Hacker & Moore's Essentials of Obstetrics and Gynecology (Essentials of Obstetrics & Gynecology (Hacker)) by Hacker Neville F. & Gambone Joseph C. & Hobel Calvin J

Author:Hacker, Neville F. & Gambone, Joseph C. & Hobel, Calvin J. [Hacker, Neville F.]
Language: eng
Format: mobi, epub
ISBN: 9781437725162
Publisher: Elsevier Health Sciences
Published: 2009-03-11T00:00:00+00:00

FIGURE 19-5 Gross appearance of an irregularly enlarged uterus with multiple leiomyomas.

(From Voet RL: Color Atlas of Obstetric and Gynecologic Pathology. St. Louis, Mosby, 1997.)

Management of Leiomyomas

In general, if a small, asymptomatic fibroid is detected, treatment is not necessary. Unless the fibroid uterus is excessively large (>12-week gestational size) or is implicated as a cause of infertility in a woman seeking pregnancy, the first line of treatment is targeted to her symptoms.

Medical Management

Heavy or prolonged menstruation caused by fibroids may be managed hormonally in many cases. Progestin-only therapies (oral or injected medroxyprogesterone acetate, progestin-only oral contraceptive pills, or levonorgestrel-releasing intrauterine devices) or combination hormonal contraceptive methods (oral contraceptive pills, vaginal rings, or patches) are usually the first therapeutic option. The goal is to reduce monthly menstrual blood loss with cyclic hormonal methods or to eliminate menses with extended or continuous use of these methods. Dysmenorrhea is also markedly reduced by these measures.

Gonadotropin-releasing hormone (GnRH) agonists block ovarian steroidogenesis, which halts endometrial proliferation and reduces the volume of the myometrium and sometimes the volume of the leiomyomas. However, because of the intense vasomotor symptoms and the deleterious effect the GnRH agonists may have on bone mineral density, only short courses of these agonists can be administered. Usually their use is confined to women preparing for surgical treatments, such as endometrial ablation, myomectomy, or hysterectomy. Intermittent GnRH agonist administration has been shown to reduce side effects while achieving therapeutic goals longer term. Combining GnRH agonists with hormonal agents, such as low-dose progesterone or estrogen-progestin combinations, may minimize some adverse effects of hypoestrogenism (such as osteoporosis), but long-term data are not available. GnRH agonists are very expensive, even in the short term.

Clinical trials using the selective antiprogesterone receptor antagonist, mifepristone (RU 486), to reduce the size of uterine myomas have shown a reduction of 50% by volume over a 3-month period. Doses of 5, 25, or 50 mg/day for up to 6 months have been used to reduce the size of uterine myomas without producing the changes in bone density noted with GnRH agonists and without untoward glucocorticoid effects. However, this drug is not routinely available for this treatment.

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