UTERINE FIBROID

INTRODUCTION

A uterine fibroid (also uterine leiomyoma, myoma, fibromyoma, leiofibromyoma, fibroleiomyoma, and fibroma) is a benign tumor that originates from the myometrium and the accompanying connective tissue of the uterus. Fibroids are the most common benign tumors in females and typically found during the middle and later reproductive years. Fibroids are often multiple and if the uterus contains too many leiomyomatas to count, it is referred to as uterine leiomyomatosis. The malignant version of a fibroid is uncommon and termed a leiomyosarcoma.

PREVALENCEAbout 20-40% of women will be diagnosed with leiomyoma. The condition is about twice as common in black women as white women. Estrogen receptors on fibroids cause them to respond to estrogen stimulation during the reproductive years. During hypoestrogenic states, such as after menopause, leiomyoma are expected to shrink. Leiomyoma are more common in overweight women (because of increased estrogen from adipose aromatase activity).

PATHOLOGY AND HISTOLOGY

Leiomyomas grossly appear as round, well circumscribed (but not encapsulated), solid nodules that are white or tan, and show whorled appearance on histological section. The size varies, from microscopic to lesions of considerable size. Typically lesions the size of a grapefruit or bigger are felt by the patient herself through the abdominal wall.

Microscopically, tumor cells resemble normal cells (elongated, spindle-shaped, with a cigar-shaped nucleus) and form bundles with different directions (whorled). These cells are uniform in size and shape, with scarce mitoses. There are three benign variants: bizarre (atypical); cellular; and mitotically active.

For decades, Estrogen has been known to stimulate fibroids, but more recent studies have also revealed a possible role of progesterone and progestins to fibroid growth as well, and applicability of progestin agonists as part of treatment are currently being considered.

In very rare cases, malignant (cancerous) growths, leiomyosarcoma, of the myometrium can develop.

LOCATION

Growth and location are the main factors that determine if a fibroid leads to symptoms and problems. A small lesion can be symptomatic if located within the uterine cavity while a large lesion on the outside of

the uterus may go unnoticed. Different locations are classified as follows:

Intramural fibroids They are located within the wall of the uterus and are the most common type; unless large, they may be asymptomatic. These fibroids can cause the uterus to appear larger in size which can be mistaken for weight gain or pregnancy. Associated symptoms include heavy menstrual bleeding, pelvic and back pain, frequent urination and pressure.

Subserosal fibroids are located underneath the mucosal (peritoneal) surface of the uterus and can become very large. They develop in the outer portion of the uterus and continue to grow outward. They can also grow out in a papillary manner to become pedunculated fibroids. These pedunculated growths can actually detach from the uterus to become a parasitic leiomyoma. These fibroids typically do not affect a woman's menstrual flow, or cause excessive menstrual bleeding, but can cause pain due to their size and the added pressure on other organs.

Submucosal fibroids are located in the muscle beneath the endometrium of the uterus and distort the uterine cavity; even small lesion in this location may lead to bleeding and infertility. A pedunculated lesion within the cavity is termed an intracavitary fibroid and can be passed through the cervix.

Cervical fibroids are located in the wall of the cervix (neck of the uterus). Rarely fibroids are found in the supporting structures (round ligament, broad ligament, or uterosacral ligament) of the uterus that also contain smooth muscle tissue.

Fibroids may be single or multiple. Most fibroids start in an intramural location, that is the layer of the muscle of the uterus. With further growth, some lesions may develop towards the outside of the uterus or towards the internal cavity. Secondary changes that may develop within fibroids are hemorrhage, necrosis, calcification, and cystic changes.

SYMPTOMS: They relate to the location of the lesion and its size (mass effect).

Menstrual disturbance: Fibroid is an important cause of uterine bleeding mainly menorrhagia or intermenstrual bleeding mainly in sub mucous type and as thus can present with symptoms of anemia. Progressive menorrhagia seen in intramural and submucous myoma is due to increased vascularity, endometrial hyperplasia and enlarged uterine cavity. Further away from the cavity, lesser is the possibility of menorrhagia. For this reason, subserous and pedunculated fibroid donot cause menorrhagia.

Poly menorrhea: it occurs when cystic ovaries and pelvic inflammatory disease coexist with fibromyomas.

Metrorrhagia: it is common with submucous fibroid. An infected polyp will also cause purulent discharge. Metrorrhagia in women over 40 requires D&C to rule out endometrial cancer.

