eMedicine Specialties > Obstetrics and Gynecology > Gynecologic Surgery
Gynecologic Myomectomy: Treatment
Updated: Aug 6, 2008
Treatment
Medical Therapy
Management of symptomatic uterine fibroids includes a number of nonsurgical approaches. Of note, treatment is usually strictly for patient comfort, and withholding treatment is reasonable in patients with no symptoms or with mild, well-tolerated symptoms. While medical treatment does not currently allow a permanent cure for fibroids, therapy with nonsteroidal anti-inflammatory drugs, oral contraceptive pills, progestins, androgens, and gonadotropin-releasing hormone (GnRH) analogs is often attempted.21 In a 2007 Cochrane review evaluating the effectiveness of SERMs in treating fibroids, evidence was insufficient to show any improvement in fibroid size or clinical symptoms.22
In a review by the Agency for Health Care Research and Quality, the use of preoperative GnRH agonist was shown to decrease uterine size and increase hemoglobin. They comment about the "lack of high-quality evidence supporting the effectiveness of most interventions for symptomatic fibroids."23
No randomized trials compare medical management with surgery.
In general, surgery is reserved for people in whom medical management has failed. Despite the lack of good randomized evidence for the use of nonsteroidal anti-inflammatory drugs and oral contraceptive pills, these seem to be appropriate options for properly selected women without contraindications. Many women with fibroids, particularly those who have fibroids that are compounding dysfunctional bleeding, can be treated successfully with a combination of nonsteroidal anti-inflammatory drugs, birth control pills, or cyclic progestins. A short course is reasonable for patients with fibroids before committing to surgery because some patients can be treated successfully with medical management. Most studies of medical management are short, from 3 months to 1 year, and long-term success remains uncertain.
Patients who are treated expectantly are usually examined more frequently than once a year. If the myomas are large and extend laterally, consideration can be given to performing periodic ultrasonographic studies to monitor for the development of hydronephrosis or the rare occurrence of ureteral obstruction.
Surgical Therapy
A number of surgical therapies are available for the management of myomas, including hysterectomy, abdominal myomectomy, laparoscopic myomectomy, and hysteroscopic myomectomy. Myomas are most commonly treated with total abdominal hysterectomy. The following sections focus on conservative surgery for leiomyomas. The traditional procedure is abdominal myomectomy, although laparoscopic myomectomy is an acceptable option for experienced laparoscopic surgeons.
Myomectomy can be performed laparoscopically under certain conditions. Development of this procedure was driven by the desire to create a minimally invasive approach that would obviate a major abdominal laparotomy. Numerous published series document the feasibility of laparoscopic myomectomy.24,25,26,27
The most recent American College of Obstetricians and Gynecologists Practice Bulletin suggests that it "may be a safe and effective option for women with a small number of moderately sized uterine leiomyomas who do not desire future fertility. Further studies are necessary to evaluate the safety of this procedure for women planning pregnancy."28 However, a review of randomized studies and clinical series concluded that laparoscopic myomectomy is feasible in well-selected individuals and, with meticulous closure of the myometrium, is safe in women considering pregnancy in the future.29 A randomized control trial revealed similar cumulative pregnancy and live birth rates in women with unexplained infertility following laparoscopic versus abdominal myomectomy.30 Laparoscopic myomectomy is gradually becoming a more acceptable treatment for myomas.
A third technique, hysteroscopic resection, can also be used selectively for myomas impinging on the endometrial cavity that are thought to contribute to abnormal bleeding or infertility. Over the last 30 years, hysteroscopic resection of fibroids has become the standard for conservative treatment for submucosal fibroids. With the recent improvements in smaller scopes, continuous flow monitoring systems, and operative resecting tools the procedure has become safer and less invasive and, in many cases, can be performed with minimal anesthesia and cervical dilation. Proper patient selection and correct surgical technique are essential for optimizing operative success and reducing risk of complications.31
Women with submucosal fibroids often have symptoms related to menorrhagia or infertility. Most women have significant reduction in bleeding after undergoing hysteroscopic resection. Improved fertility is also seen after removal of submucosal fibroids, although the mechanism is not fully understood.32
Preoperative Details
Abdominal myomectomy
The use of GnRH analogues has been studied extensively in patients undergoing abdominal myomectomy and was the subject of a Cochrane review.33 The systematic review noted increased preoperative hemoglobin levels (weighted mean difference, 1.3 g) and decreased uterine size (weighted mean difference in volume, 159 mL). Intraoperatively, they noted a lower incidence of vertical incisions (odds ratio 0.11; 95% confidence interval, 0.02-0.75). They did not find any difference in duration of surgery or incidence of transfusion. They noted decreased estimated blood loss (67 mL), but only in the trials that had a no pretreatment arm as opposed to a placebo arm. They noted no difference in terms of quality of life or postoperative complications.
