Ebook Management of Uterine Fibroids: An Update of the Evidence
Uterine leiomyomata, or fibroids, are benign growths of smooth muscle and connective tissue anchored in the muscular wall of the uterus. Fibroids are the most common female pelvic tumor; their etiology is unknown. They develop from microscopic nests of uterine muscle cells and have been documented to be composed of numerous copies of the same or very few cells, which is termed monoclonal expansion.
Clinically they may initially be detected as small nodules identified only by imaging studies; they can potentially progress through a spectrum of growth from grape size to large masses that can be palpated through the abdominal wall. Research is limited for the purposes of describing the typical fibroid because most data are derived from intervention studies in which the participants had sought treatment and further determined by the inclusion and exclusion criteria of the studies. With that caveat, fibroids documented in treatment studies are often in the size range of 2 to 7.5 centimeters or the dimensions of a large marble to modestly smaller than a baseball.
Clinical convention holds that symptoms and need for treatment are in large part related to a combination of type of fibroid, position within the uterus, and fibroid size. Fibroids are most often grouped as one of four types: submucous (beneath the mucosa, or uterine lining) are immediately adjacent to or jut into the uterine cavity; intramural are entirely within the wall of the uterus; subserous (beneath the serosa) distort the contour of the outer surface of the uterus; and pedunculated are attached to the uterus by a stalk. Some larger fibroids may have characteristics of each type, for instance distorting the interior of the uterus, occupying a component of the uterine wall, and distorting the external contour. Thus, in examining articles for systematic review, noting how authors have operationalized these categories for analysis is important.
Submucous fibroids are clinically described as having the greatest influence on irregular bleeding and reproductive outcomes because the fibroid may act as a physical irritant, much like a foreign body in the uterus, that interferes with the stability of the uterine lining, called endometrium, or with successful implantation of an embryo. Architectural explanations, such as overall enlargement of the uterus by the size and number of fibroids, are often used to describe why fibroids cause common symptoms like heavy menstrual bleeding. Position and size with respect to other structures such as the bladder, bowel, vaginal vault, and nerve bundles in the pelvis are most often used to explain bulk symptoms (i.e., pressure, urinary frequency, constipation or pain with bowel movements, pressure or pain with intercourse, and more generalized pain symptoms). Nonetheless, many fibroids across a large range of sizes do not cause symptoms.
The factors that determine which women develop symptoms are unknown.Fibroids have not been identified before onset of menses. Prevalence increases with age until the hormonal changes of menopause, after which new fibroids are rare. Developing a fibroid or multiple fibroids by the time of menopause is the rule rather than the exception; the cumulative incidence by age 49 is nearly 70 percent among white women and more than 80 percent among black women. Thus, across the reproductive years, most women whether with or without symptoms are developing fibroids from initial microscopic nests of monoclonal uterine muscle cells.
Prevalence estimates, from clinical populations, range from 20 percent to 77 percent. The highest of these estimates is from a study that evaluated all hysterectomy specimens from a single institution by using 2 millimeter sections to detect even very small fibroids.The central challenge in understanding the onset of fibroids and their growth is the need for uniform documentation using imaging techniques in women, across a wide age spectrum and variety of reproductive histories.
Contents
Executive Summary
Evidence Report
Chapter 1. Introduction
Risk Factors for Uterine Fibroids
Management of Uterine Fibroids
Key Questions and Analytic Framework
Key Questions
Analytic Framework for the Management of Uterine Fibroids
Production of This Evidence Report
Organization of This Evidence Report
Technical Expert Panel (TEP)
Uses of This Report
Chapter 2. Methods
Literature Review Methods
Inclusion and Exclusion Criteria
Literature Search and Retrieval Process
Literature Synthesis
Development of Evidence Tables and Data Abstraction Process
Quality Rating of Individual Studies
Strength of Available Evidence
External Peer Review
Chapter 3. Results
KQ 1: Incidence and Prevalence of Uterine Fibroids
KQ 2: Outcomes of Interventions for Relief of Symptoms Related to Uterine Fibroids
- Expectant Management: Overview and Nomenclature
Expectant Management: Results
Pharmaceutical Management: Overview and Nomenclature
Pharmaceutical Management: Results
Uterine Artery Embolization: Overview and Nomenclature
Endometrial Ablation (With or Without Myomectomy)
In Situ Destructive Techniques (MRI-Guided Focused Ultrasound):
Overview and Nomenclature
Myomectomy: Overview and Nomenclature
Myomectomy: Results
Hysterectomy: Overview and Nomenclature
Hysterectomy: Outcomes
Complementary and Alternative Medicine
KQ 3: Treatment for Goals Other than Symptom Relief
- Pregnancy Outcomes: Overview
Pregnancy Outcomes: Results
Preventing Further Growth: Overview
Preventing Further Growth: Results
KQ 4: Costs of Fibroid Treatment
Chapter 4. Discussion
Principal Findings
- KQ 1: Incidence and Prevalence of Uterine Fibroids
KQ 2: Outcomes of Treatment of Uterine Fibroids for Symptoms
KQ 3: Outcomes of Treatment of Uterine Fibroids for Other Reasons
KQ 4: Costs of Fibroid Treatment
KQ 5: Modifiers of Outcomes
KQ 6: Comparisons of Treatments
KQ 7: Geographic Variation in Treatment
Limitations of the Evidence Base and this Review
Limitations of the Evidence Base
Limitations of the Review
Future Research Directions
Ability To Assess Internal and External Validity
Study Populations of Adequate Size for Assessing Key Outcomes
Standard Nomenclature and Validated Measures
Analysis Methods Matched to the Outcomes of Interest
Direct Comparisons of Treatment Options
Content Priorities
Conclusions
References
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