UTERINE

MYOMA:
Surgical or Medical?
Manuela Tibay - De Jesus, MD
 UTERINE LEIOMYOMAS
• Most common benign uterine
tumors
• Monoclonal tumors of uterine
smooth muscle 2
• Occur in 50 – 60% of women
Ø Rising to 70% by the age of 50

1. CPG for Uterine Leiomyomas. 2017. Philippine Society for Reproductive Medicine, INC. POGS
2. Uterine fibroid management: from the present to the future. Donnez & Dolmans. Human Reproduction Update,
Vol.22, No.6 pp. 665–686, 2016
 PATHOPHYSIOLOGY
PR-B mRNA NUMBER of
myomas Symptoms
PR-B
mRNA PR-A

PR-B
Proteins Higher proliferative
activity during luteal
phase

Uterine fibroid management: from the present to the future. Donnez & Dolmans. Human Reproduction Update, Vol.22,
No.6 pp. 665–686, 2016
PATHOPHYSIOLOGY
New Insights
Smooth
Fibroblast
Muscle

Progesterone Estrogen
Dependent Dependent

Smooth
Muscle MED12 gene
Progesterone
Dependent HMGA2 gene Role of Fibroblasts and
smooth muscle cells in
Laughlin-Tamaso, S. and Stewart, E. 2018. Moving towards individualized leiomyoma biology
medicine for uterine leiomyomas. Leiomyomas: Clinical Expert Series. Vol 132,
No. 4, October 2018. Obstet Gynecol 2018
 SYMPTOMS

Pressure
AUB Symptoms

Abdominal
enlargement Infertility
 DIAGNOSIS

Pelvic Examination Hysteroscopy

Ultrasonography Magnetic Resonance Imaging

 FIGO CLASSIFICATION Uterine fibroids m

Uterine fibroid management: from the present to the future. Donnez & Dolmans. Human Reproduction Update, Vol.22,
nternational Federation of Gynecology and Obstetrics classification system for uterine fibroids.
No.6 pp. 665–686, 2016

eous cure,” avoiding the need for treatment with suggest it. In these specific cases, MRI may b
 Uterine
Leiomyoma Surgical
VS
Medical
 6

What to
he third decade of life

consider?
broids (Petraglia et al.,

1. Age
eveloping fibroids and
2. mediated
monally Severity of symptoms
dis-
ers (Kim and Sefton,
3. Preservation of uterus
and/or fertility
4. Myoma volume and
effect on the develop-
localization (FIGO
emains unclear. It has
Figure 2 FIGO classification of uterine fibroids according to
Classification) Munro et al. (2011). Fibroid types range from 0 to
ine remodeling, small
8
urthermore fibroid tis- = Pedunculated, = Submucosal, <50% intramura
Donnez et al. Rewriting the script: time to0rethink intracavitary;
the indications for myoma surgery. 2016.1https://www.fertstertdialog.com/users/16110-
g both uterine
fertility- remod-
and-sterility/posts/13562-23441 2 = Submucosal, ≥50% intramural; 3 = Contact with endometrium
Laughlin et al., 2010). 100% intramural; 4 = Intramural; 5 = Subserosal, ≥50% intramura
6 = Subserosal, <50% intramural; 7 = Subserosal, pedunculated
Current Management Options is now growin
ways in the pa
UPA (one me
in large clinica
been evaluate
Interventional tives. It was fo
Radiology
maximizes its
fibroid volume
(infertility, ble
to surgical the
stances, as illu
In conclusio
the diagnosis i
be made awar
and surgical)
Gynecologists
opening up no