One of the most important questions is whether using a GnRH analog preoperatively may increase the risk of recurrence due to making small myomas harder to find at surgery. Using ultrasonographic detection as the outcome, they noted an increased risk, but the clinical significance of this is not clear. GnRH agonists are likely a useful adjunct in patients who need to correct anemia prior to surgery and may improve the likelihood of completing the procedure through a more cosmetic incision, but they do not appear to routinely improve other relevant clinical outcomes.
Reported in 1997, Deligdisch et al performed a histologic study of the cleavage planes between the myoma and the myometrium in hysterectomy specimens in patients treated with GnRH analogues and a group of untreated controls. They noted that loss of the histologic cleavage plane occurred in 91% of patients pretreated with GnRH analogues and in 50% of controls.34 Theoretically, by decreasing the size of fibroids, some fibroids may decrease in size to the point they are not detectable at the time of surgery, thus increasing the recurrence rate.
A small, placebo-controlled, randomized trial suggests that administering misoprostol at 400 mcg intravaginally 1 hour before surgery significantly increases postoperative hemoglobin levels (9.7 g/dL vs 8.9 g/dL) and decreases estimated blood loss (472 mL vs 621 mL), operating time (48.5 min vs 58 min), and need for transfusion (15.3% vs 33.3%).35
Preoperative bowel preparation is not necessary for these patients unless unusual adhesions are expected. No studies are available on prophylactic antibiotic use. Because this procedure is usually performed on patients who want to retain their fertility and because the consequences of infection on tubal function are severe, many providers administer prophylactic antibiotics empirically. A vaginal preparation is also a sensible precaution because 1-2% of these procedures, by necessity, are converted into abdominal hysterectomies.
Laparoscopic myomectomy
A number of authors have attempted to define who is a candidate for a laparoscopic myomectomy. The size, number, and location of the fibroids as well as the experience of the surgeon all must be factors in the decision to proceed with the laparoscopic approach. Although several suggestions have been made, opinions differ.
In 1991, Nezhat et al reported on the laparoscopic removal of myomas as large as 15 cm in diameter.36 Other authors are more conservative. In 1996, Dubuisson and Chapron suggested not removing any myoma larger than 8 cm and not performing laparoscopic myomectomy if more than 2 myomas are present.37 In 1994, Parker and Rodi suggested limiting the procedure to patients with uteri smaller than 14 weeks' size, fibroids smaller than 8 cm, at least 50% of the myoma being subserosal, and myomas located in noncritical locations.38 In 2003, Sinha et al reported on 51 laparoscopic myomectomies for large myomas ranging in size from 9-21 cm with a mean myoma weight of 700 g and concluded that the laparoscopic approach was a safe alternative to laparotomy.39
GnRH analog use can slightly decrease operating time and blood loss during laparoscopic myomectomy.40 Zullo et al noted that preoperative use of leuprolide acetate decreased estimated blood loss from 172 mL to 132 mL and operating time from 113 minutes to 99 minutes. On the other hand, longer operative times, 112 minutes versus 157 minutes, with preoperative GnRH analog use found by Campo and Garcia, were attributed to difficulty in detecting the myoma cleavage plane.41
All patients undergoing laparoscopic myomectomy should also give consent for laparotomy because conversion to a laparotomy intraoperatively may be necessary in as many as 8% of procedures.27
Hysteroscopic myoma resection
Patient selection is essential to achieve resolution of bleeding symptoms, enhance fertility, and reduce surgical risks. Preoperative imaging with MRI, 3-dimensional ultrasonography or saline-infused sonohysterogram can provide a map of the uterine myomas and identify the intramural component of the fibroids. The European Society of Hysteroscopy designed a classification system for submucosal fibroids based primarily on this concept.- Type 0 fibroids are pedunculated with no intramural component.
