JOGNN PRZNCIPLES & PRACTICE
Uterine Myomas: Treatment Options
T h e r e s a N . G r a b o , CRNP, PhD, P a m e l a S t e w a r t Fahs, R N , DSN,
L i n d s a y G. N a t a u p s k y , CRNP, M S N , H a r r y Reich, M D
=Myomas (also called fibroids) are the most
common solid pelvic tumors. Treatment options for
myomas include medical and surgical manage-
ment. The goals of medical management are to
shrink the myoma and reduce its blood supply.
Surgical interventions include therapies for women
who wish to preserve fertility or retain their uterus.
Newer treatment options include myomectomy
achieved through an abdominal, laparoscopic, or
hysteroscopic approach. Nurses assess and coun-
sel women regarding treatment options. JOGNN,
28, 23-3 1 ; 1999.
Accepted: March 1998
Uterine leiomyomas (also called myomas o r
fibroids) are benign growths that arise from muscle
cells and are well circumscribed but nonencapsu-
lated tumors composed mainly of muscle but with
varying amounts of fibrous Connective tissue
(Mishell & Brenner, 1988). Although myomas pri-
marily grow in the uterine fundus, they can be
found anywhere along the female genital tract, in-
cluding the vulva and vagina (Seltzer & Pcarsc,
1995).
Myomas are the most common solid pelvic
tumor, occurring in approximately 20-25% o f
women by age 40 and in more than 50% of women
overall (Hacker & Moore, 1998; Reich, 1995).
One out of every five white women and as many as
one o u t of every three black women will develop a
myoma (Seltzer & Pearse, 1995). LMyomas are seen
most frequently among nulliparous women, non-
smokers, and oral contraceptive or intrauterine de-
vice users (American College of Obstetricians and
Gynecologists [ ACOG], 1994). lMyomas usually
are found during the fourth and fifth decade of life
(Mishell & Brenner, 1988).
The exact etiology of myomas is not certain,
JanuarylFebruary 1999
but genetic factors appear to play a role in their
development. Because myomas are hormonally re-
sponsive tumors, they grow under increased estro-
genic conditions, including pregnancy and, less
commonly, oral contraceptive use. During the peri-
menopausal years, a growth spurt of the myoma
frequently is seen, most likely due to anovulatory
cycles and the relative estrogen excess experienced
during this period (Carr, Freund, & Somani,
1995). Distortion of the uterine and pelvic cavities
by myomas may interfere with fertility, impeding
conception or maintenance of pregnancy. Because
myomas interfere with fetal growth and nutrition,
they increase the risk of spontaneous abortion dur-
ing the 1" and 2"" trimesters and the risk of pre-
term labor (Hacker & Moore, 1992; Lichtman &
Papera, 1990). During pregnancy, an elevation in
both estrogen and progesterone occurs. Although
progesterone exerts an anti-estrogenic effect and is
associated with a decrease in the size of myomas,
the increased blood supply during pregnancy re-
sults in an overall trophic effect on myomas (Cra-
mcr, Robertson, Ziats, tk I'earson, 1985).
Types of Myomas
Types of myomas, which are generally de-
scribed by their location, include (a) intramural,
within the uterine or myometrial wall; (b) suhmu-
cow, protruding into the uterine cavity, and (c)
subserous, growing toward the serous surface of
the uterus (see Table 1 ) . Myomas may move over
time. As they migrate, they change in shape, be-
coming irregular. The blood supply within their
connective attachment may become thin and atten-
uated, resulting in pcdunculation. blyomas pro-
truding into the broad ligament may develop a
completely new blood supply within the ligament,
becoming parasitic. Pedunculated and parasitic
JOGNN 23
 TABLE 1
Types ofMyomas

Type ofMyoma by Location Descriptiorr

Intramural (interstitial) Has a round shape due to pressure from all sides. Stays within the uterine (myometrial) wall.
These occur as isolated encapsulated modules of varying size. The most common form of
myoma.
Submucousal Located beneath the endometrium. Grows into the uterine cavity, maintaining an attachment
to the uterus by a pedicle. Pedunculated myomas may protrude to or through the cervical 0s.
Frequently associated with an abnormality of the overlying endometrium, resulting in a
distributed bleeding pattern. Accounts for 5% of all myomas.
Subserosal (subperitoneal) Grows out toward the peritoneal cavity and causes the peritoneal surface of the uterus to
bulge. May also develop a pedicle, become pedunculated, and reach a large size within the
peritoneal cavity without producing symptoms.
Intraligamentous Extends into the broad ligament.
