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).
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).
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.
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).
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).