HPE HPE 85 – Spring 2017 - Page 53

Practical therapeutics Issue 85 | Spring 2017 Medical treatment of uterine fibroids Surgical treatments have been the traditional gold standard definitive therapies for symptomatic fibroids; however, not all women want to undergo surgery and a range of non-surgical alternatives, such as medical management, are now available Vikram Talaulikar MD MRCOG PhD Ertan Saridogan MD PhD FRCOG Reproductive Medicine Unit University College London Hospital NHS Trust, London, UK Uterine fibroids (als o known as myomas or leiomyomas) are benign tumours characterised by the proliferation of uterine smooth muscle cells and associated collagen matrix and are the most common benign tumours in women of reproductive age group. They are estimated to be symptomatic in 50% of women who have them, with the peak incidence of symptoms occurring among women aged 30 to 40. 1 Uterine fibroids are thought to result from increased mitotic activity within the myometrium under the influence of female hormones, however what initiates the fibroid growth is not yet clear. Symptoms from fibroids depend on size and position of the fibroids. Symptoms include bleeding disturbances (usually heavy and prolonged periods, sometimes frequent and unpredictable bleeds), pressure symptoms (bladder and bowel symptoms, bloating, chronic pelvic pain and dyspareunia) and subfertility. 2 While bleeding disturbances are more suggestive of submucosal or intramural fibroids which distort the endometrial cavity, pressure symptoms depend on the fibroid size and the extent to which fibroids encroach on the surrounding pelvic structures. The impact of fibroids on fertility remains controversial but most clinicians recommend surgical removal of fibroids distorting the endometrial cavity to improve chances of conception. Asymptomatic women with small fibroids may benefit from expectant management, especially those approaching the menopause. Surgical treatments such as hysterectomy and myomectomy have been the traditional gold standard definitive therapies for symptomatic fibroids. However, not all women wish to have surgery and would like to consider non-surgical alternatives such as medical management. Medical treatments for symptomatic fibroids Women with asymptomatic uterine fibroids may not need any active treatment and only require monitoring with periodic assessments to review fibroid size and symptoms. Current medical therapeutic approaches exploit the observations that uterine fibroids have significantly increased concentrations of both oestrogen and progesterone receptors compared to normal myometrium, and that ovarian steroids influence fibroid growth. 3,4 Women with symptomatic uterine fibroids who wish to avoid surgery, who have recurrent fibroids following previous surgery, or are unfit for surgical treatment have different medical treatment options for alleviation of symptoms. Most of the medical treatments produce significant, but usually temporary, reductions in both uterine size and symptoms. Although medical management can be an effective option for selected women, there is limited evidence to support many of the treatments suggested. Treatment choice hospitalpharmacyeurope.com 51