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Guideline No. 389-Medical Management of Symptomatic Uterine Leiomyomas – An Addendum

      Abstract

      Objectives

      The aim of this guideline is to provide clinicians with an update to the 2015 Clinical Practice Guideline on the Management of Uterine Fibroids. As new information and evidence has become available since 2015, the Gynaecology Clinical Practice Committee of the Society for Obstetricians and Gynaecologists of Canada has determined that an addendum to that document was necessary to inform members about treatment modalities for uterine fibroids.

      Outcomes

      Implementation of this guideline update should optimize the decision-making process of women and their health care providers in proceeding with further investigation or therapy for uterine leiomyomas, having considered the disease process and available treatment options and reviewed the risks and anticipated benefits.

      Evidence

      Published literature was retrieved through searches of PubMed, CINAHL, and Cochrane Systematic Reviews in February 2015 to April 2018, using appropriate controlled vocabulary (uterine fibroids, myoma, leiomyoma, myomectomy, myolysis, heavy menstrual bleeding, and menorrhagia) and key words (myoma, leiomyoma, fibroid, myomectomy, uterine artery embolization, hysterectomy, heavy menstrual bleeding, menorrhagia). The reference lists of articles identified were also searched for other relevant publications. Results were restricted to systematic reviews, randomized controlled trials or controlled clinical trials, and observational studies. There were no date limits, but results were limited to English or French language materials. Searches were updated on a regular basis and incorporated in the guideline to April 2018. Most of the unpublished data have not been evaluated scientifically. The product monograph was also reviewed up to December 31st, 2018.

      Benefits, Harms, and Costs

      The majority of fibroids are asymptomatic and require no intervention or further investigations. For symptomatic fibroids such as those causing menstrual abnormalities (e.g., heavy, irregular, and prolonged uterine bleeding), iron deficiency anemia, or bulk symptoms (e.g., pelvic pressure/pain, obstructive symptoms), hysterectomy is a definitive solution. However, it is not the preferred solution for women who wish to preserve fertility and/or their uterus. The selected treatment should be directed towards an improvement in symptomatology and quality of life. The cost of the therapy to the health care system and to women with fibroids must be interpreted in the context of the cost of untreated disease conditions and the cost of ongoing or repeat investigative or treatment modalities.

      Values

      The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care.

      Recommendations

      • 1
        Prolonged intermittent administration of selective progesterone receptor modulators can be used to treat fibroid-related symptoms and is generally safe, well tolerated, and efficacious (I-B).
      • 2
        Women treated with ulipristal acetate should be screened for risk of liver impairment prior to commencing therapy and undergo liver enzyme monitoring monthly during treatment courses and 2 to 4 weeks following completion of the course of therapy. Physicians should be aware of the signs and symptoms of liver failure, and patients should be apprised of the symptoms of liver failure (III-C).
      • 3
        Gonadotropin-releasing hormone agonists have been shown to decrease fibroid size, improve anemia, and reduce the probability of perioperative blood transfusions (I-A).
      • 4
        Preoperative anemia (hemoglobin <120 g/dL) prior to elective gynaecologic surgery has been associated with adverse outcomes. Attempts should be made to correct anemia with menstrual suppression and/or iron therapy (II-A).

      Key Words

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      Linked Article

      • The Management of Uterine Leiomyomas
        Journal of Obstetrics and Gynaecology Canada Vol. 37Issue 2
        • Preview
          The aim of this guideline is to provide clinicians with an understanding of the pathophysiology, prevalence, and clinical significance of myomata and the best evidence available on treatment modalities.
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