Medical and Surgical Management: of Uterine Leiomyomas

Jose Reyes Memorial Medical Center 5 May 2006
Updates
Medical and surgical management
of uterine leiomyomas
DELFIN A. TAN, M.D.
Department of Obstetrics and Gynecology

United Doctors Medical Center
Uterine leiomyomas: incidence varies
depending on method of diagnosis
Transvaginal 5.4% (95% CI 3-7.8%) in 335
ultrasound1 women aged 25 to 40 years
Postmortem 50% of women
examination2
Gross serial 73% (50/68) in
sectioning of premenopausal women
hysterectomy 84% (27/32) in
specimens3 postmenopausal women
1BorgfeldtC, Andolf E. Acta Obstet Gynecol Scand 2000;79:202. 2Thompson JD,
Rock JA, eds. Te Linde's Operative Gynecology, ed 7, London: JB Lippincott
Company, 1992. 3Cramer SF, Patel A. Am J Clin Pathol 1990;90:435.
Medical and surgical management of uterine leiomyomas 2
C – cervical
Uterine I – intramural
IC – intracavitary
leiomyomas P – pedunculated
PA – parasitic
SM – submucosal
SS – subserosal
Types
according to
location
Clark BM, Johnson JV.

Contemp OB/GYN 45:86, 2000
Uterine leiomyomas: symptomatology
Asymptomatic
Menorrhagia 30 %
Pelvic pain with or without 34

dysmenorrhea or
pressure symptoms
Infertility 27
Recurrent pregnancy loss 3
Buttram VC, Reiter RC. Fertil Steril 1981;6: 433. Lumsden MA, Wallace EM. Baillieres
Clin Obstet Gynaecol 1998;12:177. Valle RF. Am J Obstet Gynecol 1980;137:425.
Medical and surgical management of
uterine leiomyomas
Updates Part 1 Changing views on
pathogenesis
Part 2 Treatment approaches
Surgical
Medical
Embolization
Focused ultrasound
Part 3 Summary and conclusions
Tan D. 2006
Part 1
Changing views on
pathogenesis of
uterine leiomyomas
Tan D. 2006
Uterine myoma formation: Multistep
process
Myometrial
smooth
Abnormal
muscle cells
myometrial cells
Sensitivity to
Clonal expansion
Fibroid
Transformation due to:
 Genetic predisposition
 Hypoxia
 Environmental
exposure
Uterus
Stewart EA, Faur A. Contemp OB/GYN 45:26, 2000

Uterine myomas: Changing concepts
on pathogenesis
Traditional As a surgical disease
Non- As a medical disease
traditional Steroid-hormone responsive
neoplasms
Abnormal angiogenesis
Abnormal smooth muscle cell
proliferation
Genetic disease
Tan D. 2006
The vascular system of a myoma is the
important factor controlling development
and growth
Pre-existing blood
vessels regress
New vessels invade SEM of
intramural
tumor from periphery leiomyomata:
vascular system
Intense angiogenesis revealed by
promoted by tumor- corrosion
secreted growth casting. Note
multiple
factors myomata of
Formation of different sizes
(encircled) and
‘vascular capsule’ to avascular
supply growing tumor regions
Walocha JA, et al. Hum Reprod 2003;18:1088.

