Current Obstetrics and Gynecology Reports

https://doi.org/10.1007/s13669-018-0242-6

UTERINE FIBROIDS (N NARVEKAR, SECTION EDITOR)

New Horizons in Fibroid Management

Rohan Chodankar 1 & Jennifer Allison 2

# Springer Science+Business Media, LLC, part of Springer Nature 2018

Abstract
Purpose of Review Review of the latest advances in the treatment of uterine fibroids. Addressing conservative management,
medical therapy, interventional radiological procedures (non-surgical alternatives or non-excisional procedures) and conservative
or radical endoscopic or open surgery (myomectomy, hysterectomy).
Recent Findings Newer medical therapy relied on the use of selective progesterone receptor modulators (SPRMs) (Esmya/UPA) for
management of heavy menstrual bleeding (HMB) associated with fibroids. However, the drug is currently under investigation for a
link with hepatic damage associated with its use. Other SPRMs currently showing promise include vilaprisan and telapristone. New
medical therapy also includes oral small molecule GnRH antagonists such as Relugolix, Elagolix and Lizagolix which are undergoing
phase 2 and 3 trials and have shown promise. The new NICE guidance on HMB also suggests limited effectiveness of pharmaco-
logical methods in fibroids > 3 cm and therefore referral to an expert with possible consideration of surgery as a first-line treatment.
Non-excisional procedures include the use of uterine artery embolisation which is currently being compared to myomectomy and its
effect on the quality of life in the FEMME study. With regard to excisional therapies, controversy still surrounds the use of laparoscopic
power morcellators (LMPs). A white paper has been issued by the US FDA in December 2017 on the matter, and a PneumoLiner still
remains the only containment device approved by the US FDA for use with LMPs. With advancing surgical expertise and use the
bipolar sealing devices, TLHs are increasingly being performed for larger uteri (> 12 weeks or > 280 g). Hysteroscopic retrieval
systems (HRTs) are found to be increasingly used successfully for type 2 submucous myomas as one-step procedures.
Summary Many treatments are available for fibroids that can help women reach the age of menopause prior to embarking on
radical surgery. It seems sensible to start with conservative (medical) measures; however, for women with large fibroids, often
non-excisional or surgical solution is needed. Which technique is chosen will depend upon local expertise as well as patient
preference, especially the need for uterine/fertility preservation, following a detailed discussion regarding risks and benefits.

Keywords Fibroids . Heavy menstrual bleeding . SPRMs . Myomectomy

Introduction Fibroids tend to be twice or even three times more common in

Uterine fibroids (myomas, leiomyomas) are the most common
benign tumours in women of reproductive age. Women who
have incidentally diagnosed fibroids and are asymptomatic do
not require treatment [1]. The treatment of symptomatic fi-
broids often needs to be individualised based on the nature
of symptoms, the number of fibroids, size and location, the
desire for uterine and/or fertility preservation, age of the pa-
tient, general performance status and previous treatments.
This article is part of the Topical Collection on Uterine Fibroids
black women as compared to other racial or ethnic groups.
Although hysterectomy offers a permanent solution, a significant
proportion of symptomatic fibroids are seen in younger women
fertility wishing uterine and/or fertility preservation [2, 3].
The treatment options for symptomatic fibroids include in
carefully selected women a period of watchful expectancy
when approaching the menopause, medical therapy, interven-
tional radiological procedures (non-surgical alternatives or
non-excisional procedures) and conservative or radical endo-
scopic or open surgery (myomectomy, hysterectomy).

* Rohan Chodankar Medical Therapy

rohan.chodankar@gmail.com

The current medical approaches to fibroids are based on the

1
Victoria Hospital, Scotland, UK knowledge that fibroid growth, and consequently, symptoms
2
Royal Infirmary of Edinburgh, Scotland, UK are influenced by ovarian steroid hormones via specific

