eMedicine Specialties > Obstetrics and Gynecology > Gynecologic Surgery
Gynecologic Myomectomy
Updated: Aug 6, 2008
Introduction
Uterine leiomyomas are among the most common problems encountered by the obstetrician/gynecologist. They are a frequent cause of pain and abnormal bleeding and are thought to be involved in infertility. Uterine leiomyomas are the most frequent indication for hysterectomy in the United States. Many patients develop myomas but still desire to retain the option of future childbearing or simply want to preserve their uterus. For these women, myomectomy, the removal of the myomas with reconstruction and preservation of the uterus, is an important option.
For excellent patient education resources, visit eMedicine's Women's Health Center. Also, see eMedicine's patient education article Fibroids.
History of the Procedure
Successful abdominal myomectomy was reported as early as 1845 by brothers Washington and John Atlee in the American Journal of Medical Science. Washington, the older brother, eventually published his experience with 14 abdominal myomectomies, winning the annual prize essay award of the American Medical Association despite the death of 5 of the patients.1
The operation was slow to gain widespread use. In 1875, W.H. Byford gave the Chairman's address to the American Medical Association Section on Obstetrics and Gynecology and said abdominal myomectomy was "so dangerous and difficult as not to be thought of except in desperate conditions."1
At the turn of the 20th century, abdominal myomectomy was associated with a mortality rate of 40%, compared with 6-7% for abdominal hysterectomy. Victor Bonney is credited for advocating and popularizing the procedure in the 1920s.2
Problem
Uterine leiomyomata, or fibroids as they are more frequently but less correctly known, affect more than 20% of reproductive-aged women. Patients can have a single myoma or numerous myomas. They are benign growths in the wall of the uterus (see Media file 1). Most are small, do not cause symptoms, and are noted as incidental findings during routine pelvic examinations or pelvic imaging studies. When they enlarge, they can cause a mass effect, resulting in pelvic pressure or pain or a distortion of the uterine wall or endometrial cavity, which leads to abnormal uterine bleeding. At times they can cause other problems; for instance, they can prolapse through the cervix or may be confused for an ovarian mass. They are one of the most frequently encountered problems by the obstetrician/gynecologist. They can also cause problems in pregnancy, and, in some patients, myomas are thought to be linked to infertility.
For related information on pregnancy, see Medscape's Pregnancy Resource Center.
Frequency
Uterine leiomyomata occur in 20-40% of reproductive-aged women.3 Results from some ultrasonographic studies indicate the presence of at least 1 small myoma in 51% of women. Of these women, 10-35% of Caucasian women and 30-50% of African American women have fibroids of clinical significance.4 Myomas grow in response to estrogen stimulation and regress after menopause. Thus, they are most frequently found in women in their fifth decade of life and are quite rare in those younger than 20 years. In 2001, Schwartz reviewed the epidemiology of leiomyomas. The risk is 2-3 times higher in African American women than in white women, increases with age, decreases with having a live-born child, may increase with body mass index, and may decrease with cigarette smoking. Risk may also increase with diets high in red meat and ham and it may decrease with diets high in intake of green vegetables.5
Most myomas are asymptomatic and inconsequential. Nonetheless, many women have significant symptoms from myomas, and myomas are the most frequent indication for hysterectomy in the United States. This indication constituted 38.1% of all hysterectomies (1.36 million) from 1994-1999.6 Figures for myomectomy are older, but, in 1984, 18,000 myomectomies were performed, compared with 112,000 hysterectomies, suggesting approximately 1 myomectomy per 6 hysterectomies among women aged 15-44 years.7 The symptoms of fibroids, along with both surgical and medical treatments, result in enormous costs for affected women and society. To date in the United States, few data exist regarding the annual economic burden of uterine fibroids.8
Etiology
Leiomyomas are smooth muscle tumors that form in the uterine wall. The development and growth of uterine fibroids are influenced by multiple features including autocrine and paracrine growth factors, genetic abnormalities, race, and environmental estrogen exposure related to age of menarche, obesity, and parity.9
The precise etiology is not known, although many cytogenetic and genetic studies have been performed. Approximately 40-50% of myomas have karyotypic abnormalities, particularly involving chromosomes 6, 7, 12, and 14. Within a myoma, all cells are identical and a monoclonal origin has been confirmed. In patients with multiple myomas, different karyotypes are noted, which suggests that each myoma arises as an individual event.10 Other changes noted include increased expression of estrogen, progesterone, and insulinlike growth factor 1 and 2 receptors and abnormalities in the myometrium adjacent to the myoma.11
Pathophysiology
Although myomas are common, relatively few actually cause symptoms. Whether symptoms are present depends largely on a combination of size, number, and location of the myomas. In general, myoma growth is a result of the stimulation of estrogen, which is present until menopause. Over time, previously asymptomatic myomas may grow and become symptomatic. Conversely, many myomas begin to shrink as menopause removes the estrogen stimulation and many myoma-related symptoms resolve spontaneously shortly after menopause.
