immediate(during the procedure):Hematoma
formation, thrombosis, or pseudo-aneurysm.
2) Early (within the first 30 days):post-embolization
syndrome-flu-like illness, mild pyrexia, and raised
inflammatory markers.
3) Late (beyond the first 30 days): chronic vaginal
discharge, adverse changes in sexual function, and
temporary amenorrheaIndraneel Jadhav

14. Minimally invasive techniques
Uterine artery embolization (UAE)
 Placement of an angiographic catheter ⇒ Common
femoral artery approach ⇒ Uterine arteries ⇒ Injection
of embolic agents (polyvinyl alcohol particles or
trisacryl gelatin microspheres) ⇒ Sluggish flow
Indraneel Jadhav

15. Magnetic resonance-guided focused
ultrasound surgery (MRgFUS)
 High-intensity focused ultrasound ⇒ Anterior abdominal wall ⇒
Uterine fibroid ⇒ converges into a precise target point -temperature
rise (55°C–90°C) ⇒ Coagulative necrosis
 Concurrent MRI ⇒ Accurate tissue targeting ⇒ Real-time
temperature feedback ⇒ Controlled localized thermal ablation
Indraneel Jadhav

16. Magnetic resonance-guided focused
ultrasound surgery (MRgFUS)
 Advantages :
 Incision-less (non-invasive) and re-treatable
 No ionizing radiation
 No hospitalization(Next day return to work)
 Disadvantage: Relatively few patients are eligible
Indraneel Jadhav

17. Other ablation procedures
(VizAblate™ and Acessa™)
Intrauterine sonography ⇒ Graphical
interface ⇒ Radiofrequency (RF) ablation
⇒Avoids thermal injury to the serosa with its
potential for adhesiogenesis and injury to
bowel or bladder
Indraneel Jadhav

18. Hysteroscopic myomectomy
Journal of Minimally Invasive Gynecology, Vol 19, No 2, March/April
2012
.
Indraneel Jadhav
European Society of Gynaecological
Endoscopy(ESGE)
Wamsteker Classification of submucous myomas
Type 0 Entirely within endometrial cavity
No myometrial extension (pedunculated)
Type I < 50% myometrial extension (sessile)
< 90-degree angle of myoma surface to uterine
wall
Type II > 50% myometrial extension (sessile)
> 90-degree angle of myoma surface to uterine
wall

19. Hysteroscopic myomectomy
Journal of Minimally Invasive Gynecology, Vol 19, No 2, March/April
2012
.
Indraneel Jadhav
Lasmar’s Pre-surgical classification of SM myomas (STEP-W)
Size cm Topography Extension
Base
Penetration
%
Lateral wall Total
0 < 2 lower < 1/3 0
+ 11 2-5 middle 1/3-2/3 < 50
2 > 5 upper > 2/3 > 50
Score + + + + =
Score Group Indication
0 - 4 I Low Complexity .Hysteroscopic Myomectomy
5 - 6 II High Complexity . Hysteroscopic Myomectomy (? GnRH)
Two-step Hysteroscopic Myomectomy
7 - 9 III Hysteroscopic Myomectomy not indicated

20. Laparoscopic myomectomy
 Performed when myomas are easily accessible, as in
superficial subserous or pedunculated myomas
 These can be morcellated and removed through the
laparoscopic cannula or placed in the cul-de-sac and
removed via a colpotomy incision
 With intramural fibroids had significantly lower clinical
pregnancy rates
 Significant reductions in blood loss was found with
misoprostol, vasopressin, bupivacaine and epinephrine,
tranexamic acid, peri-cervical tourniquet, and gelatin–
thrombin matrix.
Indraneel Jadhav

21. Laparoscopic myomectomy
Novel Approach
 Laparoscopic coagulation of a myoma, or myolysis
 conservative alternative to myomectomy in women
wishing to preserve fertility
 Nd:YAG laser via degeneration of protein and
destruction of vascularity
 Laparoscopic assisted myomectomy involves
laparoscopic dissection of the myomas from the uterine
wall and their extraction through a minilaparotomy
incision, thus sparing a large abdominal incision
Indraneel Jadhav

