Gynecology_Novak

Gynecology_Novak. The presence of submucous fibroids decreases fertility rates and removing them increases fertility rates. Subserosal fibroids do not affect fertility rates but removing them does increase fertility. Intramural fibroids may slightly decrease fertility, but removal does not increase fertility (66). A meta-analysis of the effect of fibroids on fertility and the effect of myomectomy on fertility found that submucous fibroids that distort the uterine cavity appear to decrease fertility, with ongoing pregnancy/live birth rates decreased by about 70% (relative risk [RR] 0.32; 95% confidence interval [CI], 0.12–0.85) (66). Resection of submucous fibroids slightly increased fertility relative to infertile controls without fibroids (ongoing pregnancy/live birth rate, RR 1.13; 95% CI, 0.96–1.33).


Gynecology_Novak

Gynecology_Novak. Analysis of studies that routinely used hysteroscopy to confirm clear nondistortion of the cavity by intramural fibroids found ongoing pregnancy/live birth rates were not significantly different compared to controls (RR 0.73; 95% CI, 0.38–1.40) (66). Importantly, removal of intramural or subserosal fibroids did not improve ongoing pregnancy/live birth rates (RR 1.67; 95% CI, 0.75–3.72). Myomectomy may involve operative and anesthetic risks, risks of infection or postoperative adhesions, a slight risk of uterine rupture during pregnancy, an increased likelihood that a cesarean section will be recommended for delivery, and the expense of surgery and time for recovery. Therefore, until intramural fibroids are shown to decrease and myomectomy to increase fertility rates, surgery should be undertaken with reluctance (66). Randomized studies are needed to clarify the relative risks and benefits of surgical intervention.


Gynecology_Novak

Gynecology_Novak. Figure 15.3 MR images. A: Degenerating fibroid. Left to right. Preenhanced T1 image, T2 image, and no enhancement on T1 Gd-DPTA at 60 seconds. B: Leiomyosarcoma. Left to right, preenhanced T1 image, T2 image (arrow to dorsal part of tumor), and enhancement of dorsal part of tumor (arrow) on T1 Gd-DPTA at 60 seconds. (From Goto A, Takeuchi S, Sugimura K, et al. Usefulness of Gd-DTPA contrast-enhanced dynamic MRI and serum determination of LDH and its isozymes in the differential diagnosis of leiomyosarcoma from degenerated leiomyoma of the uterus. Int J Gynecol Cancer 2002;12:354–361.) women had no increase in fibroid volume throughout pregnancy (69). In the 31% of women noted to have an increase in volume, the greatest increase occurred before the 10th week of gestation. There was no relationship between initial fibroid volume and fibroid growth during gestational periods. A reduction in fibroid size toward baseline measurements was observed 4 weeks after delivery.


Gynecology_Novak

Gynecology_Novak. In women noted to have fibroids during pregnancy, clinical symptoms and sonographic evidence of fibroid degeneration occurs in about 5% (70). Among 113 women followed during pregnancy with serial sonography, 10 (9%) developed anechoic spaces or coarse heterogenous patterns consistent with fibroid degeneration. Seven of 10 women had severe abdominal pain requiring hospitalization, consistent with clinical symptoms of degeneration. No sonographic changes were noted in the other 103 women, and only 11.7% had similar abdominal pain. A small study of women with fibroid-associated pain during pregnancy found use of ibuprofen shortened the hospital stay and decreased the rate of readmission (71). Inﬂuence of Fibroids on Pregnancy Very rarely does the presence of a fibroid during pregnancy lead to an unfavorable outcome.


Gynecology_Novak

Gynecology_Novak. Inﬂuence of Fibroids on Pregnancy Very rarely does the presence of a fibroid during pregnancy lead to an unfavorable outcome. Research was conducted on large populations of pregnant women examined with routine second trimester sonography with follow-up care and delivery at the same institution (72,73). In a study of 12,600 pregnant women, the outcomes of 167 women with fibroids were no different with regard to the incidence of preterm delivery, premature rupture of membranes, fetal growth restriction, placenta previa, placental abruption, postpartum hemorrhage, or retained placenta (72). Cesarean section was more common among women with fibroids (23% vs. 12%).


Gynecology_Novak

Gynecology_Novak. The other study of 15,104 pregnancies, including 401 women with fibroids, found no increased risk of premature rupture of membranes, operative vaginal delivery, chorioamnionitis, or endometritis (73). However, there were increased risks of preterm delivery (19.2% vs. 12.7%), placenta previa (3.5% vs. 1.8%), and postpartum hemorrhage (8.3% vs. 2.9%). Cesarean section was again more common (49.1% vs. 21.4%). Fetal injury attributed to mechanical compression by fibroids is uncommon. A search of the PubMed database from 1980 to 2010 revealed one case of fetal head anomalies with fetal growth restriction, one case of a postural deformity, one case of a limb reduction, and one case of fetal head deformation with torticollis (74–75).


Gynecology_Novak

Gynecology_Novak. Any decision to perform a myomectomy in order to prevent problems during pregnancy should take into account the risks of surgery, anesthesia, postoperative adhesions, and an increased likelihood of subsequent cesarean delivery, along with concerns about discomfort, expense, and time away from work or family. Rupture of Myomectomy Scar during Pregnancy Following abdominal myomectomy, uterine rupture during pregnancy appears to be a rare event. Two studies comprising 236,454 deliveries reported 209 instances of uterine rupture, with only 4 cases attributable to prior myomectomy (78,79). Because the number of women who had a previous myomectomy was not known, the incidence of rupture in these studies could not be determined. However, a retrospective study of 412 women who had abdominal myomectomies reported only one woman with uterine rupture (0.2%) (80).


Gynecology_Novak

Gynecology_Novak. Operative techniques, instruments, and energy sources used during laparoscopic myomectomy may differ from those employed during laparotomy. A study of 19 published and unpublished cases of uterine rupture during pregnancy following laparoscopic myomectomy found that almost all cases involved deviations from standard surgical technique as described for abdominal myomectomy (81). In seven cases, the uterine defect was not repaired; in three cases it was repaired with a single suture; in four cases it was repaired with only one layer of suture; and in one case only the serosa was closed. In only three cases was a multilayered closure employed. In 16 of the cases, monopolar or bipolar energy was used for hemostasis.


Gynecology_Novak

Gynecology_Novak. Although definite conclusions and recommendations regarding appropriate technique for laparoscopic myomectomy must await proper study of myometrial wound healing, it appears prudent for surgeons to adhere to time-tested techniques developed for abdominal myomectomy, including multilayered closure of myometrium (for other than superficial uterine defects) and limited use of electro-surgery for hemostasis. Yet, even with ideal surgical technique, individual wound healing characteristics may predispose to uterine rupture.


Gynecology_Novak

Gynecology_Novak. The development of new treatments for fibroids is slow, perhaps because many women with fibroids are asymptomatic, fibroids are benign, and mortality is very low (82). If offered hysterectomy as a first, and sometimes only, treatment option, some women choose to accommodate to symptoms and stop seeking treatment. This may lead physicians to underestimate the true impact of the condition, despite the fact that women who have hysterectomies as a result of fibroid-related symptoms have significantly worse scores on SF-36 quality-of-life questionnaires than women diagnosed with hypertension, heart disease, chronic lung disease, or arthritis (44).


Gynecology_Novak

Gynecology_Novak. After an exhaustive review of the medical literature published between 1975 and 2000, with evaluation of 637 relevant articles and careful study of 200 articles, the authors found no satisfactory answers to fundamental question about fibroid treatments (83). Women and their physicians need information on which to base decisions regarding possible treatments. This section summarizes the literature regarding the management of fibroids. Treatment options include observation, medical therapy, hysteroscopic myomectomy, laparoscopic myomectomy, hysterectomy, uterine artery embolization, and focused ultrasound.


Gynecology_Novak

Gynecology_Novak. Watchful Waiting Not having treatment for fibroids rarely results in harm, except for women with severe anemia from fibroid-related menorrhagia or hydronephrosis from ureteric obstruction from an massively enlarged fibroid uterus. Predicting future fibroid growth or onset of new symptoms is not possible (84). During observation, the average fibroid volume increases 9% per year with a range of −25% to +138% (84). A nonrandomized study of women with uterine size 8 weeks or greater who chose watchful waiting found that 77% of women had no significant changes in the self-reported amount of bleeding, pain, or degree of bothersome symptoms at the end of 1 year (85). Furthermore, mental health, general health, and activity indexes were also unchanged. Of the 106 women who initially chose watchful waiting, 23% opted for hysterectomy during the course of the year.


Gynecology_Novak

Gynecology_Novak. Therefore, for women who are mildly or moderately symptomatic with fibroids, watchful waiting may allow treatment to be deferred, perhaps indefinitely. As women approach menopause, watchful waiting may be considered, because there is limited time to develop new symptoms and after menopause, bleeding stops and fibroids decrease in size (19). Although not specifically studied, the incidence of hysterectomy for fibroids declines considerably after menopause, suggesting that there is a significant decline in symptoms. Nonsteroidal anti-inﬂammatory drugs (NSAIDs) were not shown to be effective for the treatment of menorrhagia in women with fibroids. A placebo-controlled, double-blind study of 25 women with menorrhagia, 11 of whom also had fibroids, found a 36% decrease in blood loss among women with idiopathic menorrhagia, but no decrease in women with fibroids. No other studies examined this treatment (86).