- Type I fibroids are sessile submucosal fibroids with less than 50% intramural component.
- Type II fibroids have a greater than 50% myometrial invasion.42
When complete resection of the fibroid is accomplished, recurrence of bleeding is unlikely regardless of the type of fibroid resected. Incomplete resection of the fibroid is more likely in type II fibroids with more extensive intramural component. Calculated from one study was a 50% chance per procedure of complete resection of type II fibroids, 60% of type I fibroids, and 92% of type 0. After an incomplete resection, the residual intramural component is likely to be expelled into the cavity and a second procedure is often successful. The patient with type II fibroids should be counseled on the risk of failure and the procedure should be performed by experienced hysteroscopic surgeons.
Preoperative treatment with danazol or a GnRH agonist has been shown to reduce surgical time, bleeding, and absorbed distension media.43,44 Some authors have recommended pretreatment with a GnRH analogue for submucosal fibroids greater then 3 cm in diameter.45 Other studies have found no benefit and have even suggested a longer operating time possibly due to difficulty with cervical dilation in the pretreated group. Whether the cost and side effects of pretreatment are outweighed by any potential benefit remains unclear.46
The most common complications with hysteroscopic myomectomy are uterine perforation, false cervical canal, and excessive absorption of distension media.47,48 . Hemorrhage and infection are rare and antibiotic prophylaxis is not recommended routinely.49 Preoperative cervical ripening with a prostaglandin analogue has been demonstrated to facilitate cervical dilation. Misoprostol 200 mcg applied vaginally 8-12 hours prior to surgery is well tolerated and can decrease surgical time and reduce the risk of surgical complications.50
Intraoperative Details
Abdominal myomectomy
Patients undergoing abdominal myomectomy require anesthesia adequate for a laparotomy, usually general endotracheal anesthesia. An incision is chosen that allows maximal exposure. Many myomectomies can be performed through a Pfannenstiel incision, but vertical incisions can be used when necessary. In some cases, better exposure could be the difference between the ability to stop hemorrhage and preserve the uterus and the need to proceed with hysterectomy to control bleeding. Several excellent atlases are available for full details of surgery.51,52
One important issue with myomectomy is controlling blood loss from the raw myoma beds after they have been excised. Several techniques have been studied. A randomized trial comparing vasopressin and saline injected into the serosa prior to the uterine incision showed that vasopressin is extremely effective for decreasing blood loss. In this study, 50% of patients receiving saline required transfusion, while none of those in the vasopressin group required transfusion (13% vs 5% decrease in hematocrit values).53
Many providers place tourniquets to control bleeding.54 This is usually performed by making a window in the broad ligament at the level of the internal cervical os bilaterally and passing a Foley catheter or red rubber catheter through the windows and around the cervix and then tightening it with a clamp to constrict the uterine vessels. In combination with this, vascular clamps are generally placed on the utero-ovarian ligaments.
Two randomized trials compared vasopressin and tourniquet use. In 1996, Fletcher et al showed that vasopressin was associated with less blood loss and lower risk of either transfusion or blood loss of more than 1 L.55 In 1993, Ginsberg et al noted no statistically significant difference between the groups, although their study was much smaller.56 No studies are available comparing tourniquet use with no tourniquet use. Study results clearly suggest that vasopressin (usually 20 U in 50-100 mL normal saline) should be injected routinely prior to making the incision in the wall of the uterus. Whether additional use of a tourniquet further decreases blood loss remains unclear. A Cochrane review evaluating techniques to decrease intraoperative blood loss in both abdominal and laparoscopic approaches found that misoprostol, vasopressin, bupivacaine plus epinephrine, and pericervical tourniquet all lead to significant reduction in bloodloss.57
After dilute vasopressin has been injected, an incision is made through the wall of the uterus into the myoma. Once the plane between the myometrium and myoma has been defined, it is dissected bluntly and sharply until the entire fibroid is removed. As many fibroids as possible are removed through a single incision. Once the fibroids have been removed, the defect is closed in layers with delayed absorbable suture.
