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vaginitis
Vaginitis is the general term for disorders of the vagina caused by
infection, inflammation, or changes in the normal vaginal flora.
Symptoms include vaginal discharge, odor,
pruritus, and/or discomfort.
The most common causes of vaginal discharge, odor,
pruritus, and/or discomfort are bacterial vaginosis, candida
vulvovaginitis, and trichomoniasis. These disorders account for
over 90 percent of cases.
Less common causes of these symptoms include
vaginal atrophy/atrophic vaginitis, cervicitis, foreign body, irritants
and allergens, and several rarer entities, including some
systemic medical disorders.
PATHOGENESIS
The nonkeratinized stratified squamous epithelium of
the vagina in premenopausal women is rich in
glycogen. Glycogen from sloughed cells is the
substrate for Döderlein's lactobacilli, which convert
glucose into lactic acid, thereby creating an acidic
vaginal environment (pH 4.0 to 4.5). This acidity helps
maintain the normal vaginal flora and inhibits growth of
pathogenic organisms. Disruption of the normal
ecosystem can lead to conditions favorable for
development of vaginitis. Some of these potentially
disruptive factors include phase of the menstrual
cycle, sexual activity, contraceptive choice,
pregnancy, foreign bodies, estrogen level, sexually
transmitted diseases, and use of hygienic products
or antibiotics
PATIENT PRESENTATION
Women with vaginitis typically present with one
or more of the following vulvovaginal
symptoms:
●Change in the volume, color, or odor of
vaginal discharge
●Pruritus
●Burning
●Irritation
●Erythema
●Dyspareunia
●Spotting
●Dysuria
Vaginal discharge is a prominent symptom of
vaginitis, but may be difficult to distinguish from
normal vaginal discharge.
In reproductive aged women, normal vaginal
discharge consists of 1 to 4 mL fluid (per 24 hours),
which is white or transparent, thick or thin, and mostly
odorless.
This physiologic discharge is formed by mucoid
endocervical secretions in combination with sloughing
epithelial cells, normal vaginal flora, and vaginal
transudate
GENERAL PRINCIPLES
Empiric therapy based on history and physical examination alone should be
avoided because of frequent misdiagnosis and inappropriate therapy.
However, 25 to 40 percent of patients with genital symptoms do not have a
specific cause identified after initial diagnostic testing.
The three main steps in the evaluation of women with symptoms of
vaginitis are:
●Obtain a history and perform a physical examination
●Test for bacterial vaginosis, vulvovaginal candidiasis, and trichomoniasis
since these disorders account for over 90 percent of vaginitis in
premenopausal women and can be diagnosed by pH testing,
microscopy, and/or culture (or rapid antigen and nucleic acid amplification
test].
●If this evaluation does not lead to a diagnosis, then evaluate for less
common and rare causes of vaginitis.
Patients who continue to exhibit symptoms and/or have positive tests for
sexually transmitted infections after treatment are most likely to have been reinfected by their sexual partner
Bacterial vaginosis (BV) is the most common cause of
vaginal discharge in women of childbearing age,
accounting for 40 to 50 percent of cases.
The absence of inflammation is the basis for the term
"vaginosis" rather than "vaginitis."
Bacterial vaginosis (BV) represents a complex change in
the vaginal flora characterized by a reduction in
concentration of the normally dominant hydrogen-peroxide
producing lactobacilli and an increase in concentration of
other organisms, especially anaerobic gram negative rods
.The major bacteria detected are Gardnerella vaginalis,
Prevotella species, Porphyromonas species, Bacteroides
species, Peptostreptococcus species, Mycoplasma
hominis, Ureaplasma urealyticum, and Mobiluncus
species. Fusobacterium species and Atopobium vaginae
are also common
RISK FACTORS
Sexual activity is a risk factor for bacterial vaginosis (BV)
BV is highly prevalent (25 to 50 percent) in women who
have sex with women (WSW)
Douching and cigarette smoking
Use of condoms and estrogen-containing contraceptives
may be protective factors
CLINICAL FEATURES
Fifty to 75 percent of women with bacterial vaginosis (BV) are
asymptomatic .
Symptomatic women typically present with vaginal
discharge and/or vaginal odor .The discharge is off-white, thin,
and homogeneous; the odor is an unpleasant "fishy smell" that
may be more noticeable after sexual intercourse and during
menses .