22. NICE Recommendations for Uterine
Fibroids-Interventional
 For patients with fibroids >3 cm size (and especially
those with pelvic pain or other symptoms) then…
 Uterine artery embolisation (UAE) , myomectomy
and Hysterectomy, should all be offered
 Myomectomy recommended if fertility is desired
 Hysteroscopic resection of the entire fibroid with
endometrial resection is appropriate if the fibroid (s)
are submucous
 Pre treatment with GnRH analogue for 3 – 4 months
is worthwhile before hysterectomy and myomectomy
 Reduces uterine size and makes surgery easier
 Better Hemoglobin pre operative and less bleeding
 But GnRH analogues are contraindicated before
UAE
Indraneel Jadhav

23. Hysterectomy
 Hysterectomy should be considered only when
 other treatment options have failed, are
contraindicated or are declined by the woman and
requests it
 history of previous surgery
 Hysterectomy is for symptomatic myomas in patients
who have significant bleeding, pain, pressure or anemia
for whom fertility is not an issue.
 The discussion should include: fertility impact, bladder
function, treatment complications(ureteral injury,
vesico-vaginal fistula, stress incontinence, bowel injury
vaginal vault prolapse etc.)
NICE Guideline January 2007
Indraneel Jadhav

24. NICE Survellience for Uterine Fibroids
30 March 2015
 Hysterectomy vs levonorgestrel inter-uterine
device
 Hysterectomy was the most cost-effective treatment
 Progesterone receptor modulators for the
treatment of uterine fibroids
 Progesterone receptor modulators (ulipristal acetate or
mifepristone) were also identified as a potential new
treatment by members of the Guideline Development
group (GDG)
 Pre-surgical medical treatment of uterine fibroids
(progesterone receptor modulaters and gonadotrophin
releasing hormone analogues)
 The new evidence may favour ulipristal acetate over
gonadotrophin releasing hormone analogue for some, but
not all outcomes as a pre-treatment for uterine fibroids
before myomectomyIndraneel Jadhav

25. SOGC CLINICAL PRACTICE
GUIDELINE
No. 318, February 2015 (Replaces, No. 128, May 2003)
 Asymptomatic fibroids :reassured
 Treatment must be individualized
 In women who do not wish to preserve fertility
:Hysterectomy by the least invasive approach
 Hysteroscopic myomectomy : firstline conservative
surgical therapy for intracavitary fibroids.
Indraneel Jadhav

26. SOGC CLINICAL PRACTICE
GUIDELINE
No. 318, February 2015 (Replaces, No. 128, May 2003)
Acute uterine bleeding associated with uterine
fibroids: conservative management with
Estrogens
Selective progesterone receptor modulators
Antifibrinolytics
Foley catheter tamponade
Operative hysteroscopic intervention
Intervention by uterine artery embolization
Indraneel Jadhav

27. SOGC CLINICAL PRACTICE
GUIDELINE
No. 318, February 2015 (Replaces, No. 128, May 2003)
 Anemia should be corrected prior to proceeding with
elective surgery.
 Use of vasopressin, bupivacaine and epinephrine,
misoprostol, peri-cervical tourniquet, or gelatin-thrombin
matrix reduce blood loss at myomectomy and should be
considered.
 Surgical planning for myomectomy :mapping with
appropriate imaging.
 Symptomatic uterine fibroids who wish to preserve their
uterus : Uterine artery occlusion by embolization or
surgical methods
Indraneel Jadhav

28. National Guideline
Clearinghouse
(QUIZ)
American College of Radiology (ACR); 2012. 8 p
Recommendations
Indraneel Jadhav

29. Indraneel Jadhav
45-year-old woman with:
 multiple uterine fibroids
20-week-sized uterus on physical
examination
Menorrhagia.
No desire for future fertility.