Part 2
Current
management
options for uterine
leiomyomas
Tan D. 2006
Uterine myoma: Current management
options
Surgical Hysterectomy Laparotomy,
laparoscopy, vaginal
Myomectomy Laparotomy,
laparoscopy,
laparoscopy-assisted,
vaginal, hysteroscopy
Myolysis Laparoscopy
Uterine artery Laparoscopy, vaginal
ligation
Tan D. 2006
options cont’d
Medical GnRH analogs Agonist,
antagonist
Progesterone Mifepristone (RU
antagonist 486), gestrinone,
asoprisnil (J867)
Antifibrotic agent Pirfenidone
Growth factor Interferon-,
blocker interferon-
Gene therapy Suicide gene
Others Danazol, tibolone,
raloxifene
Tan D. 2006
options cont’d
Embolization Uterine fibroid
embolization
(uterine artery
embolization)
Tan D. 2006
options cont’d
Focused Magnetic
ultrasound resonance
guided-focused
utrasound
surgery
Tan D. 2006
options cont’d
Laser ablation Magnetic resonance
guided-percutaneous
laser ablation under local
anesthesia1
Cryotherapy Magnetic resonance
guided-transvaginal
cryotherapy2
Magnetotherapy General magnetotherapy3
1Law P, et al. J Magn Reson Imaging 2000;12:565. 2Dohi M, et al. Radiat Med
2004;22:391. 3Kulishova TV, et al. Vopr Kurortol Fizioter Lech Fiz Kult 2005;1:26.
Management of uterine leiomyomas
Surgical options

Abdominal hysterectomy
Classic definitive treatment for women who
have completed childbearing
ST, 49, years, menorrhagia, multiple submucous, intramural, and

subserous myomas
Tan D. 2004
Vaginal hysterectomy
Transvaginal
morcellation
by hemisection
begins at
cervix (A),
myomata (B,C)
are grasped
and
enucleated.
Completely
divided
uterine
specimen
shown (D)
Pelosi MA, Pelosi III MA. Contemporary OB/GYN 42:107, 1997

Laparoscopy-assisted vaginal
hysterectomy
A B
LT, 34, G5P2, ab 4, pelvic pain

Laparoscopic views before (A) and after (B) surgery
Tan D. 2004
Ovarian conservation at the time of
hysterectomy for benign disease
Study Markov decision analysis model to estimate
optimal strategy for maximizing survival for
women at average risk of ovarian cancer
Based on published data for absolute and
relative risk for ovarian cancer, coronary
heart disease, hip fracture, breast cancer,
and stroke
Results Excess mortality by age 80
Oophorectomy before age 55 8.58 %
Oophorectomy before age 59 3.92
Oophorectomy before age 75 <1.0
Parker WH, et al. Obstet Gynecol 2005;106:214.
Ovarian conservation at the time of
hysterectomy for benign disease cont’d
Conclusions 1 Oophorectomy in women <65
years increased risk of mortality
from coronary heart disease and
risk of hip fracture; these risks
outweighed any benefits due to
oophorectomy
3 No reduction in long-term
mortality when oophorectomy was
performed before age 65
4 Hysterectomy itself reduces the
risk of ovarian cancer
Ovarian conservation until age 65
benefits long-term survival for
women undergoing hysterectomy for
benign disease.

Role of prophylactic oophorectomy in
ovarian cancer prevention
Family history of Prophylactic
ovarian cancer oophorectomy
Positive With hereditary Indicated after
cancer childbearing or at
syndromes 35-40
No hereditary Patient’s decision
cancer after properly
syndrome informed
Negative Not indicated
Tan D. 2006
Abdominal myomectomy
A B
Large multiple C D
leiomyomas in a
woman desirous of
uterine
conservation and
future pregnancies
Tan D. 2004.
Case study: Laparoscopic
myomectomy 1
VC, 29,
primary
infertility
Posterior wall
subserous
myoma, 11 cm
on ultrasound.
Had goserelin
depot 3
doses.
A. Myoma reduced to 6.6 cm

Tan D. 1995
myomectomy 2
B. Laparoscopy C. Further dissection

myomectomy started
Tan D. 1995
myomectomy 3
D. Hemostasis with bipolar E. Wound surface covered

cautery with surgicel
Tan D. 1995
myomectomy 4
F. Myoma morcellation
Outcome Had spontaneous abortion but second
pregnancy delivered by Cesarean section
27 months after myomectomy
Tan D. 1995
Laparoscopy-assisted myomectomy
Combined laparoscopy and
minilaparotomy for large myomas
Laparoscopy Treats associated pathology
Brings myoma to
minilaparotomy incision
Allows thorough cleansing
of pelvic cavity
Minilaparotomy Allows dissection and
morcellation of myomas
Facilitates proper repair of
uterine defect
Tan D. 2006
Case study: Laparoscopy-assisted
myomectomy 1
IC, 29,
primary
infertility for
2 years
Intramural
myoma, 9.7
cm. Goserelin
depot for 3
doses.
A. Myoma reduced to 6.2 cm