receptor subtypes [4]. Heavy menstrual bleeding (HMB) is the
most common symptom of a fibroid uterus and is thought to
occur due to increased endometrial surface area, increased
uterine vascularity, impaired uterine contractility, endometrial
ulceration by submucosal fibroids and compression of the
venous plexus within the myometrium leading to endometrial
venule ectasia and resulting in congestion of the myometrium
and endometrium [5].
Non-hormonal therapies include using non-steroidal anti-
inflammatory drugs (NSAIDS) and tranexamic acid. They
have the advantage of needing limited dosing around the time
of menstruation. NSAIDs block the prostaglandin pathway
within the uterus and can reduce HMB by 20–40% and dys-
menorrhea; however, there is limited evidence for their effec-
tiveness in women with fibroids [6–8]. Tranexamic acid is an
anti-fibrinolytic drug and can reduce bleeding by 40% [9].
Hormonal therapies include combined oral contraception
as pills, patches or rings, progesterone only methods (depot
medroxyprogesterone acetate—DMPA, levonorgestrel intra-
uterine system—LNG-IUS, progesterone only pill),
gonadotropin-releasing hormone analogues (GnRH-a), aro-
matase inhibitors (AIs), selective progesterone receptor mod-
ulators (SPRMs), selective oestrogen receptor modulators
(SERMs) and GnRH antagonists.
Combined oral contraception is effective in controlling
HMB associated with fibroids with a possible protective effect
on future fibroid growth without a significant size impact [10].
The LNG-IUS is highly effective in reducing HMB in as-
sociation with fibroids; however, the effect on reduction in
fibroid volume/size is less convincing [11]. The current
NICE guidance suggests using an LNG-IUS as a first-line
method to treat HMB in women with fibroids < 3 cm in size,
not distorting the cavity and with no other identified pathology
[12]. The most common device used is the Mirena® LNG-
IUS which contains 52 mg levonorgestrel (LNG). Jaydess®
(Bayer plc) is a LNG-IUS that was launched in the UK market
in April 2014. It has been designed with smaller dimensions
than Mirena. As a result, the LNG content (13. 5 mg) and
release rate are lower such that it is licenced for 3 years of
use. It is known as Skyla® in the USA. Currently, the Jaydess
is licenced only for contraceptive use.
For women with fibroids > 3 cm, the guidance suggests
that the limited effectiveness of pharmacological therapies
should be considered in treatment planning. Uterine artery
embolisation (UAE), myomectomy or a hysterectomy can be
considered as a treatment choice for such fibroids, including
the use of second-generation endometrial ablation devices
where the manufacturer’s instructions have been met [12].
DMPA is thought to exert a protective effective against
development of fibroids in the future in addition to reduction
in HMB [13, 14].
GnRH-a consistently reduce fibroid volume and control
symptoms and are especially useful pre-operatively in
Curr Obstet Gynecol Rep
decreasing fibroid volume, improving haematocrit, reducing
the need for blood transfusion and allowing for less invasive
surgical techniques [15–17]. Oestrogen deficiency side effects
such as hot flushes, vaginal dryness, sleep disturbances and
reduction in bone mineral density limit prolonged use. In ad-
dition, regrowth of fibroids to pre-treatment levels after dis-
continuation limits its usefulness [18]. An improvement in
menopausal symptoms is seen with various add back therapies
(tibolone, DMPA, combined oral contraception) although they
negatively impact fibroid size [19].
Aromatase inhibitors such as letrozole and anastrozole
block the ovarian and extra-ovarian oestrogen synthesis and
have an increased expression in myomas when compared to
