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).
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.
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.
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.