Sonography is the most readily available and least costly imaging technique to differentiate fibroids from other pelvic pathology; however, MRI permits more precise evaluation of the number, size and position of fibroids and can better evaluate the proximity to the endometrial cavity.
The presence of submucosal fibroids decreases fertility and removing them can increase fertility; subserosal fibroids do not affect fertility and removing them does not increase fertility; and intramural fibroids may slightly decrease fertility, but removal does not increase fertility.
Most fibroids do not increase in size during pregnancy.
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.
Surgical treatment options include abdominal myomectomy, laparoscopic myomectomy, hysteroscopic myomectomy, endometrial ablation, and abdominal, vaginal, or laparoscopic hysterectomy.
An inability to evaluate the ovaries on pelvic examination is not an indication for surgery.
Myomectomy should be considered as a safe alternative to hysterectomy, even for those women who have large uterine fibroids and wish to retain their uterus.
Submucous fibroids, sometimes associated with increased menstrual bleeding or infertility, often can be removed hysteroscopically.
Routine ultrasound follow-up is sensitive, but may detect many clinically insignificant fibroids.
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.
Fibroids (leiomyomas, myomas) are an important health care concern because they are the most frequent indication for the performance of hysterectomy, accounting for nearly 240,000 such procedures in the United States (1). In comparison, approximately 30,000 myomectomies were performed that year. Inpatient surgery for fibroids costs $2.1 billion per year in the United States, and the cost of outpatient surgeries, medical and nonmedical costs, and time away from work or family add significantly to these expenditures (2).
Origins of Uterine Fibroids
Fibroids are benign, monoclonal tumors of the smooth muscle cells of the myometrium and contain large aggregations of extracellular matrix composed of collagen, elastin, fibronectin, and proteoglycan (3).
Incidence Fibroids are remarkably common. Fine serial sectioning of uteri from 100 consecutive women subjected to hysterectomy discovered fibroids in 77%, some as small as 2 mm (4). A random sampling of women ages 35 to 49, screened by self-report, medical record review, and sonography, found that among African American women by age 35 the incidence of fibroids was 60%, and it was over 80% by age 50 (Fig. 15.1). White women have an incidence of 40% at age 35 and almost 70% by age 50 (5).
Rate 0.004 0.0035 0.003 0.0025 0.002 0.0015 0.001 0.0005 0 White Black Hispanic
White Black Hispanic Hysterectomy rate 0.018 0.016 0.014 0.012 0.01 0.008 0.006 0.004 0.002 0
Figure 15.1 A: Age-and race-specific incidence of myomectomy, 1997, based on NIS and