Pressure symptoms: anterior and posterior fibroids lodged in the pouch of Douglas causes frequency and retention of urine more often premenstrually because of premenstrual congestion and enlargement of the tumor. Broad ligament fibroid can cause hydroureter and hydronephrosis which is reversible following surgery. Constipation is rare, intestinal obstruction is due to a loop of intestine round the pedunculated fibroid.

Pain: acute pain is seen when a fibroid is complicated by torsion. Hemorrhage and red degeneration. Pain in a rapidly growing fibroid in an elderly women may be due to sarcoma.

Sub- fertility: Due to mechanical distortion or occlusion of the fallopian tubes and distortion of the endometrial cavity by a sub mucous fibroid which can prevent implantation of the fertilized ova.

Obstetric complications : In late pregnancy if the fibroid is located in the cervix or the lower uterine segment it can cause fetal abnormal lie or presentation and obstructed labor. After delivery, there is a risk of postpartum hemorrhage due to inefficient uterine contractions.

Heavy or painful periods Abdominal discomfort or bloating Back ache There may also be pain during intercourse, depending on the location of the fibroid.

PREDISPOSING FACTORS

-Nulliparity -Obesity -Family history -African racial origin

TYPES OF FIBROID DEGENERATION Atrophy: as a result of diminished vascularity after menopause, there is shrinkage in the size of the tumor, which becomes firmer and more fibrotic. A similar change occurs in myomas after delivery, when a tumor easily palpable during pregnancy may be difficult to define.Hyaline and cystic and fatty degenerations that occur in the central areas are of no clinical significance and are caused by diminished vascularity in large fibromyomas.Red degeneration : It follows an acute loss of blood supply to the fibroid during its active growth mainly seen during pregnancy. Patients present with sudden onset of abdominal pain and tenderness localized to the uterus associated with mild pyrexia and leukocytosis. The symptoms and signs resolve over a few days and surgical intervention is rarely required.

Hyaline degeneration : This type of degeneration is caused by gradual decrease in the blood supply to the fibroid. It is asymptomatic and can cause central necrosis leaving cystic spaces at the center termed cystic degeneration.

Calcareous degeneration: in this phosphates and carbonates of lime are deposited in the periphery along the course of the vessels. The best e.g. of calcareous myomas are those in old patients with long standing myomas. They have been found as “womb stones” in graveyards. Calcareous tumors are easily identified by radiography.

Sacromatous changes: these are exteremely rare and the incidence is not more than 0.5% of all myomas. Intramural and submucous tumors have a higher potential for sacromatous change than subserous tumor.it is rare for malignant change to develop in a women under the age of 40. It is commonly seen in a postmenopausal women when the tumor is noticed to grow suddenly, causing pain and postmenopausal bleeding. To the naked eye a sacromatous myoma is yellowish grey in color and hemorrhagic. Anpther important sign is non encapsulation of the tumor. Sarcoma is highly malignant and spreads through the blood stream.

Calcification of fibroid : This type of change in the fibroid is caused by deposition of calcium in the fibroid and can be detected on the abdominal x-ray in postmenopausal women.

Malignant changes : Occurs in 0.1 -0 .5 % of fibroids termed as sarcoma, and is characterized by rapidly increasing tumor size.

DIFFERENTIAL DIAGNOSIS

- Ovarian tumor whether benign or malignant. - Adenomyosis.

- Leiomyosarcoma; patient presents with a history of rapidly enlarging abdominal-pelvic mass and decreased mobility of the uterus. In addition to general signs of cachexia.

DIAGNOSIS

Bimanual examination typically can identify the presence of larger fibroids Gynecologic ultrasonography: it will depict the fibroids as focal masses with a heterogeneous

texture, which usually cause shadowing of the ultrasound beam. The location can be determined and dimensions of the lesion measured.

Magnetic resonance imaging (MRI) can be used to define the depiction of the size and location of the fibroids within the uterus.

hysterosalpingography or sonohysterography.

Imaging modalities cannot clearly distinguish between the benign uterine leiomyoma and the malignant uterine leiomyosarcoma, however, the latter is quite rare. However fast growth or unexpected growth such as enlargement of a lesion after the menopause raise the level of suspicion that the lesion might be a sarcoma. Also, with advanced malignant lesions there may be evidence of local invasion. A more recent study has suggested that diagnostic capabilities using MRI have improved the ability to detect sarcomatous lesions.