Acknow
Uterine fibroid management: from the present to the future. Donnez & Dolmans. Human Reproduction
Update, Vol.22, No.6 pp. 665–686, 2016 The authors
th
Figure 15 Surgical, non-surgical and medical therapy for the man-
ation of MRI
agement of fibroids: the current armamentarium.
 Uterine fibroid management: from the present to the future. Donnez & Dolmans. Human Reproduction Update, Vol.22, No.6 pp. 665–686, 2016
are emerging in medical fibroid therapy. The first goal of medical therapy is clearly to treat s
menstrual bleeding, pelvic pain, bulk symptoms, infertility, etc.), as well as to postpone or av
 Medical Management
Therapy for HMB
1. Non - hormonal
a. Nonsteroidal Anti-Inflammatory Drugs
(NSAIDs)**
b. Tranexamic Acid – prevent fibrin degradation
*increased risk of necrosis and infarction of
leiomyoma pain and potential site for infection.

*K. Wellington et. al., “Tranexamic acid. A review of its use in the management of menorrhagia,” Drugs, vol. 63, no.
13, pp. 1417-1433, 2003.
** A. Lethaby, K. Duckitt, and C. Farquhar, “Non-steroidal anti-inhammatory drugs for heavy menstrual bleeding,”
Cochrane Database of Systematic Reviews (Online), vol. 1, p. CD000400, 2013. View at Google Scholar · View at
Scopus
 Medical Management
Therapy for HMB
2. Hormonal
a. Combined oral contraceptives – suppressive
effects on endometrial proliferation
b. Progestins – *varied result; lack of high quality
evidence assessing its efficacy and may even
promote uterine fibroid cell growth
*J.Qin,T.Yang,F.Kong,andQ.Zhou,“Oralcontraceptiveuseanduterineleiomyomarisk:Ameta-
analysisbasedoncohortandcase-control studies,” Archives of Gynecology and Obstetrics, vol. 288, no. 1, pp.
139–148, 2013.
M. Harrison-Woolrych and R. Robinson, “Fibroid growth in response to high-dose progestogen,” Fertility and
Sterility, vol. 64, no. 1, pp. 191-192, 1995. View at Google Scholar · View at Scopus
A.J.Friedman,M.Daly,M.Juneau-
Norcross,C.Fine,andM.S.Rein,“Recurrenceofmyomasapermyomectomyinwomenpretreatedwith leuprolide S.
Venkatachalam, J. S. Bagratee, and J. Moodley, “Medical management of uterine dbroids with
medroxyprogesterone acetate (Depo Provera): a pilot study,” Journal of Obstetrics & Gynaecology, vol. 24,
no. 7, pp. 798–800, 2004. View at Publisher · View at Google Scholar · View at Scopus
 Medical Management
Therapy for HMB
2. Hormonal
c. Levonorgestrel-releasing intrauterine system –
produced thinned endometrial lining
d. Danazol – caused amenorrhea but no effect on
uterine myoma

Socolov D, Blidaru I, Tamba B, Miron N, Boiculese L, Socolov R. Levonorgestrel releasing-intrauterine system for
the treatment of menorrhagia and/or frequent irregular uterine bleeding associated with uterine leiomyoma.
Eur J Contracept Reprod Health Care. 2011;16:480– 487
Zapata LB, Whiteman MK, Tepper NK, Jamieson DJ, Marchbanks PA, Curtis KM. Intrauterine device use among
women with uterine fibroids: a systematic review. Contraception. 2010;82:41–55.
Kriplani A, Awasthi D, Kulshrestha V, Agarwal N. Efficacy of the levonorgestrel-releasing intrauterine system in
uterine leiomyoma. Int J Gynaecol Obstet. 2012;116:35–38.
 Medical Management
Therapy for HMB
2. Hormonal
e. Selective Estrogen Receptor Modulators (SERMS)
- Tamoxifen - there is improvement in menstrual
blood loss but not in fibroid size
- Raloxifene – increase risk of venous thrombosis