Gynecology_Novak

Gynecology_Novak. Treatment with GnRH-a decreases uterine volume, fibroid volume, and bleeding. However, the benefits of GnRH-a are limited by side effects and risks associated with long-term use (87,88). Monthly GnRH-a given for 6 months reduced fibroid volume by 30% and total uterine volume by 35% (87). Reduction in uterine size occurs mostly within the first 3 months of treatment (88). Menorrhagia responds well to GnRH-a; 37 of 38 women had resolution by 6 months. Following discontinuation of GnRH-a, menses returns in 4 to 8 weeks and uterine size returns to pretreatment levels within 4 to 6 months (89). In this study 64% of women remained asymptomatic 8 to 12 months after treatment.


Gynecology_Novak

Gynecology_Novak. Side effects occur in 95% of women treated with GnRH-a (89). Seventy-eight percent experience hot ﬂushes, 32% vaginal dryness, and 55% have transient frontal headaches. However, during 6 months of treatment only 8% of women discontinued GnRH-a because of the side effects. Arthralgia, myalgia, insomnia, edema, emotional lability, depression, and decreased libido are reported. The hypoestrogenic state induced by GnRH-a causes significant bone loss after 6 months of therapy (90). In an effort to reduce side effects, inhibit bone loss, and allow longer-term use of GnRH-a, low doses of estrogen and progestins may be added while continuing GnRH-a. However, a study of long-term use of GnRH-a over 6 years found a wide range of reduction in bone density among women and no difference in bone loss between groups given estrogen and progestin versus those treated with GnRH-a alone (91). Gonadotropin-Releasing Hormone Agonist as Temporary Treatment for Perimenopausal Women


Gynecology_Novak

Gynecology_Novak. Gonadotropin-Releasing Hormone Agonist as Temporary Treatment for Perimenopausal Women Women in late perimenopause who are symptomatic from uterine fibroids may consider short-term use of GnRH-a. Thirty-four perimenopausal women with symptomatic fibroids were treated with GnRH-a for 6 months, 12 of whom required repeat treatment 6 months after discontinuation of the medication (92). Thirty-one women avoided surgery; 15 of the women went into natural menopause. Although not specifically studied, add-back therapy might be considered in this setting. Gonadotropin-Releasing The immediate suppression of endogenous GnRH by daily subcutaneous injection of the GnRH Hormone Antagonist antagonist ganirelix results in a 29% reduction in fibroid volume within 3 weeks (93). Treatment is accompanied by hypoestrogenic symptoms. When long-acting compounds are available, a GnRH antagonist might be considered for medical treatment prior to surgery.


Gynecology_Novak

Gynecology_Novak. The reduction in uterine size following treatment with the progesterone-blocking drug mifepristone is similar to that found with GnRH-a (94). A prospective, randomized, controlled trial of mifepristone treatment found a 48% decrease in mean uterine volume after 6 months (95). Mifepristone blocks progesterone, and the unopposed exposure of the endometrium to estrogen may lead to endometrial hyperplasia. A systematic review found endometrial hyperplasia in 10 of 36 (28%) women screened with endometrial biopsies (96).


Gynecology_Novak

Gynecology_Novak. The levonorgestrel-releasing intrauterine system (LNG-IUS) may be reasonable treatment for selected women with fibroid-associated menorrhagia. In women with fibroids, uterine size no larger than 12 weeks, and a normal uterine cavity, LNG-IUS substantially reduces menstrual bleeding (97). Twenty-two of 26 (85%) women with documented fibroid-related menorrhagia returned to normal bleeding within 3 months. By 12 months, 27 of 67 (40%) women had amenorrhea and 66 women had hemoglobin levels above 12 g/dL.


Gynecology_Novak

Gynecology_Novak. One study examined 32 women with at least one fibroid less than 5 cm in diameter and less than 50% of the tumor volume projecting into the endometrial cavity (type II) who had insertion of an LNG-IUS (98). After 12 months, mean estimated blood loss, measured by pictorial blood loss assessment, decreased from 392 to 37 mL with an associated increase in hemoglobin levels. There was no change in uterine volume over the course of the study. Some studies show that LNG-IUS expulsion rates are higher in women with fibroids than in women without fibroids (99).


Gynecology_Novak

Gynecology_Novak. A nonrandomized, nonblinded study compared fibroid growth in 37 women treated with Chinese medicine, body therapy, and guided imagery to 37 controls treated with nonsteroidal anti-inﬂammatory medications, progestins, or oral contraceptive pills (100). After 6 months, sonographic evaluation demonstrated that fibroids stopped growing or shrank in 22 of 37 (59%) women treated with Chinese medicine compared to 3 of 37 (8%) controls. Although symptoms responded equally well in both groups, satisfaction was higher in the Chinese medicine group. Participants actively sought alternative therapy, however, and assessment of satisfaction may reﬂect selection bias.


Gynecology_Novak

Gynecology_Novak. An uncontrolled study reported treatment of 110 women with fibroids smaller than 10 cm with the Chinese herbal medicine kuei-chih-fu-ling-wan for at least 12 weeks (101). Clinical and sonographic evaluation found complete resolution of fibroids in 19% of women, a decrease in size in 43%, no change in 34%, and an increase in 4%. Menorrhagia improved in 60 of 63 (95%) of women and dysmenorrhea improved in 48 of 51 (94%). Fifteen of the 110 (14%) women chose to have a hysterectomy during the 4 years of the study. Surgical treatment options currently include abdominal myomectomy, laparoscopic myomectomy, hysteroscopic myomectomy, endometrial ablation, and abdominal, vaginal, or laparoscopic hysterectomy.


Gynecology_Novak

Gynecology_Novak. Surgical treatment options currently include abdominal myomectomy, laparoscopic myomectomy, hysteroscopic myomectomy, endometrial ablation, and abdominal, vaginal, or laparoscopic hysterectomy. Serious medical conditions, such as severe anemia or ureteral obstruction, often need to be addressed surgically. Pain from fibroid degeneration is usually successfully treated with analgesics until symptoms resolve, but if severe the patient may opt for surgery. Torsion of a pedunculated subserosal fibroid may produce acute pain that requires surgical intervention. Surgical intervention may be indicated in women with fibroids associated with menorrhagia, pelvic pain or pressure, urinary frequency, or incontinence that compromises quality of life (102).


Gynecology_Novak

Gynecology_Novak. Abdominal myomectomy was long employed as a conservative treatment for uterine fibroids, and much of the literature predates the use of prospective, randomized controlled trials. Although myomectomy is stated to relieve symptoms in 80% of women, there is scant literature documenting its efficacy and many large series have not reported data for relief of symptoms following surgery (102–104). A prospective, nonrandomized study comparing myomectomy with uterine artery embolization did report that 75% of women in the myomectomy group had a significant decrease in symptom scores after 6 months (105).


Gynecology_Novak

Gynecology_Novak. Back pain may, on occasion, be related to the presence of fibroids, but other possible causes should be considered. Inability to evaluate the ovaries on pelvic examination is not an indication for surgery (106). There is no evidence that pelvic examination increases early detection or decreases the mortality related to ovarian cancer, and sonography can be used to evaluate the adnexa should symptoms develop.


Gynecology_Novak

Gynecology_Novak. Severe anemia can be rapidly corrected using recombinant forms of erythropoietin and iron supplementation. Erythropoietin alfa and epoetin are commonly used to increase preoperative hemoglobin concentrations in cardiac, orthopaedic, and neurologic surgery. A randomized study showed that use of epoetin 250 IU/kg (approximately 15,000 U) per week for 3 weeks prior to elective orthopaedic or cardiac surgery increased the hemoglobin concentrations by 1.6 g/dL and significantly reduced transfusion rates when compared to controls (107). No side effects were experienced. A prospective, nonrandomized study of epoetin given preoperatively found a significant increase in hemoglobin concentrations prior to, and following, gynecologic surgery (108). For best results, iron stores should be increased with supplemental iron. Vitamin C, 1,000 IU per day, increases iron absorption in the intestines.


Gynecology_Novak

Gynecology_Novak. GnRH-a may be used preoperatively to mitigate abnormal bleeding, with a resultant increase of hemoglobin concentration. Women with fibroids and initial mean hemoglobin concentrations of 10.2 g were randomized preoperatively to GnRH-a plus oral iron or placebo plus oral iron (109). After 12 weeks, 74% of the women treated with GnRH-a and iron had hemoglobins greater than 12 g compared with 46% of the women treated with iron alone. A Cochrane review found that women with fibroids treated preoperatively with 3 to 4 months of GnRH-a had improved preoperative hemoglobins (110). Although operative blood loss was less for abdominal myomectomy patients treated with GnRH, there was no significant difference in transfusion rates compared with untreated women.


Gynecology_Novak

Gynecology_Novak. Myomectomy should be considered a safe alternative to hysterectomy. Victor Bonney, an early advocate of abdominal myomectomy, stated in 1931 that “The restoration and maintenance of physiologic function is, or should be, the ultimate goal of surgical treatment.” Case-controlled studies suggest that there may be less risk of intraoperative injury with myomectomy when compared with hysterectomy (111). A retrospective review of 197 women who had myomectomies and 197 women who underwent hysterectomies with similar uterine size (14 versus 15 weeks) found operating times were longer in the myomectomy group (200 versus 175 minutes), but estimated blood loss was greater in the hysterectomy group (227 versus 484 mL) (111). The risks of hemorrhage, febrile morbidity, unintended surgical procedure, life-threatening events, and rehospitalization were no different between groups. However, 26 (13%) women in the hysterectomy group suffered complications, including 1 bladder injury, 1 ureteral


Gynecology_Novak

Gynecology_Novak. life-threatening events, and rehospitalization were no different between groups. However, 26 (13%) women in the hysterectomy group suffered complications, including 1 bladder injury, 1 ureteral injury, 3 bowel injuries, 8 women with ileus, and 6 women with pelvic abscesses. In contrast, complications occurred in 11 (5%) of the myomectomy patients, including 1 bladder injury, 2 women with reoperation for small bowel obstruction, and 6 women with ileus.


