Documentos de Académico
Documentos de Profesional
Documentos de Cultura
The incidence of uterine fibroid tumors increases as women grow older, and they may occur in more than 30 percent
of women 40 to 60 years of age. Risk factors include nulliparity, obesity, family history, black race, and hypertension.
Many tumors are asymptomatic and may be diagnosed incidentally. Although a causal relationship has not been
established, fibroid tumors are associated with menorrhagia, pelvic pain, pelvic or urinary obstructive symptoms,
infertility, and pregnancy loss. Transvaginal ultrasonography, magnetic resonance imaging, sonohysterography, and
hysteroscopy are available to evaluate the size and position of tumors. Ultrasonography should be used initially
because it is the least invasive and most cost-effective investigation. Treatment options include hysterectomy, myomectomy, uterine artery embolization, myolysis, and medical therapy. Treatment must be individualized based on such
considerations as the presence and severity of symptoms, the patients desire for definitive treatment, the desire to
preserve childbearing capacity, the importance of uterine preservation, infertility related to uterine cavity distortions,
and previous pregnancy complications related to fibroid tumors. (Am Fam Physician 2007;75:1503-8. Copyright
2007 American Academy of Family Physicians.)
Patient information:
A handout on uterine
artery embolization is
available at http://familydoctor.org/601.xml.
Clinical Features
Because of the high prevalence of uterine
fibroid tumors and the fact that many are
asymptomatic, attributing symptoms specifically to the tumors is problematic. Although
evidence is largely drawn from uncontrolled studies, uterine fibroid tumors are
commonly identified in women who have
Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright 2007 American Academy of Family Physicians. For the private, noncommercial
use of one individual user of the Web site. All other rights reserved. Contact copyrights@aafp.org for copyright questions and/or permission requests.
Fibroid Tumors
Evidence
rating
References
24
25-27
30, 31
27, 33
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, diseaseoriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, see page 1430 or
http://www.aafp.org/afpsort.xml.
www.aafp.org/afp
Fibroid Tumors
Table 2. Comparison of Treatment Options for Women with Uterine Fibroid Tumors
Fertility
preserved?
Treatment
Description
Advantages
Disadvantages
Gonadotropinreleasing
hormone
agonists
Preoperative treatment
to decrease size
of tumors before
hysterectomy,
myomectomy, or
myolysis
Surgical removal
of the uterus
(transabdominal,
transvaginal, or
laparoscopic)
Dependent on
subsequent
procedure
Surgical risks
No
Unknown
No (limited
experience)
Hysterectomy
Myolysis
Myomectomy
Uterine artery
embolization
In situ destruction
of tumors by heat,
laser, or cryotherapy
Surgical or endoscopic
excision of tumors
Interventional
radiologic procedure
to occlude uterine
arteries
Yes
Expectant management with observation is increasingly recognized as a reasonable course for women with
asymptomatic small and large fibroid tumors. Even rapidly growing tumors should not be removed routinely
because the risk of a malignant leiomyosarcoma is small
(0.23 percent in one study).28,29
surgical treatments
www.aafp.org/afp
Fibroid Tumors
and severe symptoms associated with gynecologic disorders. The Maine study enrolled a comparison group of
women who received nonsurgical medical treatment.31
Medical therapy for abnormal bleeding and chronic
pelvic pain produced significant improvements, but one
quarter of the nonsurgical group subsequently underwent hysterectomy. Women with uterine fibroid tumors
who continued with nonsurgical treatment reported
no significant changes in symptoms or quality of life
over the one year follow-up. Not all women who are
treated surgically report improvement. In the Maryland
study, almost 8 percent of women had more or the same
number of symptoms 24 months after hysterectomy.30
Baseline depression, therapy for emotional problems,
annual income of less than $35,000, and bilateral oophorectomy were significantly associated with poorer outcomes. Some women in the Maine study reported new
symptoms after hysterectomy (e.g., hot flashes, weight
gain, depression).31 Most studies evaluating the effect of
hysterectomy on sexuality are poorly designed, but the
available evidence suggests that hysterectomy does not
adversely affect sexuality.32
Myomectomy. Myomectomy (i.e., surgical removal
of fibroid tumors while preserving the uterus) traditionally has been performed by laparotomy. Endoscopic myomectomy is now a treatment option for
many women, and hysteroscopic myomectomy may be
considered in women with symptomatic submucosal
fibroid tumors. Ultimately, however, the choice of surgical approach is largely dependent on the expertise of
the physician. Although elective cesarean delivery traditionally has been recommended for women
who become pregnant after myomectomy
Table 3. Recommended Treatment Options
(especially when the uterine cavity has been
for Women with Uterine Fibroid Tumors
entered), data to support this recommendation are limited.33
Patient characteristics
Treatment options
Uterine Artery Embolization. Uterine artery
embolization
is performed under intravenous
Asymptomatic women
Observation
sedation.
Using
a femoral approach, a microSymptomatic women who desire fertility
Nonsurgical treatment
catheter is introduced into the uterine artery.
preservation
or myomectomy
Polyvinyl alcohol foam particles or other
Symptomatic women who do not desire
Nonsurgical treatment
future fertility but wish to preserve the
or myomectomy,
occluding agents are then injected. Complete
uterus
myolysis, or uterine artery
occlusion of both uterine arteries initially
embolization
was the goal of this treatment, but recent data
Women who desire fertility preservation
Myomectomy
suggest that incomplete embolization may
and have had a pregnancy complicated
produce effective infarction of myomas with
by uterine fibroid tumors
less severe pain.34 The Fibroid Registry for
Infertile women with distortion of uterine
Myomectomy
Outcomes Data was formed in 1999 to collect
cavity
prospective data on more than 3,000 women
Women with severe symptoms who desire
Hysterectomy
definitive treatment
undergoing embolization for fibroid tumors.