Pedunculated Attaches to the uterine base with a thin pedicle or stem.
Parasitic Completely extrudes from the uterus, has an accessory blood supply.

myomas are difficult to distinguish from ovarian masses,
thus necessitating treatment so that adequate assessment
of the adnexa can be made. Occasionally an intramural
myoma may extend laterally into the leaves of the broad
ligament and is referred to as a intraligamentary tumor
(Mishell & Brenner, 1988).
Symptoms
Most myomas are asymptomatic; however, symp-
toms can range from pelvic pressure, bloating, urinary
frequency, dysmenorrhea, dyspareunia, hypermcnor-
rhea/menorrhagia, and pelvic pain to infertility. In addi-
tion, problems after conception can occur, such as spon-
taneous abortion, pain from acute degeneration of the
myoma during pregnancy, premature labor, fetal malpo-
sition, dysfunctional labor, obstruction of labor, re-
tained placenta, and postpartum hemorrhage secondary
to atony (Appuzzio, Pelosi, Kaminetzky, & Louria,
1985; Reich, 1995). The severity of symptoms depends
on the number, size, and location of the myomas. Some
20-50% of myomas are estimated to produce symptoms
(Buttram & Reiter, 1981). The major complaint in
women who seek treatment for myoma(s) is hypermen-
orrhea. LMyomas require treatment when any of the fol-
lowing symptoms or conditions dcvelop: ( a ) hypermen-
orrhea leads to anemia, (b) pain develops that is due t o
myoma degeneration, (c) pressure symptoms result from
large size, and ( d ) size of myoma increases rapidly
(ACOG, 1994; Reich, 1995; Reich, Thompson, Na-
taupsky, Grabo, & Sekel, 1997). Transvaginal ultra-
sound is an effective way to monitor myoma size and rule
o u t ovarian neoplasm.
Therapeutic intervention is determined by the
symptoms, the location and size of the myoma, and the
woman's desire for continued fertility (Youngkin &
Davis, 1994). Most women can be monitored conserva-
tively (Buttram tk Reiter, 1981; Reich, 199.5; Wallach,
Hamnwnd, Goldfarb, Icc Kempers, 1983) by evaluating
myoma growth cvery 3 months for two visits and then
cvery 6 months.
Given the various treatment options and signifi-
cantly different outcomes, it is important for health care
providers to include women in the decision making pro-
cess. Advanced practice nurses who work in primary
care, women's health care, or infertility practices are in a
position to assess and monitor women with myomas and
explain the various treatment options. Additional nurs-
ing roles may include identifying signs and symptoms of
myomas, making referrals, providing teaching and coun-
seling, and rendering support during treatment. Serving
as a client advocate in helping women understand the
nature of their condition and the effects of various treat-
ments is a nursing role that is routinely exercised but too
often undervalued.
Treatment
Treatment of myomas should be individualized.
Each woman has variations that must be examined be-
W o m e n with myomas are demanding
and being offered alternatives to
hysterectomy, including medical and
surgical therapies.

24 JOG" Volume 28, Number 1

fore a treatment can be recommended. Small, asymptom-
atic myomas usually do not require treatment but should
be observed for growth or change i n size. If the peri-
menopausal woman is using combination oral contra-
ceptives, she should d o so with caution because a corre-
lation exists between the presence of estrogen and the
growth of myomas. Generally, the myoma will diminish
in size after menopause because of the decrease in estro-
gen levels. For those women who arc nearing postmcno-
pause, conservative treatment may buy time, allowing
them to avoid surgery. If the woman is postmenopausal,
pelvic examinations are indicated at about 6 month in-
tervals and estrogen replacement therapy if desired
should be prescribed at the lowest possible dosage that
will control menopausal symptoms and avoid growth of
the myoma (Lacey, 1991; Mishell & Brenner, 1988;
Moore, 1986).
