New Horizons in Fibroid Management
Purpose of Review
Review of the latest advances in the treatment of uterine fibroids. Addressing conservative management, medical therapy, interventional radiological procedures (non-surgical alternatives or non-excisional procedures) and conservative or radical endoscopic or open surgery (myomectomy, hysterectomy).
Newer medical therapy relied on the use of selective progesterone receptor modulators (SPRMs) (Esmya/UPA) for management of heavy menstrual bleeding (HMB) associated with fibroids. However, the drug is currently under investigation for a link with hepatic damage associated with its use. Other SPRMs currently showing promise include vilaprisan and telapristone. New medical therapy also includes oral small molecule GnRH antagonists such as Relugolix, Elagolix and Lizagolix which are undergoing phase 2 and 3 trials and have shown promise. The new NICE guidance on HMB also suggests limited effectiveness of pharmacological methods in fibroids > 3 cm and therefore referral to an expert with possible consideration of surgery as a first-line treatment. Non-excisional procedures include the use of uterine artery embolisation which is currently being compared to myomectomy and its effect on the quality of life in the FEMME study. With regard to excisional therapies, controversy still surrounds the use of laparoscopic power morcellators (LMPs). A white paper has been issued by the US FDA in December 2017 on the matter, and a PneumoLiner still remains the only containment device approved by the US FDA for use with LMPs. With advancing surgical expertise and use the bipolar sealing devices, TLHs are increasingly being performed for larger uteri (> 12 weeks or > 280 g). Hysteroscopic retrieval systems (HRTs) are found to be increasingly used successfully for type 2 submucous myomas as one-step procedures.
Many treatments are available for fibroids that can help women reach the age of menopause prior to embarking on radical surgery. It seems sensible to start with conservative (medical) measures; however, for women with large fibroids, often non-excisional or surgical solution is needed. Which technique is chosen will depend upon local expertise as well as patient preference, especially the need for uterine/fertility preservation, following a detailed discussion regarding risks and benefits.
KeywordsFibroids Heavy menstrual bleeding SPRMs Myomectomy
Compliance with Ethical Standards
Conflict of Interest
Rohan Chodankar and Jennifer Allison declare no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
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