Gynecology_Novak

Gynecology_Novak. Myomectomy may be considered even for those women who have large uterine fibroids and wish to retain their uterus. A study of 91 women with uterine size larger than 16 cm (range 16– 36 cm) reported one bowel injury, one bladder injury, and one reoperation for bowel obstruction, but no women had conversion to hysterectomy (112). The cell saver, which is a devise used to collect blood intraoperatively and reinfuse, was used in 70 women, and only 7 required homologous blood transfusion. A retrospective cohort study compared 89 women having abdominal hysterectomy for fibroids (mean uterine size 15 cm) to abdominal myomectomy in 103 women (mean uterine size 12 cm) (113). Although selection bias was likely, the hysterectomy group suffered two ureteral, one bladder, one bowel, and one nerve injury and two reoperations for bowel obstruction, while there were no visceral injuries in the myomectomy group.


Gynecology_Novak

Gynecology_Novak. In carefully selected women, myomectomy may be safely accomplished at the time of cesarean section by experienced surgeons. One series reported 25 women with removal of 84 fibroids (2 to 10 cm) at the time of cesarean section without the need for cesarean hysterectomy (114). Estimated blood loss was 876 mL (range 400 to 1,700 mL) and five women required blood transfusion. Another study compared 111 women who had myomectomy at the time of cesarean section with 257 women with fibroids who were not subjected to myomectomy during cesarean section (115). Only one of the women in the myomectomy group required transfusion and none required hysterectomy or embolization. There were no differences in mean operative times, incidence of fever, or length of hospital stay between the two groups. Although the cases were likely selected carefully, the authors concluded that, in experienced hands, myomectomy might be safely performed in selected women during cesarean section.


Gynecology_Novak

Gynecology_Novak. Available surgical techniques allow safe removal of even large fibroids. Use of tourniquets or vasoconstrictive agents may be used to limit blood loss. Vasopressin, an antidiuretic hormone, causes constriction of smooth muscle in the walls of capillaries, small arterioles and venules. Synthetic vasopressin (Pitressin, Parke-Davis, NJ) decreases blood loss during myomectomy and in a prospective, randomized study was as effective as mechanical occlusion of the uterine and ovarian vessels (116,117). Rare cases of bradycardia and cardiovascular collapse were reported; intravascular injection should be carefully avoided and patients should be carefully monitored (118). The use of vasopressin to decrease blood loss during myomectomy is an off-label use of this drug.


Gynecology_Novak

Gynecology_Novak. Cell savers may be considered for use during myomectomy. Use of the cell saver avoids the risks of infection and transfusion reaction, the oxygen transport capacity of salvaged red blood cells is equal to or better than stored allogeneic red cells, and the survival of red blood cells appears to be at least as good as transfused allogeneic red cells (119). The device suctions blood from the operative field, mixes it with heparinized saline, and stores the blood in a canister. If the patient requires blood reinfusion, the stored blood is washed with saline, filtered, centrifuged to a hematocrit of approximately 50%, and given back to the patient intravenously. Consequently, the need for preoperative autologous blood donation or heterologous blood transfusion often can be avoided (120). In a study of 92 women who had myomectomy for uterine size greater than 16 cm the cell saver was used for 70 women with a mean volume of reinfused packed red blood cells of 355 mL (121).


Gynecology_Novak

Gynecology_Novak. The cost of using a cell saver compared with donation of autologous blood was not studied for abdominal myomectomy. However, economic models suggest it is cost effective (121). Most hospitals charge a minimal fee for having the cell saver available “on-call” and charge an additional fee if it is used. Assuming that most women who donate autologous blood prior to myomectomy do not require blood transfusion, availability of the cell saver should spare many women the time and expense of donating, storing, and processing autologous blood. For a cohort of women, the cost of using the cell saver should, therefore, be significantly lower than the cost of autologous blood.


Gynecology_Novak

Gynecology_Novak. When heavy bleeding is anticipated or if copious bleeding is encountered, ligation of both uterine arteries can be performed (122). Uterine artery embolization was used successfully to control bleeding at the time of, or following, myomectomy (123). Because the uterine arteries recanulate, future fertility should not be compromised. These techniques often obviate the need for hysterectomy. Uterine incisions can be made either vertically or transversely, because fibroids distort normal vascular architecture, making attempts to avoid the arcuate vessels impossible (124). However, Figure 15.4 Corrosion casting of fibroid vessels. careful planning and placement of uterine incisions can avoid inadvertent extension of the incision to the uterine cornua or ascending uterine vessels.


Gynecology_Novak

Gynecology_Novak. careful planning and placement of uterine incisions can avoid inadvertent extension of the incision to the uterine cornua or ascending uterine vessels. Based on vascular corrosion casting and examination by electron microscopy, fibroids are completely surrounded by a dense blood supply and no distinct vascular pedicle exists at the base of the fibroid (125) (Fig. 15.4). Extending the uterine incisions through the myometrium and entire pseudocapsule until the fibroid is clearly distinguished identifies a less vascular surgical plane, which is deeper than commonly recognized.


Gynecology_Novak

Gynecology_Novak. Limiting the number of uterine incisions has been suggested in order to reduce the risk of adhesions to the uterine serosa (126). However, in this manner tunnels must be created within the myometrium in order to extract distant fibroids, making hemostasis more difficult within these defects. Hemostasis is important in order to avoid adhesion formation, and fibrin, leucocytes, and platelets in the presence of erythrocytes leads to adhesion formation. If tunneling incisions are avoided and hemostasis secured immediately, the risk of adhesion formation should be lessened. Therefore, if incisions are made directly over the fibroids and only those fibroids that are easily accessed are removed, the defects can be promptly closed and hemostasis can be secured immediately (112). Multiple uterine incisions may be needed, but adhesion barriers may help limit adhesion formation (127).


Gynecology_Novak

Gynecology_Novak. Currently available instruments make laparoscopic myomectomy feasible, although the size and number of fibroids reasonably removed limits the wide application of this approach because of the technical difficulty of both the procedure and laparoscopic suturing (128). Although microprocessor-assisted myomectomy (robotic) may obviate some of these technical problems, the added cost and longer operating times associated with this approach must be considered (see Chapter 25). A systematic review of randomized controlled trials of laparoscopic versus open myomectomy included six studies with a total of 576 patients (129). Laparoscopic myomectomy was associated with longer operating times but reduced operative blood loss, less postoperative decline in hemoglobin levels, reduced postoperative pain, more patients fully recuperated at day 15, and fewer overall complications. Major complications, pregnancy rates, and new appearance of fibroids were comparable in the two groups.


Gynecology_Novak

Gynecology_Novak. Case series without controls show the feasibility of laparoscopic surgery in women with large fibroids. In a series of 144 women with mean fibroid diameter of 7.8 cm (range, 5 to 18 cm), only 2 women required conversion to laparotomy (130). In another series of 332 consecutive women undergoing laparoscopic myomectomy for symptomatic fibroids as large as 15 cm, only 3 women required conversion to laparotomy (131). Port placement should be based on the position and size of the fibroids to be removed (Fig. 15.5). Laparoscopic suturing may be more ergonomic if there are two ports on either the patient’s right side for right-handed surgeons or left side for left-handed surgeons; a 12-mm port about 2 cm medial to the iliac crest for suture access, and another 5-mm lateral port near the level of the umbilicus (132). A left upper quadrant approach may be used for initial access when uterine size is near or above the umbilicus (133).


Gynecology_Novak

Gynecology_Novak. Pitressin is injected into the fibroid. An incision is made directly over the fibroid and carried deeply until definite fibroid tissue and the avascular surgical plane is noted. Transverse incisions permit more ergonomic suturing. The fibroid is grasped with a tenaculum for traction and the plane between the myometrium and fibroid is dissected until the fibroid is free. Bleeding vessels in the myometrial defect are desiccated sparingly with bipolar electrosurgical paddles, taking care not to devascularize the myometrium and interfere with wound healing. Delayed absorbable sutures are placed in one, two, or three layers, as needed, adhering to accepted surgical technique at laparotomy. Morcellation of the fibroid with an electromechanical device is accomplished under direct vision. The pelvis and abdomen are irrigated, the ﬂuid suctioned, and an adhesion barrier may be placed.


Gynecology_Novak

Gynecology_Novak. A number of energy sources including bipolar electrosurgery, Nd:YAG laser and cryogenic probes were used under laparoscopic direction to reduce fibroid size by means of fibroid destruction and interference with local vascular supply (134). Although uterine and fibroid volumes decreased by approximately 50%, there were dense adhesions to the uterine serosa in 6 of 15 (53%) women undergoing subsequent laparoscopic evaluations for other reasons (135). Myolysis is not recommended for women who wish future fertility.


