Miomas uterinos: opciones terapéuticas
Written by:The doctor. Monleón is a specialist in Gynecology and Obstetrics and has focused his career on the investigation of uterine fibroids, pathology of which he is an expert and develops in this article.
The treatment of myomas has been throughout the surgical time whenever it has exceeded the possibilities of expectant treatment, that is, with few options for pharmacotherapy.
However, over time, new treatments have been developed thanks to the application of new technologies and drugs that manage to act directly on the fibroid.
Uterine myomas: drug treatment
A distinction is made between those drugs intended to act specifically on fibroids, decreasing their size and, therefore, their symptoms, which we call specific treatment, and the group of drugs whose objective is to reduce symptoms such as pain and bleeding, and who frequently use patients with myomatous uteri to improve their quality of life.
- Symptomatic treatment
They are focused on the management of bleeding, reducing in turn problems such as oligovulation. As a general rule, it usually has a high failure rate, and it ends up in a surgical process, although since they are relatively innocuous they can be tested during a period of between three and six months.
Antifibrinolytic agents such as traxenamic acid contribute to decrease menorrhagia, and are used as a first option, since they are well tolerated and safe.
The progesterone IUD shows an improvement in bleeding and uterine volume, although it requires more caution in submucosal fibroids.
The Estroprogestágenos have a limited effectiveness, but help regulating the cycle.
Other substances such as NSAIDs have not shown a direct benefit, although they can be used in selected cases.
- Myoma specific therapy
Its main objective is to reduce the size of the myoma itself. To this day they are still a provisional therapy prior to surgery, but the development of new drugs is promising. The most outstanding are the following:
o GnRH analogues: they are an effective therapy, creating a menopausal climate that leads to an improvement in anemia and a reduction in tumor volume, although they should not be prolonged beyond four or six months due to side effects and the osteoporosis it causes.
o Mifepristone: it is an antiprogestogen that has shown reduction of symptoms such as anemia, bleeding and pain, as well as uterine volume.
o Aromatase inhibitors: selective modulators of the progesterone receptor and another series of molecules that have shown effects in volume reduction.
Uterine myomas: interventionist techniques
This category includes so-called interventional techniques, including surgical techniques and radiological techniques.
Hysterectomy is the definitive and radical treatment to solve myomatous pathology. Myomectomy offers the possibility of conserving the uterus, being the Hysterectomy a technique of choice to preserve the uterus.
o Myolysis : refers to thermal coagulation with heat or cold of myomatous tissue directed by laparoscopy or percutaneously. Although in principle it is an application technique that myomectomy, the complexity of delimiting the energy field with possible injuries of organs and neighbors and their own limitations, reduce their indications of use to very specific cases.
o Hysterectomy : is the radical treatment that in addition to solving the symptoms eliminates the possibility of recurrence of myomas and provides a definitive and therefore attractive solution for women who have completed their genetic desire and who wish to avoid future problems.
o Myomectomy : is the classic solution for women who want to keep the uterus being an effective therapy for bleeding and pelvic pressure. The time of operation and hospital stay are comparable to hysterectomy. To perform a myomectomy we must contemplate three possible surgical routes. If it is a submucosal myoma, hysteroscopy is the choice, while in the subserosal or intramural areas we have laparotomy (LPT) and laparoscopy (LPS).
o Embolization of the uterine artery or myoma : it is a minimally invasive option with shorter time of admission and better recovery than surgery. However, it entails a greater number of complications and re-admissions, as well as a higher failure rate. It should be reserved for very conscientious women, who want to preserve the uterus and do not want to spend, although in recent times it has lost prominence in favor of other less invasive techniques.
Conclusions
In asymptomatic women expectant management as a general rule is of choice. In cases of infertility, hydronephrosis or giant tumors, other possibilities must be considered.
The idea of prophylactic treatment has to be abandoned both in case the myoma grows in the future or becomes malignant, since the risk of intervention overcomes the low probability of potential complications.
Those premenopausal patients who have already been mothers can benefit from asymptomatic medical treatment suited to their needs.
In cases where a definitive process is indicated, hysterectomy is the choice, generating adequate levels of satisfaction.
Special mention must be made of submucosal fibroids, in which hysteroscopic resection is recommended.
In women with genetic desire, myomectomy is recommended, although the route of choice will depend on the surgeon's experience and the size of the fibroids.
