Uterine leiomyomas, current concepts: pathogenesis, impact on reproductive health, and medical, procedural, and surgical management

Abstract

Leiomyomas are such common tumors of the uterus that at least two-thirds of women will have at least one by the age of 50. Despite this high incidence, we know relatively little about their cause, growth and development, and contribution to the genesis of reproductive disorders. The prevalence of lesions puts women with associated butun related symptoms at risk for unnecessary and/or unsuccessful interventions,especially if they have not been carefully evaluated and counseled. Indeed, because the majority of leiomyomas do not cause symptoms, when a woman presents with AUB, infertility, pelvic pain, or vague abdominal complaints, it is possible if not likely that the cause of the problem exists elsewhere. The other overwhelming impression that can be gleaned is this: when leiomyomas are the cause of the symptoms,particularly in women desiring to preserve fertility, the tumors have already and frequently induced irreparable harm, a circumstance that cries out for a strategy of early detection and interventions designed to minimize morbidity.Fortunately, because of the efforts of a few, we are just beginning to understand the potential molecular mechanisms by which leiomyomas may contribute to reproductive tract symptoms such as AUB, infertility, and pregnancy loss, work that may contribute to the development of more specific medical therapeutic techniques and strategies. The use of increasingly precise and accessible imaging for diagnosis,combined with the application of customized intrauterine drug-releasing systems or minimally invasive and highly accurate targeted ablative technologies that minimize collateral damage, may provide women the opportunity to avoid the mutilating,painful, expensive, and frequently unsuccessful surgical interventions of today that are applied to end-stage disease.For the present, clinicians should evaluate any woman with reproductive tract symptoms and leiomyomas carefully and with skepticism, ensuring that they have done all that is necessary to determine if the lesion or lesions are related to the problem. If leiomyomas are the suspected or known cause, clinicians must also be prepared to offer or otherwise provide access to the complete spectrum of care that the patient deserves, regardless of the limitations of the clinician’s training, experience,or institutional environment. Such an approach will limit the number of unnecessary and ineffective interventions and, it is hoped, minimize morbidity while optimizing quality of life for affected women.