An evidence-based guideline for the management of uterine fibroids

Appraisal of national and international uterine fibroid management guidelines: a systematic review

BACKGROUND

Guidelines standardise high-quality evidence-based management strategies for clinicians. Uterine fibroids are a highly prevalent condition and may exert significant morbidity.

OBJECTIVES

To appraise national and international uterine fibroid guidelines using the validated AGREE-II instrument.

SELECTION STRATEGY

Database search of PubMed and EMBASE from inception to October 2020 for all published English-language uterine fibroid clinical practice guidelines.

DATA COLLECTION AND ANALYSIS

In all, 939 abstracts were screened for eligibility by two reviewers independently. Three reviewers used the AGREE-II instrument to assess guideline quality in six domains. Recommendations were mapped to allow a narrative synthesis regarding areas of consensus and disagreement.

MAIN RESULTS

Eight national guidelines (AAGL, SOGC 2014, ACOG, ACR, SOGC 2019, CNGOF, ASRM and SOGC 2015) and one international guideline (RANZOG) were appraised. The highest scoring guideline was RANZOG 2001(score 56.5%). None of the guidelines met the a priori criteria for being high-quality overall (score ≥66%). There were 166 recommendations across guidelines. There were several areas of disagreement and uncertainty. There were only three areas of consensus. Supporting evidence was not evident for many recommendations; 27.7% of recommendations were based on expert opinion only.

CONCLUSIONS

There is a need for high-quality guidelines on fibroids given their heterogeneity across individuals and the large range of treatment modalities available. There are also areas of controversy in the management of fibroids (e.g. Ulipristal acetate, power morcellation), which should also be addressed in any guidelines. Future guidelines should be methodologically robust to allow high-quality decision-making regarding fibroid treatments.

TWEETABLE ABSTRACT

Current national fibroid guidelines have deficiencies in quality when appraised using the validated AGREE instrument.

Efficacy assessment of acupuncture in improving symptoms of uterine fibroids: A randomized controlled trial

INTRODUCTION

Uterine fibroids are a common benign genital tumor disease in gynecological diseases. It is mainly a change in physical function caused by the growth of smooth muscle cells in the factor uterus. Modern medicine's treatment of this disease is based on the dependence of uterine fibroids on sex hormones. Treatment with antiprogestin and estrogen drugs can reduce the volume of fibroids or slow the rate of increase in volume, thereby achieving the goal of alleviating clinical symptoms. In order to meet the needs of the majority of women of childbearing age and to maintain fertility, acupuncture treatment of uterine fibroids has a broad prospect for development.

METHODS/DESIGN

This study plans to select 60 cases that meet the corresponding selection criteria. According to the random principle, they will be divided into intervention group and control group, with 30 cases in each group. The general information, fibroid size, and TCM syndrome scores of the two groups of patients will be compared before treatment. In terms of treatment, the intervention group will be given acupuncture combined therapy; the control group will be given Chinese patent medicine. The treatment cycles in both groups will be three menstrual cycles. After the treatment is completed, the data of the relevant curative effect indicators are analyzed by using SPSS software to draw conclusions.

DISCUSSION

We aim to provide higher evidence-based medical evidence for acupuncture treatment of uterine fibroids.

TRIAL REGISTRATION

ClinicalTrials.gov, ChiCTR2000030438, Registered on March 01, 2020.

Uterine fibroids: an update on current and emerging medical treatment options

Uterine fibroids are the most common gynecological disorder, classically requiring surgery when symptomatic. Although attempts at finding a nonsurgical cure date back to centuries, it is only around the middle of the last century that serious attempts at a medical treatment were carried out. Initially, both progestins and estrogen–progestin combinations have been utilized, although proof of their usefulness is lacking. A major step forward was achieved when peptide analogs of the GnRH were introduced, first those with superagonist properties and subsequently those acting as antagonists. Initially, the latter produced side effects preventing their routine utilization; eventually, this problem was overcome following the synthesis of cetrorelix. Because both types of analogs produce hypoestrogenism, their use is limited to a maximum of 6 months and, for this reason, today they are utilized as an adjuvant treatment before surgery with overall good results. Over the last decade, new, nonpeptidic, orally active GnRH-receptor blockers have also been synthesized. One of them, Elagolix, is in the early stages of testing in women with fibroids. Another fundamental development has been the utilization of the so-called selective progesterone receptor modulators, sometimes referred to as “antiprogestins”. The first such compound to be applied to the long-term treatment of fibroids was Mifepristone; today, this compound is mostly used outside of Western Countries, where the substance of choice is Ulipristal acetate. Large clinical trials have proven the effectiveness of Ulipristal in the long-term medical therapy of fibroids, although some caution must be exercised because of the rare occurrence of liver complications. All selective progesterone receptor modulators produce unique endometrial changes that are today considered benign, reversible, and without negative consequences. In conclusion, long-term medical treatment of fibroids seems possible today, especially in premenopausal women.

