Bases of a uterine leiomyoma’s nonsurgical treatment

Abstract

Objective. A uterine leiomyoma presents largely benign monoclonal tumors originating from the smooth muscle of the uterus. In the majority of cases, the said pathology is а progressive disorder; a distress of es­trogen/progesterone balance in the myometrium tissues is apparent in its pathogenesis. The leiomyoma is widely spread among women of reproductive age (30-40%). The pathogenesis remains subject to further study, though certain risk factors were identified, among which are the racial background and age. It is dem­onstrated that uterine fibroids tends to regress following menopause, and this serves as a reliable proof of the estrogen/progesterone activity in the pathogenesis of this disorder. The treatment methods choice is limited by 2 mainstays: medical (conservative) and surgical depending on the intensity of symptoms and pa­tients' desire to retain fertility or to preserve the uterus. In the absence of symptoms immediate interven­tion is not imperative, a watchful waiting rather is recommended as the most conservative method. How­ever, of a severity of symptoms is registered, a surgical intervention of various invasion is suggested, however, only radical surgery(hysterectomy) serves as guaranty of almost complete elimination of symptoms, while less invasive methods can result in uterine fibroids progress already within 3-6 months after their application.

Aims: 1) comparison of efficiency of different methods of conservative treatment (medication) of leio­myoma; 2) representation of recent pharmacologic methods of UFs treatment focusing in the new promising methods based on selective progesterone receptors modulators (SPRMs) and antigestagens.

Material and methods. To form the review on the EH problem and methods of its treatment, PubMed, EM-BASE, Medline, and the Cochrane Library were searched for randomized trials in 2013-2015, limited to English literature in the area. Relevant publications were identified by the key terms: leiomyoma, ulipristal acetate, antigestagens, selective progesterone receptor modulators, myolysis, myomectomy uterine artery embolization

(UAE).

Results. Conservative treatment (medication) of uterine fibroids is associated with a rapid relief of signs and symptoms and an improvement of quality of patients' life and also with a minor regression of proliferation processes in the myometrium resulting in sustained reduction of leiomyoma size on the background of retained fertility, so in certain number of patients a conservative approach combined with a back-up hormonal therapy presents itself as adequate. At the same time, less invasive methods allowing to preserve the uterus, are not recommended for patients planning pregnancy in a future period. However, none of the methods above a radi­cal surgical interference (hysterectomy) cannot guarantee a full elimination of leiomyomas and accompanying symptoms let aside their potential progress.

Conclusion. Taking into account the largely benign character of leiomyomas, an optimal treatment should aim primarily at a rapid relief of symptoms and an improvement f the quality of life of patients with symptoms. In treatment of asymptomatic patients of the reproductive age willing to retain fertility, no immediate inter­vention is recommended; alternatively, SPRMs present a new promising therapeutic medium, causing a partial shrinking the tumor and is much more preferable as compared to invasive treatments of various intensity, espe­cially for patients aiming at maintaining fertility or preserving the uterus. Further trials are required. SPRMs can be effective both as an independent means and as pre-operative short-term treatment, as a means of reducing the uterine bleeding and the tumor size. Invasive methods of treatment are recommended to patients with symptoms who do not aim at retaining fertility or uterus provided there are no contraindications to a major surgical interference.

Keywords:leiomyomas, heavy menstrual bleeding, selective progesterone receptor modulators, ulipristal acetate, antigestagens, leuprolide acetate, mifepristone, gonadotrophin-releasing hormone agonists, medical management, watchful waiting, hysterectomy, myomectomy, uterine artery embolization, endometrial ablation, myolysis

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