Current evidence based management of fibroids. Consideration of UK practice recommendations.

1. Rajesh Varma MA PhD MRCOG Consultant Obstetrician and Gynaecologist Guy’s and St.Thomas’ NHS Foundation Trust 1415-1515: Tue 25 th November 2008 Hot Topics in Clinical Practice Postgraduate Centre, Gassiot House, St.Thomas’ Hospital

3. Wamsteker K et al. Transcervical hysteroscopic resection of submucous fibroids for abnormal uterine bleeding: results regarding the degree of intramural extension. Obstet Gynecol 1993; 82(5):736-740.

7. Myomectomy and Fertility Klatsky PC et al. Fibroids and reproductive outcomes: a systematic literature review from conception to delivery. Am J Obstet Gynecol. 2008 Apr;198(4):357-66. ASRM. Myomas and reproductive function. Fertility and Sterility, Volume 90, Issue 5, Supplement 1, November 2008, Pages S125-S130 Pritts EA et al. Fibroids and infertility: an updated systematic review of the evidence. Fertil Steril. 2008 Mar 11 Removal of the intracavity component of the submucous fibroid improves fertility (RR 1.72; 95% CI 1.13-2.58) Subserosal fibroids do not affect fertility outcome Intramural fibroids appear to decrease fertility, but the results of therapy are unclear. (Level II evidence)

8. NICE (Jan 2007) HMB

9. MEDICAL THERAPIES FIBROID SIZE AUB FERTILITY NSAIDs No effect fibroid size Decrease 30% No effect COC No data Decrease 20-30% Contraceptive GNRHa * (3m-6m) Decrease 30% Decrease uterine volume by 35% Decrease >80% Contraceptive Progestins LARC LNG-IUS Mirena (uterine cavity<12cm) Decrease 30% Decrease uterine volume by 35% Decrease>60% Breakthrough bleeding systemic side effects Contraceptive

11. NEW MEDICAL THERAPIES (UNDER TRIAL) FIBROID SIZE AUB FERTILITY GnRH antagonist Ganirelix (sc daily/6m) Decrease 30-40% Decrease Contraceptive Mifepristone (5mg daily/6m) Decrease 40% Decrease uterine size 40% Decrease (risk of endometrial hyperplasia) Contraceptive SPRM Asoprisnil (10mg daily/6m) Decrease Decrease Contraceptive Aromatase Inhibitors Decrease Decrease Contraceptive

12. Fibroids >3cm size Fertility preserved Contraceptive Fertility is potentially retained

14. Abdominal Myomectomy

15. Value of adhesion prevention ?

16. Hysteroscopic Myomectomy Versapoint ® Resectoscope

17. Hysteroscopic myomectomy Fibroid size Intracavity fibroid 90-100% AUB Decrease >80% Fertility Increase 40-60% Secondary treatment (2yr 10%; 5yr 30%) Complication rate 1-2% Uterine perforation Sepsis; intrauterine adhesions Haemorrhage Hyponatraemic fluid overload Additional treatment May be combined with endometrial resection or ablation-improved effect on AUB

19. 3.5mm diameter disposable outer sheath

20. Video clip Outpatient fibroid resection

23. NICE (Oct 2004) Audit and review clinical outcomes of all patients having UAE . Data should be submitted to the British Society of Interventional Radiology registry (www.bsir.org).

26. NICE (Sept 2007) Audit and review clinical outcomes of all patients having MRgFUS. Data should be submitted to the British Society of Interventional Radiology registry (www.bsir.org).

27. MRI-guided focused ultrasound (MRgFUS) Hindley, J. et al. Am. J. Roentgenol. 2004;183:1713-1719 Woman lying on ExAblate 2000 (InSightec) focused ultrasound system ready to be placed into MRI unit

29. Hindley, J. et al. Am. J. Roentgenol. 2004;183:1713-19 AFTER MRgFUS: Non-Perfused Volume (NPV) ratio calculated from the gadolinium-enhanced MRI performed immediately after treatment BEFORE

32. CONSUMER WEBSITE UNDER DEVELOPMENT