30. Indraneel Jadhav
Treatment/Procedure Rating Comments
Hormonal therapy 3 May be useful as a temporizing therapy in
some instances
MR-guided high-frequency
focused ultrasound ablation
2
Endometrial ablation 2 Controls bleeding, but patient remains at
risk for bulk-related symptoms
eventually.
Uterine artery embolization 8 Based on patient preference
Laparoscopic uterine artery
occlusion
1 No long-term data. Unproven long-term
clinical success.
Myomectomy 3
Hysterectomy 8 Based on patient preference
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually
appropriate

31. Indraneel Jadhav
29-year-old woman
Multiple submucosal and intramural
fibroids
Menorrhagia and pelvic pain
Most of the fibroids measure <4 cm,
with two dominant fibroids
measuring >6 cm
Does not desire future pregnancies
Concerned about the loss of
femininity with hysterectomy.

32. Indraneel Jadhav
Treatment/Procedure Rating Comments
Hormonal therapy 3 May be useful as a temporizing therapy in
some instances
MR-guided high-frequency
focused ultrasound ablation
3
Endometrial ablation 2 Useful for menorrhagia but not pelvic
pain. Young patient may change her mind
about pregnancy.
Uterine artery embolization 8 Based on patient preference.
Laparoscopic uterine artery
occlusion
1 No long-term data. Unproven long-term
clinical success.
Myomectomy 3 Suboptimal procedure due to multifocal
fibroids.
Hysterectomy 4 Should be considered. Patient preference
important.
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually
appropriate

33. Indraneel Jadhav
36-year-old woman
Menometrorrhagia
 MRI- three dominant leiomyomas,
ranging in size from 6 to 8 cm and
intramural in location
No plans for future pregnancy but
would like to have the option in the
future.

34. Indraneel Jadhav
Treatment/Procedure Rating Comments
Hormonal therapy 3 May be useful as a temporizing therapy in
some instances
MR-guided high-frequency
focused ultrasound ablation
4 Early data favorable, but long-term data
lacking.
Endometrial ablation 1
Uterine artery embolization 7
Laparoscopic uterine artery
occlusion
1 No long-term data. Unproven long-term
clinical success.
Myomectomy 7 May be most viable option if lesions are
anatomically amenable to myomectomy.
Viable solution to preserve fertility.
Hysterectomy 2
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually
appropriate

35. Indraneel Jadhav
41-year-old woman with
Menorrhagia
 MRI reveals a single 3 cm
intramural fibroid and diffuse
adenomyosis

36. Indraneel Jadhav
Treatment/Procedure Rating Comments
Hormonal therapy 3 May be useful as a temporizing therapy in
some instances
MR-guided high-frequency
focused ultrasound ablation
3
Endometrial ablation 4
Uterine artery embolization 7 Higher recurrence risk with adenomyosis.
Laparoscopic uterine artery
occlusion
1 No long-term data. Unproven long-term
clinical success.
Myomectomy 3
Hysterectomy 7 May be best option, depending on patient
preference.
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually
appropriate

37. Indraneel Jadhav
45-year-old woman with
pelvic discomfort
8 cm pedunculated subserosal fibroid
on MRI.

38. Indraneel Jadhav
Treatment/Procedure Rating Comments
Hormonal therapy 4
MR-guided high-frequency
focused ultrasound ablation
3
Endometrial ablation 1
Uterine artery embolization 7
Laparoscopic uterine artery
occlusion
2
Myomectomy 8
Hysterectomy 7 Depends on desire for future fertility.
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually
appropriate

39. Indraneel Jadhav
43-year-old woman with
Constipation
MRI reveals a 12 cm subserosal
leiomyoma compressing the rectum.

40. Indraneel Jadhav
Treatment/Procedure Rating Comments
Hormonal therapy 3 May be useful as a temporizing therapy
in some instances.
MR-guided high-frequency
focused ultrasound ablation
3
Endometrial ablation 1
Uterine artery embolization 7 Less effective for bulk-related symptoms.
If not an operative candidate or refuses
surgery
Laparoscopic uterine artery
occlusion
1 No long-term data. Unproven long-term
clinical success.
Myomectomy 8 May be most viable option if lesions are
anatomically amenable to myomectomy.
Hysterectomy 7
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually
appropriate

41. Indraneel Jadhav