the surrounding myometrium. Studies report a reduction in
fibroid size between 50 and 70% [20, 21]. However, robust
evidence is lacking to recommend their routine use in the
treatment of symptomatic fibroids.
Raloxifene is the most studied SERM, and current knowl-
edge suggests that there is no consistent evidence from the
limited number of studies that it reduces the size of fibroids
or improves clinical outcomes. This risk of VTE events asso-
ciated with its use, in addition to hot flushes, increased appe-
tite, weight gain, gastralgia and dry skin, means that it has
found no favour in the treatment of symptomatic fibroids [22].
Vitamin D is thought to exert anti-oestrogenic effects in
myoma cells and may have a role to play in women with
hypovitaminosis D [23].
Probably the most important medical therapy for manage-
ment of fibroids in recent years is SPRMs, and the most stud-
ied agent in this class of drugs is ulipristal acetate (UPA). UPA
is the only SPRM specifically approved and commercialised
to date for management of uterine fibroids. UPA controls
HMB in over 90% of women, with an overall decrease in
bleeding similar to GnRH agonist use but has a faster onset
of amenorrhea usually within 10 days. Estradiol levels are
maintained in the follicular phase range during treatment
thereby reducing the menopausal symptoms. In addition, fi-
broid volume reduction (≥ 25%) is seen in nearly in a third of
women and the reduction in myoma volume is sustained lon-
ger than with GnRH analogues. Trials evaluating up to four
repeated courses of UPA show promise for long-term use.
UPA does cause the benign endometrial changes described
as PAEC—progesterone receptor modulator-associated endo-
metrial changes. These changes are reversible after treatment
completion or discontinuation [24, 25].
More recently in February 2018, the European Medicines
Agency (EMA) and the Medicines and Healthcare Products
Regulatory Agency (MHRA) issued guidance for patients and
health professionals with regard to the use of UPA/Esmya due
to five reports of serious liver injury, including four cases of
hepatic failure needing liver transplantation, which have been
reported worldwide in women using Esmya for uterine fi-
broids. The recommendations are as follows:
Curr Obstet Gynecol Rep
& Do not start new patients on Esmya or new treatment
courses in patients who have already completed a previous
one.
& Perform liver function tests at least once a month for all
patients taking Esmya. If the patient develops transami-
nase levels more than two times the upper limit of normal,
stop treatment and monitor the patient closely. Liver test
should be repeated 2 to 4 weeks after stopping treatment.
& For any patient with signs or symptoms consistent with
liver injury (such as nausea, vomiting, right hypochondrial
pain, anorexia, asthenia, jaundice), check transaminase
levels immediately. If transaminase levels are more than
two times the upper limit of normal, stop treatment and
closely monitor the patient.
& Advise your patients about the signs and symptoms of
liver injury.
Other SPRMS
Several other SPRMs have been studied, notably asoprisnil,
telapristone acetate and vilaprisan. Two randomised trials eval-
uating asoprisnil from 5 to 20 mg per day and showed that
asoprisnil is able to suppress uterine bleeding in a dose-
dependent manner [26, 27]. Its clinical development was halted
in 2007 due to a change in priorities by its developer.
Telapristone has shown promise in animal models and prelimi-
nary clinical research; its development was briefly suspended in
2009 due to liver toxicity concerns [28]. At present time, there is
an ongoing phase II clinical trial that started on 2014 that aims to
evaluate both safety and efficacy of lower oral as well as vaginal