Deng L, Wu T, Chen XY, Xie L, Yang J. Selective estrogen receptor modulators (SERMs) for uterine leiomyomas.
Cochrane Database Syst Rev. 2012;10:CD005287. [PubMed]
Lingxia X, Taixiang W, Xiaoyan C. Selective estrogen receptor modulators (SERMs) for uterine leiomyomas.
Cochrane Database Syst Rev. 2007:CD005287.
 Selective Estrogen Receptor
Modulator
Tamoxifen – significant improvement in MBL but no
improvement in fibroid size; many side effects
including benign endometrial thickening

Raloxifene – increased risk of venous thrombosis

- effect on fibroid size and bleeding pattern
unclear

Palomba S, Orio F Jr, Morelli M, et al. Raloxifene administration in premenopausal women with uterine
leiomyomas: a pilot study. J Clin Endocrinol Metab 2002; 87:3603.
 Medical Management
Etiologic Treatment
1. Aromatase inhibitors
ØBlock ovarian and peripheral estrogen production
and decrease estradiol levels

ACOG Practice Bulletin

Clinical Management Guideline for Obstetrician-Gynecologists
 Medical Management
Etiologic Treatment
2. Gonadotrophin - releasing hormone Agonist
(GnRH)
• Leuprolide, nafarelin, goserelin
• Reduce the size of fibroids (35 – 60%)
• Produce amenorrhea, improve AUB
• ACOG recommends surgery within 6 months of
treatment
Lewis et al. 2018. A Comprehensive Review of the Pharmacologic Management of Uterine
Leiomyoma
 Medical Management
3. Gonadotropin-releasing hormone antagonists
• Advantage over agonist - rapid onset of clinical
effects
• Disadvantage - need for daily injections
• Elagolix
• Recently approved new generation
• More acceptable and well-tolerated by patients,
especially with add-back estrogen and progestin
therapy

Archer DF, Stewart EA, Jain RI, et al. Elagolix for the management of heavy menstrual bleeding associated
with uterine fibroids: results from a phase 2a proof-of-concept study. Fertil Steril 2017; 108:152.
Gonadotropin-releasing hormone
antagonists
Elagolix

• 2 randomized trials:
a. Dose-finding study – MBL reduction was greater
with 300mg twice daily than with 600mg daily
b. Elagolix alone vs. elagolix with add-back therapy
– adverse effects (hot flashes and head aches)
less with add-back; significant decrease in
lumbar spine bone density

Archer DF, Stewart EA, Jain RI, et al. Elagolix for the management of heavy menstrual bleeding associated
with uterine fibroids: results from a phase 2a proof-of-concept study. Fertil Steril 2017; 108:152.
 Medical Management
4. Selective Progesterone Receptor Modulators
(SPRMs)
• Mifepristone, asoprisnil, telapristone acetate, ulipristal
acetate
• Anti-progestin
• Decreases progesterone effect on leiomyoma growth
• High affinity to progesterone receptors leading to
mixed agonist and antagonist action.
 Mode of Action

Ulipristal acetate
• Decrease blood loss and fibroid volume
• Synthetic progesterone receptor modulator
• Prevents stimulation of fibroid growth by inhibiting
cell proliferation apoptosis

Powell and Dutta. 2019. PEARL Studies. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5373264/

 Uterine fibroid management: from the present to the future. Donnez & Dolmans. Human Reproduction
Update, Vol.22, No.6 pp. 665–686, 2016

de of action of GnRH agonists and SPRMs (Selective Progesterone Receptor Modulators). GnRH agonists have a d
GnRHs SPRMs
• 89% control of uterine • 90 - 98% control of uterine
bleeding bleeding
• 40% Hot flushes • 10 - 11% Hot flushes
• Increased bone loss after 3 • No bone loss
doses • Fibroid Volume reduction
• Greater decrease in fibroid maintained after 6 months
volume but Fibroid of treatment
enlargement after 1 month • Surgical plane on the
off-treatment pseudo-capsule preserved
• Pseudo-capsule lost Mas, A. et al. 2017. Updated approaches for the
management of uterine fibroids. International Journal of
Women’s Health. 2017:9 607 – 617.
 Ulipristal acetate and the PGL4001
Efficacy Assessment in Reduction of
Symptoms due to Uterine Leiomyomata
(PEARL) Studies