Abnormal uterine bleeding as a presenting symptom is related to multiple uterine leiomyoma: an ultrasound-based study

Purpose

To determine the prevalence of uterine leiomyomas, diagnosed by ultrasound, in a private health care setting located in the central eastern region of Portugal, and to explore the demographic and clinical factors related to diagnosis and symptomatology.

Patients and methods

The files of 624 patients attending a private clinic in Covilhã, Portugal, from January 2 to December 31, 2010 were retrieved for evaluation. Pelvic ultrasound record, age, weight, height, age at menarche, number of pregnancies and deliveries, marital status, menstrual cycles characteristic, and contraceptive method at consultation were included in the analysis.

Results

Uterine leiomyoma (UL) was diagnosed by ultrasonography in 161 (25.8%) patients. A single UL was diagnosed in 80 (49.7%) patients. In 79 (49.1%) patients, the largest leiomyoma had a dimension <20 mm. Prevalence of UL was age dependent: at 11.0% for women 20–39 years old; 45.4% for those aged 40–59 years; and 19.5% for women 60 years or older. Metrorrhagia was the most distressing presenting symptom. When menorrhagia was the presenting symptom, the probability of having an ultrasound diagnosis of UL was 73.3%. Metrorrhagia or menorrhagia, as presenting symptom, was significantly related to the ultrasound diagnosis of multiple ULs.

Conclusion

UL was especially prevalent in women aged between 40 and 59 years. Patients with multiple ULs had significantly more abnormal uterine bleeding. In patients with menorrhagia or metrorrhagia, special attention should be taken in searching for the presence of multiple ULs during ultrasound.

Is fibroid heterogeneity a significant issue for clinicians and researchers?

The clinical and scientific literature overwhelmingly deals with fibroids as a single entity or disease. This convenient assumption of homogeneity may be an important oversight given that substantial evidence exists for heterogeneity between fibroids at many levels. Failure to recognize and accommodate fibroid heterogeneity can have significant ramifications for both clinical treatment decisions and research protocol design. The aim of this article is to review the current knowledge of fibroid heterogeneity and to identify key areas where fibroid heterogeneity should be taken into consideration both clinically and when designing research protocols. Uterine leiomyomata display significant and well-documented heterogeneity in symptoms, diagnostic imaging appearance, pathology, genetic background and therapeutic requirements. Additional research is needed to better understand fibroid heterogeneity as it relates to pathogenesis, molecular targets for potential new therapies, patient symptoms and, ultimately, treatment. To this list should also be added heterogeneity of genetics, lifestyle and individual clinical characteristics of the fibroid. Increasingly, an understanding of uterine leiomyoma heterogeneity will be of importance for clinicians who see patients with this common and costly disease.

Hysteroscopic myomectomy for menorrhagia using Versascope bipolar system: efficacy and prognostic factors at a minimum of one year follow up

OBJECTIVE

To evaluate the effectiveness of hysteroscopic submucous myomectomy for women with heavy menstrual bleeding (HMB) over a minimum 1-year period and assess prognostic factors associated with treatment success.

STUDY DESIGN

Prospective observational study set in a university teaching hospital in UK involving 92 women symptomatic of HMB with submucous myomas consecutively recruited between June 2003 and November 2006. Hysteroscopic myomectomy was performed under outpatient local anaesthetic (n=35, 38%) or daycase general anaesthesia (n=57, 62%) using Gynecare Versascope bipolar system. The main outcome measures were: the need for secondary surgical or medical re-intervention, menstrual improvement and patient satisfaction. Other outcome measures include: successful completion of primary resection, type of secondary treatment.

RESULT

Mean follow up was 2.6 years (95% CI 2.3-2.9). Complete fibroid excision was achieved in 66%. Secondary surgical re-intervention was required in 27 (29%) of which 11 (12%) were repeat hysteroscopic myomectomy and 10 (11%) were hysterectomy procedures. Multiple uterine fibroids and adenomyosis were identified in 80% of hysterectomies. At follow up, improved menstrual symptoms and patient satisfaction were reported by 91% and 86%, respectively. Irregular cycle HMB and incomplete fibroid excision were associated with secondary retreatment. Size of the submucous fibroid resected, presence of intramural and subserosal fibroids, or LA vs. GA setting were unrelated to treatment success.

CONCLUSION

HMB with submucous myomas may be successfully treated by completely removing the intracavity myoma component, irrespective of co-existent intramural or subserosal fibroids or size of fibroid resected. This effect remains sustained over at least a 1-2 year period.