Gynecology_Novak

Gynecology_Novak. Adhesion formation after myomectomy is well documented (136). A Cochrane review found that Interceed reduced the incidence of adhesion formation, both de novo and reformation, at laparoscopy and laparotomy (137). Data were insufficient, however, to support its use to improve pregnancy rates. There was limited evidence of effectiveness of Seprafilm (Genzyme, Cambridge, MA) in preventing adhesion formation in a prospective study that randomized 127 women undergoing abdominal myomectomy to treatment or no treatment with Seprafilm (127). During second-look laparoscopy, women treated with Seprafilm had significantly fewer adhesions and lower adhesion severity scores than untreated women. This study and others find an increased incidence of adhesions with posterior uterine incisions compared to anterior incisions (138).


Gynecology_Novak

Gynecology_Novak. Submucous fibroids, sometimes associated with increased menstrual bleeding or infertility, often can be removed hysteroscopically. Classification of submucous fibroids is based on the degree of the fibroid within the cavity; class 0 fibroids are intracavitary; class I have 50% or more of the fibroid within the cavity; and class II have less than 50% of the fibroid within the cavity (60) (Fig. 15.6). A meta-analysis of the effect of fibroids on fertility found that submucous fibroids with distortion of the uterine cavity decreased ongoing pregnancy/live birth rates by 70% (RR 0.32; 95% CI, 0.12–0.850) and resection increased ongoing pregnancy/live birth rates (RR 1.13; 95% CI, 0.96–1.33) (66).


Gynecology_Novak

Gynecology_Novak. No meta-analysis of the association of submucous fibroids and abnormal uterine bleeding was performed. However, most studies show a reduction in bleeding following resection. Using pictorial assessment to estimate menstrual blood loss prior to and for 41 months following hysteroscopic resection of submucous fibroids, a significant decrease in bleeding was reported in 42 of 51 (82%) women with submucous pedunculated (type 0), 24 of 28 (86%) with sessile (type I), and 15 of 22 (68%) with intramural fibroids (type II) (140). A study of 285 consecutive women with menorrhagia or metrorrhagia who had hysteroscopic resection of submucous fibroid(s) found that additional surgery was required for 9.5% at 2 years, 10.8% at 5 years, and 26.7% at 8 years (141). Figure 15.5 Laparoscopic myomectomy. A. 7 cm. posterior intramural fibroid. B. Transverse incision through myometrium until fibroid reached. C. Traction on fibroid and counter-traction on myometrium to tease fibroid away from myometrium.


Gynecology_Novak

Gynecology_Novak. Figure 15.5 (Continued) D. Adherent attachments to myometrium are cut. E. Minimal use of bipolar electrosurgery to control larger vessels. F. Three layer suture close of myometrium. Figure 15.5 (Continued) G. Morcellator used to remove fibroid from abdominal cavity. H. Pelvis irrigated and suctioned. I. Adhesion barrier placed over uterine incision. Figure 15.6 Fibroid classification. (From Munro MG, Critchley HO, Broder MS, et al. FIGO Working Group on Menstrual Disorders. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet 2011;113:3–13)


Gynecology_Novak

Gynecology_Novak. Hysteroscopic resection of a submucous fibroid can be accomplished under visual control using a telescope and continuous ﬂow of distension ﬂuid through the uterine cavity. The electrosurgical working element uses monopolar or bipolar electrodes. Monopolar electrodes require nonconducting distending solution (sorbitol 5%, sorbitol 3% with mannitol 0.5%, or glycine 1.5%), while bipolar electrodes can be used with saline.


Gynecology_Novak

Gynecology_Novak. Cervical dilation is usually required prior to insertion of the hysteroscope. Cytotec may facilitate easier dilation (142). The cutting loop is passed beyond the fibroid and cutting activated only when the loop is moving toward the surgeon and in direct view. Fibroids should be resected down to the level of the surrounding myometrium and, if fertility is desired, care should be taken to avoid excessive thermal damage to normal myometrium. Often, the remaining portion of the fibroid will be expressed into the uterine cavity by uterine contractions, allowing further resection. Fragments of fibroid are removed from the cavity with a grasping forceps or by capturing the fragments with the loop and extracting the telescope. G0 and G1 fibroids up to about 5 cm may be resected hysteroscopically.


Gynecology_Novak

Gynecology_Novak. G2 fibroids require careful preoperative evaluation with saline-infusion sonography or MRI to gauge the thickness of normal myometrium between the fibroid and the serosa in order to assess the potential risk of uterine perforation with the loop electrode. The risk of perforation increases with deeper myometrial involvement of the fibroid (143). In some cases, repeat resection may be required after a few weeks, as the remaining portion of the fibroid is expressed into the uterine cavity by uterine contractions. Procedure-Specific Risks Cervical dilatation or insertion of the hysteroscope can cause uterine perforation, as can deep myometrial resection. Often the first sign of perforation is a rapid increase in the ﬂuid deficit. Careful inspection of the uterine cavity should be undertaken to look for brisk bleeding or bowel injury. If no injury is apparent, the procedure should be terminated and the patient should be


Gynecology_Novak

Gynecology_Novak. Endometrial Ablation for Abnormal Bleeding Associated with Fibroids observed and may be discharged if stable (144). If a perforation occurs during activation of the electrode, then laparoscopy should be performed to carefully inspect for bowel or bladder injury. Intravascular absorption of distending media is a potentially dangerous complication that can result in pulmonary edema, hyponatremia, heart failure, cerebral edema, and even death (145). Careful monitoring of the ﬂuid deficit is important and a ﬂuid deficit of 750 mL during surgery should serve as a warning sign, with planned termination of the procedure.


Gynecology_Novak

Gynecology_Novak. Many authors suggest termination of the procedure when the ﬂuid deficit exceeds 1,000 mL, although other guidelines suggest termination after introduction of 1,500 mL of a nonelectrolyte solution or 2,000 mL of an electrolyte solution (145). Electrolytes should be assessed and corrected if necessary and diuretics considered. Risk factors for ﬂuid overload include resection of fibroids with deep intramural extension or prolonged operating time. The use of normal saline combined with bipolar energy reduces the risk of hyponatremia, but a ﬂuid deficit over 1,500 mL can lead to cardiac overload (146).


Gynecology_Novak

Gynecology_Novak. In selected women not desiring future childbearing, endometrial ablation with or without hysteroscopic myomectomy may be efficacious. Pad counts following ablation with or without fibroid resection found that 48 of 51 (94%) women had resolution of abnormal bleeding after a mean follow-up of 2 years (range, 1 to 5 years) (147). A study of 62 women followed for an average of 29 months (range, 12 to 60 months) found that 74% of the women had hypomenorrhea or amenorrhea, and only 12% required a hysterectomy (148). Hydrothermal ablation was used to treat 22 women with known submucous fibroids up to 4 cm, with 91% reporting amenorrhea, hypomenorrhea, or eumenorrhea after a minimum of 12 months’ follow-up (149). In a study of 65 women with menometrorrhagia and type I or II submucous myomas up to 3 cm, after treatment with NovaSure endometrial ablation device (Hologic, Bedford, MA), normal bleeding or amenorrhea was observed in most women at 1 year (150). New Appearance of Fibroids


Gynecology_Novak

Gynecology_Novak. New Appearance of Fibroids Although new fibroids may sometimes develop following myomectomy, most women will not require additional treatment. If the first surgery is performed in the presence of a single fibroid, only 11% of women will need subsequent surgery (151). If multiple fibroids are removed during the initial surgery, only 26% will need subsequent surgery (mean follow-up 7.6 years). Individual fibroids, once removed, do not grow back. Fibroids detected after myomectomy, often referred to as “recurrence,” result either from failure to remove fibroids at the time of surgery or they are newly developed fibroids. Perhaps this circumstance is best designated “new appearance” of fibroids (152).


Gynecology_Novak

Gynecology_Novak. Sonography found that 29% of women had persistent fibroids 6 months after myomectomy (153). Additionally, the background formation of new fibroids in the general population should be considered. As previously noted, a hysterectomy study found fibroids in 77% of specimens from women who did not have a preoperative diagnosis of fibroids (4). Incomplete follow-up, insufficient length of follow-up, the use of either transabdominal or transvaginal sonography (with different sensitivity), detection of very small clinically insignificant fibroids, or use of calculations other than life-table analysis confound many studies of new fibroid appearance (154).


Gynecology_Novak

Gynecology_Novak. Clinical Follow-Up Self-reported diagnosis based on symptom questionnaires has reasonably good correlation with sonographic or pathologic confirmation of significant fibroids and may be the most appropriate method of gauging clinical evidence of new appearance (22). One study of 622 patients ages 22 to 44 at the time of surgery and followed over 14 years found the cumulative new appearance rate based on clinical examination and confirmed by ultrasound was 27% (155) (Fig. 15.7). An excellent review of life-table analysis studies found a cumulative risk of clinically significant new appearance of 10% 5 years after abdominal myomectomy (156). Figure 15.7 Overall 10-year new appearance after initial myomectomy. (From Candiani G, Fedele L, Parazzini F, et al. Risk of recurrence after myomectomy. Br J Obsete Gynecol 1991;98:385–389.)


Gynecology_Novak

Gynecology_Novak. Figure 15.7 Overall 10-year new appearance after initial myomectomy. (From Candiani G, Fedele L, Parazzini F, et al. Risk of recurrence after myomectomy. Br J Obsete Gynecol 1991;98:385–389.) Sonographic Follow-Up Routine ultrasound follow-up is sensitive but detects many clinically insignificant fibroids. One hundred forty-five women, mean age 38 (range, 21 to 52), were followed after abdominal myomectomy with clinical evaluation every 12 months and transvaginal sonography at 24 and 60 months (sooner, with clinical suspicion of new fibroids) (153). However, no lower size limit was used for the sonographic diagnosis of fibroids and, thus, the cumulative probability of new appearance was 51% at 5 years. A study of 40 women who had a normal sonogram 2 weeks following abdominal myomectomy found that the cumulative risk of sonographically detected new fibroids larger than 2 cm was 15% over 3 years (157).