BV alone does not cause dysuria, dyspareunia, pruritus,
burning, or vaginal inflammation (erythema, edema) .The
presence of these symptoms suggests mixed vaginitis
(symptoms due to two pathogens)
Although BV does not involve the cervix, the disorder may be
associated with acute cervicitis (endocervical mucopurulent
discharge or easily induced cervical bleeding
)
DIAGNOSIS
Amsel criteria
The diagnosis of BV is usually based on Amsel criteria, which are simple
and useful in an office practice where microscopy is available .
The first three findings are sometimes also present in patients with
trichomoniasis .
Amsel criteria for diagnosis of BV (at least three
criteria must be present):
●Homogeneous, thin, grayish-white discharge that smoothly coats the
vaginal walls
●Vaginal pH >4.5
●Positive whiff-amine test, defined as the presence of a fishy odor when
a drop of 10 percent potassium hydroxide (KOH) is added to a sample of
vaginal discharge
●Clue cells on saline wet mount . For a positive result, at least 20 percent
of the epithelial cells on wet mount should be clue cells. The presence of
clue cells diagnosed by an experienced microscopist is the single most
reliable predictor of BV
Gram's stain
Gram’s stain of vaginal discharge is the gold standard for diagnosis of BV
but
is mostly performed in research studies
Cytology
The Papanicolaou smear is not reliable for diagnosis of BV.
If a cytology smear suggests BV (ie, shift in flora from predominantly
lactobacilli to predominantly coccobacilli with or without clue cells), the
patient should be asked about symptoms, and if symptomatic, she should
undergo standard diagnostic testing for BV and treatment, if appropriate.
Treatment of asymptomatic women is not routinely indicated
Culture
Because BV represents complex changes in the vaginal flora, vaginal
culture has no role in diagnosis
TREATMENT
Bacterial vaginosis (BV) resolves spontaneously in up to one-third of
nonpregnant and one-half of pregnant women.
Treatment is indicated for relief of symptoms in women with symptomatic
infection and to prevent postoperative infection in those with asymptomatic
infection prior to abortion or hysterectomy .
Treatment of BV may also reduce the risk of acquiringSTDs , including HIV.
For this reason, some experts support the concept of treating all women with
BV regardless of presence or absence of symptoms; however, we agree
withCDC recommendations to not treat asymptomatic women.
Asymptomatic pregnant women with previous preterm births may also
benefit, but screening and treatment of these women is controversial
Nonpregnant women
Drugs — Metronidazole or clindamycin administered either
orally or intravaginally .
Oral medication is more convenient, but associated with a
higher rate of systemic side effects than vaginal administration.
Tinidazole is a reasonable oral alternative.
Metronidazole — The efficacy of metronidazole has been
established. The oral regimen we recommend is 500 mg twice
daily for seven days.
Treatment with a single oral dose of 2 grams of metronidazole
has lower efficacy and is no longer recommended for treatment
of BV. Alcohol should not be consumed during therapy and for
one day after completion of therapy.
Vaginal therapy with 0.75 percent metronidazole gel 5
grams once daily for five days is as effective as oral
metronidazole (5 grams of gel contains 37.5 mg of
metronidazole) .The choice of oral versus vaginal therapy
should depend upon patient preference.
Side effects of metronidazole include a metallic taste,
nausea (in 10 percent of patients), transient neutropenia
(7.5 percent), a disulfiram-like effect with alcohol,
prolongation of INR in patients taking vitamin K antagonists
(eg, warfarin), and peripheral neuropathy.
Gastrointestinal side effects are less common with vaginal
administration .Allergy to metronidazole is uncommon; it
manifests as rash, urticaria, pruritus, and rarely,
anaphylaxis, which can be successfully treated by oral
desensitization
Clindamycin
The preferred regimen is a seven-day course of 2 percent clindamycin
cream vaginally (5 grams of cream containing 100 mg of clindamycin
phosphate), but may be less effective than the metronidazole regimens
Alternative regimens include oral clindamycin (300 mg twice daily for seven
days) or clindamycin ovules (100 mg intravaginally once daily for three days.
