Sarcomas and the conservative management of uterine fibroids: a cause for concern?

The introduction of conservative management options has further increased the choices available to clinicians treating women with symptomatic uterine fibroids. However, in the absence of a tissue diagnosis, the possibility of mismanaging an underlying uterine sarcoma is still present, placing these patients at potential risk of a delayed diagnosis of this serious pathology. Evidence suggests that 1 in 250-400 women presenting with what are thought to be symptomatic fibroids, will in fact have an underlying sarcoma, making this an important clinical issue. This paper therefore reviews the methods currently available for the assessment of women in whom conservative management of symptomatic fibroids is contemplated.

Uterine artery embolisation for symptomatic fibroids.

Traditional operative treatments for symptomatic fibroids--hysterectomy and myomectomy--involve considerable morbidity. Although morbidity is reduced with endoscopic surgery, this technique is not widely available, and has limitations. Embolisation of the pelvic vasculature is not a new procedure, having been used to treat postpartum and postsurgical bleeding for 20 years. It has only recently been used to treat symptomatic fibroids. Uterine artery embolisation can produce a mean reduction of 29%-51% in uterine volume at the time of the three-month review, with longer follow-up showing continued shrinkage and no regrowth. The range of shrinkage is highly variable, which needs to be explained to all potential candidates. Symptomatic relief is a more certain outcome, with relief of pelvic pressure symptoms in 91%-96% of women. There is a small risk of complications requiring hysterectomy, and the long-term effect on ovarian function is unknown.

The effect of combined estrogen/progestogen treatment in women with hyperprolactinemic amenorrhea.

Eleven women with hyperprolactinemic amenorrhea were treated with a combined estrogen/progestogen preparation (Loestrin 30) for 3 months as hormone replacement therapy because of estrogen deficiency, with a view to protection against osteoporosis. Serum prolactin levels rose during the 1st month of treatment (p < 0.05) but did not rise significantly further during the 2nd and 3rd months. The levels rose in proportion to pretreatment levels by 28% (median), and fell significantly but not completely during the 1-week treatment-free intervals. After the study period, prolactin values appeared to remain stable in those women who continued longer on treatment, and returned to around pretreatment values in those who stopped. In one woman there was radiological evidence of pituitary tumor growth during treatment. This study shows that estrogen/progestogen treatment in standard contraceptive dosage usually leads to only moderate and non-progressive stimulation of pituitary activity in women with hyperprolactinemic amenorrhea, but occasional excessive growth of a prolactinoma can occur and treatment needs to be monitored. Women with relatively high prolactin levels seem to be at particular risk. Safer variations of estrogen therapy such as lower dosage or combination with a protective low dose of a dopamine agonist should also be considered.

The role of chlamydial antibodies in an in vitro fertilization program.

The reported incidence of antibodies to Chlamydia trachomatis in patients attending infertility clinics is at least 30%. It has been reported that chlamydial antibodies are associated with decreased pregnancy rates following in vitro fertilization (IVF). A study was performed to investigate the significance of chlamydial antibodies in an established IVF program. The results did not show a decreased pregnancy rate in the presence of chlamydial antibodies. Of the women achieving pregnancy, 41% were seropositive compared with 38% seropositivity in women who did not become pregnant. There was no apparent benefit of the use of prophylactic antibiotics. The results also suggested that past infection with C. trachomatis in men did not adversely affect semen analysis or fertilization.

Oocyte pickup by laparoscopy replaced by transvaginal aspiration in an in vitro fertilization program.

The results of laparoscopic (lap) and transvaginal (TV) oocyte pickups (OPUs) performed concurrently for in vitro fertilization in 232 consecutive treatment cycles have been reviewed. The patients were compared for age, preoperative estradiol concentration, luteal-phase support, and number of follicles aspirated and were found to be similar but were not matched for cause of infertility. The lap OPU group had more oocytes recovered per follicle aspirated (P less than 0.001), but because of a lower fertilization rate (P less than 0.01), the number of embryos transferred was similar. Nevertheless, more (P less than 0.05) pregnancies occurred in the TV OPU group. Patients were subgrouped so that comparisons of patients with the same cause of infertility, tubal disease alone, were considered. This showed that the pregnancy rate was still higher in the TV OPU group (P less than 0.05). TV OPU was less painful and not associated with increased morbidity, and since the data suggest that TV OPU was at least as successful as lap OPU, it is recommended that all oocyte pickups in the future be performed transvaginally.