Medical
Initially, symptoms such as menorrhagia, if
present, should be suppressed and any anemia treated
with iron supplements (Christiansen, 1993).However, it
must be noted that hemochromatosis (iron overload), an
inherited disorder o f excessive body accumulation o f
iron common among white individuals, occurs in women
in their 50s and 60s. Therefore, an initial screening with
hemoglobin and fcrritin lcvcls is suggcstcd (klcdi-
cineNet, 1997). It is feasible to treat myomas medically
by reducing the circulating level of estrogen (Herbst,
Mishell, Stenchever, 8c Droegemueller, 1992). Some of
the medical treatments for nicnorrhagia include progcs-
tational agents, such as mcdroxyprogesterone acetate
(I’rovera, I’harmacia & Upjohn, Inc., Kalamazoo, MI);
norethindrone acetate (Aygestin, ESI-Pharm / I.ederle
Generics, Philadelphia, PA); mcdrogcstcronc; and dana-
zol, a synthetic steroid (Danocrine, Sanofi/Whithrop,
New York, S Y ) . The rationale for using progesterone
agents to treat myomas is that they produce a hypocstro-
genic effect by inhibiting pituitary gonadotropin secre-
tion and suppressing ovarian function. They also may
exert a direct anti-estrogenic effect. No consensus exists
regarding routine use of progestational agents to treat
myomas (Verkauf, 1993; Wallach, 1992). Progesterone
drugs have been used to treat menorrhagia that is due to
myomas and other conditions, such as dysfunctional
uterine bleeding in the postmenarche and premeno-
pausal years that may occur with anovulation. In the
absence o f organic disease, menorrhagia in the premeno-
pausal woman that is due to anovulation or dissynchro-
nous cycles is treated with progesterone to bring about
the conversion of the endometrium from a proliferative
to secretory state. Side effects o f this treatment includc
weight gain, bloating, nausea, headaches, mood changes,
and dccrcascd libido (Wood, 1995).
Danazol used for 6 months has been shown to
JanuarylFehrunry I999
decrease myoma volume by 20-2.5%0. However, this
drug produces undesirable side effects related both to the
hypoestrogenic environment it creates and its androgenic
properties (Moghissi, 1991). ’T’he most frequently en-
countered side effects are weight gain, fluid retention,
fatigue, decreased breast size, acne, oily skin, growth of
facial hair, atrophic vaginitis, hot flashes, muscle cramps,
and emotional lability (Speroff, Glass, 8c Kase, 1989).
More recent pharmacologic treatment of myomas
has centered around the use of gonadotropin-releasing
hormone ((;n-RH) agonists, such as Lupron (TAP Phar-
maceuticals, Deerfield, II-), Zoladcx (Zeneca Pharma-
ceuticals, Wilmington, DE), Synarcl (Syntex 1.aborato-
rics Inc., Palo Alto, CA), and Supprelin (Roberts
P ha r inaceu t ica Is Corporation, Eat on town, 9J ) ( Ca nd i -
ani et al., 1990). The continuow administration of
(in-RH agonists results in an initial release of luteinizing
hormone ( l . H ) and follicle-stimulating hormone (FSH)
(agonist phase) that lasts for approximately 2 weeks and
is followed by the nearly complete suppression of 1.H
and FSH secretion (desensitization phase). Changes in
gonadotropin secretion cause the ovaries to respond
with an initial increase in estradiol production, followed
b y a profound and sustaincd decrease in estradiol pro-
duction (Rarbieri, 199 1). Gn-KH agonists provide tem-
porary control of bleeding by inducing a hypoestrogenic
state and shrinkage in myoma size. Atrophy of the endo-
metrium also occurs, leading to amenorrhea (Candiani et
al., 1990). (in-RH agonists are effective in reducing
myoma and uterine size in 80%0 of women (Verkauf,
1993). Most reduction in size occurs within 8 weeks
(Stovall, I.ing, Henry, & Woodruff, 1991), and a maxi-
mum reduction occurs within approximately I2 weeks
(Moghissi, 1991; Nakaniura et al., 1991). These agents
provide temporary control of bleeding and reduction of
myoma size. Myoma regrowth occurs after ending treat-
ment. In women with dysfunctional utcrinc bleeding,
inenorrhagia reoccurs rapidly. Researchers (West, Lums-
den, Lcc Baird, 1992) have reported that despite myoma
regrowth, a significant number of women maintain a
carry-over benefit of this treatment, and many arc able to
avoid hysterectomy, especially older women. In most
instanccs, myomas are dependent on estrogen and re-
gress after menopause. Xledical treatment offers women
in the climacteric with symptomatic myomas time to
have their myomas regress spontaneously with the hy-
poestrogenic phase that characterizes the menopausal
period (Verkauf, 1993). I h r m o n c replacement therapy
(HKT) was initially thought to promotc the growth of
myomas. However, recent evidence regarding the use of
estrogen-progcstin formulations indicates they d o not
result in myoma growth (Parazzini et al., 1992).
