“Not unlike many issues in women’s health, there are many challenges for women to access evidenced-based medical, surgical and radiological interventions for uterine fibroids,” said Senior Author Nicholas Leyland, MD, a Professor and Immediate Past Chair of OB/GYN at McMaster University in Hamilton, Ontario, Canada. “Change in medicine is also difficult for many in the field.”
Leyland noted that many medical and surgical strategies are available to treat uterine fibroids, with healthcare providers perhaps benefiting from practical guidance in developing treatment plans with a personalized approach. Patient-centered, uterine-preserving procedures can generally be prioritized, based on the patient’s goals and the clinical scenario. “Occasionally, though, hysterectomy performed in the least invasive manner may be the preferred treatment option for some patients who require definitive treatment,” Leyland told Contemporary OB/GYN.
A diagnostic challenge for uterine fibroids is lack of adherence by physicians to standardized imaging guidelines. The quality of the ultrasound reports frequently fail to meet internally endorsed guidelines. “Clear, high-quality imaging is needed to determine fibroid size, number, location and impact on the endometrial cavity and the endometrium,” Leyland said. The key to providing surgical interventions is to pursue less invasive options, based on the best available evidence, according to Leyland.
Two less invasive non-surgical alternatives are uterine artery embolization to interrupt blood flow to the uterus and fibroids, and magnetic resonance imaging-guided, high-intensity-focused ultrasound (HIFU) to induce fibroid necrosis and regression. Ultrasound-guided HIFU ablation has also been shown to improve fibroid symptoms and reduce fibroid volume, without causing permanent adverse effects.
“Unfortunately, clinicians who are trained as surgeons are often negatively biased toward management strategies that are nonsurgical,” Leyland said. “Exploring these issues at depth would bring us closer to understanding such biases. In addition, there are still many clinicians who have not been afforded the training, the technology or the appropriate compensation to provide the less invasive options.”
Myomectomy or hysterectomy, particularly by open surgery, may produce high psychological and economic burden. The risk of recurrence of uterine fibroids with uterine-sparing procedures also looms. “Surgical management should ideally be performed by higher volume surgeons and medical centers to improve outcomes, decrease length of surgery and decrease risk of complications,” Leyland said. “Patients undergoing surgery also benefit from enhanced recovery protocols that bolster recovery and improve the patient experience.”
A recent challenge to patient care, due to the COVID-19 pandemic, are physician–patient interactions that have shifted from in-person consultations to virtual appointments. Curtailing in-person assessment may limit accurate evaluation or examination of the patient and prevent or delay tissue sampling.
There are also recent changes to evidence-based, clinically approved therapies for uterine fibroids, such as elagolix (Orilissa, AbbVie), an oral gonadotropin-releasing hormone receptor antagonist given in combination with hormonal add-back therapy, which in May 2020 became the first approved oral treatment by the Food and Drug Administration (FDA). The drug is indicated for the management of heavy menstrual bleeding (HMB) associated with fibroids in premenopausal women for up to 24-months.
Disclosure
Leyland serves on advisory boards for Bayer, AbbVie, Ethicon and Baxter.
REFERENCE: Contemporary OB/GYN; 17 MAY 2022; Bob Kronemyer [Leyland N, Leonardi M, Murji A, et al. A call?to?action for clinicians to implement evidence?based best practices when caring for women with uterine fibroids. Reprod Sci. 2022. 29:1188–1196]