Case study: Laparoscopically-
assisted myomectomy 2
B. Bipolar cautery over C. Hysterotomy incision

incision site

D. Further dissection E. Bipolar cautery of

myoma base

F. Conventional repair of G. Laparoscopic view

hysterotomy

Outcome
Pregnancy on
fifth stimulation
cycle; delivered
by C-section.
Had second
pregnancy and
repeat section 2
years later.
H. Extensive pelvic irrigation
Tan D. 2000

Laparoscopy-assisted myomectomy
LH, 34 years, 1 abortion, 20 years subfertility
Presurgical Postsurgical
Laparoscopy view: cervical Laparoscopic view: pelvis

myoma, right intraligamentary restored to normal
myoma, normal left adnexal area
Tan D. 2004
Laparoscopy-assisted myomectomy and
hysteroscopy
A B
FA, 33, single. A. Multiple subserous,

intramural myomas. B. Type 2 submucous
myoma. C. After LAM
Tan D. 2004
Laparoscopic myolysis
A B
A. Bipolar coagulation needles (2 C

parallel 5 cm long needles)
B. Perfornation of myoma with
bipolar needles
C. Second-look laparoscopy at 6
months: radial pattern of
superficial blood vessels

How long does it take the uterus to
reach a stable state after myomectomy?
Study Time-dependent changes in uterine
structure* during the recovery process after
myomectomy evaluated by magnetic
resonance imaging
Results Stabilization of cavity length, 6 weeks
volume of uterus, and
myometrium
Stabilization of endometrium** 12 weeks
*Length of uterine cavity, uterine volume, recovery of junctional zone, prevalence of
modification of endometrium, and uterine structure in the region of enucleated
myoma. **If there are no hematoma or edema formation in the myometrium.
Tsuji S, et al. Gynecol Obstet Invest 2006;61:106.

Predictors of leiomyoma recurrence after
myomectomy
Study 145 cases of myomectomy by laparotomy
evaluated for recurrence by transvaginal
sonography
Results Myoma recurrence 62 %
5-year Number Single 11 P=.011
cumulative removed Multiple 74
rates
Intraoperative ≤10 weeks 46 P=.032
uterine size* >10 weeks 82
*Uterine size
associated Subsequent With 26 P=.010
with number
of myomas parity Without 76
removed (P
=.009) Subsequent major surgery 9%
Hanafi M. Obstet Gynecol 2005;105:877.
Submucous myomas
Conditions for hysteroscopic surgery
>50% of tumor protrudes
into cavity (type 2)
Tumor diameter is ≤5 cm
When tumor is >5cm,
GnRH agonist (goserelin or
leuprolide depot 3.75 mg every 28
given to
days for 2-3 doses)
reduce tumor volume
Gallinat A, Leuken RP. In Phillips JM, et al. Hysteroscopy Update, AAGL 1997
Submucosal myomas
Saline instillation sonography
A B
Transverse (A) and sagitall (B) images showing type 2 submucosal

myoma (≥50% of myoma protrudes into the endometrial cavity)
Wolanske KA, Gordon RL. Appl Radiol 2004;33:18.