Proper placement of the incision is frequently overlooked but is important. Reported in 1993, Tulandi et al studied 26 women with uteri larger than 6-8 weeks' size. Abdominal myomectomies were performed, followed by a second-look laparoscopy 6 weeks later. Patients with incisions in the posterior wall of the uterus had a much higher likelihood of significant adhesions as measured by percentage with adhesions or American Fertility Society (AFS) adhesion score compared with patients with incisions in the fundus or anterior wall of the uterus.58 Use of adhesion barriers, including Interceed and Seprafilm, is associated with decreased incidence of adhesion formation.59
Laparoscopic myomectomy
Unfortunately, a number of important unresolved technical issues remain regarding laparoscopic myomectomy. One difficulty is in the removal of the fibroids, which has been performed using morcellation60 , minilaparotomy61 , or colpotomy. Alternatives to these are to destroy the fibroids in place with cryotherapy62 , bipolar cautery63 , or laser64 . No trials have compared these techniques to determine which is the safest or most effective.
Articles by Peacock65 and Parker59 reviewed techniques for laparoscopic myomectomy. Intraoperative port placement depends on uterine size, and size and location of the fibroids. Often, 2 ports are used on the patients left or right side for fibroid enucleation and suturing, including a port 2 cm medial to the iliac crest, as well as a 5 mm port lateral to the umbilicus. For retraction and exposure purposes, another port is placed on the opposite side of these ports. An umbilical port site is made for the laparoscope; however, an upper quadrant port may be necessary for a large uterus.
After vasopressin injection into the myoma, a transverse incision over the fibroid with the Harmonic scalpel or other cautery is extended down to the avascular myoma plane. A tenaculum is then used to grasp the myoma to create countertraction. The cleavage plane between fibroid and uterus is identified, and the myoma is dissected out of the uterus. One to three layers of delayed absorbable sutures are used to repair the myometrium and serosal defect. Morcellation of the myoma is followed by irrigation and placement of adhesion barrier.
Closing the uterine defect left by the destruction or removal of the fibroid is a critical technical issue. This is much more difficult than during an open procedure. As reported in 1991 and 1996, Nezhat et al performed laparoscopic myomectomy and then performed a second-look laparoscopy on 28 women 6 weeks later. They had removed 37 myomas from these women and closed the defects with laparoscopically placed sutures. At the second look, indentations were visible at all of the sites where the myomas had been excised. In addition, 6 uterine fistulas were visible on postoperative HSG findings.36,66
Three prospective randomized trials comparing abdominal and laparoscopic myomectomy are as follows:
- In 2000, Seracchioli et al compared 65 women undergoing abdominal myomectomy with 66 women who underwent a laparoscopic procedure. They excluded patients with more than 3 myomas greater than 5 cm or uterine size extending above the umbilicus. They found significantly less febrile morbidity, lower transfusion rates, and shorter hospitalization stays in the group of women treated laparoscopically.67
- In 2001, Rossetti et al reported on 81 women randomized to laparotomy or laparoscopy for treatment of myomas greater than 3 cm, with no more than 7 myomas per patient. At 40-month follow-up, the recurrence rates were similar between the 2 groups.68
- Alessandri and colleagues randomly assigned 148 women to either laparoscopy or minilaparotomy for fibroid removal. Laparotomy resulted in shorter operative times and lower postoperative hemoglobin, while hospital stay and pain were less in the laparoscopic group. No recurrences were detected in either group after 6 months.69
Hysteroscopic resection of myomas
A thorough discussion of hysteroscopy can be found in eMedicine's Hysteroscopy article. Patients undergoing diagnostic hysteroscopy should also give consent for resection of myomas projecting into the endometrial cavity. Myoma resection is usually performed with a loop electrode by shaving the visible portion of the myoma into small pieces (see Media file 5).70,71,72 Sometimes, myomas deeply embedded in the myometrium cannot be completely excised. Other techniques for removing the myoma hysteroscopically include using an Nd:YAG laser fiber73 or electric myoma vaporizer74 .
Various sizes of operating hysteroscopes are now available, but they all include a telescope with a fiberoptic light source and camera. The angle of the telescope is either 0º or an acute angle of 12-30º. The straight visual 0º scope might be helpful with fundal myomas but an angled perspective is more commonly used for fibroid resection. The telescope inserts through an external sheath and internal sheath for continuous outflow and inflow of distension media.