Powell and Dutta. 2019. PEARL Studies. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5373264/

 The n e w e ng l a n d j o u r na l of m e dic i n e

PEARL original article

I
Ulipristal Acetate versus Placebo for Fibroid
Treatment before Surgery
Jacques Donnez, M.D., Ph.D., Tetyana F. Tatarchuk, M.D., Ph.D.,
Philippe Bouchard, M.D., Lucian Puscasiu, M.D., Ph.D.,
Nataliya F. Zakharenko, M.D., Ph.D., Tatiana Ivanova, M.D., Ph.D.,
Gyula Ugocsai, M.D., Ph.D., Michal Mara, M.D., Ph.D., Manju P. Jilla, M.B., B.S., M.D.,
Elke Bestel, M.D., Paul Terrill, Ph.D., Ian Osterloh, M.R.C.P.,
and Ernest Loumaye, M.D., Ph.D., for the PEARL I Study Group*

• Compared UPA 5 and 10 mg/day A BSwith

T R AC T placebo for a 13-

week treatmentBackground
period.
• Effectively controlled uterine
before surgery bleeding and reduced the
The efficacy and safety of oral ulipristal acetate for the treatment of symptomatic
uterine fibroids are uncertain.
From Cliniq
Catholic Un
(J.D.); the D

size of fibroids Methods necology, K

16 (T.F.T.), a
We randomly assigned women with symptomatic fibroids, excessive uterine bleeding cology, Kiev
(a score of >100 on the pictorial blood-loss assessment chart [PBAC, an objective as- (N.F.Z.) —
St. Antoine,
sessment of blood loss, in which monthly scores range from 0 to >500, with higher de Paris and
numbers indicating more bleeding]) and anemia (hemoglobin level of ≤10.2 g per deci- Spitalul Clin
liter) to receive treatment for up to 13 weeks with oral ulipristal acetate at a dose of de Obstetric
Romania (L
5 mg per day (96 women) or 10 mg per day (98 women) or to receive placebo (48 women). versity, Kurs
All patients received iron supplementation. The coprimary efficacy end points were Hospital of
control of uterine bleeding (PBAC score of <75) and reduction of fibroid volume at stetrics and
 The n e w e ng l a n d j o u r na l of m e dic i n e

PEARL
PEARL II original article

II
Ulipristal Acetate versus Leuprolide Acetate
for Uterine Fibroids
Jacques Donnez, M.D., Ph.D., Janusz Tomaszewski, M.D., Ph.D.,
Francisco Vázquez, M.D., Ph.D., Philippe Bouchard, M.D.,
Boguslav Lemieszczuk, M.D., Francesco Baró, M.D., Ph.D., Kazem Nouri, M.D.,
Luigi Selvaggi, M.D., Krzysztof Sodowski, M.D., Elke Bestel, M.D.,
Paul Terrill, Ph.D., Ian Osterloh, M.R.C.P., and Ernest Loumaye, M.D., Ph.D.,
for the PEARL II Study Group*

A bs t r ac t
Both 5mg and 10mg daily doses of UPA were non-
inferior to onceBackground
monthyl leuprolide in controlling
The efficacy and side-effect profile of ulipristal acetate as compared with those of From C

uterine bleedingleuprolide
are unclear. were significantly less likely to
and acetate for the treatment of symptomatic uterine fibroids before surgery Catholic
(J.D.);
Ginekol

cause hot flashes.Methods Lekarsk

(B.L.), a
Sodows
In this double-blind noninferiority trial, we randomly assigned 307 patients with symp- Clinica G
tomatic fibroids and excessive uterine bleeding to receive 3 months of daily therapy de Obs
with oral ulipristal acetate (at a dose of either 5 mg or 10 mg) or once-monthly intra- Lugo, S
Assistan
muscular injections of leuprolide acetate (at a dose of 3.75 mg). The primary outcome and Uni
was the proportion of patients with controlled bleeding at week 13, with a prespeci- pital Val
 SEMINAL CONTRIBUTIONS