Asymptomatic uterine fibroids

It is estimated that at least 50% of fibroids are asymptomatic, but this figure is likely to be an underestimate as it is based on women in whom fibroids are found incidentally during another procedure (e.g. cervical screening), and there is little, if any, data from population studies on the true incidence of fibroids. If a prevalence of 50% by 50 years of age is accepted, a large number of women have asymptomatic fibroids. Working on the cliché, 'if it ain't broken, don't fix it', it may seem surprising that there should be a chapter dedicated to the issue of asymptomatic fibroids, since the simplistic approach might be to leave the asymptomatic fibroids well alone. However, asymptomatic fibroids may become symptomatic in the future, so it may be wiser to treat fibroids before they grow to a size when they become symptomatic, or treatment becomes more challenging, especially in young women who may desire fertility at a later stage, and in view of the fact that many women are starting their families in their mid-thirties when they have a 30% chance of having a fibroid(s). Despite their common occurrence, fibroids are still poorly understood. It is not known why they form in the first place, what determines their number and ultimate size, the best treatment approaches, or the factors that determine which women develop symptoms. Even when women present with disorders such as infertility, pelvic pain and abnormal bleeding, it is not always possible to be certain that a given myoma is not simply an innocent bystander rather than the cause of the symptom. This chapter addresses the challenging issue of what to do when fibroids are diagnosed incidentally. Firstly, there is the need to ascertain that the pelvic mass palpated is indeed a fibroid, and not an early, more sinister tumour, especially if conservative management is adopted. In addition, there is the issue of size, position and potential for becoming symptomatic at a later date. With the availability of uterine-preserving and largely non-invasive treatment modalities, should more asymptomatic, younger women be offered treatment if it is deemed that their fibroids may cause problems as they grow? Where treatment is not offered, is it necessary to follow-up such women, and if so, with what modality of surveillance and how frequently?

A multicenter randomized, controlled study comparing laparoscopic versus minilaparotomic myomectomy: reproductive outcomes

OBJECTIVE

To assess the reproductive outcomes after minilaparotomic and laparoscopic myomectomy in patients wishing to conceive.

DESIGN

Randomized controlled trial.

SETTING

Departments of obstetrics and gynecology of the universities of Catanzaro, Rome, and Florence, Italy.

PATIENT(S)

One hundred thirty-six women with symptomatic uterine leiomyomas or unexplained infertility.

INTERVENTION(S)

Laparoscopic and minilaparotomic myomectomy.

MAIN OUTCOME MEASURE(S)

Pregnancy, abortion, and live-birth rates.

RESULT(S)

Between the laparoscopic and minilaparotomic groups no difference was observed in cumulative pregnancy, live-birth, and abortion rates, whereas pregnancy and live-birth rates per cycle, and time to first pregnancy and live-birth were significantly higher in the laparoscopic than in the minilaparotomic group. Categorizing the patients according to surgical indication for myomectomy, cumulative pregnancy rate, pregnancy, and live-birth rates per cycle, and time to first pregnancy and live-birth were significantly better after laparoscopic myomectomy in symptomatic patients, whereas all reproductive outcomes were similar between the two groups in patients with unexplained infertility.

CONCLUSION(S)

Minilaparotomic and laparoscopic myomectomy improves in a similar manner the reproductive outcomes in patients with unexplained infertility, whereas the laparoscopic approach provides the best benefits in fertile patients with symptomatic leiomyomas.

Hysterectomy and endometrial ablation in New South Wales, 1981 to 1999-2000

OBJECTIVE

To examine the trends in hysterectomy in New South Wales (NSW) from 1981 to 1999-2000 and the impact of endometrial ablation.

DATA

Computerised discharge summaries from private and public hospitals for the years 1981, 1991, 1994-1995 and 1999-2000 obtained from the NSW Health Department. All records listing hysterectomy in women over the age of 20 in each period were selected and those listing endometrial ablation since 1991 were also selected. Operative procedure, diagnosis, hospital type, length of stay and demographic data were recorded. Annual figures since 1988-1989 for hysterectomy and ablation were also obtained.

FINDINGS

Initially it appeared that the introduction of endometrial ablation might reduce hysterectomy rates, but the combined rate of hysterectomy and endometrial ablation continued to rise to a peak in 1992-1993 and has declined since. The hysterectomy rate in 1999-2000 was lower than in 1981. There has been a marked shift from abdominal to vaginal hysterectomy, with an increase in laparoscopically assisted operations. Overall, the mean age at operation has been rising, although the mean age for vaginal hysterectomy has fallen. The shift to private hospitals and reduction in hospital stay have continued.

CONCLUSION

The trends are consistent with the increased use of laparoscopic and ablation techniques, improvements in hormonal contraceptive use, and better access to abortion, which have facilitated women's decisions to postpone their births and to conserve their childbearing to older ages. Further development of these techniques will have an impact on gynaecological training and practice in the next decade.