The working element of the operating hysteroscope is the resecting loop that is available in many sizes and angles. The electrosurgical energy connected to the loop can be monopolar or bipolar. With the monopolar loops, using nonionic distension media such as glycene 5% or sorbitol 1.5% is necessary. With bipolar loops, both electrodes are within the cavity and normal saline can be used for distending solution. For hysteroscopic myomectomy, various laser types and mechanical loops without electrical energy have also been described.
There are multiple methods of using the electrosurgical loop to optimize fibroid resection. To maintain good visualization, fragments of resected fibroid need to be removed during the procedure. The surgeon may transfer fragments out of the field of resection or retrieve them from the cavity by grasping the tissue with the resecting loop. An intrauterine morcellator has recently been introduced that may improve surgical time by aspirating fibroid fragments through the hysteroscope.75 When applying the monopolar loop, currents as high as 75-150 W are required for smooth tissue cutting.76 Current should only be applied while the loop is being retracted into the hysteroscope or while the entire resectoscope is being pulled away from the fundus. A combination of the 2 movements is used by the surgeon to safely and effectively slice through the tissue.
Resection of type 0 fibroids can be accomplished in 1 step by most hysteroscopic surgeons since the border of the fibroid with the endometrium is easily identified.77 Type I and type II fibroids require more surgical expertise as resection of the fibroid extends into the myometrial space. Intraoperative cervical injection of carboprost, a methyl analogue of prostaglandin F2-alpha, has been shown to cause uterine contractions and thereby squeeze the remaining fibroid into the cavity to facilitate a single step.
Concomitantly performing laparoscopy with intramuscular injection of prostaglandin F2-alpha is also effective for resection of large fundal fibroids and provides transabdominal visualization.78 In many circumstances, resection of large fibroids with significant intramural component is a 2-step approach since there is often further intracavitary expulsion of the fibroid after the initial surgery. The second procedure can be performed 3-6 weeks later when the residual fibroid has migrated into the submucosal space.79
Postoperative Details
After abdominal myomectomy, patients are treated as any other patients who have had a laparotomy. Patients should attempt ambulation early, and the diet should be advanced at the surgeon's discretion. The patients tend to be young and healthy; therefore, recovery is usually fairly rapid. Postoperative vaginal bleeding is common. Fever is also common, particularly in the first 48 hours, but does not appear to be due to infection.80 No studies have determined the optimal amount of time patients should wait prior to attempting conception. A prudent plan is to allow patients to heal for at least several months prior to any attempts. Patients should not use tampons, douche, engage in sex, or place anything in their vagina for at least 4-6 weeks postoperatively.
For hysteroscopic myoma resection, some authors advocate the postoperative administration of oral estrogen to decrease the chance of intrauterine synechiae formation, although no studies support this measure.81,82
Follow-up
Patients who have had myomectomies should be monitored for recurrence of myomas. Patients are typically seen for a routine postoperative examination 2-6 weeks postoperatively. A pelvic examination at 3 months, 6 months, and 1 year to assess for myoma recurrence seems reasonable, although no studies have been performed to support this protocol. If no recurrence is observed in 1 year, annual examinations are likely adequate.
In 1997, Vavala et al studied the use of GnRH analog for preventing the recurrence of myomas after myomectomy. The 65 patients who were studied were given leuprolide acetate (Lupron) depot for 3 months each year for 3 years. At the end of this time, the patients showed significantly reduced uterine volume and a reduced myoma recurrence rate compared with untreated patients. Although this suggests that GnRH analog might be useful, the authors did not present data on symptoms or the need for repeat surgery.83 Further study clearly is needed.
Complications
Abdominal myomectomy
Abdominal myomectomy is associated with both short- and long-term problems. Short-term complications include all of the usual complications of gynecologic laparotomy, including bleeding, infection, visceral damage, and thromboembolism. Intraoperative blood loss is variable depending on the size and location of uterine fibroids.