Gynecology_Novak

Gynecology_Novak. Meaningful information for a woman considering treatment for her fibroids is the approximate risk of developing symptoms that would require yet additional treatment. A study of 125 women followed by symptoms and clinical examination after a first abdominal myomectomy found that a second surgery was required during the follow-up period (average 7.6 years) for 11% of women who had one fibroid removed initially and for 26% of women who had multiple fibroids removed (151). Crude rates of hysterectomy after myomectomy vary from 4% to 16% over 5 years (158,159). Gonadotropin-Releasing Preoperative treatment with GnRH-a decreases fibroid volume and may make smaller fibroids Hormone Agonists harder to identify during surgery. A randomized study found that 3 months following abdominal myomectomy, 5 (63%) of 8 women in the GnRH group had fibroids less than 1.5 cm detected sonographically, while only 2 of 16 (13%) untreated women had small fibroids detected (153).


Gynecology_Novak

Gynecology_Novak. New appearance of fibroids is not more common following laparoscopic myomectomy when compared with abdominal myomectomy. Eighty-one women randomized to either laparoscopic or abdominal myomectomy were followed with transvaginal sonography every 6 months for at least 40 months (160). Fibroids larger than 1 cm were detected in 27% of women following laparoscopic myomectomy compared to 23% in the abdominal myomectomy group, and no woman in either group required any further intervention. Uterine artery embolization (UAE) is an effective treatment for selected women with uterine fibroids. The effects of UAE on early ovarian failure, fertility and pregnancy are unclear.


Gynecology_Novak

Gynecology_Novak. Uterine artery embolization (UAE) is an effective treatment for selected women with uterine fibroids. The effects of UAE on early ovarian failure, fertility and pregnancy are unclear. Therefore, many interventional radiologists advise against the procedure for women considering future fertility. Appropriate candidates for UAE include women who have bothersome enough symptoms to warrant hysterectomy or myomectomy. Although extremely rare, complications of UAE may necessitate life-saving hysterectomy, and women who would not accept hysterectomy even for a life-threatening complication should not undergo UAE. Contraindications to treatment of fibroids with UAE include women with active genital infection, genital tract malignancy, diminished immune status, and severe vascular disease limiting access to the uterine arteries, contrast allergy, or impaired renal function (161).


Gynecology_Novak

Gynecology_Novak. UAE outcomes are well studied and documented. A validated fibroid-specific quality-of-life questionnaire was used to measure outcome data on UAE patients (162). The American College of Obstetricians and Gynecologists recommends that women considering UAE have a thorough evaluation with a gynecologist to help facilitate collaboration with the interventional radiologist and that responsibility of caring for the patient be clear (163). Percutaneous cannulation of the femoral artery is performed by a properly trained and experienced interventional radiologist (164) (Fig. 15.8). Embolization of the uterine artery and its branches is accomplished by injecting gelatin sponges, polyvinyl alcohol particles (PVA), or trisacryl gelatin microspheres via the catheter until occlusion, or slow ﬂow, is documented. Total radiation exposure (approximately 15 cGy) is comparable to one or two computed tomography scans or barium enemas (165).


Gynecology_Novak

Gynecology_Novak. Tissue hypoxia secondary to UAE causes postprocedural pain that usually requires pain management in the hospital for 1 day. NSAID medications are usually taken for 1 to 2 weeks, and many women return to normal activity within 1 to 3 weeks. Approximately 5% to 10% of women have pain for longer than 2 weeks (165). Ten percent of women require readmission to the hospital for postembolization syndrome, characterized by diffuse abdominal pain, nausea, vomiting, low-grade fever, malaise, anorexia, and leucocytosis. Treatment with intravenous ﬂuids, NSAID medications, and pain management usually leads to resolution of symptoms within 2 to 3 days (165). Persistent fever should be managed with antibiotics. Failure to respond to antibiotics may indicate sepsis, which needs to be aggressively managed with hysterectomy.


Gynecology_Novak

Gynecology_Novak. The largest prospective study reported to date includes 555 women ages 18 to 59 (mean, 43), 80% of whom had heavy bleeding, 75% had pelvic pain, 73% had urinary frequency or urgency, and 40% of women had required time off work due to fibroid-related symptoms (166). Telephone interviews 3 months after UAE found that menorrhagia improved in 83% of women, dysmenorrhea improved in 77%, and urinary frequency in 86%. Mean fibroid volume reduction of the dominant fibroid was 33% at 3 months, but improvement in menorrhagia was not related to preprocedural uterine volume (even >1,000 cm3) or to the degree of volume reduction obtained. Of note, two women (0.4%) had continued uterine growth and worsening pain and were found to have sarcomas. The hysterectomy rate due to complications was 1.5%. Within the follow-up period, 3% of women under 40, but 41% of women over 50, had amenorrhea.


Gynecology_Novak

Gynecology_Novak. A prospective, randomized trial comparing hysterectomy and UAE in 177 women with symptomatic fibroids found that major complications were rare (167). Hospital stay was significantly shorter for UAE (2 versus 5 days), but UAE was associated with more readmissions (9 versus 0) for pain and/or fever in the 6-week postoperative period. Significant complications included one woman who required resection of a submucous fibroid and one who had sepsis in the UAE group and one woman who had a vesico-vaginal fistula following hysterectomy. Figure 15.8 A–C: UAE techniques. A. A catheter is threaded to the uterine arteries and embolic material injected to block off blood ﬂow to the uterus.


Gynecology_Novak

Gynecology_Novak. Figure 15.8 A–C: UAE techniques. A. A catheter is threaded to the uterine arteries and embolic material injected to block off blood ﬂow to the uterus. Estimates suggest that more than 100,000 UAE procedures have been performed worldwide with 12 deaths Therefore, the estimated mortality rate of 1/10,000 compares well with the mortality rate of approximately 3/10,000 for a similar group of women under age 50 and without malignancy or compromised immunity undergoing hysterectomy (168). Early Ovarian Failure The risk of premature ovarian failure following UAE needs further study. Transient amenorrhea was reported in as many as 15% of women. Ovarian arterial perfusion as measured by Doppler sonography immediately following UAE shows that 35% of women had decreased ovarian perfusion and 54% had complete loss of perfusion (169). However, basal follicle-stimulating hormone (FSH) and antim¨ullerian hormone levels indicated decreased ovarian reserve in all women in one study (170).


Gynecology_Novak

Gynecology_Novak. Although normal FSH, estradiol, ovarian volume and antral follicle counts were documented in most women following UAE, these tests cannot predict earlier onset of menopause (171). Figure 15.8 (Continued) B. Contrast dye shows the vessels supplying the fibroid prior to UAE. C. Following UAE, embolic material blocks blood ﬂow to the fibroid. Younger women, whose ovaries contain a large number of follicles, are likely to maintain a normal FSH despite destruction of a significant number of follicles, but it is not clear if future fertility will be impaired. Loss of follicles might cause menopause at an age earlier than would otherwise be expected. Long-term follow-up of women having UAE will be necessary to answer this important question.


Gynecology_Novak

Gynecology_Novak. Alternative methods of uterine artery occlusion were developed, both more and less invasive than UAE, including laparoscopic uterine artery occlusion and nonincisional transvaginal uterine artery occlusion. Fifty-eight patients were randomized to UAE or laparoscopic uterine artery occlusion (177). After a median follow-up time of 48 months clinical failures and symptom recurrence occurred in 14 women after laparoscopy (48%) and in five women after UAE (17%). Laparoscopic occlusion requires general anesthesia, is invasive, and requires a skilled laparoscopic surgeon. Transvaginal occlusion is performed by placing a specially designed clamp in the vaginal fornices and, guided by Doppler ultrasound auditory signals, is positioned to occlude the uterine arteries (178). The clamp is left in place for 6 hours and then removed. Results of this approach are not yet known.


Gynecology_Novak

Gynecology_Novak. Ultrasound energy can be focused to create sufficient heat at a focal point so that protein is denatured and cell death occurs. Concurrent MRI allows precise targeting of tissue and monitoring of therapy by assessing the temperature of treated tissue (179). The advantages of this procedure are a very low morbidity and a very rapid recovery, with return to normal activity in one day. The procedure is not recommended for women wishing future fertility (179). Initial studies had treatment limited by the U.S. Food and Drug Administration to approximately 10% of fibroid volume, and while a 15% reduction in fibroid size was reported 6 months following treatment, only a 4% reduction was noted at 24 months (180). More recent studies with larger treatment areas reported better results; 6 months after treatment, the average volume reduction was 31% (+/−28%) (181).


Gynecology_Novak

Gynecology_Novak. An evaluation of clinical outcomes 6 months after treatment found that 71% of women had significant symptom reduction, but at 12 months about 50% still had significant symptom reduction (180). Twenty-three of 82 (28%) evaluable patients had undergone subsequent hysterectomy, myomectomy, or UAE. Women actively sought out magnetic resonance–guided focused ultrasound (MRgFUS), and no control group (sham MRgFUS) was included, so a placebo effect cannot be ruled out. One woman had a sciatic nerve injury caused by ultrasound energy and 5% had superficial skin burns. It remains to be seen whether increased treatment volumes will be associated with increased risks. As the technology continues to develop, further studies will be needed to evaluate the risks and efficacy of MRgFUS in the treatment of uterine fibroids.