Long-term treatment of uterine

PEARL
PEARL III fibroids with ulipristal acetate*
III Jacques Donnez, M.D.,a Francisco Va !zquez, M.D.,b Janusz Tomaszewski, M.D.,c Kazem Nouri, M.D.,d
Philippe Bouchard, M.D., Bart C. J. M. Fauser, M.D.,f David H. Barlow, F.R.C.O.G.,g Santiago Palacios, M.D.,h
e

Olivier Donnez, M.D.,i Elke Bestel, M.D.,j Ian Osterloh, M.R.C.P.,k and Ernest Loumaye, M.D.,l for the PEARL III
and PEARL III Extension Study Group
a
Socie
! te ! , Brussels, Belgium; b Centro de Estudios de Obstetricia y Ginecología Asociado,
! de Recherche pour l'Infertilite
Lugo, Spain; c Prywatna Klinika Polozniczo-Ginekologiczna, Bialystok, Poland; d Department of Gynecological
Endocrinology and Reproductive Medicine, Medical School of Vienna, Vienna, Austria; e Endocrinology Unit, AP-HP

• Assessed the efficacy and safety of long term UPA

Hospital Saint-Antoine, Paris, France; f Department of Reproductive Medicine and Gynecology, University Medical
Center Utrecht, Utrecht, the Netherlands; g College of Medical, Veterinary, and Life Sciences, University of Glasgow,
Glasgow, Scotland; h Palacios' Institute of Women's Health, Madrid, Spain; i Centre Hospitalier Universitaire Universite !
Catholique de Louvain Mont-Godinne Dinant, Yvoir, Belgium; j PregLem S.A., Geneva, Switzerland; k OsterMed Ltd.,
treatment in women with symptomatic fibroids
Birmingham, United Kingdom; and l ObsEva S.A. Geneva, Switzerland

• Patients treated with 10mg/tab UPA daily followed by

Objective: To investigate the efficacy and safety of ulipristal acetate (UPA) for long-term treatment of symptomatic uteri
NETA/placebo (add-back) for 12 week courses
Design: Repeated intermittent open-label UPA courses, each followed by randomized double-blind norethisterone acetat
placebo.
Setting: European clinical gynecology centers.
• Repeat courses of ulipristal acetate control symptoms
Patient(s): Two hundred and nine women with symptomatic fibroids including heavy menstrual bleeding.
Intervention(s): Patients received up to four 3-month courses of UPA 10 mg daily, immediately followed by 10-day d

and significantly reduce leiomyoma volume

treatment with NETA (10 mg daily) or placebo.
Main Outcome Measure(s): Amenorrhea, fibroid volume, endometrial histology.
Result(s): After the first UPA course, amenorrhea occurred in 79% of women, with median onset (from treatment start) of
terquartile range, 2–6 days). Median fibroid volume change was !45% (interquartile range, !66%; !25%). Amenorrhea
89%, 88%, and 90% for the 131, 119, and 107 women who received treatment courses 2, 3, and 4, respectively. Median tim
orrhea were 2, 3, and 3 days for treatment courses 2, 3, and 4, respectively. Median fibroid volume changes from baseline w