Myomas are generally categorized by location. Intramural myomas are entirely or mostly contained within the myometrium. Subserosal myomas project outward from the uterus (see Media file 1). Submucosal myomas project into the endometrial cavity (see Media file 2). Pedunculated myomas are attached to the uterine wall by stalks and can be directed into either the peritoneal or the uterine cavity.
Pelvic pressure and pain symptoms are usually the result of mass effect. This can occur either from a single large myoma or from a combination of multiple smaller myomas. A fibroid uterus can grow to be quite large, at times reaching the size of a term gravid uterus. Interestingly, perhaps due to the slow growth and accommodation by the patient, some extremely large uteri are well tolerated by patients and do not require intervention. Some large myomas that impinge on the ureters can cause hydronephrosis and, very rarely, ureteral obstruction.
Bleeding abnormalities are usually the result of distortion of the endometrial cavity by myomas. Unlike pain, which is usually caused by large or multiple myomas, some patients have significant intermenstrual bleeding or menorrhagia from a single, small, strategically placed myoma. A submucosal myoma sometimes can prolapse through the cervix and may cause no symptoms or may cause significant bleeding.
Acute pain resulting from myomas is uncommon and usually stems from 1 of 2 possibilities. Some pedunculated myomas can undergo torsion, causing the same severe pain as torsion of the ovary. Large myomas can also outgrow their blood supply, leading to infarction (degenerating myoma), which can be extremely painful.
Although general agreement is lacking on the mechanism, myomas are also thought to be related to infertility, fetal malpresentations, preterm labor, and IUGR. Possible mechanisms for infertility include distortion of the endometrial cavity and abnormal endometrial surface, thereby affecting both sperm transport and embryo implantation.12
Very rarely, myomas can be associated with erythrocytosis. This triad of myomatous uterus, erythrocytosis, and restoration and maintenance of normal hematologic values after hysterectomy is called myomatous erythrocytosis syndrome.13 A number of etiologies have been hypothesized, but alterations in erythropoietin levels seem likely.
Presentation
Most leiomyomata are small and do not cause symptoms. Many are found as incidental findings after an obstetric or gynecologic ultrasonographic examination (see Media file 3) or after a routine pelvic examination.
However, myomas can cause a number of symptoms. They can cause menstrual irregularities, particularly intermenstrual bleeding or menorrhagia. This bleeding usually begins gradually and progressively worsens as the responsible myoma enlarges. A regular menstrual pattern should be discernible within the extra bleeding. If no regular pattern is noted, an etiology such as chronic anovulation is more likely. Bleeding from chronic anovulation can be severely compounded if concomitant myomas are present.
Some patients present with progressive pelvic pressure, pelvic pain, or low back pain. The problems can also have many other possible etiologies; however, if they are noted in someone with a medium- or large-sized uterus (>14-15 weeks' size), the myomas are likely contributing. Some fibroid uteri can grow out of the pelvis and into the abdomen, where they can be palpated by the patient. This can be disturbing, even if the patient is having mild or no symptoms. Some are visible, distorting the abdominal wall and, at times, making the patient appear pregnant.
Most myomas grow slowly, and some remain relatively unchanged over prolonged periods. In the past, rapid growth was considered worrisome for leiomyosarcoma. In 1994, Parker et al showed that sarcoma was quite rare (0.27%), even in rapidly growing uteri, and that this risk was identical to stable myomas (0.21%).14 However, most of the patients were premenopausal. Rapid growth in postmenopausal women should be treated with greater caution.
The diagnosis of degenerating myoma should be considered in a patient with known fibroids and an acute onset of pelvic pain. This pain is generally acute in onset and can be quite severe. The patient can also develop fever and an elevated white blood cell count (without a left shift) that can be confused with infection. Upon examination, tenderness is usually quite specific and localized to the exact region of the degenerating myoma.
Infertility evaluations usually include an investigation for myomas, specifically submucosal myomas. Ultrasonography, hysterosalpingography (HSG), sonohysterography, or hysteroscopy are used frequently because submucosal myomas may not be detectable during pelvic examination.
Several unusual presentations can also occur. A prolapsed myoma (see Media file 4) is sometimes found after a routine speculum examination. A pedunculated myoma is a possible cause for an adnexal mass.