Gynecology_Novak

Gynecology_Novak. A woman’s individual circumstance, including fibroid-related symptoms and their effect on quality of life, desire (or not) to preserve fertility, and her wishes regarding treatment options should be considered when discussing possible treatments. Multiple treatment options usually exist and the following points might be considered. For an asymptomatic woman diagnosed with fibroids who desires fertility in the near future, evaluation of the uterine cavity with saline infusion sonography, hysteroscopy, or MRI provides useful information regarding the presence of submucous fibroids and their potential impact on fertility. If the cavity is not deformed, fibroids need not be treated and conception may be attempted. If the cavity is deformed, myomectomy (hysteroscopic or abdominal) can be considered. An experienced laparoscopic surgeon may offer laparoscopic myomectomy, with a multilayered myometrial closure.


Gynecology_Novak

Gynecology_Novak. For an asymptomatic woman who does not desire future fertility, observation (watchful waiting) should be considered. A periodic review of the patient’s symptoms and a pelvic examination to evaluate uterine size should be accomplished. In the presence of very large fibroids, renal ultrasound or computed tomography urogram can be considered to rule out significant hydronephrosis. For a symptomatic woman who desires future fertility and her primary symptom is abnormal bleeding, baseline hemoglobin measurement should be considered because accommodation to anemia can occur. If indicated, further evaluation of the endometrium with endometrial biopsy can be performed. Evaluation of the uterine cavity with saline-infusion sonography, hysteroscopy, or MRI can help determine the appropriate treatment options. If the cavity is deformed, myomectomy (hysteroscopic or abdominal) should be considered.


Gynecology_Novak

Gynecology_Novak. If the cavity is deformed, myomectomy (hysteroscopic or abdominal) should be considered. An experienced laparoscopic surgeon may offer laparoscopic myomectomy. If the symptoms of pain or pressure (bulk symptoms) are present, and if the uterine cavity is not deformed, myomectomy (abdominal or laparoscopic) can be considered.


Gynecology_Novak

Gynecology_Novak. For a symptomatic woman who does not desire future fertility, observation (watchful waiting) can be considered if no treatment is desired at that time. A symptomatic perimenopausal woman may desire observation until she enters menopause, when symptoms often diminish. Baseline hemoglobin measurements should be obtained and if a significant anemia exists, then treatment should be considered. If metrorrhagia is present, evaluation of the endometrium with sonography or endometrial biopsy should be considered. If the endometrium is normal, a levonorgestrel-IUS or endometrial ablation may be appropriate treatment. Myomectomy (hysteroscopic, abdominal, or laparoscopic), hysterectomy (vaginal, laparoscopic, or abdominal), or uterine artery embolization can be considered.


Gynecology_Novak

Gynecology_Novak. For a woman with primarily fibroid-related pain or pressure symptoms (bulk symptoms), myomectomy, hysterectomy, and uterine artery embolization or focused ultrasound (presently limited by size and number of fibroids) may be considered. 1. Whiteman MK, Hillis SD, Jamieson DJ, et al. Inpatient hysterectomy surveillance in the United States, 2000–2004. Am J Obstet Gynecol 2008;198:34.e1–34.e7. 2. Myers E, Barber M, Couchman G, et al. Management of uterine fibroids. AHRQ Evidence Reports Volume 1, Number 34. 2001. http://www.ncbi.nlm.nih.gov/books/NBK33649/#A48853 3. Leppert PC, Catherino WH, Segars JH. A new hypothesis about the origin of uterine fibroids based on gene expression profiling with microarrays. Am J Obstet Gynecol 2006;195:415–420. 4. Cramer SF, Patel A. The frequency of uterine leiomyomas. Am J Clin Pathol 1990;94:435–438. 5.


Gynecology_Novak

Gynecology_Novak. 4. Cramer SF, Patel A. The frequency of uterine leiomyomas. Am J Clin Pathol 1990;94:435–438. 5. Day Baird D, Dunson DB, Hill MC, et al. High cumulative incidence of uterine leiomyoma in black and white women: ultrasound evidence. Am J Obstet Gynecol 2003;188:100–107. 6. Flake GP, Andersen J, Dixon D. Etiology and pathogenesis of uterine leiomyomas: a review. Environ Health Perspect 2003;111:1037–1054. 7. Hashimoto K, Azuma C, Kamiura S, et al. Clonal determination of uterine leiomyomas by analyzing differential inactivation of the X-chromosome-linked phosphoglycerokinase gene. Gynecol Obstet Invest 1995;40:204–208. 8. Ligon AH, Morton CC. Genetics of uterine leiomyomata. Genes Chromosomes Cancer 2000;28:235–245. 9. Lee EJ, Kong G, Lee SH, et al. Profiling of differentially expressed genes in human uterine leiomyomas. Int J Gynecol Cancer 2005;15:146–154. 10.


Gynecology_Novak

Gynecology_Novak. 9. Lee EJ, Kong G, Lee SH, et al. Profiling of differentially expressed genes in human uterine leiomyomas. Int J Gynecol Cancer 2005;15:146–154. 10. Ferenczy A, Richart RM, Okagaki T. A comparative ultrastructural study of leiomyosarcoma, cellular leiomyoma, and leiomyoma of the uterus. Cancer 1971;28:1004–1018. 11. Quade BJ, Wang TY, Sornberger K, et al. Molecular pathogenesis of uterine smooth muscle tumors from transcriptional profiling. Genes Chromosomes Cancer 2004;40:97–108. 12. Cook JD, Walker CL. Treatment strategies for uterine leiomyoma: the role of hormonal modulation. Semin Reprod Med 2004;22:105– 111. 13. Englund K, Blanck A, Gustavsson I, et al. Sex steroid receptors in human myometrium and fibroids: changes during the menstrual cycle and gonadotropin-releasing hormone treatment. J Clin Endocrinol Metab 1998;83:4092–4096. 14.


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Gynecology_Novak. 14. Nisolle M, Gillerot S, Casanas-Roux F, et al. Immunohistochemical study of the proliferation index, oestrogen receptors and progesterone receptors A and B in leiomyomata and normal myometrium during the menstrual cycle and under gonadotrophinreleasing hormone agonist therapy. Hum Reprod 1999;14:2844– 50. 15. Kawaguchi K, Fujii S, Konishi I, et al. Mitotic activity in uterine leiomyomas during the menstrual cycle. Am J Obstet Gynecol 1989;160:637–641. 16. Ishikawa H, Ishi K, Serna VA, et al. Progesterone is essential for maintenance and growth of uterine leiomyoma. Endocrinology. 2010;151:2433–2442. 17. Peddada SD, Laughlin SK, Miner K, et al. Growth of uterine leiomyomata among premenopausal black and white women. Proc Natl Acad SciU S A 2008;105:19887–19892. 18. Marshall LM, Spiegelman D, Goldman MB, et al. A prospective study of reproductive factors and oral contraceptive use in relation to the risk of uterine leiomyomata. Fertil Steril 1998;70:432–439. 19.


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Gynecology_Novak. 19. Cramer SF, Marchetti C, Freedman J, et al. Relationship of myoma cell size and menopausal status in small uterine leiomyomas. Arch Pathol Lab Med 2000;124:1448–1453. 20. Vikhlyaeva EM, Khodzhaeva ZS, Fantschenko ND. Familial predisposition to uterine leiomyomas. Int J Gynaecol Obstet 1995;51:127– 131. 21. Treloar SA, Martin NG, Dennerstein L, et al. Pathways to hysterectomy: insights from longitudinal twin research. Am J Obstet Gynecol 1992;167:82–88. 22. Marshall LM, Spiegelman D, Barbieri RL, et al. Variation in the incidence of uterine leiomyoma among premenopausal women by age and race. Obstet Gynecol 1997;90:967–973. 23. Kjerulff KH, Langenberg P, Seidman JD, et al. Uterine leiomyomas. Racial differences in severity, symptoms and age at diagnosis. J Reprod Med 1996;41:483–490. 24. Ross RK, Pike MC, Vessey MP, et al. Risk factors for uterine fibroids: reduced risk associated with oral contraceptives. BMJ (Clin Res Ed) 1986;293:359–362. 25.


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Gynecology_Novak. 24. Ross RK, Pike MC, Vessey MP, et al. Risk factors for uterine fibroids: reduced risk associated with oral contraceptives. BMJ (Clin Res Ed) 1986;293:359–362. 25. Shikora SA, Niloff JM, Bistrian BR, et al. Relationship between obesity and uterine leiomyomata. Nutrition 1991;7:251–255. 26. Chiaffarino F, Parazzini F, La Vecchia C, et al. Diet and uterine myomas. Obstet Gynecol 1999;94:395–398. 27. Baird D, Dunson D, Hill M, et al. Association of physical activity with development of uterine leiomyoma. Am J Epidemiol 2007;165:157–163. 28. Parazzini F, Negri E, La Vecchia C, et al. Oral contraceptive use and risk of uterine fibroids. Obstet Gynecol 1992;79:430–433. 29. Samadi AR, Lee NC, Flanders WD, et al. Risk factors for self-reported uterine fibroids: a case-control study. Am J Public Health 1996;86:858–862. 30. Ratner H. Risk factors for uterine fibroids: reduced risk associated with oral contraceptives. BMJ 1986;293:1027. 31.