The major disadvantage of the Gn-RH agonist is
the postmenopausal side effects that occur to some cx-
tent in the majority of women treated, including hot
JOGNN 25
flashes, vaginal dryness, and decreased libido (Henzl,
Corson, ihloghissi, Buttram, & Berquist, 1988). Women
receiving Gn-RH agonists frequently have estradiol se-
rum levels and estrogen deficiency symptoms similar to
those of menopausal women. Prolonged treatment with
Cn-RH analogues can lead to bone loss, increasc in total
cholesterol, and reduction in high-density lipoprotein
cholesterol level. Women receiving Gn-RH agonist ther-
apy for 6 months develop similar changes in bone density
and lipoproteins. Approximately 3% of the bone density
is lost within 6 months of Gn-RH agonist therapy
(Scialli, Jestila, & Simon, 1993); however, this loss can
be completely o r almost completely reversed when
Gn-RH is stopped (Waibel-Treber et al., 1989). Fricd-
man, Lobel, Rein, and Barbieri (1990) developed a strat-
egy to take advantage of the differential sensitivities of
various target organs to estrogen. Gn-RH agonist thcr-
apy is given for 3 months, then estrogen o r estrogen plus
progestin are added back in appropriate dosages to
maintain myoma and uterine regression but prevent os-
teoporosis and other side effects of menopause (Fried-
man et al., 1990). The concept of adding back estrogen
and progesterone during Gn-RH agonist therapy is
based o n the utility of H R T for menopausal hormone
replacement. The aim of Gn-RH agonist hormone add-
back therapy would be first to control the estrogen-dc-
pendent disease process by producing a hypogonadal
state with Gn-RH agonist treatment. Then, after hy-
poestrogenism has been accomplished and the disease
has been adequately controlled, small amounts o f estro-
gen, progestin, or both could be added back to reduce
menopausal symptoms without causing regrowth of my-
omas (Friedman et al., 1990). In a prospective random-
ized trial of Gn-RH agonist plus estrogen-progesterone
or progestin add-back regimens for women with uterine
myomas, Friedman, Daly, Juneau-Norcross, Rcin, and
Gleason (1993) concluded that Gn-RH agonists add-
back regimens provide a useful long-term treatment
strategy in women with large, symptomatic uterine my-
omas. They found that the estrogen-progesterone add-
back regimen was superior or equal to the progestin
add-back regimen in efficacy and safety parameters as-
sessed (Friedman et al., 1993). The value and safety o f
long-term Gn-RH agonists and add-back therapy require
further study. When therapy is withdrawn, the uterus
and myoma in most instances once again enlarge and
symptoms may recur. Gn-RH agonist therapy is most
useful at this time as a surgical adjunct (Verkauf, 1993).
The use of Gn-RH analogues preoperativcly pro-
vides a number of benefits, including ( a ) reducing men-
orrhagia, (b) restoring hemoglobin level, and (c) allow-
ing the patient to bank blood. Additionally, this therapy
permits elective surgery, reduces the size of the incision,
may convert open procedures to laparoscopic o r vaginal
procedures, decreases arterial blood flow to the myoma,
26 JOG"
reduces blood loss during surgery, and may expedite
removal of the myoma (Candiani et a]., 1990; West et a].,
1992).
Clinical trials using mifepristone (RU-486) to re-
duce the size of uterine myomas have shown a reduction
of 50% over a 3-month period. Doses of 5, 25, or 50
m d d a y for up to 6 months have been used to reduce the
size of uterine myomas without producing the changes in
bone density seen with Gn-RH agonists (Hacker &
Moore, 1998). This therapy may provide a long-term
medical approach to the treatment of myomas.
Surgical
Myomas are the most common indication for ma-
jor surgery in women, accounting for approximately
3 0 % of all hysterectomies and 40% of abdominal hys-
terectomies (Moghissi, 1991). Myomectomy should be
considered when a woman desires to preserve her uterus
for childbearing or is opposed to hysterectomy. Negative
publicity surrounding unnecessary hysterectomy has
sensitized women to the decision-making process rcgard-
ing preserving their uterus. The most common reason for
laparoscopic myomectomy is a woman's decision to
avoid hystcrectomy a t all costs. When individuals elect
myomectomy, the physician is obliged to review the risks
and benefits of all the options. If an abdominal incision is
the major concern, the woman may accept laparoscopic
hystcrectomy with morcellation and ovarian preserva-
tion as an alternative if counseled adequately. For some
womcn, any type of hysterectomy is unacceptable, and
the surgeon's decision to undertake these challenging
myomectomy cases, despite attendant risks, is propor-
tional to his or her surgical skills. Insurance coverage
may be critical to these decisions. If an abdominal myo-
mectomy o r hysterectomy is indicated and the woman
chooses laparoscopic myomectomy, the insurance com-
pany may consider the surgery cosmetic (to avoid an
abdominal scar), and the woman may have to cover a
large portion of the cost. Insurance companies should
provide reasonable reimbursement to their participating
physicians who perform laparoscopic myomectomy
(Reich, 1995).
