Abstract

UTERINE FIBROID RISK FACTORS CLASSIFICATIONS AND APPROACHES FOR MANAGEMENT

Dr. Liqaa Shaher Saleh* and Dr. Wasan Hameed Salman

ABSTRACT

Uterine fibroids (also known as leiomyomas or myomas) are the most common form of benign uterine tumors. Clinical presentations include abnormal bleeding, pelvic masses, pelvic pain, infertility, bulk symptoms and obstetric complications. Almost a third of women with leiomyomas will request treatment due to symptoms. Current management strategies mainly involve surgical interventions, but the choice of treatment is guided by patient‟s age and desire to preserve fertility or avoid „radical‟ surgery such as hysterectomy. The management of uterine fibroids also depends on the number, size and location of the fibroids. Other surgical and non-surgical approaches include myomectomy by hysteroscopy, myomectomy by laparotomy or laparoscopy, uterine artery embolization and interventions performed under radiologic or ultrasound guidance to induce thermal ablation of the uterine fibroids. There are only a few randomized trials comparing various therapies for fibroids. Further investigations are required as there is a lack of concrete evidence of effectiveness and areas of uncertainty surrounding correct management according to symptoms. The economic impact of uterine fibroid management is significant and it is imperative that new treatments be developed to provide alternatives to surgical intervention. There is growing evidence of the crucial role of progesterone pathways in the pathophysiology of uterine fibroids due to the use of selective progesterone receptor modulators (SPRMs) such as ulipristal acetate (UPA). The efficacy of long-term intermittent use of UPA was recently demonstrated by randomized controlled studies. The need for alternatives to surgical intervention is very real, especially for women seeking to preserve their fertility. These options now exist, with SPRMs which are proven to treat fibroid symptoms effectively. Gynecologists now have new tools in their armamentarium, opening up novel strategies for the management of uterine fibroids. Objectives: In this review paper, the pros and cons of the available pharmacological options for the treatment of uterine fibroids are explored, including oral progestogens, levonorgestrel intra-uterine device, gonadotropin-releasing hormone analogs and progesterone receptor modulators with an emphasis on ulipristal acetate. Study design: The choice of the appropriate therapeutic approach for uterine fibroids depends on several factors, including women's age, parity, childbearing aspirations and wish to preserve fertility, extent and severity of symptoms, size, number and location of myomas, risk of malignancy and proximity to menopause. Some treatment algorithms have been proposed for uterine fibroids, considering both efficacy and safety data from clinical trials, and women characteristics and choices. Therefore, we propose two optimized treatment algorithms for the treatment of uterine fibroids, one for the treatment of uterine fibroids in women of reproductive age with the desire to spare reproductive capacity, and another for the treatment of uterine fibroids in women >40 years with no desire for pregnancy. Results: Symptoms associated with uterine fibroids may significantly impair a patient quality of life. Therapy includes surgery, which may range from a hysterectomy to several other uterus-sparing techniques and several different types of pharmacological therapies. Studies with ulipristal acetate have provided a change of paradigm in the treatment of uterine fibroids, demonstrating the efficacy and favorable tolerability profile, not only for the preoperative treatment of moderate to severe fibroid-associated symptoms, but also, and very importantly, for the long-term medical management of patients with symptomatic fibroids.

Keywords: Uterine fibroids; ulipristal acetate; fertility; pregnancy; treatment algorithms.