Short-term outcomes in women included in
www.aafp.org/afp
Fibroid Tumors
The Authors
PATRICIA EVANS, MD, is an assistant professor and the program director of the Georgetown University-Providence Hospital Family Practice
Residency Program, Colmar Manor, Md. She received her medical degree
from Michigan State University College of Human Medicine, East Lansing,
and completed a family medicine residency and obstetrics fellowship at
Franklin Square Hospital, Baltimore, Md.
SUSAN BRUNSELL, MD, is a family physician in the Executive Healthcare
Department at the National Naval Medical Center, Bethesda, Md. She
received her medical degree from Northwestern University Feinberg
School of Medicine, Chicago, Ill. Dr. Brunsell completed a family medicine
residency at Malcolm Grow U.S. Air Force Medical Center, Andrews Air
Force Base, Md., and a womens health fellowship at the University of
Tennessee Graduate School of Medicine, Knoxville.
Address correspondence to Patricia Evans, MD, Georgetown
University-Providence Hospital Family Practice Residency Program,
4151 Bladensburg Rd., Colmar Manor, MD 20722. Reprints are not
available from the authors.
Author disclosure: Nothing to disclose.
REFERENCES
1. Lurie S, Piper I, Woliovitch I, Glezerman M. Age-related prevalence
of sonographically confirmed uterine myomas. J Obstet Gynaecol
2005;25:42-4.
2. Lethaby A, Vollenhoven B. Fibroids (uterine myomatosis, leiomyomas).
Am Fam Physician 2005;71:1753-6.
3. Hashimoto K, Azuma C, Kamiura S, Kimura T, Nobunaga T, Kanai T, et
al. Clonal determination of uterine leiomyomas by analyzing differential
inactivation of the X-chromosome-linked phosphoglycerokinase gene.
Gynecol Obstet Invest 1995;40:204-8.
4. Chalas E, Constantino JP, Wickerham DL, Wolmark N, Lewis GC, Bergman C, et al. Benign gynecologic conditions among participants in the
Breast Cancer Prevention Trial. Am J Obstet Gynecol 2005;192:1230-7.
5. Wise LA, Palmer JR, Stewart EA, Rosenberg L. Age-specific incidence
rates for self-reported uterine leiomyomata in the Black Womens
Health Study. Obstet Gynecol 2005;105:563-8.
6. Kjerulff KH, Langenberg P, Seidman JD, Stolley PD, Guzinski GM. Uterine leiomyomas. Racial differences in severity, symptoms and age of
diagnosis. J Reprod Med 1996;41:483-90.
7. Ross RK, Pike MC, Vessey MP, Bull D, Yeates D, Casagrande JT. Risk
www.aafp.org/afp
Fibroid Tumors
factors for uterine fibroids: reduced risk associated with oral contraceptives [Published correction appears in Br Med J (Clin Res Ed)
1986;293:1027]. Br Med J (Clin Res Ed) 1986;293:359-62.
8. Ligon AH, Morton CC. Leiomyomata: heritability and cytogenetic studies. Hum Reprod Update 2001;7:8-14.
30. Kjerulff KH, Rhodes JC, Langenberg PW, Harvey LA. Patient satisfaction
with results of hysterectomy. Am J Obstet Gynecol 2000;183:1440-7.
31. Carlson KJ, Miller BA, Fowler FJ Jr. The Maine Womens Health Study: I.
Outcomes of hysterectomy. Obstet Gynecol 1994;83:556-65.
32. Farrell SA, Kieser K. Sexuality after hysterectomy. Obstet Gynecol
2000;95(6 pt 2):1045-51.
33. American College of Obstetricians and Gynecologists. ACOG practice bulletin. Surgical alternatives to hysterectomy in the management of leiomyomas. Number 16, May 2000. Int J Gynaecol Obstet
2001;73:285-93.
34. Marshburn PB, Matthews ML, Hurst BS. Uterine artery embolization as
a treatment option for uterine myomas. Obstet Gynecol Clin North Am
2006;33:125-44.
35. Worthington-Kirsch R, Spies JB, Myers ER, Mulgund J, Mauro M, Pron
G, et al. The Fibroid Registry for outcomes data (FIBROID) for uterine
embolization: short-term outcomes [Published correction appears in
Obstet Gynecol 2005;106:869]. Obstet Gynecol 2005;106:52-9.
36. Goldfarb HA. Myoma coagulation (myolysis). Obstet Gynecol Clin
North Am 2000;27:421-30.
37. Rackow BW, Arici A. Options for medical treatment of myomas. Obstet
Gynecol Clin North Am 2006;33:97-113.
38. Venkatachalam S, Bagratee JS, Moodley J. Medical management of
uterine fibroids with medroxyprogesterone acetate (Depo Provera): a
pilot study. J Obstet Gynaecol 2004;24:798-800.
39. Steinauer J, Pritts EA, Jackson R, Jacoby AF. Systematic review of mifepristone for the treatment of uterine leiomyomata. Obstet Gynecol
2004;103:1331-6.
40. Sammartino PS, Di Carlo C, Affinoto P, Zullo F, Nappi C. Effects of raloxifene treatment on uterine leiomyomas in postmenopausal women.
Fertil Steril 2001;76:38-43.
41. Lethaby A, Vollenhoven B. Fibroids (uterine myomatosis, leiomyomas).
Clin Evid 2005:(14):2264-82.
42. Stewart EA, Gedroyc WM, Tempany CM, Quade BJ, Inbar Y, Ehrenstein
T, et al. Focused ultrasound treatment of uterine fibroid tumors: safety
and feasibility of a noninvasive thermoablative technique. Am J Obstet
Gynecol 2003;189:48-54.
www.aafp.org/afp