Two-step hysteroscopic resection for
type 2 submucous myomas
Step 1 Pretreatment with
GnRH agonist for 8
weeks: partial
myomectomy
Step 2 GnRH agonist therapy
for 8 weeks: complete
myomectomy
Donnez J, et al: In Lunenfeld B, Insler V: GnRH Analogues - The State of the Art 1996.
Parthenon, Carnforth, 1996
Case study: Hysteroscopic
resection of submucous myoma 1
GG, 35, menorrhagia and infertility. Submucous
myoma 6 cm; goserelin depot for 2 doses.
A B
A. Submucous myoma, type 1, before (A) and after (B)

goserelin

B. Resection with loop C. Further resection

electrode

D. Cautery of base E. Resection to endometrial

line

Outcome
Had first
pregnancy and
delivered at term
15 months after
resection
F. Hemostasis with roller ball
Tan D. 2000
Case report Submucous myoma and infertility
CM, 27, complained of infertility and menorrhagia
Preoperative GnRH agonist therapy followed by

transcervical resection (hysteroscopic) of myoma.
Normal pregnancy after 3 cycles of controlled ovarian
hyperstimulation.
Cruz-Tordesillas RL. 2002

Multiple submucous myomas
RA, age 34,
infertility,
severe
menorrhagia
and anemia
Goserelin 3.6
mg depot for 3
monthly doses
Hysteroscopic
resection not
done,
hysterectomy
suggested
Tan D. 2002
Surgical occlusion of uterine artery
Laparoscopic application of
vascular clips1
Laparoscopic bipolar
coagulation2
Ultrasound-directed
transvaginal electrosurgical
Uterine artery isolated and
secured with endoclips occlusion3
1Lee PI, et al. J Am Assoc Gynecol Laparosc 6:S27, 1999. 2Liu WM. J Am Assoc
Gynecol Laparosc 7:125, 2000. 3Forcier N, et al. 11th Meeting, Society for Minimally
Invasive Therapy, Boston, 1999.
Collateral blood supply of the uterus
Fallopian
Tube
Ovary
Ovarian
Uterus artery
Cervix Uterine artery
Vagina Hypogastric
artery
Vaginal Vaginal
arteries arteries
When uterine artery is blocked, blood flow decreases by 42%, sufficient to

cause ischemic reduction of myomas. Ovarian and vaginal arteries supply
58% of blood flow to the uterus, thus preventing total ischemia.
www.laparoscopic.com
Medical options

Uterine myoma: Medical therapy of
choice
GnRH agonist Useful for preoperative
treatment
Not as sole treatment

because of rapid regrowth
after therapy
Speroff L, et al. Clinical Gynecologic Endocrinology and Infertility, ed 6,

Lippincott Williams & Wilkins, Baltimore, 1999
GnRH agonist: mode of action
GnRHa administered
Pituitary GnRH receptors occupied and internalized

gland
Initial LH and FSH surge
Loss of available GnRH receptors
Decreased LH and FSH synthesis and release
Ovaries Suppression of follicular development
Decreased estradiol synthesis and release
Conn PM, Crowley WF Jr: Ann Rev Med 45:391, 1994

GnRH agonists before hysterectomy
or myomectomy for fibroids
Cochrane review of 26 randomized trials
Results Reduced uterine volume and fibroid size
Improved hematologic indices
Reduced intraoperative blood loss and
operating time
Comments Not warranted for routine preoperative

use
Indicated for anemia or greatly enlarged
uterus
Lethaby A, et al. In: The Cochrane Library, Issue 3, 2003. Oxford: Update Software
Anemia due to uterine myomas
GnRH agonist and iron versus placebo and iron
in the anemic patient before surgery
GnRH agonist + oral iron Oral iron % patients who achieved Hb 12 g/dL
40 39.1 80 74
35.7
35 70
60
Mean hematocrit %
30 28.1 27.6
25 50 46
20 40
15 30
10 20
5 10
0 0
0 3 months GnRHa + oral iron Oral iron
Stovall TG, et al. Obstet Gynecol 86:65, 1995

Preoperative GnRH agonists for
submucous myoma necessary
Prior to Reduced facilitates
hysteroscopic tumor size excision
resection Endometrial improves
atrophy and visibility
less bleeding
Less less risk of
distention fluid
media absorption
Donnez J, et al: In Lunenfeld B, Insler V: GnRH Analogues - The State of the Art 1996.
Parthenon, Carnforth, 1996.
Myomas: Long term control with
intermittent GnRHa therapy
Study of 30 cases with abnormal bleeding or discomfort
Intervention 6-month course of leuprolide acetate, symptom
recurrence managed by repeated 6-month courses
Results Median of 9 months of symptom control (range, 2 to
>25 months) after each course
2.4% mean decrease in lumbar spine bone mineral
density; no change in hip BMD
Conclusions Intermittent courses of GnRH agonist can be used
for symptomatic myomas
BMD monitoring and antiresorptive add-back therapy
with repeated courses
Scialli AR, Levi AJ. Fertil Steril 2000;74:540.