Coexisting disordersFibroids that lead to heavy vaginal bleeding lead to anemia and iron deficiency. Due to pressure effects gastrointestinal problems are possible such as constipation and bloatedness. Compression of the ureter may lead to hydronephrosis. Fibroids may also present alongside endometriosis, which itself may cause infertility. Adenomyosis may be mistaken for or coexist with fibroids.

TREATMENT

Expectant management

Asymptomatic fibroids do not require treatment. Patients are reevaluated periodically (eg, every 6 to 12 months). The presence of fibroids does not mean that they need to be treated; lesions can be managed expectantly depending on the symptomatology and presence of related conditions. Thus most cases of fibroids are managed by "watchful waiting" which includes periodic sonographic assessment. After menopause fibroids shrink and it is unusual for fibroids to cause problems.

For symptomatic fibroids, medical options, including suppression of ovarian hormones to stop the bleeding, are suboptimal and limited. However, menorrhagia or menometrorrhagia should be treated before surgery is considered. Gonadotropin-releasing hormone (GnRH) analogues are commonly given before surgery to shrink fibroid tissues, often stopping menses and allowing blood counts to increase. In postmenopausal women, expectant management can be tried because symptoms may resolve as fibroids regress.

MEDICATION

Primary

Medical therapy: Currently, the only medication approved to reduce fibroids are the Gonadotropin-releasing hormone analogs. GNRH analogs, however, are short term treatments only because they lead to estrogen-deficiency and may cause osteoporosis. Aromatase inhibitors have been used experimentally to reduce fibroids. Progesterone antagonists have been shown in small studies to decrease the size of uterine

fibroids. Thus mifepristone was effective in a placebo-controlled pilot study. Selective progesterone receptor modulators, such as Progenta, have been under investigation.

Gonadotropin-releasing hormone (Gn-RH) agonists given IM or sc

Leuprolide (lupron) 3.75 mg IM q mo, Goserelin (zoladex) 3.6 mg sc q 28 days), subdermal pellet, or nasal spray can decrease estrogen production. These drugs are most commonly used. GnRH analogues are most helpful when given preoperatively to reduce fibroid and uterine volume, Gn-RH agonist produces the opposite effect to that of natural hormone. Estrogen and progesterone levels fall, menstruation stops, fibroids shrink and anemia often improves making surgery technically more feasible and reducing blood loss. In general, these drugs should not be used in the long term because rebound growth to pretreatment size within 6 month is common and bone demineralization may occur.

Secondary

A number of secondary medications are in use to alleviate symptoms caused by fibroids. This allows an otherwise expectant approach to bring the patient hopefully to menopause when symptoms naturally regress. Thus oral contraceptive pills, either combination pills with low-dose estrogens or progestin-only, are prescribed in an effort to reduce uterine bleeding and cramps. Such medications seem to have little or no effect on the size of the lesions. Anemia may have to be treated with iron supplementation. NSAIDs can be used to reduce painful menses.

Exogenous progestins can partially suppress estrogen stimulation of uterine fibroid growth. Medroxyprogesterone (PROVERA) acetate 5 to 10 mg po once/day

Megestrol( Megace) acetate 10 to 20 mg po once/day given 10 to 14 days each menstrual cycle can limit heavy bleeding, beginning after 1 or 2 treatment cycles. Alternatively, oral therapy every day of the month (continuous therapy) may be given; it often reduces bleeding and provides contraception.

Depot medroxyprogesterone (provera) acetate 150 mg IM q 3 mo has effects similar to those of continuous oral therapy. Before IM therapy, oral progestins should be tried to determine whether patients can tolerate the adverse effects (eg, weight gain, depression, irregular bleeding). Progestin therapy causes fibroids to grow in some women.

Antiprogestins (eg, mifepristone MIFEPREX) can also help reduce fibroid growth. The dose is 5 to 50 mg (once/day for 3 to 6 mo), which is lower than the 200-mg dose used for termination of pregnancy; thus, it must be mixed specially by the pharmacy and may not always be available.

Selective estrogen receptor modulators (SERMs; eg, raloxifene Some Trade Names EVISTA) may help reduce fibroid growth. However, whether efficacy in reducing symptoms is comparable to that of other drugs is unclear.

Danazol, an androgenic agonist, can suppress fibroid growth but has a high rate of adverse effects (eg, weight gain, acne, hirsutism, edema, hair loss, deepening of the voice, flushing, sweating, vaginal dryness) and is thus often less acceptable to patients.

NSAIDs can be used to treat pain but probably do not decrease bleeding.