Indications
The American College of Obstetricians and Gynecologists previously had criteria for hysterectomy for leiomyomata. Although this technical bulletin has been superseded by more recent ones that do not specify indications, these criteria are also reasonable for myomectomy. They are as follows:
- Asymptomatic leiomyomata that are palpable abdominally and are a concern to the patient
- Excessive uterine bleeding
- Profuse bleeding
- Anemia
- Pelvic discomfort caused by myomata
- Acute and severe
- Chronic lower abdominal or low back pressure
- Bladder pressure with urinary frequency not due to a urinary tract infection
All of these criteria are directed at relieving symptoms or improving quality of life by decreasing the patient's concerns. No indications exist for removing asymptomatic fibroids. Most of these patients never develop symptoms, and evidence does not support that earlier intervention improves long-term outcomes. An older argument proposed as an indication for hysterectomy, that the removal of uteri larger than 12 weeks' size improves the capability to detect adnexal masses, is also fallacious or obviated by ultrasonography. No evidence shows that routine pelvic examination improves the early detection of ovarian cancer. Similarly, no reason exists to believe that removing large uteri in an effort to make adnexa easier to examine would alter long-term ovarian cancer risk, detection, or outcome.
Additional criteria include the patient's interest in preserving her fertility or a personal preference of retaining her uterus. A definite risk exists for myoma recurrence after myomectomy and, with it, the need for a repeat surgical procedure in the future. If the patient no longer desires to retain her fertility or her uterus, hysterectomy is the usual procedure of choice. Interestingly, a number of women who have completed childbearing still request myomectomy for management of symptomatic myoma. This decision is usually motivated by patient preference and a desire to retain organs. Because the short-term risks of myomectomy compare favorably with hysterectomy15 and despite the risk of recurrence (ie, most patients do not require future surgery), a myomectomy is not unreasonable for appropriately counseled patients.
Although controversial, myomectomies are also performed for patients with infertility in the presence of uterine fibroids. Several papers suggest that patients with fibroids who are undergoing assisted reproductive technology procedures may have lower success rates compared with patients without fibroids.16,17 On the other hand, a retrospective evaluation of donor oocyte cycles in patients with IVF revealed no difference in pregnancy rates between women without fibroids and women with non—cavity-distorting fibroids.18
Importantly, no randomized studies have been performed to show improved pregnancy success rates after myomectomy.
Current recommendations include consideration of myomectomy in infertile women after eliminating other causes of infertility and in patients with cavity-distorting submucosal myomas prior to IVF.12
Relevant Anatomy
Leiomyomata are usually confined to the myometrium but can occur in the lower uterine segment or cervix or can project out into the broad ligament. These myomas are frequently the most difficult to remove and are problematic during both hysterectomy and myomectomy.
Within the uterus, the myomas can be at any level within the uterine wall. Those mostly confined to the wall are termed intramural. Myomas projecting into the endometrial cavity are termed submucosal (see Media file 2), whereas myomas projecting outward from the uterus are subserosal (see Media file 1).
Some myomas are attached by pedicles, which can extend outward into the abdomen and may be confused with adnexal masses or can project into the endometrial cavity and cause bleeding. Some prolapse through the cervix (see Media file 4).
Contraindications
Myomectomy has a number of important contraindications. Myomectomy is not reasonable in the management of symptomatic leiomyomata in patients who no longer desire fertility or uterine preservation. It should not be performed if the patient possibly has endometrial cancer or uterine sarcoma. It should be avoided if the patient is pregnant. With the possible exception of otherwise unexplained infertility, it should not be performed in asymptomatic patients. No evidence whatsoever supports prophylactic myomectomy of asymptomatic myomas for decreasing the risk of any adverse outcome later in life.
Relative contraindications include the strong possibility that a functional uterus could not be reconstructed after excision of the myomas. For myomectomy to be considered successful, reconstructing the uterus with patent tubes must be possible. Leiomyomata located in the region of the uterine vessels or broad ligament are sometimes difficult to remove without performing a hysterectomy. If the patient has numerous small myomas, removing them and reconstructing the uterus in such a way as to support a future pregnancy may be impossible. Excision of very large leiomyomata that constitute the entire anterior or posterior wall of the uterus may leave defects so large that closure is prohibited. In addition, if adenomyosis is present, it is not amenable to resection and cannot be treated by myomectomy.
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References
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Further Reading
Keywords
abdominal myomectomy, hysteroscopic myomectomy, laparoscopic myomectomy, uterine leiomyomas, uterine artery embolization, MR guided focused ultrasound, infertility, pregnancy, conception, myomas, leiomyomata, fibroids, hysterectomy, childbearing, uterine preservation, benign uterine growths, abnormal uterine bleeding, estrogen stimulation, smooth muscle tumors, intermenstrual bleeding, menorrhagia, menstrual irregularity