GnRH antagonists: Mechanism of action
Action Pituitary-ovarian axis suppression
without flare effect
Compete with GnRH for its
receptors
Prevent synthesis and release of
GnRH antagonist LH/FSH
consensus model
Induce immediate and transient
hypogonadism
Suppress gonadal steroidogenesis
Loy RA: Curr Opin Obstet Gynecol 6:262, 1994

Myomas: Treatment with GnRH
antagonists
Compared to GnRH agonists
Effect Same levels of amenorrhea and
uterine shrinkage
Advantages No initial increase in estrogen
and less likely to cause
estrogen-withdrawal bleed
Rapid shrinkage over ~2 weeks
Kettel LM, et al. Fertil Steril 60:642, 1993. Felberbaum RE, et al. Hum Reprod 13:1660,
1998
Treatment of uterine fibroids with cetrorelix
RCT 20 patients, symptomatic fibroids, for surgery
On cycle day 2, cetrorelix 60 mg im; randomized
for second dose 30 or 60 mg based on degree of E2
suppression (<50 pg/ml) on day 21 or 28
Weekly TVS/MRI for fibroid volume assessment
Surgery after 6 or 8 weeks
Result 16 patients: gonadotropins and sex steroid
secretion suppressed
Mean shrinkage rate at day 14 31.3 %
Mean shrinkage rate at end of treatment 33.5
In good responders (shrinkage >20%) 56.7
largest fibroid volume at day 14
Felberbaum RE, et al. Hum Reprod 13(6):1660, 1998
Myomas: Regression in response to
antiprogesterone mifepristone (RU 486)
Study 10 patients with leiomyomas treated with
mifepristone 50 mg/d for 3 months
Results Amenorrhea induced in all patients
Decreased myoma volume (mean ± SE)
% decrease in myoma volume
0
-15
-21.9
-30
-39.5 *
-45
-49
-60
*
4 weeks 8 weeks 12 weeks
Treatment periods
* P < 0.001
Murphy AA, et al. J Clin Endocrinol Metab 1993;76:513.
SPRM for the treatment of uterine
leiomyomas
Asoprisnil (J867) Member of class of 11ß-
benzaldoxime-substituted
Selective progesterone
receptor modulator
estratrienes
(mesoprogestin) Phase II studies: 5-, 10-, and 25
mg daily oral doses over 12 weeks
Induced amenorrhea without
breakthrough or intermenstrual
flow
Reduced uterine and tumor
volumes in the absence of
Asoprisnil molecular formula estrogen deprivation
Chwalisz K, et al. Endoc Rev 2005;26:423.
Raloxifene reduces uterine size and leiomyoma
dimensions in postmenopausal women
Study 40 postmenopausal women with uterine leiomyomas
treated with raloxifene 180 mg/day for 3 cycles of 28 days
or placebo tablets orally
Ultrasound before and after hysterectomy
Results Baseline After treatment
400
313.1 327.7 327.5
300 274.9
200 141.7 150.3 150.4

116.3
100
0
Raloxifene Placebo Raloxifene Placebo
Uterine dimensions, mean, cm2 Leiomyoma dimensions, mean, cm2
Palomba S, et al. Fertil Steril 2005;84:154.