The issue regarding decreased or lack of libido after
hysterectomy has not been supported in the literature.
Helstrom, Weiner, Sorbom, and Backstrom (1994)
found n o difference in pre- and posthysterectomy sexu-
ality. Hclstrom, Lundberg, Sorbom, and Backstrom
(1993) reported that preoperative sexual activity and
enjoyment is the most important factor in predicting
sexuality after hysterectomy than is dyspareunia or de-
terioration of sexual activity due to uterine discase.
There is a growing consensus that hysterectomy with
ovarian preservation does not lead to an increase in psy-
chosexual morbidity (Harris, 1997). The ACOG criteria
for hysterectomy are presented in Table 2. ACOG crite-
Volume 28, Number 1

TABLE 2
American College of Obstetricians and
Gynecologists Criteria for Hysterectomy
for My omas
Procedure
Hysterectomy, abdominal or vaginal
krdication
Myomas
C o d h a t i o n of indication
Presence of 1,2, or 3
1. Asymptomatic myomas of such size that they
are palpable abdominally and are a concern to
the patient
2. Excessive uterine bleeding evidenced by either
of the following:
A. Profuse bleedmg and flooding or clots of
repetitive periods lasting for more than 8 days
B. Anemia due to acute or chronic blood loss
3. Pelvic discomfort caused by myomas (A, B, or C)
A. Acute and severe
B. Chronic lower-abdominal or lower-back
pressure
C. Bladder pressure with urinary frequency not
caused by urinary tract infection
Actions prior to procedure
1. Confirm the absence of cervical malignancy
2. Eliminate anovulation and other causes of
abnormal bleeding
3. When abnormal bleeding is present, confirm the
absence of endometrial malignancy
4. Assess surgical risk from anemia and need for
treatment
5. Consider patient’s medical and psychologic risks
concerning hysterectomy
Contraindications
1. Desire to maintain fertility, in which case
myomectomy should be considered
2. Asymptomatic myomas of size less than 12 weeks
gestation determined by physical or ultrasound
examination
Unless otherwise stated, each numbered and lettered
item (except contraindications) must be present.
Note. Evaluauon of the quality of care provided with this pro-
cedure, when performed for indications 2 and 3, is possible
through assessment of ongoing or repetitive patterns of care
(trending). From Qwlity Assessrnmr and Improvement m Ob-
stenics ond Gynecology, p. 98, by American Colleges of Obste-
tricians and Gynecologists (ACOG).Copyright 1994 by ACOG.
Adapted with permission.
ria for myomectomy arc divided into two major indica-
tions, women with infertility (see Table 3) and women
who wish to retain their uterus (see Table 4).
JanuarylFebruary 3 999
Until recently, myomectomy usually was per-
formed via an abdominal incision (laparotomy) with a
3-5 day hospital stay and a 6 - 8 week recovery period.
Other alternatives include laparoscopic and hystero-
scopic myomectomy.
Laparoscopic Myomectomy. Laparoscopic myo-
mectoniy involves three abdominal puncture sites, in-
cluding the umbilicus: ( a ) 1 0 mm umbilical incision, ( b )5
mm right, and (c) 5 mm left lower quadrant incisions
(Reich, 1995). The laparoscope and other instruments
are placed through these small incisions in the abdomen.
Techniques such as laser, argon beam coagulation, or
clcctrosurgery are used to remove myomas and repair the
uterine wall. In a study of overall satisfaction rate with
laparoscopic myomectomy, 6 2 out of 6.5 women re-
ported being satisfied with their decision to undergo this
procedure even though 13 patients later underwent hys-
terectomy (Reich et al., 1997). For many women, the
TABLE 3
American College of Obstetricians and
Gynecologists Criteria for Myomectomy in
Infertility Patients
Procedure
Myomectomy (laparoscopy with removal of
leiomyomata), (abdominal approach), or (vaginal
approach)
Indication
Myomas in infertility patients as a probable factor in
failure to conceive or in recurrent pregnancy loss
C o n h a t i o n of indication
In the presence of failure to conceive or recurrent
pregnancy loss:
1. Presence of myomas of sufficient size or location
to be a probable facror
2. No more likely explanation exists for failure to
conceive o r recurrent pregnancy loss
Actions prior to procedure
1. Evaluate other causes of male and female
infertility o r recurrent pregnancy loss
2. Evaluate the endometrial cavity and fallopian
tubes (e.g. hysterosalpinogram)
3. Document discussion that complexity of disease
process may require hysterectomy
Unless otherwise stated, each numbered item must be
present.