doses of telapristone acetate (https://clinicaltrials.gov/ct2/show/
NCT02323646). Vilaprisan is a novel SPRM currently in the
late stages of clinical development [29].
Small Molecule Oral GnRH Antagonists
Relugolix was found to significantly reduce menstrual blood
loss in a dose-dependent fashion when compared to placebo,
in a phase 2 double-blind randomised study [30]. Ten, 20, and
40 mg doses were used, and Pictorial Blood Loss Assessment
Chart (PBAC) score of < 10 from weeks 6 to 12 of drug
commencement was used as the primary end point. The drug
was well tolerated, and adverse effects in mild to moderate
severity such as headache, metrorrhagia, menorrhagia and hot
flush were more than 10% higher in Relugolix 20 mg and
40 mg groups than in placebo group.
Elagolix has been studied in a phase 2a proof of concept,
dose ranging, multiple cohort study [31]. The study recruited
pre-menopausal women with uterine fibroids, with menstrual
blood loss of > 80 mL/cycle. Elagolix was used by itself in
doses ranging from 200 mg to 600 mg/day and in combination
with add back therapy for doses of 400 mg and more per day.
The study concluded that Elagolix significantly reduced heavy
menstrual bleeding in women with fibroids, and low-dose
add-back regimens substantially reduced flushing which was
the most common adverse effect associated with the use of the
drug. A similar conclusion was noted in a double-blind,
randomised, placebo-controlled, parallel group study which
used 600 mg of Elagolix a day with and without add back
therapy in pre-menopausal women with uterine fibroid with
menstrual blood of loss of > 80 mL/month [32].
Linzagolix is currently being evaluated in a prospective,
randomised, parallel group, double-blind, placebo-controlled
phase 3 study (PRIMROSE 2), alone and in combination with
add-back therapy for the treatment of heavy menstrual bleed-
ing associated with uterine fibroids (ClinicalTrials.gov
Identifier: NCT03070951).
Non-excisional Management of Fibroids
The principle of non-excisional therapies is to reduce myoma
size and therefore to reduce symptoms. Patients need to be
informed that myomas are likely to still be present which
may need further treatment. Success is often measured as the
need for reintervention, usually within 3 to 5 years.
UAE
Uterine artery embolisation involves reduction in the blood
supply to the fibroid using interventional radiological tech-
niques. Although UAE has been widely used to treat other
conditions (postpartum haemorrhage, gestational trophoblas-
tic disease, uterine arteriovenous malformations—AVMs), its
use to manage uterine fibroids successfully was first described
in 1995 [33]. The procedure is generally reserved for women
where conservative and/or medical management has failed
and uterine preservation is desired.
Contraindications include suspected gynaecological can-
cer, active pelvic infection, pregnancy, single fibroids >
10 cm (relative), reduced vascular access (previous internal
iliac or uterine artery occlusion), desire for future fertility
(relative) and possibly fibroid location (pedunculated submu-
cosal myoma, pedunculated fibroids) [34–36]. The proposed
risks with UAE in pedunculated fibroids with a narrow stalk
include torsion, fibroid detachment and subsequent sepsis.
Submucous fibroid embolisation entails the risk of vaginal
discharge, bleeding and infection. The RCOG (2013) and
SOGC (2005) guidelines further stipulate that UAE should
not be recommended to patients who cannot accept the possi-
bility of hysterectomy re-intervention. SOGC (2005) recom-
mends discontinuation of GnRH agonists prior to UAE, sug-
gesting that they can increase the risk of vasospasm, leading to
technical failure although other clinical guidelines disagree
with this view.