Perfinidone: Effect on myometrial and
leiomyoma cell proliferation
Pirfenidone Myometrium Leiomyoma
caused dose-
120
dependent
Thymidine incorporation
100
inhibition of
(% of control)
serum- 80
stimulated DNA 60
synthesis for
40
both normal
20
myometrial and
leiomyoma 0
0 0.01 0.1 0.3 1
SMCs after 24 h
Pirfenidone (mg/ml)
of treatment
Lee B-s, et al. J Clin Endocrinol Metab 83: 219, 1998

Basic fibroblastic growth factor or its
receptor may be targeted for treatment of
uterine leiomyomas
Basis Overproduced and stored in myoma
tissue1
Affects blood vessel structure and
function: promotes angiogenesis and
causes smooth muscle cell growth2
bFGF receptor expressed at different
times in menstrual cycle in women with
myoma-related bleeding3
1Mangrulkar
RS, et al. Biol Reprod 53:636, 1995. 2Stewart EA, Nowak RA. Hum
Reprod Update 2:295, 1996. 3Anania CA, et al. Mol Hum Reprod 3:685, 1997

Myomas: Treatment with interferon
Interferon- or interferon- oppose bFGF
actions
Interferon- decreased
proliferation of myoma cells in
culture1
Case report:2 Woman received
Interferon protein interferon for hepatitis C,
molecular graphic simultaneously had shrinkage of
myoma, sustained for 17 months
1Lee BS, et al. Am J Reprod Immunol 40.19, 1998. 2Minakuchi K, et al. Lancet
353:2127, 1999
Myomas: Use of gene therapy
Suicide Uses recombinant DNA technology
gene to create a plasmid containing
Herpes Simples Virus (I) thymidine
therapy
kinase gene
approach
Plasmid introduced in vitro into myoma
cells and treated with prodrug
Ganciclovir
Thymidine kinase converts Ganciclovir
into cytotoxin that arrests DNA
synthesis in transfected cells, leading
to apoptosis
Niu H, et al: Obstet Gynecol 91:735, 1998
Embolization

Uterine fibroid embolization
Uterine arteries blocks blood supply
Size reduction
embolized by and resolution
angiography death and degeneration of symptoms
Fibroid Medical Center of Northern California, www.fibroidworld.com, 2000

Uterine
fibroid
embolization
Uterine artery
(fibroid)
embolization
causes reduction
in tumor size and
decrease or
resolution of
symptoms
Fibroid Medical Center of

Northern California.
www.fibroidworld.com

Case 1. Uterine fibroid embolization
39 years
old,
recurrent
vaginal
bleeding
even with
leuprolide
use
Angiography before Angiography after
embolization: 8 in fibroid embolization: no fibroid
Menstrual periods normal starting first cycle after
embolization
Ohio Health and Science University: http://www.ohsu.edu

Uterine artery embolization
Key UAE may be especially useful in women who are
poor surgical candidates, have extensive
points adhesive disease, refuse blood products, or
perimenopausal
Average symptom improvement is 87%
Mean reduction in fibroid volume is 46%
Most patients discharged within 24 hours;
average recovery period of 8 days
Women undergoing UAE more likely to need
further invasive treatment within 3 to 5 years
than those undergoing myomectomy
Desire for fertility is considered relative
contraindication
Goldberg J, et al. OBG Management Online 2003
Focused ultrasound

Magnetic resonance imaging-guided
focused ultrasound surgery of uterine
leiomyomas
ExAblate 2000 ultrasound MRI-guided focused ultrasound

system heats and destroys tumors without
damaging surrounding structures
www.medgadget.com/.../ 04/exablate_making_1.html
MRgFUS treatment of uterine leiomyomas
results in short-term symptom reduction
Study 109 premenopausal women with symptomatic
myomas, no plans for future pregnancy
Single treatment session of MRgFUS
Symptom severity score measured with Uterine
Fibroid Quality-of-Life Instrument
Results 6 months 12 months
Reached targeted 71 % 51 %
reduction
Mean decrease in SSS 39 36
Adverse events Low incidence
Stewart A, et al. Fertil Steril 2006;85:22.