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Gynecology_Novak. 30. Ratner H. Risk factors for uterine fibroids: reduced risk associated with oral contraceptives. BMJ 1986;293:1027. 31. Orsini G, Laricchia L, Fanelli M. Low-dose combination oral contraceptives use in women with uterine leiomyomas. Minerva Ginecol 2002;54:253–261. 32. Palomba S, Sena T, Morelli M, et al. Effect of different doses of progestin on uterine leiomyomas in postmenopausal women. Eur J Obstet Gynecol Reprod Biol 2002;102:199–201. 33. Yang CH, Lee JN, Hsu SC, et al. Effect of hormone replacement therapy on uterine fibroids in postmenopausal women—a 3-year study. Maturitas 2002;43:35–39. 34. Reed SD, Cushing-Haugen KL, Daling JR, et al. Postmenopausal estrogen and progestogen therapy and the risk of uterine leiomyomas. Menopause 2004;11:214–222. 35. Parazzini F, Negri E, La Vecchia C, et al. Reproductive factors and risk of uterine fibroids. Epidemiology 1996;7:440–442. 36.


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Gynecology_Novak. 35. Parazzini F, Negri E, La Vecchia C, et al. Reproductive factors and risk of uterine fibroids. Epidemiology 1996;7:440–442. 36. Lumbiganon P, Rugpao S, Phandhu-fung S, et al. Protective effect of depot-medroxyprogesterone acetate on surgically treated uterine leiomyomas: a multicentre case-control study. Br J Obstet Gynaecol 1996;103:909–914. 37. Baird DD, Dunson DB. Why is parity protective for uterine fibroids? Epidemiology 2003;14:247–250. 38. Cesen-Cummings K, Houston KD, Copland JA, et al. Uterine leiomyomas express myometrial contractile-associated proteins involved in pregnancy-related hormone signaling. J Soc Gynecol Investig 2003;10:11–20. 39. Burbank F. Childbirth and myoma treatment by uterine artery occlusion: do they share a common biology? J Am Assoc Gynecol Laparosc 2004;11:138–152. 40. Barbieri RL, McShane PM, Ryan KJ. Constituents of cigarette smoke inhibit human granulosa cell aromatase. Fertil Steril 1986;46:232–236. 41.


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Gynecology_Novak. 40. Barbieri RL, McShane PM, Ryan KJ. Constituents of cigarette smoke inhibit human granulosa cell aromatase. Fertil Steril 1986;46:232–236. 41. Michnovicz JJ, Hershcopf RJ, Naganuma H, et al. Increased 2hydroxylation of estradiol as a possible mechanism for the antiestrogenic effect of cigarette smoking. N Engl J Med 1986;315:1305– 1309. 42. Daniel M, Martin AD, Drinkwater DT. Cigarette smoking, steroid hormones, and bone mineral density in young women. Calcif Tissue Int 1992;50:300–305. 43. Cramer SF, Mann L, Calianese E, et al. Association of seedling myomas with myometrial hyperplasia. Hum Pathol 2009;40:218–225. 44. Rowe MK, Kanouse DE, Mittman BS, et al. Quality of life among women undergoing hysterectomies. Obstet Gynecol 1999;93:915– 921. 45. Davis BJ, Haneke KE, Miner K, et al. The fibroid growth study: determinants of therapeutic intervention. J Womens Health (Larchmt) 2009;18:725–732. 46.


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Gynecology_Novak. 45. Davis BJ, Haneke KE, Miner K, et al. The fibroid growth study: determinants of therapeutic intervention. J Womens Health (Larchmt) 2009;18:725–732. 46. Munro MG, Lukes AS. Abnormal uterine bleeding and underlying hemostatic disorders: report of a consensus process. Fertil Steril 2005;84:1335–1337. 47. Marino JL, Eskenazi B, Warner M, et al. Uterine leiomyoma and menstrual cycle characteristics in a population-based cohort study. Hum Reprod 2004;19:2350–2355. 48. Wegienka G, Baird DD, Hertz-Picciotto I, et al. Self-reported heavy bleeding associated with uterine leiomyomata. Obstet Gynecol 2003;101:431–437. 49. Lippman SA, Warner M, Samuels S, et al. Uterine fibroids and gynecologic pain symptoms in a population-based study. Fertil Steril 2003;80:1488–1494. 50. Murase E, Siegelman ES, Outwater EK, et al. Uterine leiomyomas: histopathologic features, MR imaging findings, differential diagnosis, and treatment. Radiographics 1999;19:1179–1197. 51.


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Gynecology_Novak. 50. Murase E, Siegelman ES, Outwater EK, et al. Uterine leiomyomas: histopathologic features, MR imaging findings, differential diagnosis, and treatment. Radiographics 1999;19:1179–1197. 51. Gaym A, Tilahun S. Torsion of pedunculated subserous myoma–a rare cause of acute abdomen. Ethiop Med J 2007;45:203–207. 52. Pron G, Bennett J, Common A, et al. The Ontario Uterine Fibroid Embolization Trial. Part 2. Uterine fibroid reduction and symptom relief after uterine artery embolization for fibroids. Fertil Steril 2003;79:120–127. 53. Langer R, Golan A, Neuman M, et al. The effect of large uterine fibroids on urinary bladder function and symptoms. Am J Obstet Gynecol 1990;163:1139–1141. 54. Parker W, Fu Y, Berek J. Uterine sarcoma in patients operated on for presumed leiomyoma and rapidly growing leiomyoma. Obstet Gynecol 1994;83:414–418. 55. Boutselis J, Ullery J. Sarcoma of the uterus. Obstet Gynecol 1962;20:23–35. 56.


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Gynecology_Novak. Agarwala N, Liu CY. Safe entry techniques during laparoscopy: left upper quadrant entry using the ninth intercostal space–a review of 918 procedures. J Minim Invasive Gynecol 2005;12:55–61. 134. Zupi E, Marconi D, Sbracia M, et al. Directed laparoscopic cryomyolysis for symptomatic leiomyomata: one-year follow up. J Minim Invasive Gynecol 2005;12:343–346. 135. Donnez J, Squifﬂet J, Polet R, et al. Laparoscopic myolysis. Hum Reprod Update 2000;6:609–613. 136. Dubuisson JB, Fauconnier A, Chapron C, et al. Second look after laparoscopic myomectomy. Hum Reprod 1998;13:2102–2106. 137. Farquhar C, Vandekerckhove P, Watson A, et al. Barrier agents for preventing adhesions after surgery for subfertility. Cochrane Database Syst Rev 2000;2:CD000475. 138. Tulandi T, Murray C, Guralnick M. Adhesion formation and reproductive outcome after myomectomy and second-look laparoscopy. Obstet Gynecol 1993;82:213–215. 139.


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Gynecology_Novak. 142. Darwish AM, Ahmad AM, Mohammad AM. Cervical priming prior to operative hysteroscopy: a randomized comparison of laminaria versus misoprostol. Hum Reprod 2004;19:2391–2394. 143. Murakami T, Hayasaka S, Terada Y, et al. Predicting outcome of one-step total hysteroscopic resection of sessile submucous myoma. J Minim Invasive Gynecol 2008;15:74–77. 144. Indman PD. Hysteroscopic treatment of submucous myomas. Clin Obstet Gynecol 2006;49:811–820. 145. Loffer FD, Bradley LD, Brill AI, et al. Hysteroscopic ﬂuid monitoring guidelines. The ad hoc committee on hysteroscopic training guidelines of the American Association of Gynecologic Laparoscopists. J Am Assoc Gynecol Laparosc 2000;7:167–168. 146. Murakami T, Tamura M, Ozawa Y, et al. Safe techniques in surgery for hysteroscopic myomectomy. J Obstet Gynaecol Res 2005;31:216– 223. 147. Indman PD. Hysteroscopic treatment of menorrhagia associated with uterine leiomyomas. Obstet Gynecol 1993;81:716–720. 148.


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Gynecology_Novak. Malone L. Myomectomy: recurrence after removal of solitary and multiple myomas. Obstet Gynecol 1969;34:200–203. 152. Parker WH. Uterine myomas: management. Fertil Steril 2007;88:255–271. 153. Fedele L, Parazzini F, Luchini L, et al. Recurrence of fibroids after myomectomy: a transvaginal ultrasonographic study. Hum Reprod 1995;10:1795–1796. 154. Olive DL. Review of the evidence for treatment of leiomyomata. Environ Health Perspect 2000;108(Suppl 5):841–843. 155. Candiani GB, Fedele L, Parazzini F, et al. Risk of recurrence after myomectomy. Br J Obstet Gynaecol 1991;98:385–389. 156. Fauconnier A, Chapron C, Babaki-Fard K, et al. Recurrence of leiomyomata after myomectomy. Hum Reprod Update 2000;6:595– 602. 157. Vavala V, Lanzone A, Monaco A, et al. Postoperative GnRH analog treatment for the prevention of recurrences of uterine myomas after myomectomy. A pilot study. Gynecol Obstet Invest 1997;43:251– 254. 158.


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Gynecology_Novak. 164. Spies JB, Sacks D. Credentials for uterine artery embolization. J Vasc Interv Radiol 2004;15:111–113. 165. Zupi E, Pocek M, Dauri M, et al. Selective uterine artery embolization in the management of uterine myomas. Fertil Steril 2003;79:107– 111. 166. Pron G, Cohen M, Soucie J, et al. The Ontario Uterine Fibroid Embolization Trial. Part 1. Baseline patient characteristics, fibroid burden, and impact on life. Fertil Steril 2003;79:112–119. 167. Hehenkamp WJ, Volkers NA, Donderwinkel PF, et al. Uterine artery embolization versus hysterectomy in the treatment of symptomatic uterine fibroids (EMMY trial): peri-and postprocedural results from a randomized controlled trial. Am J Obstet Gynecol 2005;193:1618–1629. 168. Agency for Healthcare Research and Quality. National inpatient sample of the HCUP database of the Agency for HealthCare Research and Quality. http://hcupnet.ahrq.gov/HCUPnet.jsp 169.


