RESUMEN
A debate among gynecologic and reproductive surgeons is whether or not there is a clinical need to treat all intramural myomas. Considerations include myoma size and number, ability to access them, whether or not they compromise the endometrium, and treatment effect on gynecologic, reproductive, and obstetric outcomes. We conducted a detailed study regarding intramural myomas, their prevalence in subject populations, the imaging methods used to detect them, their growth rate, their suspected adverse effects on gynecologic, fertility, and obstetric outcomes, and the effectiveness of various treatment methods. The growing body of evidence reported in the literature supports the need to manage intramural myomas and to treat them appropriately.
RESUMEN
STUDY OBJECTIVE: To evaluate the effect of radiofrequency volumetric thermal ablation (RFVTA) on menstrual bleeding in patients with intramural myomas. DESIGN: Retrospective analysis of a recently completed prospective trial of laparoscopic ultrasound-guided RFVTA in which 135 subjects had objectively measured heavy menstrual bleeding (≥160 to ≤500 mL) and confirmed submucosal, intramural, and subserosal myomas. We analyzed the pretreatment monthly menstrual blood loss as well as the response to treatment based on the types of myomas, specifically those subjects with only intramural myomas versus those with only submucosal myomas or those with both (Canadian Task Force classification II-2). SETTING: Outpatient hospital and private surgery centers. PATIENTS: One hundred thirty-five premenopausal symptomatic women (mean age: 42.4 ± 4.5 years) with uterine myomas and heavy menstrual bleeding confirmed by alkaline hematin analysis. INTERVENTIONS: Laparoscopic ultrasound-guided RFVTA. MEASUREMENTS AND MAIN RESULTS: Menstrual blood loss (MBL) at baseline and at 12 months after the procedure was quantified in 122 subjects with intramural myomas (including those that abut the endometrium, those that are within the myometrium, and those that extend from the serosa into the myometrium) and/or submucous myomas. Although 91.8% (112/122) of these subjects had 1 or more intramural myomas, submucous myomas were present in fewer than half of the subjects ([48.4%]). We identified 10 subjects who had submucous but no intramural myomas. This group had a significant (-45.1%) posttreatment decrease in monthly bleeding (95% confidence interval [CI], -78.0% to -12.2%; p = .013). In this same study, there were 63 subjects with intramural myomas and no submucosal myomas, and their posttreatment decrease in MBL of -31.8% was also clinically and statistically significant (95% CI, -41.4% to -22.2%; p<.001). Of those 63 subjects was a subset with intramural myomas (n = 27) without myomas abutting the endometrium or submucous myomas; this third set also resulted in a clinically and statistically significant reduction in MBL (-25.0% and -65.22 mL; 95% CI, -38.8% to -11.2%; p = .001). CONCLUSION: Although it has been known that the treatment of submucous myomas results in a reduction of MBL, this is the first study to show that radiofrequency ablative therapy for intramural myomas without a submucosal component will also result in a significant reduction in menstrual blood loss.