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Uterine leiomyomas (fibroids) are common in women of reproductive age and are the most frequent indication for major gynecologic surgery, yet their characteristics and optimal management remain incompletely defined. Three studies add to our knowledge.
Treatment for leiomyomas is often advocated in women with the condition who experience miscarriages, but do leiomyomas actually raise risk for miscarriage? Investigators conducted a systematic review and meta-analysis of five studies in the general obstetric population (21,829 pregnancies; 1394 women with fibroids). Meta-analysis showed no significant increase in spontaneous miscarriage among women with leiomyomas compared with those without (11.5% and 8.0%; risk ratio, 1.2; 95% confidence interval, 0.80–1.52). After adjusting, the risk ratio was 0.8 (95% CI, 0.68–0.98).
The development of new approaches to leiomyoma treatment led investigators to evaluate reintervention and long-term outcomes in a retrospective analysis including 135,000 women undergoing first-line hysterectomy (82.2%), myomectomy (14.7%), uterine artery embolization (UAE; 3.1%), or magnetic resonance-guided, focused ultrasound surgery (MRI-US; 0.0003%). Small but statistically significant differences favored myomectomy over UAE with respect to risk for reintervention (15.0% vs. 17.1%; P=0.02) and risk for subsequent hysterectomy (11.1% vs. 13.2%; P<0.01), but more women in the myomectomy group underwent at least one subsequent surgical procedure (24.6% vs. 18.1%; P<0.001). After myomectomy, 17.8% of women became pregnant compared with 2.0% after UAE (P<0.001), with both groups having a high overall rate of adverse maternal and perinatal outcomes (69.4%).
To evaluate the effects of the FDA's 2014 safety communication about power morcellation, investigators analyzed data on 78,000 hysterectomies and myomectomies in four U.S. states in 2013 and 2014. Use of laparoscopic hysterectomy fell by 4% after the FDA communication. The decrease in laparoscopic hysterectomy was more pronounced for inpatient procedures, with laparoscopic hysterectomy decreasing by 7% (from 24% to 17%) of all hysterectomies and abdominal hysterectomy increasing by 8% (from 71% to 79%). The proportion of women undergoing vaginal hysterectomy — and rates of myomectomy compared with hysterectomy — did not change appreciably.
Sundermann AC et al. Leiomyomas in pregnancy and spontaneous abortion: A systematic review and meta-analysis. Obstet Gynecol 2017 Oct 6; 130:1065. (http://dx.doi.org/10.1097/AOG.0000000000002313)
Borah BJ et al. Comparative effectiveness of uterine leiomyoma procedures using a large insurance claims database. Obstet Gynecol 2017 Oct 6; 130:1047. (http://dx.doi.org/10.1097/AOG.0000000000002331)
Clark NM et al. Change in surgical practice for women with leiomyomas after the U.S. Food and Drug Administration morcellator safety communication. Obstet Gynecol 2017 Oct 6; 130:1057. (http://dx.doi.org/10.1097/AOG.0000000000002309)
Comment
Although there's no evidence that fibroids raise risk for miscarriage, my clinical experience says individualization is necessary because submucous fibroids may well interfere with embryo implantation in some women. It's too early to discern the effects of MRI-US, but the data suggest that UAE is a reasonable alternative to myomectomy for some women who turn down hysterectomy — although myomectomy is preferred (and UAE should be avoided) by clinicians and women seeking to preserve fertility. Lastly, surgeons will continue to develop different approaches for managing leiomyomas; but whether these alternatives are safer and more effective than power morcellation remains to be firmly established.