The basic principles include occlusion of the uterine and/or
fibroid blood supply, accessed via the femoral artery under
fluoroscopic guidance by an interventional radiologist.
Using embolic agents (polyvinyl alcohol—PVA micro-
spheres, tris-acryl gelatine, acrylamido PVA microspheres,
or gelfoam) of differing sizes up to 900 μm, unilateral or
bilateral vascular occlusion at the arteriolar level can be
achieved, with consequent reduction in fibroid dimensions
due to tissue necrosis [34, 37].
With UAE the expected reduction in fibroid size is 50–60%
over 12 months, with control of bleeding and pressure symp-
toms in up to 90% of women [38]. Evidence suggests that
UAE has similar benefits to a hysterectomy when analysed
over a 10-year period. There are similar improvements in
symptoms (bleeding, pain, pressure symptoms) and quality
of life. After 10 years of follow-up, in 69% of all women
undergoing a technically successful UAE, a hysterectomy
was avoided. [39].
Although ultrasonography is appropriate for fibroid map-
ping prior to UAE, magnetic resonance imaging (MRI) has
further advantages including information on fibroid viability,
presence of adenomyosis and possibility of using contrast to
delineate the feeding blood supply to the fibroid(s) [40].
The most common complication associated with UAE, seen
in nearly half of women, is post embolisation syndrome. The
syndrome is characterised by abdominal pain, fever, raised in-
flammatory markers, nausea and vomiting. The pain is associ-
ated with fibroid necrosis. The syndrome is usually self-
limiting and resolves in 48 h. Persisting pain following UAE
is a red flag symptoms and uterine infection should be ruled
out. Up to 2% of women may experience infections including
infected fibroids, endometritis, endomyometritis, salpingitis
and tuboovarian abscesses, usually secondary to Escherichia
coli. If untreated, these infections can progress to overwhelm-
ing sepsis and death, although routine use of antibiotics in low-
risk women undergoing UAE is not routinely recommended.
Other major complications including femoral haematomas,
anaphylaxis to contrast media and non-target pelvic organ em-
bolisation may be seen in 1–2% of women [37, 41, 42].
Fertility potential and UAE still continues to be a conten-
tious issue. Women should be aware of the lack of data on
potential risk for pregnancy outcomes. Most clinical guide-
lines suggest that desire for fertility is a contraindication to
UAE, except SIR (2014) who suggest that UAE may be con-
sidered in certain specific cases. The use of UAE to improve
fertility in fibroid-associated subfertility is discussed in the
RCOG (2013) guidelines, which advises that UAE may be
an option in patients with characteristics unfavourable for
myomectomy, i.e., multiple or inaccessible fibroids.
The overall pregnancy rate varies between 14 and 69% post
UAE. Studies suggest a higher rate miscarriage, abnormal
placentation, postpartum haemorrhage, reduced ovarian func-
tion, premature delivery and increase caesarean section rates,
Curr Obstet Gynecol Rep
although the effect of confounders such as age, previous sur-
gery and infertility remains unclear [43–45].
Myomectomy remains the gold standard treatment for
women with symptomatic fibroids desiring fertility.
The FEMME study is a randomised trial of treating fibroids
with either embolisation or myomectomy to measure the ef-
fect on quality of life among women wishing to avoid hyster-
ectomy [46]. The FEMME trial’s primary outcome is the qual-
ity of life women with symptomatic uterine fibroid experience
2 years after they have been treated with either UAE or myo-
mectomy, as measured by the disease-specific uterine fibroid
symptom quality-of-life (UFS-QoL) questionnaire.
MRgFUS
Magnetic resonance imaging-guided high-frequency ultra-
sound (MRgFUS) is a US FDA approved treatment modality,
which involves the use of MRI to map the fibroids, followed
by the use of high-intensity focused ultrasound (HiFU) to a
localised area within the fibroid with resultant coagulative
necrosis. This also ensures minimal damage to the surround-
ing tissues [47].
Contraindications to the procedure include pedunculated,
non-enhancing or heavily calcified fibroids, general MR con-
traindications (claustrophobia, implants, defibrillators), pelvic
inflammatory disease and suspected gynaecological malig-
nancy [48–50].
Several studies have shown that MRgFUS significantly
improves symptoms in 70–80% of women with fibroids. In
a review considering a 12-month follow-up of 130 clinical
patients after magnetic resonance guided focused ultrasound
for uterine leiomyomas, the symptomatic relief was, respec-
tively, 86% (90 of 105), 93% (92 of 99),and 88% (78 of 89) at
the 3-, 6- and 12-month follow-up [51, 52].
The effectiveness of the MRgFUS procedure can be deter-
mined by the non-perfused volume (NPV) ratio, defined as the
volume of myoma, which is no longer perfused by gadolinium
after treatment as assessed by MRI, divided by the total myo-
ma volume. The higher the NPV compared with myoma size
(NPV ratio), the better the symptom relief and subsequent
myoma reduction [53].
The initial evidence of the use of MRgFUS in women
desiring fertility is promising, and the US FDA now approves
its use to include women who desire fertility as long as there
has been appropriate counselling on the limited available stud-
ies. Rabinovici et al. reported 54 pregnancies in 51 with a
mean time to conception of 8 months after treatment. Live