SURGERY

Surgery is usually reserved for women with any of the following:

Rapidly enlarging pelvic mass Recurrent uterine bleeding refractory to drug therapy Persistent or intolerable pain or pressure Urinary or intestinal symptoms Infertility (if pregnancy is desired) Recurrent spontaneous abortions (if pregnancy is desired)

Surgery: Surgical removal of a uterine fibroid usually takes place via hysterectomy, in which the entire uterus is removed, or myomectomy, in which only the fibroid is removed. It is possible to remove multiple fibroids during a myomectomy. Although a myomectomy cannot prevent the recurrence of fibroids at a later date, such surgery is increasingly recommended, especially in the case of women who have not completed bearing children or who express an explicit desire to retain the uterus. There are three different types of myomectomy

In a hysteroscopic myomectomy, the fibroid is removed by the use of a resectoscope, an endoscopic instrument that can use high-frequency electrical energy to cut tissue. Hysteroscopic myomectomies can be done as an outpatient procedure, with either local or general anesthesia used. Hysteroscopic myomectomy is most often recommended for submucosal fibroids.

A laparoscopic myomectomy requires a small incision near the navel. The physician then inserts a laparoscope into the uterus and uses surgical instruments to remove the fibroids. Studies have suggested that laparoscopic myomectomy leads to lower morbidity rates and faster recovery than does laparotomic myomectomy. As with hysteroscopic myomectomy, laparoscopic myomectomy is not generally used on very large fibroids.

A laparotomic myomectomy (also known as an open or abdominal myomectomy) is the most invasive surgical procedure to remove fibroids. The physician makes an incision in the abdominal wall and removes the fibroid from the uterus. A particularly extensive laparotomic procedure may necessitate that any future births be conducted by Caesarean section. Recovery time from a laparatomic procedure is generally expected to be four to six weeks.

Robotic Myomectomy with da Vinci Surgical Robot: The da Vinci surgical robot is a major advance in the ability to precisely operate through small incisions.  The surgeon sits at a console photo) and looks through a 3-dimensional videocamera.  The hand movements in the surgeon are duplicated in the patient by the robot.  Most importantly, the instruments duplicate the wrist movements of the surgeon, allowing the instruments to change angles to allow precise suturing.

UTERINE FIBROID EMBOLIZATION (UTERINE ARTERY EMBOLIZATION)

Introduction

Uterine fibroid embolization (also known as uterine artery embolization) represents a fundamentally new approach to the treatment of fibroids. Embolization is a minimally invasive means of blocking the arteries that supply blood to the fibroids. It is a procedure that uses angiographic techniques (similar to those used in heart catheterization) to place a catheter into the uterine arteries. Small particles are injected into the

arteries, which results in the blockage of the arteries feeding the fibroids. This technique is essentially the same as that used to control bleeding that occurs after birth or pelvic fracture, or bleeding caused by malignant tumors.

The Procedure is usually done in the hospital with an overnight stay after the procedure. The patient is sedated and very sleepy during the procedure. The uterine arteries are most easily accessed from the femoral artery, which is at the crease at the top of the leg as shown in the figure. Initially, a needle is used to enter the artery to provide access for the catheter. Local anesthesia is used, so the needle puncture is not painful. The catheter is advanced over the branch of the aorta and into the uterine artery on the side opposite the puncture. A second arterial catheter is then placed from the opposite femoral artery to the other uterine artery. Before the embolization is started, an arteriogram (x-ray) is performed to provide a road map of the blood supply to the uterus and fibroids.

After the arteriogram, particles of polyvinyl alcohol (PVA) are injected slowly with X-ray, the particles flow to the fibroids first. The particles wedge in the vessels and cannot travel to any other parts of the body. Over several minutes the arteries are slowly blocked. The embolization is continued until there is nearly complete blockage of flow in the vessel. Once one side is completed, the other side is embolized. After the embolization, another arteriogram is performed to confirm the completion of the procedure. Arterial flow will still be present to some extent to the normal portions of the uterus, but flow to the fibroids is blocked. The procedure takes approximately 1 to 1 1/2 hours.

Side Effects

Most patients will experience several hours of moderate to severe pain after the procedure. There may also be nausea, and possibly fever. The pain and nausea is controlled with intravenous medications, usually with a pump that allows self-administration of the medications. After an initial period of bed rest for six to eight hours, those patients with mild to moderate symptoms may be discharged. Most patients are hospitalized overnight. Most symptoms are substantially improved by the next morning allowing discharge from the hospital.