Note. Evaluanon of the quality of care provided with this pro-
cedure, when performed for the Indication listed, is possible
through assessment of ongoing or repetitive patterns of care
(trending). From Qualrty Assessment ond lrnprovernent rn Ob-
stetrtcs ond Gynecology, p. 97, by American Colleges of Obste-
tricians and Gynecologtsts (ACOG). Copyright 1994 by ACOG.
Adapred with permission.
JOG” 27
advantages of a shorter hospital stay, a more rapid rc-
covery and return to full activity, absence of an abdom-
inal incision and thus a superior cosmetic result, along
with decreased morbidity (Reich et al., 1997) make lapa-
roscopic myomectomy an attractive alternative to myo-
mectomy or hysterectomy through an abdominal inci-
sion.
Hysteroscopic Myomectomy. Hysteroscopic myo-
mectomy is pcrformed through the cervical canal using
TABLE 4
American College of Obstetricians and
Gynecologists Criteria for Myomectomy in
Patients Desiring to Retain Uterus
Procedure
Myomectomy (laparoscopy with removal of
myomas), (abdominal approach), or (vaginal
approach)
Indication
Myomas for patients desiring to retain uterus
Confirmation of indication
Presence of 1 or 2
1. Asymptomatic myomas of such size that they are
palpable abdominally and are a concern to the
patient
2. Ovulatory patients with myomas as probable
cause of excessive uterine bleeding evidenced by
either of the following:
A. Profuse bleeding with flooding or clots or
repetitive periods lasting for more than 8 days
B. Anemia that is due to acute or chronic blood
loss
Actions prior to procedure
1. Confirm by cytologic study the absence of cervical
malignancy
2. Eliminate anovulation and other causes of
abnormal bleeding
3. When abnormal bleeding is present with ovulatory
cycles, assess for submucous fibroid by dilation
and curettage, hysteroscopy, or imaging technique
4. Assess surgical risk from anemia and need for
treatment
5. Discuss with patient the advantages and
disadvantages of myomectomy versus
hysterectomy and document
Unless otherwise stated, each numbered and lettered
item must be present.
Note. Evaluation of the quality of care provided with this pro-
cedure, when performed for the indication listed, is possible
through assessment of ongoing or repetitive patterns of care
(trending).From Qwlity Assessment and Improvement in Ob-
stetrics and Gynecology, p. 96, by American Colleges of Obste-
tricians and Gynecologists (ACOG). Copyright 1994 by ACOG.
Adapted with permission.
28 JOGNN
L a p a r o s c o p i c myomectomy offers a shorter
hospital stay, reduced recovery time,
resolution of symptoms, smaller incisions, and
superior cosmetic results.
either an instrument called a resectoscope to cut away
fibroids or an electrical current to evaporate the fibroid.
This procedure is indicated when a fibroid protrudes into
or distorts the endometrial cavity (submucous fibroid)
(Reich, 1995).
Myolysis or Myoma Coagulation. A new proce-
dure for treatment of scrosal and subserosal fibroids uses
laser laparoscopic coagulation to devascularize the fi-
broid. A bipolar electric needle or laser is used to perform
myolysis of fibroids by coagulating the fibroids, thus
causing them to shrink. ‘This procedure coagulates both
the fibroid and its blood supply. The fibroid shrinks up to
50% in size after surgery. Regrowth does not occur with
this procedure (Goldfarb, 1992).
Tbromboembolism or Uterine Arte y Emboliza-
tion. New treatments are being introduced to control
bleeding from uterine myomas in women who wish to
avoid surgery and are not concerned about preserving
fertility. One new procedure performed by intcrvcn-
tional radiologists is called thromboembolism or uterine
artery embolization. Basically, a catheter is inserted
through a small incision in the femoral artery, then
threaded up to the uterine artery. Plastic particles are
injected through the catheter. These particles lodge in
tiny blood vessels, cutting off blood to the myomas,
which then shrink over the next several months
(Wallach, 1997). With these procedures, the woman is
discharged on the same or next day and most women arc
back to full activity in a week or two (Reich, 1995). New
procedures such as myolysis and thromboembolism lack
the follow-up to enable sufficient evaluation of safety
and future fertility potential (Wallach, 1997).