births occurred in 41% of pregnancies; the spontaneous abor-
tion rate was 28% and the elective pregnancy termination rate
11%. A vaginal delivery rate of 64% was seen [54].
MRgFUS could require up to 3 h per treatment session, and
its cost often precludes routine use [48].
Curr Obstet Gynecol Rep
RFVTA
Radiofrequency volumetric thermal ablation (RFVTA) is an
invasive, uterine sparing modality to treat uterine fibroids. It
can be performed laparoscopically (US FDA approved) or
using the vaginal route. RFVTA works by delivering radiofre-
quency energy to the myoma using a laparoscopic hand piece,
creating intracellular heat, which in turn causes coagulative
necrosis of the fibroid tissue with thermal feedback [55].
The safety and efficacy of the technique have been demon-
strated by various studies [56–58]. Symptom relief can be
maintained up to a 3-year period [59].
The VizAblate system is a transcervical device that utilises
radiofrequency energy to ablate fibroids under the guidance of a
built-in intrauterine ultrasound probe. Although approved for
use in Europe, this device has not yet received US FDA approv-
al for non-investigational use. A small study of 50 women un-
dergoing VizAblate demonstrated an increase in health-related
quality of life (HRQOL) scores by an average of 263% and a
decrease in menstrual pictogram and symptom severity scores
by approximately 60% over a 6-month period [56].
RFVTA versus laparoscopic myomectomy was compared in
a randomised trial and although treatment time was similar,
women undergoing RFVTA had a higher proportion of myomas
treated (98.6 vs 80.3%), less intraoperative blood loss and
shorter hospital stays [57]. In another study, both groups of
women had improved symptom severity and HRQOL post-
treatment, with no significant differences in improvements be-
tween the groups [55].
Studies have demonstrated that full term pregnancies are
possible following the use of this technique to treat symptom-
atic fibroids, although the numbers are very small to draw
meaningful conclusions [57, 60, 61].
Laparoscopic Uterine Artery Ligation
Laparoscopic bilateral uterine artery ligation involves occlusion
of the uterine artery at the origin from the anterior division of the
internal iliac artery. This can be achieved using vascular clips or
diathermy. The principle is similar to UAE; however, it is not
associated with the risk of non-target embolisation. Nevertheless,
laparoscopic uterine artery ligation is a surgical procedure that
carries the risks of laparoscopy and anaesthesia [62, 63].
A randomised trial comparing UAE versus Laparoscopic
uterine artery occlusion for symptomatic myomas (n = 14)
concluded that that the cumulative clinical failure and recur-
rence rate were significantly lower for patients treated with
UAE compared to those treated with laparoscopy [64].
Vaginal Uterine Artery Ligation
Vaginal bilateral uterine artery ligation involves occlusion of
the uterine artery at the lateral vaginal fornices at the lateral
uterine borders using a vaginal clamp. The pulsations of the
uterine arteries are identified using a Doppler ultrasound. A
check hysteroscopy is performed prior to commencing the
procedure. The procedure can be performed under a general
or regional anaesthetic, and the clamp is left in situ for 6 h.
This results in uterine and myoma ischemia [65, 66].
The procedure is not recommended in women with a desire
for future fertility and is contraindicated in women with a
history of venous thromboembolism, an intrauterine device,
pessaries or intravaginal devices and pelvic infection [65, 66].
Evidence suggests that heavy menstrual bleeding may re-
duce by 51% with marginal benefits on myoma and uterine
size at the end of 6 months. Most studies report few or no
complications associated with the technique [67, 68].
Laparoscopic Thermomyolysis
Laparoscopic thermomyolysis (or myolysis) is a procedure
where a bipolar electrocautery, unipolar cautery or laser is
used to coagulate the fibroid. One observational study report-
ed favourable results in terms of symptom control and fibroid
size at 6-months post procedure. However, this procedure is
associated with a marked degree of adhesion formation and
uterine rupture has been reported [69, 70].
Laparoscopic Cryomyolysis
Ultrasound-assisted laparoscopic cryomyolysis involves in-
sertion of a cryoprobe into the fibroid, using gas under pres-
sure (liquid nitrogen) to freeze the fibroid tissue. Ultrasound
monitoring limits damage to surrounding tissue during the
procedure. The cryoprobe reaches temperatures of < 90 °C,
creating a 3.5–5-cm cryozone destroying the fibroid tissue
with subsequent sclerohyaline degeneration. Evidence does
suggest a beneficial effect on fibroid size and symptom con-
trol; however, the limited number of studies precludes the
routine use of this technique [71, 72].
Excisional Management of Fibroids
Myomectomy
Myomectomy is a surgical technique that involves myoma
removal in women who desire fertility and/or uterine preser-
vation. It may be performed endoscopically (hysteroscopic,
laparoscopic, robotic) or as an open procedure. Cochrane
(2014) suggests that laparoscopic myomectomy is associated
with lower postoperative pain scores, a shorter hospital stay
and no difference in leiomyoma recurrence risk [73]. Both
laparoscopic and robotic myomectomies are associated with
lower estimated blood loss and fewer transfusions than open
myomectomies [74].