In 1996, Iverson et al reviewed the relative morbidity of abdominal myomectomy compared with abdominal hysterectomy in patients at Tufts Medical Center. Patients who underwent myomectomy had an average blood loss of 464 mL and a risk of transfusion of approximately 28%. However, nearly three quarters of these transfused units were autologous blood replacement, and many of these patients likely would not have received blood if only random donor blood had been available. Approximately 13% of patients had temperatures of at least 38.5°C (101.3°F) 48 hours postoperatively and were started on antibiotics for presumed infection. When compared with hysterectomy, operative times were nearly identical. The blood loss, traditionally thought to be more than with hysterectomy, was actually significantly lower.15
No intraoperative visceral injuries occurred in patients who underwent myomectomy, although a number occurred in patients who underwent hysterectomy. In 1993, LaMorte et al noted similar complication rates in an uncontrolled series of patients at Yale84 , and, in 2000, Sawin and coworkers noted similar results when hysterectomy and myomectomy were compared85 .
Patients undergoing myomectomy have an unusually high incidence of fever occurring in the first 48 hours postoperatively, a phenomenon that appears to be unique to this procedure. This was also studied by Iverson et al in 1999.80 They noted a baseline risk of approximately 33% for fever of at least 38.5°C (101.3°F) within the first 48 hours. When compared with hysterectomy and using multivariate analysis to control for age, parity, estimated blood loss, and type of physician performing the surgery, they noticed a 3.9-fold increased risk. This "myomectomy fever" may be due to the release of unknown pyrogenic factors during the myoma dissection or from hematomas forming in defects left by the removed myomas.
The most significant short-term risk is the potential need to convert a myomectomy to a hysterectomy intraoperatively. This occurs largely for 2 reasons. First, reconstructing the uterus may not always be possible because of the many defects left by the removal of multiple small fibroids or a single large fibroid. Second, a hysterectomy may be necessary intraoperatively to control bleeding. In the Tufts series reported by Iverson et al in 1996, conversion to hysterectomy intraoperatively became necessary in 2 of 103 myomectomies..15 In the Yale series reported by LaMorte et al in 1993, 1 of 128 required a hysterectomy.84 All patients undergoing myomectomies should be apprised of this possibility as part of the consent process.
Only one study separately examined complications in patients who underwent a second myomectomy. In 2002, Frederick et al reported on a study of 58 women who underwent repeat abdominal myomectomy, and they noted 33% febrile morbidity and 700 mL median blood loss. Of these women, 12% were transfused and 1 required hysterectomy.86
Overall, data evaluating abdominal myomectomy and subsequent uterine rupture is lacking. However, 2 case reports revealed postabdominal myomectomy uterine rupture at 20 weeks' and 12 weeks' gestational age87,88 , and 1 study reported 3 uterine ruptures in 24 patients with prior myomectomies involving uterine cavity entry89 .
Laparoscopic myomectomy
Laparoscopic myomectomy has all of the usual risks of laparoscopy, predominantly those related to trocar placement. This includes injury to bladder, bowel, ureter, and blood vessels, and the need to convert to a laparotomy. Rates of conversion vary from very low to 8-10%, largely depending on the complexity of the case.
Suboptimal defect closures are of great concern for uterine rupture in future labor. A number of case reports have been published that describe uterine rupture after laparoscopic myomectomy.90,91,92,93,59 Two retrospective analysis evaluating uterine rupture after laparoscopic myomectomy showed no cases of uterine rupture.94,95 The largest published series of laparoscopic myomectomy reported 1 uterine rupture per 213 patients.27
Hysteroscopic myoma resection
Complications of hysteroscopic myoma resection include hemorrhage, uterine perforation, damage to the cervix, and excessive absorption of the distention media (usually glycine) into the vascular system, which can cause metabolic disturbances.96
The most serious potential complication with hysteroscopic myomectomy is excessive absorption of distension media, which can cause pulmonary edema, hyponatremia, cerebral edema, and even death.97 This is especially true when using nonconducting distension solution with monopolar cautery. A surgeon should also be cautious with saline during resections with bipolar cautery since large volumes of fluid can lead to overload complications. A fluid management system that can accurately calculate the amount of absorbed fluid by measuring the inflow and outflow of distension fluid should be used. Intracervical injection of dilute vasopressin, in addition to reducing the force needed to dilate the cervix, has also been shown to decrease the absorption of distention fluid.98,99
In 1991, Corson and Brooks noted 1 case of heavy bleeding that required transfusion and 3 uterine perforations out of 92 patients undergoing hysteroscopic myoma resection.70 In 1993, Indman noted distension media complications in 2 of 51 women.100 Intrauterine synechiae can also occur after hysteroscopic myoma resection.101
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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