Nursing Implications
Women need information regarding the options
available to treat myomas as well as alleviate their symp-
toms. Nurses are well-positioned to provide this educa-
tion. The patient should be informed about the nature of
myomas, symptoms, prognosis, various treatments, and
outcomes of each of the therapies. If a woman wishes to
preserve her uterus, for fertility or simple organ prescr-
vation, then myomectomy is the treatment used, partic-
ularly in women who are premenopausal o r just entering
Volume 28, Number 1

N u r s e s who are aware of the various
treatment options for these common yet
problematic tumors can counsel women
seeking treatment for their myomas.
the perimenopausal period. A woman who is approach-
ing postmenopause needs to be informed that myomas
generally rcgress in postmenopausal years and close
monitoring and treatments aimed at buying time may
meet her needs.
If a woman is a candidate for medical intervention,
treatment with Gn-RH agonists to induce a hypoestro-
genic state and decrease myoma sizc is an option. Al-
though regrowth of myomas occurs after treatment is
stopped, a significant number of women report a car-
ryover benefit and thereby avoid surgery, particularly
women who are postmenopausal (Wood, 199.5). Because
Gn-RH agonists initially stimulate an increase in estra-
diol, women should be told to expect a worsening of
their symptoms initially with subsequent resolution with
continuous therapy. This phenomena is referred to as a
flare effect.
The side effects of Gn-RH agonists also must be
presented to women before initiating treatmcnt. The
symptoms of pseudomcnopause, including hot flashes,
vaginal dryness, mood changes, and loss of libido, fre-
quently are identified in women taking Gn-RH agonists.
Another concern is the small loss in bone mass and
changes in lipid levcls that are a result of the drug-in-
duced hypoestrogenic state (Wood, 1995). Women who
elect this treatment should be offered add-back estrogen/
progestin thcrapy to minimize the sidc effects, including
bone loss (Surrey, 199.5). Women need to be informed
that while they may become amenorrheic when taking
Gn-RH agonist therapy, pregnancy remains a possibility
and options for nonhormonal or barrier contraception
should be discussed (Garner, 1994).
The method of Gn-RH agonist administration also
should be discussed. Depending on the prescribcd drug,
administration options include ( a ) daily subcutaneous
injections, ( b ) monthly intramuscular injection, (c) daily
intranasal spray, or ( d ) a monthly subcutaneous implant
(Moutos & Rock, 1992). If the woman elects treatment
with daily injections of a Gn-RH agonist, she will need to
be taught how to administer a subcutaneous injection. In
some instances, a family member or friend is taught to
administer the medication.
Regardless of choice of treatment or choice not to
treat, the patient needs to be educated about all aspects
JanuarylFebruary 1999
of the disease and its treatments and be supportcd as she
progresses through therapy.
Summary
Current literature and clinical practice reflect a
trend toward providing women alternatives to hysterec-
tomy for the treatment of myomas. While progestational
agents and danazol have been reported as effective in
treating myomas, no consensus exists regarding their
routine use (Wallach, 1992).
Gonadotropin-releasing hormone agonists also are
used to treat myomas. They reduce myoma size and
therefore uterine size, resulting in a decline of symptoms
(Friedman, Hoffman, Comite, Browneller, & LMiller,
1991).Symptom resolution is temporary, and symptoms
return with discontinuation of this drug therapy. Be-
cause there is no long-term treatment experience or
safety data with the usc of Gn-RH agonists in women,
the maximum recommended treatment with Gn-RH
agonists is 6 months (Garner, 1994). Long-term use of
Gn-RH agonists is not rccommendcd because of the hy-
poestrogenic state it induces and the resultant bone loss.
Gonadotropin-releasing hormone agonists are
used as a preoperative adjunct to hysterectomy or surgi-
cal excision of myomas. Laparoscopic, hysteroscopic, or
abdominal myomectomy are used primarily for women
who wish to preserve their fertility or avoid hystcrec-
tomy. The accepted therapeutic approaches and indica-
tions for uterine myomas are conservative follow-up
with observation by serial examination; hormone ther-
apy including the use of progestins or Gn-RH analogues;
and surgical therapy including myomcctomy (sometimes
in conjunction with hormone therapy) and hysterec-
tomy. The benefits of newer procedures, such as throm-
boembolism or uterine artery embolization and myolysis
remain to be seen (Wallach, 1997). Various thcrapies
such as Gn-RH agonists, laparoscopic and hysteroscopic
procedures, and laparotomy myomectomy are used to
control symptoms.
Laparoscopic or vaginal hysterectomy is the rec-
ommended treatment for myomas after completion of
childbearing when hypermenorrhea leads to anemia or a
symptomatic pelvic mass greater than 12 weeks gesta-
tional size is present (Reich, 1995). Extensive myomec-
tomies arc not warranted in women who have completed
childbearing because the morbidity and mortality rates
are comparable to those of hysterectomy (Reich, 1995).
