Author(s): DesireéÃ© M McCarthy-Keith 1 , Alicia Y Armstrong [[dagger]â ] 2
aromatase inhibitor; fibroid; hysterectomy; magnetic resonance-guided focused ultrasound surgery; myomectomy; uterine artery embolization
Epidemiology of fibroids
Uterine fibroids are the most common benign gynecologic tumor in reproductive-aged women. In the USA, by the time a woman reaches the age of 50 years, her lifetime risk of having fibroids is 70%  . Ultrasound screening of asymptomatic women demonstrates that black women develop fibroids at a younger age, 10-â15 years earlier than white women [2,3] , and have higher cumulative incidence at every age compared with white women  . By the end of the reproductive years, the incidence of fibroids in black women is over 80%, compared with 70% in whites  . Many uterine fibroids go undiagnosed and although the majority of women with fibroids are asymptomatic, approximately 20-â50% of women have symptoms significant enough to warrant clinical intervention  . The most common symptoms of uterine fibroids are pelvic pain, pelvic pressure and menorrhagia. Women with fibroids may also experience infertility, miscarriage, preterm deliveries and complications in late pregnancy [4-â9] . Treatment of symptomatic fibroids is the leading indication for hysterectomy in the USA and the cost to the US healthcare system for all fibroid-related care is estimated at US$2.1 billion per year  . Treatments for symptomatic fibroids include surgical, medical and minimally invasive options, and there are numerous investigations of new therapies on the horizon. At present, only surgical management with hysterectomy offers definitive treatment; however, the ideal alternative to surgery that offers long-term resolution of symptoms has not yet been identified. Since most women present for evaluation of symptomatic fibroids during their reproductive years, therapies must also be developed with preservation of reproductive potential in mind. In this article we review traditional therapies and recent advances in the management of symptomatic uterine fibroids.
Surgical treatment of fibroids
Surgery remains the mainstay of treatment for symptomatic fibroids. Hysterectomy is the only definitive procedure for permanent removal of fibroids, but myomectomy is an alternative for women who desire uterine preservation. As mentioned, treatment of symptomatic fibroids is the most common indication for hysterectomy  , which accounts for 30% of hysterectomies in white women and more than 50% in black women  . Hysterectomy may be preferred over myomectomy because it eliminates current symptoms as well as the possibility of recurrent symptoms in the future. There is significantly greater morbidity associated with hysterectomy than less invasive procedures and this must be considered when electing for surgical management.
Myomectomy is an alternative option for women desiring surgical removal of fibroids, but who plan to have children in the future or who wish to retain their uterus. Abdominal myomectomy is usually reserved for cases where the uterus is significantly enlarged, there are multiple fibroids present or the fibroids are deep within the uterine wall. The operative time, blood loss and length of postoperative hospitalization for abdominal myomectomy are similar to those for abdominal hysterectomy [12-â14] . A disadvantage of this procedure is the risk of recurrence or development of new fibroids...