After discharge, most patients will have periodic moderate to severe cramping over several days. Pain medications are prescribed to control these symptoms. These cramping episodes usually diminish over several days. Most patients will feel tired and may have a fever or nausea periodically. All these symptoms usually resolve over several days, but may last longer. Most women can anticipate returning to work 7 to 14 days after the procedure.

Complications

Complications are anticipated in less than 3% of patients. Serious possible complications include injury to the uterus from decreased blood supply or infection. Fortunately, this is quite rare and hysterectomy to treat either of these complications occurs in less than 1% of patients. Injuries to other pelvic organs is possible but has not yet occurred and the chance of other significant complications is less than 1%.

Long-term complications are not expected, although several questions about potential side effects remain. X-rays are used to guide the procedure and this raises a concern about potential long-term effects. In a study measuring the X-ray exposure during uterine embolization, the exposure was found to be below the level that would be expected to cause any health effect to the patient herself or to future children.

Pregnancy after Uterine Artery Embolization

It is also uncertain what effect blocking the uterine arteries will have on the ability to become pregnant or to carry a pregnancy to term. The large majority of the patients that had this procedure are finished with childbearing and so few women have tried to become pregnant after this procedure. Thus far, at least a dozen patients have become pregnant after this procedure worldwide. This includes a normal cesarean twin delivery and several normal single vaginal deliveries in France. There has been one reported miscarriage and other patients are pregnant at this time. It is also known that patients who have had this procedure for other reasons, such as bleeding after childbirth, have successfully carried pregnancies. However, most patients that have been treated for fibroids thus far are not interested in having a baby and have not sought to become pregnant. Therefore, without further study, we will not know what percentage of patients that wish to become pregnant will be able to do so. As the outcome of pregnancy following UAE is not know, we cannot recommend the procedure for women who plan to have children.    

Another unresolved question is the effect, if any, of this procedure on the menstrual cycle. The overwhelming majority of women who have had embolization of fibroids have had decreased bleeding with normal menstrual cycles. There have been a few women (most of whom are near the age when menopause would be expected) who have lost their menstrual periods after uterine embolization. It is uncertain whether these cases are a result of decreased ovarian function from the procedure. This question will require further study. Based on this limited information, it appears that this procedure may result in loss of menstrual cycles (premature menopause) in a very small number of patients. 

Expected Results

As of this time, approximately 2000 to 3000 patients have had this procedure world-wide. Initial results suggest that symptoms will be improved in 90% of patients with the large majority of patients markedly improved. Most patients have rated this procedure as very tolerable. The expected average reduction in the volume of the fibroids is 50% in three months, with reduction in the overall uterine volume of about 35%. The long-term outcome is not known, in that the arteries could reopen or collateral vessels could be recruited which might allow re growth of the fibroids. As of yet this has not been reported in the published series but only short term follow-up is available. Therefore, it is not yet known if the fibroids can regrow.

MYOMA COAGULATION- ( "myolysis"; "fibroid coagulation") As fibroids are dependent on an adequate blood supply in order to grow, reducing the blood supply in conjunction with destruction of some fibroid tissue, can result in fibroids not continuing to grow . In most cases in fact, the fibroids may shrink by as much as 50%. The procedure is carried out with a laparoscope in an outpatient setting. Various energy sources have been utilized-- laser, electrical, or freezing ("cryomyolysis") The latter is the newest modality, but current studies would suggest the least effective. The YAG laser is excellent, but for those facilities that do not have this equipment available, special electrical needles may be used. The laser fiber (or the electric needles) is passed in and out of the fibroid, much like repeatedly placing a toothpick in a ball of play-dough. The energy imparted to the fibroid results in a reduction of the blood supply to the fibroid which will then shrink over several months. While the fibroid will not likely totally disappear, it more than likely will regress sufficiently to obviate pressure symptoms. Pre-treatment with a GnRH agonist for 2-3 months may reduce the fibroid volume by 50%, and this may be followed by a further 50% reduction consequent to the fibroid coagulation procedure.

RADIOFREQUENCY ABLATION: One of the newest minimally invasive treatments for fibroids is radiofrequency ablation. In this technique the fibroid is shrunk by inserting a needle-like device into the fibroid through the abdomen and heating it with low frequency electrical currents. This new treatment is still under investigation in a Phase 3 clinical trial across 6 sites in the US. The treatment is a potential option for women who have fibroids, have completed child-bearing and want to avoid a hysterectomy.

