title: Therapeutic management of uterine fibroid tumors: updated French guidelines.
abstract: The medical management of symptomatic non-submucosal uterine fibroid tumors (leiomyomas or myomas) is based on the treatment of abnormal uterine bleeding by any of the following: progestogens, a levonorgestrel-releasing intrauterine device, tranexamic acid, nonsteroidal anti-inflammatory drugs, or GnRH analogs. Selective progesterone receptor modulators are currently being evaluated and have recently been approved for fibroid treatment. Neither combined estrogen-progestogen contraception nor hormone treatment of the menopause is contraindicated in women with fibroids. When pregnancy is desired, whether or not infertility is being treated by assisted reproductive technology, hysteroscopic resection in one or two separate procedures of submucosal fibroids less than 4 cm in length is recommended, regardless of whether they are symptomatic. Interstitial, also known as intramural, fibroids have a negative effect on fertility but treating them does not improve fertility. Myomectomy is therefore indicated only for symptomatic fibroids; depending on their size and number, and may be performed by laparoscopy or laparotomy. Physicians must explain to women the potential consequences of myomas and myomectomy on future pregnancy. For perimenopausal women who have been informed of the alternatives and the risks, hysterectomy is the most effective treatment for symptomatic fibroids and is associated with a high rate of patient satisfaction. When possible, the vaginal or laparoscopic routes should be preferred to laparotomy for hysterectomies for fibroids considered typical on imaging. Because uterine artery embolization is an effective treatment with low long-term morbidity, it is an option for symptomatic fibroids in women who do not want to become pregnant, and a validated alternative to myomectomy and hysterectomy that must be offered to patients. Myolysis is under assessment, and research on its use is recommended. Isolated laparoscopic ligation of the uterine arteries is a potential alternative to uterine artery embolization; it also complements myomectomy by reducing intraoperative bleeding. It is possible to use second-generation techniques of endometrial ablation to treat submucosal fibroids in women whose families are complete. Subtotal hysterectomy is a possible alternative to total hysterectomy for fibroid treatment, given that by laparotomy the former has a lower complication rate than the latter, while by laparoscopy, these rates are the same. In each case, the patient is informed about the benefit and risk associated with each therapeutic option.
authors.affiliation: Service de gynécologie, Centre Hospitalier Régional Universitaire de Tours, Hôpital Bretonneau, 2 boulevard Tonnelé, 37044 Tours, France. marret@med.univ-tours.fr
authors.forename: Henri
authors.initials: H
authors.lastname: Marret
authors.forename: Xavier
authors.initials: X
authors.lastname: Fritel
authors.forename: Lobna
authors.initials: L
authors.lastname: Ouldamer
authors.forename: Sofiane
authors.initials: S
authors.lastname: Bendifallah
authors.forename: Jean-Luc
authors.initials: JL
authors.lastname: Brun
authors.forename: Isabelle
authors.initials: I
authors.lastname: De Jesus
authors.forename: Jean
authors.initials: J
authors.lastname: Derrien
authors.forename: Géraldine
authors.initials: G
authors.lastname: Giraudet
authors.forename: Vanessa
authors.initials: V
authors.lastname: Kahn
authors.forename: Martin
authors.initials: M
authors.lastname: Koskas
authors.forename: Guillaume
authors.initials: G
authors.lastname: Legendre
authors.forename: Jean Philippe
authors.initials: JP
authors.lastname: Lucot
authors.forename: Julien
authors.initials: J
authors.lastname: Niro
authors.forename: Pierre
authors.initials: P
authors.lastname: Panel
authors.forename: Jean-Pierre
authors.initials: JP
authors.lastname: Pelage
authors.forename: Hervé
authors.initials: H
authors.lastname: Fernandez
mesh_terms: D005260:Female; D006801:Humans; D007044:Hysterectomy / Q000379:methods; D007258:Informed Consent; D007889:Leiomyoma / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000601:surgery / Q000628:therapy*; D047648:Perimenopause; D011247:Pregnancy; D014463:Ultrasonography; D055357:Uterine Artery Embolization; D014592:Uterine Hemorrhage / Q000628:therapy; D063186:Uterine Myomectomy; D014594:Uterine Neoplasms / Q000188:drug therapy / Q000628:therapy*; D014599:Uterus / Q000098:blood supply / Q000601:surgery