Received January 22, 2014; revised and accepted February 6, 2014; published online March 12, 2014.
*
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).
J.D. has been a member of the Scientific Advisory Board (SAB) of PregLem S.A. since 2007. He held PregLem stocks related to SAB activities th
October 2010 at PregLem's full acquisition by the Gedeon Richter Group. There is no relationship between stock payment value and futur
 Efficacy and safety of repeated use of
PEARL IV ulipristal acetate in uterine fibroids
PEARL
IV Jacques Donnez, M.D.,a Robert Hudecek, M.D.,b Olivier Donnez, M.D.,c Dace Matule, M.D.,d
Hans-Joachim Arhendt, M.D.,e Janos Zatik, M.D.,f Zaneta Kasilovskiene, M.D.,g
Mihai Cristian Dumitrascu, M.D.,h Herve ! Fernandez, M.D.,i David H. Barlow, F.R.C.O.G.,j
Philippe Bouchard, M.D.,k Bart C. J. M. Fauser, M.D.,l Elke Bestel, M.D.,m Paul Terrill, Ph.D.,n
Ian Osterloh, M.R.C.P.,o and Ernest Loumaye, M.D.p
a
Socie
!te !, Brussels, Belgium; b Department of Obstetrics and Gynaecology, Masaryk University
! de Recherche pour l'infertilite
and University Hospital Brno, Brno, Czech Republic; c Institut de Recherche Expe !rimentale et Clinique (IREC), Universite
! de
Louvain, Centre Hospitalier Universite ! (CHU) Université Catholique de Louvain (UCL) Mont-Godinne Dinant, Yvoir, Belgium;

• Multicenter, randomized, double-blind parallel group

d
Medical Company ARS Gynaecology, Department No.5, Riga, Latvia; e Praxis fu € r Frauenheilkunde, Klinische Forschung
und Weiterbildung, Magdeburg, Germany; f Szent Anna Szuleszeti, Nogyogyaszati es Ultrahang Maganrendelo,
Debrecen, Hungary; g Private Clinic ‘‘Maxmeda,’’ Vilnius, Lithuania; h Centrul Medical EUROMED SRL, Obstetrica-
Ginecologie, Bucuresti, Romania; i Ho ^ pital Bice
^tre-Assistance Publique-Hopitaux de Paris (APHP), Service de Gyne !cologie-

• The efficacy and safety of 5 and 10mg doses of UPA

Obste!trique, Le Kremlin Bice
d'Endocrinologie, Ho
^tre cedex, France; j Hamad Medical Corporation, Women's Health Services, Qatar; k Service
^ pital Saint-Antoine, Paris, France; l Department of Reproductive Medicine and Gynecology,
University Medical Center Utrecht, Utrecht, the Netherlands; m PregLem S.A., Plan-les-Ouates, Geneva, Switzerland;
n
CROS NT Limited, Maidenhead and o OsterMed Ltd., Birmingham, United Kingdom; and p ObsEva SA, Plan-les-Ouates,

during 2 treatment courses

Geneva, Switzerland

• Repeated 12 - week courses of daily ulipristal acetate

Objective: To investigate the efficacy and safety of repeated 12-week courses of 5 or 10 mg daily of ulipristal acetate for intermittent
treatment of symptomatic uterine fibroids.
effectively control bleeding and pain, reduce fibroid
Design: Double-blind, randomized administration of two 12-week courses of ulipristal acetate.
Setting: Gynecology centers.
Patient(s): A total of 451 patients with symptomatic uterine fibroid(s) and heavy bleeding.

volume and restore QOL in patients with

Intervention(s): Two repeated 12-week treatment courses of daily 5 or 10 mg of ulipristal acetate.
Main Outcome Measure(s): Amenorrhea, controlled bleeding, fibroid volume, quality of life (QoL), pain.
Result(s): In the 5- and 10-mg treatment groups (62% and 73% of patients, respectively) achieved amenorrhea during both treatment

symptomatic fibroids
courses. Proportions of patients achieving controlled bleeding during two treatment courses were >80%. Menstruation resumed after
each treatment course and was diminished compared with baseline. After the second treatment course, median reductions from baseline
in fibroid volume were 54% and 58% for the patients receiving 5 and 10 mg of ulipristal acetate, respectively. Pain and QoL improved
in both groups. Ulipristal acetate was well tolerated with less than 5% of patients discontinuing treatment due to adverse events.