Various techniques have been used to minimise blood loss
during a myomectomy with some authors, suggesting the pre-
operative use of GnRH analogues for 3–6 months [75] and
even the use of UAE [76]. There have been concerns
highlighted with the use of GnRH analogues and subsequent
myoma degeneration with loss of the cleavage plane for my-
oma enucleation [16], but current evidence supports their use
preoperatively. The use of GnRH analogues prior to myomec-
tomy is associated with a reduction in intraoperative bleeding,
improvement in anaemia, reduction in fibroid size and de-
creased operative time [75]. Cochrane (2014) suggests at pres-
ent that there is moderate-quality evidence that misoprostol or
vasopressin may reduce bleeding during myomectomy and
low-quality evidence that bupivacaine plus epinephrine,
tranexamic acid, gelatin-thrombin matrix, ascorbic acid,
dinoprostone, loop ligation, a fibrin sealant patch, a
pericervical tourniquet or a tourniquet tied round both cervix
and infundibulopelvic ligament may reduce bleeding during
myomectomy. There is no evidence that oxytocin,
morcellation and temporary clipping of the uterine artery re-
duce blood loss. Further well-designed studies are required to
establish the effectiveness, safety and costs of different inter-
ventions for reducing blood loss during myomectomy [77].
The evidence regarding reproductive outcomes and open
versus laparoscopic myomectomy is conflicting, with some
studies suggesting no difference [73], while others suggesting
that laparoscopic surgery is associated with higher conception
rates due less adhesion formation postoperatively [78]. A re-
cent meta-analysis compared robotic-assisted laparoscopic
myomectomy (RALM) versus laparoscopic myomectomy
(LM) and abdominal myomectomy (AM) for treatment of
uterine fibroids [79]. The meta-analysis included 20 studies
involving 2852 patients. The number of complications [odd
ratio (OR) 0.52, p = 0.009], estimated blood loss (EBL)
[weighted mean difference (WMD) − 33.03, p = 0.02], con-
versions (OR 0.34, p = 0.03), and postoperative bleeding (OR
0.18, p = 0.03) in RALM cases was significantly less than that
for LM. The numbers of complications (OR 0.56, p = 0.03),
length of hospital stay (WMD − 1.74, p < 0.00001), EBL
(WMD − 77.74, p < 0.00001) and numbers of transfusions
(OR 0.25, p < 0.0001) were significantly decreased, and the
operative time (WMD 84.88, p < 0.00001) was significantly
prolonged in RALM cases when compared to AM cases.
Compared with LM and AM, RALM was associated with
significantly fewer complications, significantly lower EBL,
significantly fewer conversions than both LM and AM and
significantly less bleeding than LM.
Another issue surrounding the use of laparoscopic myo-
mectomy is that of morcellation and/or specimen retrieval
given the risk of malignant dissemination with intraperitoneal
power morcellation of leiomyosarcoma. The US FDA issued
guidance in 2014 which was December 2017 to address these
issues [80]. The new paper suggests the risk of an occult
Curr Obstet Gynecol Rep
uterine sarcoma using a random effects model of 1 in 225 to
1 in 580 women. For leiyomyosarcomas, the risk is estimated
to be 1 in 495 to 1 in 1100, which are consistent with the
findings of the FDA in 2014. The report suggests that the
percentage of women undergoing open abdominal procedures
is higher than prior to 2014. Data from the Sentinel System
also showed a reduction in the use of laparoscopic power
morcellators (LPMs) and suggest a “flattening” of the rates
for laparoscopic procedures (which had been increasing) and
open procedures (which had been decreasing). Despite chang-
es in routes of surgery, data on rates of complications also
varied, with several noting no significant changes in perioper-
ative complications. FDA continues to caution against the use
of LPMs in the majority of women undergoing myomectomy
or hysterectomy for treatment of fibroids. The agency also
continues to recommend that the advantages and risks of using
LPMs during fibroid surgery be thoroughly discussed be-
tween the patient and physician before surgery. A recent pub-
lication addresses these issues and the current US FDA rec-
ommendations [81].
Several techniques have been with used with LMPs for
tissue containment. However, the PneumoLiner is the first
and only power morcellation containment device specifically
designed for intraabdominal insufflation for select
gynaecological procedures and has been US FDA approved
since 2016 [82].
Hysteroscopic myomectomy for types 0 and I fibroids is a
low-risk procedure with a quick recovery when classified