Intravaginal clindamycin therapy has been associated with an increased
prevalence of clindamycin resistant anaerobic bacteria in the vagina
posttreatment .
This effect persisted in most women for at least 90 days after clindamycin
treatment. In contrast, increased resistance to metronidazole was not
observed in women treated with that drug.
Clindamycin cream should not be used concurrently with latex condoms,
which may be weakened.
Pseudomembranous colitis has been reported with both oral and
topical clindamycin.
Tinidazole
Tinidazole is a second generation nitroimidazole. It has a
longer half-life than metronidazole (12 to 14 hours versus
6 to 7 hours) and fewer side effects.
a single dose regimen appears to be as effective as
vaginal clindamycin cream
Probiotics
Probiotics (live microorganisms which confer a health
benefit on the host when administered in adequate
amounts) have been used alone and as adjunctive
therapy to antibiotics for treatment of BV and
prevention of relapse
In the United States, the content of these products is
not standardized and often of poor quality
Less effective and ineffective therapies
Triple-sulfa
creams, erythromycin, tetracycline, ampicillin, am
oxicillin, lactic acid gel, acetic acid gel, ascorbic
acid, azithromycin, chlorhexidine, hydrogen
peroxide, and povidone-iodine vaginal douches
are significantly less effective
than metronidazole and clindamycin and should
not be used
We suggest symptomatic relapse be treated initially with a sevenday course of oral or vaginal metronidazole or clindamycin. The
treatment regimen may be the same or different from the initial or
previous treatment regimen.
We believe any patient with more than three documented
episodes of BV in the previous 12 months should be offered a
long-term maintenance regimen consisting of
maintenance metronidazole gel.
Long-term clindamycin regimens, oral or topical, are not
advised because of toxicity and lack of documented efficacy .
Accordingly, if any of the aforementioned antimicrobials
fail, we prescribe metronidazole gel 0.75 percent or an oral
nitroimidazole for 7 to 10 days followed by twice weekly
dosing of gel for four to six months .Secondary vaginal
candidiasis was a common side effect.
Pregnant women
Symptomatic BV infection — All women with symptomatic BV should be
treated to relieve bothersome symptoms. Oral treatment is effective and
has not been associated with adverse fetal or obstetrical effects. The
therapeutic options include:
●Metronidazole 500 mg orally twice daily for 7 days
●Metronidazole 250 mg orally 3 times daily for 7 days
●Clindamycin 300 mg orally twice daily for 7 days
Some clinicians avoid use of metronidazole in the first trimester because it
crosses the placenta, and thus has a potential for teratogenicity. However,
meta-analysis has not found any relationship between metronidazole
exposure during the first trimester of pregnancy and birth defects , and the
CDC no longer discourage the use of metronidazole in the first trimester .
An additional concern is that the drug is mutagenic in bacteria and
carcinogenic in mice, but there is no evidence of harm in humans.
It is the second most common cause of vaginitis symptoms (after
bacterial vaginosis) and accounts for approximately one-third of
vaginitis cases.
Identification of vulvovaginal Candida is not necessarily
indicative of candidal disease, as the diagnosis of vulvovaginitis
requires the presence of vulvovaginal inflammation.
MICROBIOLOGY — Candida albicans is responsible for 80 to 92
percent of episodes of vulvovaginal candidiasis and C. glabrata accounts
for almost all of the remainder
RISK FACTORS
Sporadic attacks of vulvovaginal candidiasis usually occur without an identifiable
precipitating factor. Nevertheless, a number of factors predispose to symptomatic
infection :
●Diabetes mellitus — Women with diabetes mellitus who have poor glycemic
control are more prone to vulvovaginal candidiasis than euglycemic women .In
particular, women with Type 2 diabetes appear prone to non-albicans Candida
species.
●Antibiotic use — Use of broad spectrum antibiotics significantly increases the
risk of developing vulvovaginal candidiasis. As many as one-quarter to one-third
of women develop the disorder during or after taking these antibiotics because
inhibition of normal bacterial flora favors growth of potential fungal pathogens,
such as Candida. Administration of lactobacillus (oral or vaginal) during and for
four days after antibiotic therapy does not prevent postantibiotic vulvovaginitis .
●Increased estrogen levels — Vulvovaginal candidiasis appears to occur more
often in the setting of increased estrogen levels, such as oral contraceptive use
(especially when estrogen dose is high), pregnancy, and estrogen therapy.