Multiple myomectomy generally is a more difficult and
time-consuming procedure than hysterectomy.
For women who wish to retain their reproductive
organs, myomectomy is a viable alternative to hysterec-
tomy. In the hands of a skilled laparoscopist, laparo-
scopic myomcctomy allows for a more rapid recovery
and has been successful in relieving symptoms. IVurses
JOG" 29
need t o be aware of t h e various t r e a t m e n t o p t i o n s for
these c o m m o n yct problematic t u m o r s so t h a t they can
counsel w o m e n who a r e seeking t r e a t m e n t f o r m y o m a s .
W o m e n with s y m p t o m a t i c m y o m a s s h o u l d be m a d e
a w a r e of t r e a t m e n t options, including those allowing for
uterine preservation.
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Theresa N. Grabo is an associate professor and family nurse
practitionerprogram coordinatorat the Decker School of Nurs-
ing, Binghamton University, State University ofNew York, and
has a clinical practice in women’s health at Wyoming Valley
C;YN/lnferh’lity Associates, Kingston, PA.
Pamela Stewart Fahs is an assistant professor at the Decker
School of Nursing, Binghamton University, State University of
New York.
Lindsay G. Nataupsky is a women’s health care nursepractitio-
ner in private practice with Harry Reich in Kingston, PA.
Harty Reich is an associate clinical professor and chief of lapa-
roscopic sutgery at Columbia Presbyterian Medical Center,
New York, NY, and maintains a private practice in Kingston,
PA.
Address for correspondence: Theresa N. Grabo, CRNP, PhD,
Decker School of Nursing, Binghamton University, Box 6000;
Binghamton, NY 13902-6000.

JOG” Review Panel: I999

Kcbecca Attenborough, RN, M N
Linda Bell, RN, MSc
Xlarie Biancuzzo, RN, MS
Caroline Brown, RNC, MS, DEd
hlary Rrucker, CNXl, DNSc
Lynn Clark Callister, RN, PhD
Elizabeth C;. I h m a t o , KN, CS, I’hD
Barbara Dion, RNC, ICCE, MA, MSN
Grace-Elizabeth Djupe, RNC, MS
Robin G.Fleschler, RNC, CNS, .MSN
Catherine lngram Fogel, RNC, PhD,
FAAK
Heidi Funk, RNC, M S
Colleen Gerlach, RN, HSN, MHA
Cheryl A. Glass, RNC, MSN
Jeanne T. Grace, KNC, PhD
Annette (;upton, RN, PhD
Judith Harris, AKNI’, EdD
Carol Hartwig, RN, .US, CNAA
Mary Henrikson, RNC, MN,
ARNP, W H C N P
JoAnne Kirk Henry, RN, CS, EdD
Debra Jackson, RNC, BSY, LlPH
Shirley L. Jones, RNC, PhD
S w a n Kardong-Edgren, RNC, hlS,
FACCE
Anne Katz, RN, M N
Margaret H. Kearney, RNC, I’hD
Cheryl 1’. Kish, RN, EdD, W H C N P
Linda J. Kobokovich, RNC, MScN
lllira Lessick, RN, PhD
Kelly Lindgren, RN, PhD
Sharon Lock, RNC, FNI’, I’hD
Laura Mahlmcister, KN, I’hD
Cathleen K. Maiolatesi, RN, MS
Judith IMaloni, RN, PhD
Louise Martell, RN, PhD
Sharon McCoy, RNC, MS
Emily S. McKinney, RN, C, IMSN
Dianne Morrison-Beedy, RNC, WHNI’, PhD
Paulina G. Perez, RN, BSN, LCCE, FACCE,
CD
Cynthia Armstrong Persily, RN, PhD
Martina I.etko Porter, RNC, MS, MBA
Diana J. Reiser, RN, iMAEd, M N
Mary Ann Stark, RNC, MS
Martha Tabas, RN, C, MS
Suzanne Thayre, RN, I’hD
Rosemary Theroux, RNC, hlS
Cecilia Tiller, RNC, DSN, WHSI’
Judith Carveth Trexler, RN, I’hD, CN.M
IM. Terese Verklan, RNC, I’hD
Luanne Wielichowski, RNC, MSN
I t n o r e R. Williams, KN, MSN
Jeanne M. Wilton, KN, MS, IBCLC
Lucia D. Wocial, IINC, MSN, PhD

]anuaryll.’ehruary 1999 JOG” 31