using the FIGO classification [83, 84]. Type 2 fibroids and
fibroids greater than 3 cm increase the risk of incomplete
resection, often requiring a two-stage procedure.
Electrosurgical resection and newer morcellator devices
have similar outcomes [85]. Different hysteroscopic tissue
retrieval systems (HTRs) are commercially available:
Truclear 8.0 (Medtronic, Minneapolis, Minnesota),
Truclear 5C (Medtronic, Minneapolis, Minnesota) and
MyoSure (Hologic, Marlborough, Massachusetts). A recent
systematic review [86] compared the use of these devices
and concluded good performance of HTRs when used to
treat type 0 and type 1 submucous myomas (SMs) and a
more difficult procedure for type 2 SMs. There are indi-
vidual studies that support the use of HTRs as a one-step
procedure in type 2 SM [87]. The systematic review also
concluded that HTRs were safe and did not increase the
complication rate and postoperative adhesions. Several
studies reported a significant reduction of operative time
using HTRs, which may allow a consequent reduction of
fluid deficit and avoid its overload. Finally, the medium-
term follow-up seemed to show good results after HTRs
use, especially in terms of patient’s satisfaction [86].
Symptomatic relief is seen between 75 and 89% of
women. Pre-treatment with GnRH agonists has also
been found to reduce operative time and thus reduce
Curr Obstet Gynecol Rep
the risk of hyponatremia due to fluid overload. Risk of
intrauterine synechiae with hysteroscopic myomectomy
has varied in the literature from 0% to almost 50%.
Reproductive outcomes appear to be good with reduc-
tions in miscarriage rates and increased live birth rates
in retrospective studies; however, no randomised control
trials have been undertaken to confirm a benefit [88].
Hysterectomy
Hysterectomy offers definitive treatment of fibroid-
related symptoms and guarantees no recurrence of dis-
ease, but at the expense of future fertility and therefore
can only be considered in those women who have com-
pleted their family. The route chosen to perform hyster-
ectomy for benign disease needs individualisation, given
fibroid/uterine volume and available surgical expertise.
AAGL (Elevating Gynecologic Surgery) suggests that
vaginal or laparoscopic hysterectomy should be offered
in the first instance for women with benign uterine dis-
ease, and the abdominal route should be reserved when
neither the laparoscopic nor vaginal route is feasible.
AAGL suggests the laparoscopic route may not be suitable
in women with significant cardiopulmonary disease where
risks of a general anaesthetic and raised intraabdominal
pressure are deemed unacceptable and where morcellation
is known or likely to be required and uterine malignancy
is either known or suspected [89].
Uteri > 12 weeks size or 280 g in weight are consid-
ered large and have been considered as a relative con-
traindication to laparoscopic hysterectomy limited visi-
bility and access to uterine vascular associated with the
high risk of complications such as haemorrhage, bowel
and urinary tract injury, difficulty in extracting the uter-
us and extended duration of the procedure as well as
conversion to laparotomy [90]. However, current evi-
dence suggests that size of the uterus should not be a
contraindication to using the laparoscopic route [91–93].
A study of 514 patients comparing the vaginal route
versus the laparoscopic route for uteri ≥ 500g concluded
that the laparoscopic route results in lower blood loss
and a lower incidence of perioperative complications,
compared with a vaginal hysterectomy when using a
bipolar vessel sealing system [94].
Conclusion
Fibroids represent a common heterogeneous condition
that range from being diagnosed incidentally to causing
debilitating symptoms with a profound effect on the
quality of life for women and an economic health bur-
den. Many treatments offer short-term benefits that can
help women reach menopause. It seems sensible to start
with conservative (medical) measures; however, for
women with large fibroids, often a non-excisional or
surgical solution is needed. The technique chosen will
depend upon local expertise as well as patient prefer-
ence, especially the need for uterine/fertility preserva-
tion, following a detailed discussion regarding risks
and benefits.
Compliance with Ethical Standards
Conflict of Interest Rohan Chodankar and Jennifer Allison declare no
conflict of interest.
Human and Animal Rights and Informed Consent This article does not
contain any studies with human or animal subjects performed by any of
the authors.
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