Medical management of Myomas -beningn tumour of uterus

 Planning Tr for myomas:-It is important to consider the position, size and number of the fibroids when making any comparison between different treatment modalities. Until recently, many women have undergone hysterectomy even though they would have preferred a treatment that allowed them to maintain their fertility. It is for this reason that a number of options have been developed , WE should remember that myomectomy may also be associated with a risk of hysterectomy, postoperative adhesion formation and recurrence.. It is for this reason that a number of options have been developed  .Drug A) Mifepristone can be prescribed for small sized myoma/myomas but not for subfertility cases. Problem is symp may recur after stoppage of mifepristone. Progesterone receptor modulators exhibit partial and mixed agonist/antagonist effects on various progesterone target tissues in animals and humans and have been shown to be effective in decreasing menstrual blood loss. This is associated with an endometrial antiproliferative effect, although ovarian function may not change. The histological findings have proved difficult to interpret, although they are not thought to represent an increased likelihood of malignancy. However, progesterone receptor modulators produce unusual effects on the endometrium that are difficult to interpret, which is limiting their long-term use. Recent publications suggest that progesterone receptor modulators increase the haemoglobin when administered for 3 months preoperatively and, since they relieve menstrual problems during this period, may be used in this context in the same way as GnRH agonists. There is decrease in uterine artery blood flow with mifepristone which also may contribute to the efficacy of other treatments for fibroid-related symptoms such as GnRH agonists, in, addition to the decrease in fibroid . When developed further, Mifepristone are likely to be very popular agents for use by women who wish to have conservative treatment for their uterine fibroids.

Progesterone receptor modulators have been studied in women with uterine fibroids over a 3-month treatment period and have a dose- dependent effect leading to decreased menstrual blood loss in up to 83% of women. They also decrease uterine artery blood flow.

Progesterone receptor modulators have a modest effect on size which is not related to decreased menstrual blood loss. This means they are unlikely to be effective where fibroid size is the principal presenting complaint.

Progesterone receptor modulators:

• are effective

• improve menstrual problems

• improve quality of life

• have little impact on ovarian function. The drugs are affordable.

Drug B :- Gonadotrophin-releasing hormone (GnRH) agonists Oestrogen is essential for fibroid growth. Gonadotrophin-releasing hormone (GnRH) agonists down regulate the pituitary with the subsequent decrease in estradiol levels leading to fibroid shrinkage. The fibroid shrinkage that occurs with hypoestrogenic may be reversed by Progesterone receptor modulators

Drug:-LNG-IUS:  But the presence of intrauterine progestogen does not have a consistent effect on fibroid size, although it is associated with relief of HMB in women with fibroids less than 4 cm in diameter. Some studies suggest that progesterone and its receptor play a key role- The role of progesterone in the control of fibroid growth needs some clarification.

• LNG IUS are well tolerated.

• Conservative Surgical Tr of myoma except TAH: à1) Myomectomy, 2)  Uterine artery Embolization .3) MRI-guided  Uterine artery Embolization)  High-intensity focused ultrasound

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Conclusion:-UAE and possibly the levonorgestrel-secreting intrauterine system are likely to be more suitable for women with multiple fibroids than MRI-guided focused ultrasound. None of these treatments is likely to be of value in women with large fibroids where size is the main symptom as the mean decrease in fibroid volume is less than 50% in most studies. Myomectomy may also be associated with a risk of hysterectomy, postoperative adhesion formation and co administration of synthetic progestins, although such  is not a consistent finding across all studies. Progesterone receptor modulators have also been developed for use preoperatively  and potentially as a long-term medical treatment.

Oestrogen is essential for fibroid growth. Gonadotrophin-releasing hormone (GnRH) agonists downregulated the pituitary with the subsequent decrease in estradiol levels leading to fibroid shrinkage. Progesterone and its receptor play a key role- The fibroid shrinkage that occurs with hypoestrogenic may be reversed by co-administration of synthetic progestins, although  such policy is not a consistent finding across all studies.