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Gynecology_Novak. 168. Agency for Healthcare Research and Quality. National inpatient sample of the HCUP database of the Agency for HealthCare Research and Quality. http://hcupnet.ahrq.gov/HCUPnet.jsp 169. Ryu RK, Chrisman HB, Omary RA, et al. The vascular impact of uterine artery embolization: prospective sonographic assessment of ovarian arterial circulation. J Vasc Interv Radiol 2001;12:1071–1074. 170. Hehenkamp WJ, Volkers NA, Broekmans FJ, et al. Loss of ovarian reserve after uterine artery embolization: a randomized comparison with hysterectomy. Hum Reprod 2007;22:1996–2005. 171. Tropeano G, Di Stasi C, Litwicka K, et al. Uterine artery embolization for fibroids does not have adverse effects on ovarian reserve in regularly cycling women younger than 40 years. Fertil Steril 2004;81:1055–1061. 172. Tulandi T, Salamah K. Fertility and uterine artery embolization. Obstet Gynecol 2010;115:857–860. 173.


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Gynecology_Novak. 172. Tulandi T, Salamah K. Fertility and uterine artery embolization. Obstet Gynecol 2010;115:857–860. 173. Mara M, Maskova J, Fucikova Z, et al. Midterm clinical and first reproductive results of a randomized controlled trial comparing uterine fibroid embolization and myomectomy. Cardiovasc Intervent Radiol 2008;31:73–85. 174. Goldberg J, Pereira L, Berghella V, et al. Pregnancy outcomes after treatment for fibromyomata: uterine artery embolization versus laparoscopic myomectomy. Am J Obstet Gynecol 2004;191:18–21. 175. Pron G, Mocarski E, Bennett J, et al. Pregnancy after uterine artery embolization for leiomyomata: the Ontario multicenter trial. Obstet Gynecol 2005;105:67–76. 176. Godfrey CD, Zbella EA. Uterine necrosis after uterine artery embolization for leiomyoma. Obstet Gynecol 2001;98:950– 952. 177.


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Gynecology_Novak. 176. Godfrey CD, Zbella EA. Uterine necrosis after uterine artery embolization for leiomyoma. Obstet Gynecol 2001;98:950– 952. 177. Hald K, Noreng HJ, Istre O, et al. Uterine artery embolization versus laparoscopic occlusion of uterine arteries for leiomyomas: longterm results of a randomized comparative trial. J Vasc Interv Radiol 2009;20:1303–1310. 178. Vilos GA, Vilos EC, Romano W, et al. Temporary uterine artery occlusion for treatment of menorrhagia and uterine fibroids using an incisionless Doppler-guided transvaginal clamp: case report. Hum Reprod 2006;21:269–271. 179. Stewart EA, Gedroyc WM, Tempany CM, et al. Focused ultrasound treatment of uterine fibroid tumors: safety and feasibility of a noninvasive thermoablative technique. Am J Obstet Gynecol 2003;189:48– 54. 180. Stewart EA, Rabinovici J, Tempany CM, et al. Clinical outcomes of focused ultrasound surgery for the treatment of uterine fibroids. Fertil Steril 2006;85:22–29. 181.


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Gynecology_Novak. 180. Stewart EA, Rabinovici J, Tempany CM, et al. Clinical outcomes of focused ultrasound surgery for the treatment of uterine fibroids. Fertil Steril 2006;85:22–29. 181. LeBlang SD, Hoctor K, Steinberg FL. Leiomyoma shrinkage after MRI-guided focused ultrasound treatment: report of 80 patients. AJR Am J Roentgenol 2010;194:274–280. Andrea J. Rapkin Leena Nathan Acute pelvic pain is rapid in onset, often associated with unstable vital signs and obvious abnormalities on physical examination and laboratory assessment. Improper diagnosis can result in significant morbidity and even mortality. Timely and thorough assessment, guided by organ system (reproductive, gastrointestinal, urinary) and category of pathology will ensure effective diagnosis and management of infection, obstruction, ischemia (torsion), leakage of irritating substance (viscus or cyst rupture), neoplasia, or pregnancy-related pain.


Gynecology_Novak

Gynecology_Novak. Chronic pelvic pain is a multifaceted disorder characterized by changes in the processing of afferent signaling in the pelvic organs, the surrounding somatic tissues, and the spinal cord and brain. The shared thoracolumbar and sacral innervations of the pelvic structures and the up-regulation processing of neural input in the central nervous system account for the multiplicity of somatic and psychological symptoms experienced by women with chronic pelvic pain. A thorough history and physical examination are important for successful management of both chronic and acute pain. The ancillary laboratory and diagnostic procedures performed to assess acute, life-threatening processes differ from those focused on chronic pain conditions. Chronic pelvic pain requires a multidisciplinary approach for both diagnosis and management.


Gynecology_Novak

Gynecology_Novak. Acute pain is intense and characterized by sudden onset, sharp rise, and short course. Cyclic pain refers to pain that occurs with a definite association to the menstrual period. Dysmenorrhea, or painful menstruation, is the most common cyclic pain phenomenon and is classified as primary or secondary on the basis of associated anatomic pathology (1). Chronic pelvic pain is defined as pain of greater than 6 months in duration, localized to the anatomic pelvis, and severe enough to cause functional disability or necessitating medical care (2).


Gynecology_Novak

Gynecology_Novak. Whereas acute pain is generally associated with autonomic reﬂex responses, such as nausea, emesis, diaphoresis, and apprehension, such autonomic reﬂex responses are not present in women with chronic pelvic pain. Acute pain is affiliated with signs of inﬂammation or infection, such as fever and leukocytosis, which are absent in chronic pain states. The pathophysiology of acute pelvic pain involves mediators of inﬂammation present in high concentration as a result of infection, ischemia, or chemical irritation.


Gynecology_Novak

Gynecology_Novak. By contrast, the etiology of chronic pelvic pain often involves changes in modulation or “upregulation” of normally nonpainful stimuli. Pain is out of proportion to the degree of tissue damage (3). Chronic pain is thus characterized by physiologic, affective, and behavioral responses that differ from those associated with acute pain (4). An inﬂammatory lesion, such as endometriosis, for example, can set up an environment of chronic neurogenic inﬂammation or stimulation, which can result in “plastic” changes in the peripheral and central nervous system and the persistence of chronic pain (5–7). Moreover, genetic predisposition, adverse environmental pressures, and hormonal milieu are thought to increase the vulnerability and predisposition for chronic pain disorders (8).


Gynecology_Novak

Gynecology_Novak. The differential diagnosis of acute pelvic pain is outlined in Table 16.1. Assessing the character of the pain helps create a differential diagnosis. Rapid onset of pain is most consistent with perforation or rupture of a hollow viscus or ischemia following the torsion of a vascular pedicle. Colic or severe cramping pain is commonly associated with muscular contraction or obstruction of a hollow viscus, such as intestine, ureter, or uterus. Pain perceived over the entire abdomen suggests a generalized reaction to an irritating ﬂuid within the peritoneal cavity such as blood, purulent ﬂuid, or contents of an ovarian cyst.


Gynecology_Novak

Gynecology_Novak. The first perception of visceral pain is a vague, deep, poorly localizable sensation associated with autonomic reﬂex responses. When the pain becomes localized to a region of the abdominal wall, the pain is called referred pain. Referred pain is well localized and more superficial and is appreciated within the nerve distribution or dermatome of the spinal cord segment innervating the involved viscus. The location of the referred pain provides insight into the location of the primary disease process (9). The innervations of the pelvic organs are outlined in Table 16.2. The upper vagina, cervix, uterus, and adnexa share the same visceral innervations with the large intestine, rectum, bladder, lower ureter, and lower small intestine. Pain from the reproductive organs, genitourinary (GU), and gastrointestinal (GI) tracts are therefore referred to the same dermatomes (10,11). Evaluation of Acute Pelvic Pain


Gynecology_Novak

Gynecology_Novak. In the evaluation of acute pelvic pain, early diagnosis is critical because significant delay increases morbidity and mortality. Central to correct diagnosis is an accurate history. The date and character of the last and previous menstrual periods and the presence of abnormal bleeding or discharge should be ascertained. The menstrual, sexual, and contraceptive history and any history of sexually transmitted conditions and previous gynecologic disorders are relevant. Pain history should include how and when the pain started, pregnancy-related symptoms (amenorrhea, irregular bleeding, nausea, breast tenderness), GI symptoms (anorexia, nausea, vomiting, constipation, obstipation, absence of ﬂatus, hematochezia), urinary symptoms (dysuria, urgency frequency, hesitancy, hematuria), signs of infection (fever, chills, purulent vaginal discharge), and symptoms attributable to a hemoperitoneum (orthostasis, abdominal distention, and right upper quadrant or shoulder pain). Document any past


Gynecology_Novak

Gynecology_Novak. infection (fever, chills, purulent vaginal discharge), and symptoms attributable to a hemoperitoneum (orthostasis, abdominal distention, and right upper quadrant or shoulder pain). Document any past medical and surgical history, and current medications.