Procedure

Patients are first carefully evaluated to determine suitability for the procedure. Each procedure starts with a diagnostic laparoscopy under general anesthesia to provide a thorough

evaluation of fibroids. This is followed by laparoscopic ultrasound of the uterus to detect tumors that may not appear on preoperative imaging studies.

The RFA catheter is placed through the skin under ultrasound guidance into a fibroid. The catheter consists of a needle containing several prongs that are deployed into the targeted tissue, allowing ablation of a spherical volume of tissue. The prongs deliver electrical energy to the fibroid and keep the ablation catheter firmly in place during treatment.

In about 10 to 15 minutes, targeted tissue is heated to 105 C, killing tumor cells. Because the heat dissipates rapidly, surrounding normal tissue is not affected.

Most procedures are completed in two to three hours and patients discharged the same day or the day following the procedure. Complications, such as bleeding and post-operative pain, are minimal.

Patient Selection: Laparoscopic RFA is suitable for women with symptomatic uterine fibroids. A team including surgeons and gynecologists carefully evaluates each patient.

HIFU (HIGH INTENSITY FOCUSED ULTRASOUND), also called Magnetic Resonance guided Focused Ultrasound, is a non-invasive intervention (requiring no incision) that uses high intensity focused ultrasound waves to ablate (destroy) tissue in combination with Magnetic Resonance Imaging (MRI), which guides and monitors the treatment. This technique is relatively new; it was approved by the FDA in 2004.

The procedure is conducted in a magnetic resonance imaging (MRI) scanner which helps the physician "see" inside the body to pinpoint, guide, and continuously monitor the treatment.

Magnetic resonance imaging (MRI) is advanced diagnostic technology which provides 3D imaging of internal organs without radiation. The MR guided FUS treatment uses the MR images to identify where the fibroid is and what portion has been treated, without the need for any incisions. It also provides real time feedback about temperature changes of the treated fibroid to make sure that the fibrotic tissue has been ablated (destroyed).

During the procedure you lie on your stomach on a patient table that fits into a standard MRI scanner.

First, the doctor identifies the fibroid(s) on MR images taken of your pelvic region. Then, after detailed planning, high energy focused ultrasound waves heat a small spot in the uterine fibroid to a temperature of up to 85oC. During the pulse or sonication, which lasts about 15 seconds, the doctor monitors the progress and reviews temperature-sensitive images. Since each sonication treats a very small volume, this process will be repeated until the required volume is treated, typically about 50 times. The procedure lasts about 3 hours depending upon the size and number of fibroids treated.

Following the treatment the body gradually removes the treated tissue over a period of months, providing

symptom relief.

Before treatment you are given a sedative and pain medication to help you relax. You lie on a patient table and are made comfortable before starting treatment. The treatment takes place with you lying on the patient table inside the MR scanner. Your clinical team will be in the next room with two-way communication using a microphone and a speaker. The doctor will inform you when images are being acquired (scanning) and when the system is sonicating (treatment).

During treatment, it is normal to feel a warming sensation in the pelvic region. You will be given a safety stop button that allows you to immediately stop the sonication if the treatment becomes painful.

You are conscious the entire time and provide feedback during the procedure to the physician. Afterwards you′ll be asked to rest for a few hours in the clinic, while the mild sedation wears off. Then you′ll be able to go home and resume normal activity.

CONCLUSION

Fibromyomas are generally benign neoplasms of the uterus affecting 5- 20% of women in the reproductive age group. They may be present without symptoms. Laparoscopy, hysteroscopy and arterial embolisation have provide minimal invasive surgery and reduced the number of abdominal surgery in women with uterine fibroids.

REFERENCE

Berek JS. Berek and Novak’s Gynecology. 14th edition: Philadelphia, Lippincott Williams and wilkins. 2007

Kumar P, Malhotra N. Jeffcoat’s principles of gynecology. 7th edition. New Delhi: Jaypee Bros Medical Publishers;2008

Mukherjee GG. Current obstetrics and gynecology. 1st edition. New Delhi: Jaypee bros medical publishers.2007.

Speroff L, Fitz M. Clinical Gynecologic Endocrinology and Infertility. 7th ed. Lippincott Williams & Wilkins; 2004.

Stenchever A. Comprehensive Gynecology. 4th ed. St. Louis, Mo: Mosby; 2001:1204-1206. http://www.fibroidworld.com/uae1.htm