Received September 17, 2014; revised and accepted October 21, 2014; published online December 24, 2014.
J.D. has been a member of the Scientific Advisory Board (SAB) of PregLem S.A. since 2007. He held PregLem stocks related to SAB activities that he sold in
October 2010 at PregLem's full acquisition by the Gedeon Richter Group. There is no relationship between stock payment value and future commercia
performance of the study drug. R.H. and his institution received a grant for this study, study equipment and support for travel to the investigator meet
 Medical Management
Ulipristal Acetate
• Concern regarding endometrial changes (“Progesterone
Receptor Modulator Associated Endometrial Changes”
PAEC) induced by continuous daily dosing of SPRM
• PAECs are reversible 1–2 months after cessation of UPA
treatment
• Rare case of serious liver toxicity
• Guidelines in 2018: pretreatment screening for liver
disease; liver function test before, during and after
treatment
 SURGICAL THERAPY
Indications
1. AUB or bulk related symptoms
2. Infertility or recurrent pregnancy losses
 SURGICAL MANAGEMENT
Hysterectomy
• Definitive treatment for leiomyoma
• Peri-menopausal age
• Completed family
• Uterine size of > 16weeks
 SURGICAL THERAPY
1. Hysterectomy
Indications
(1) Acute hemorrhage with no response to other
therapies
(2) Completed childbearing and have current or
increased future risk of other diseases
(3) Failed prior minimally invasive therapy for
leiomyomas
(4) Have significant symptoms, multiple leiomyomas,
and a desire for a definitive end to symptomatology.
 SURGICAL THERAPY
2. Myomectomy
Indications:
1. Have not completed childbearing
2. Wish to retain their uterus

• Disadvantage: risk that more leiomyomas will

develop
• Laparotomy/Laparoscopy
 Interventional Radiology
1. Uterine Artery Embolization
• Option for women who wished to preserve their
uterus
• Shrinkage of myoma in 30 - 46%

ACOG Practice Bulletin

Clinical Management Guideline for Obstetrician-Gynecologists
 Interventional Radiology
1. Uterine Artery Embolization
• Complications: myoma expulsion and hematoma
with recurrence rate
• 29% Reoperation rate
• Long-term outcome
• Contraindicated in patients desirous of pregnancy
• Ovarian reserve and healthy myometrium may be
compromised
ACOG Practice Bulletin
Clinical Management Guideline for Obstetrician-Gynecologists
 Interventional Radiology
2. Magnetic Resonance Imaging-Guided
Focused Ultrasound Surgery (MRgFUS)
• Premenopausal women who have completed
child bearing
• Modest uterine volume reduction
• Adverse effect: heavy menses, persistent pain
and bleeding

ACOG Practice Bulletin

Clinical Management Guideline for Obstetrician-Gynecologists
Uterine fibroid management: from the present to the future. Donnez & Dolmans. Human Reproduction
Update, Vol.22, No.6 pp. 665–686, 2016
 Uterine fibroid management: from the present to the future. Donnez & Dolmans. Human Reproduction
Update, Vol.22, No.6 pp. 665–686, 2016

8 Management of type 1 myomas. Depending on the myoma size, presence of anemia and the surgeon’s skill, hysteroscopic my
 Uterine fibroid management: from the present to the future. Donnez & Dolmans. Human Reproduction Update, Vol.22,
No.6 pp. 665–686, 2016

gure 9 Management in case of myomas or multiple myomas (type 2–5) in women of reproductive age, according to desire for pregnancy.
 SPRMs
associated
to significa
to explor
modificatio
trial endom

Future
SPRMs ha
therapy, t
need for s
egies, such
to this co
high risk (i

Conc
Symptoma
according
Uterine fibroid management: from the present to the future. Donnez & Dolmans. Human Reproduction
Update, Vol.22, No.6 pp. 665–686, 2016
serve the
involve ma
THANK YOU.