Part 3
Summary and
conclusions
Tan D. 2006
What is the best way to manage
uterine leiomyomas?
Current 1 New procedures and medications
continue to be developed
status
Most are not adequately evaluated
2006 None is applicable in all circumstances
2 Appropriate management should be
individualized considering
Related symptoms
Number, size, and location of tumors
Patient’s desire regarding uterine
conservation
Munro MG. Fertil Steril 2006;85:40.

‘The greatest challenge gynecologic
surgeons face on a day-to-day basis
is to accomplish more with less risk,
in less time, and at less cost.’
Sanfilippo J: Editorial: OBG Management,
September 1995

Medical and Surgical Management: of Uterine Leiomyomas

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Jose Reyes Memorial Medical Center 5 May 2006

Medical and surgical management

DELFIN A. TAN, M.D.

Department of Obstetrics and Gynecology

Clark BM, Johnson JV.

Pelvic pain with or without 34

Recurrent pregnancy loss 3

Stewart EA, Faur A. Contemp OB/GYN 45:26, 2000

Walocha JA, et al. Hum Reprod 2003;18:1088.

Medical and surgical management of uterine leiomyomas 16

ST, 49, years, menorrhagia, multiple submucous, intramural, and

Pelosi MA, Pelosi III MA. Contemporary OB/GYN 42:107, 1997

LT, 34, G5P2, ab 4, pelvic pain

Medical and surgical management of uterine leiomyomas 22

A. Myoma reduced to 6.6 cm

B. Laparoscopy C. Further dissection

D. Hemostasis with bipolar E. Wound surface covered

A. Myoma reduced to 6.2 cm

Medical and surgical management of uterine leiomyomas 30

B. Bipolar cautery over C. Hysterotomy incision

Medical and surgical management of uterine leiomyomas 31

D. Further dissection E. Bipolar cautery of

Medical and surgical management of uterine leiomyomas 32

F. Conventional repair of G. Laparoscopic view

Medical and surgical management of uterine leiomyomas 33

H. Extensive pelvic irrigation

Medical and surgical management of uterine leiomyomas 34

Laparoscopy view: cervical Laparoscopic view: pelvis

FA, 33, single. A. Multiple subserous,

A. Bipolar coagulation needles (2 C

Medical and surgical management of uterine leiomyomas 37

Tsuji S, et al. Gynecol Obstet Invest 2006;61:106.

Transverse (A) and sagitall (B) images showing type 2 submucosal

Wolanske KA, Gordon RL. Appl Radiol 2004;33:18.

A. Submucous myoma, type 1, before (A) and after (B)

Medical and surgical management of uterine leiomyomas 43

B. Resection with loop C. Further resection

Medical and surgical management of uterine leiomyomas 44

D. Cautery of base E. Resection to endometrial

Medical and surgical management of uterine leiomyomas 45

F. Hemostasis with roller ball

CM, 27, complained of infertility and menorrhagia

Preoperative GnRH agonist therapy followed by

Cruz-Tordesillas RL. 2002

Cervix Uterine artery

When uterine artery is blocked, blood flow decreases by 42%, sufficient to

Medical and surgical management of uterine leiomyomas 51

Not as sole treatment

Speroff L, et al. Clinical Gynecologic Endocrinology and Infertility, ed 6,

Pituitary GnRH receptors occupied and internalized

Loss of available GnRH receptors

Decreased LH and FSH synthesis and release

Ovaries Suppression of follicular development

Decreased estradiol synthesis and release

Conn PM, Crowley WF Jr: Ann Rev Med 45:391, 1994

Comments Not warranted for routine preoperative

Stovall TG, et al. Obstet Gynecol 86:65, 1995

Scialli AR, Levi AJ. Fertil Steril 2000;74:540.

Loy RA: Curr Opin Obstet Gynecol 6:262, 1994

200 141.7 150.3 150.4

Palomba S, et al. Fertil Steril 2005;84:154.

Lee B-s, et al. J Clin Endocrinol Metab 83: 219, 1998