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
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).
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).
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.)