●Immunosuppression — Candidal infections are more common in
immunosuppressed patients, such as those taking glucocorticoids or other
immunosuppressive drugs, or with human immunodeficiency virus (HIV) infection
Contraceptive devices — Vaginal sponges, diaphragms, and intrauterine
devices have been associated with vulvovaginal candidiasis, but not
consistently. Spermicides are not associated with Candida infection
●
TREATMENT
Treatment is indicated for relief of symptoms. Ten to 20 percent of
reproductive age women who harbor Candida species are asymptomatic;
these women do not require therapy [56].
The treatment regimen is based on whether the woman has an
uncomplicated infection (90 percent of patients) or complicated infection
(10 percent of patients).
Uncomplicated infections usually respond to treatment within a couple of
days. Complicated infections require a longer course of therapy and may
take two weeks to fully resolve.
Treatment of sexual partners is unnecessary. There is no medical
contraindication to sexual intercourse during treatment, but it may be
uncomfortable until inflammation improves
Uncomplicated infection — Criteria for uncomplicated
infection include all of the following:
●Sporadic, infrequent episodes (≤3 episodes/year)
●Mild to moderate signs/symptoms
●Probable infection with Candida albicans
●Healthy, nonpregnant woman
The absence of superiority of any formulation, agent, or route of
administration suggests that cost, patient preference, and
contraindications are the major considerations in the decision to
prescribe an anti-fungal for oral or topical administration
We suggest use of oral fluconazole, given that most women
consider oral drugs more convenient than those applied
intravaginally
Complicated infections — Characteristics of complicated infections include
one or more of the following criteria :
●Severe signs/symptoms
●Candida species other than C. albicans, particularly C. glabrata
●Pregnancy, poorly controlled diabetes, immunosuppression, debilitation
●History of recurrent (≥4/year) culture-verified vulvovaginal candidiasis
we suggest fluconazole (150 mg orally) for two to three sequential doses 72
hours apart for treatment of complicated infections, depending on the
severity of the infection
If the patient prefers topical therapy, observational series report that
complicated patients require 7 to 14 days of topical azole therapy
(eg, clotrimazole,miconazole, terconazole) rather than a one- to three-day
course
For severe Candida vulvar inflammation (vulvitis), low potency topical
corticosteroids can be applied to the vulva for 48 hours until the antifungals
exert their effect
Pregnancy
Treatment of pregnant women is primarily indicated for relief of
symptoms.
Vaginal candidiasis is not associated with adverse pregnancy
outcomes .
We suggest application of a topical imidazole
(clotrimazole or miconazole) vaginally for seven days.
Administration of oral azoles during the first trimester is not
recommended
Although treatment of vaginal candida colonization in healthy
pregnant women is unnecessary, in Germany treatment is
recommended in the third trimester because the rate of oral thrush
and diaper dermatitis in mature healthy newborns is significantly
reduced by maternal treatment
Recurrent infection
Attempts should be made to eliminate or reduce risk factors for infection if
present (eg, improve glycemic control, switch to lower estrogen dose oral
contraceptive)
we believe that the optimal therapy for recurrent vulvovaginal candidiasis in
nonpregnant women consists of initial induction therapy withfluconazole 150
mg every 72 hours for three doses, followed by maintenance fluconazole
therapy once per week for six months
Therapy is then discontinued, at which point some patients achieve a
prolonged remission, while others relapse. A short-term relapse, with culture
confirmation of the diagnosis, merits reinduction therapy with three doses of
fluconazole, followed by repeat weekly maintenance fluconazole therapy,
this time for one year
A minority of women persist in relapsing as soon as fluconazole maintenance is
withdrawn (fluconazole dependent recurrent vulvovaginal candidiasis). Symptoms in
these patients can be controlled by months or years of weekly fluconazole.
Given the safety profile of low dose fluconazole, most experts do not suggest any
laboratory monitoring; however, if other oral imidazoles (ketoconazole,itraconazole) are
used, particularly if taken daily, then monitoring liver function tests is recommended.
Idiosyncratic hepatotoxicity secondary to ketoconazole therapy is a concern, but rare in
this setting
Alternative approaches that have been suggested include:
●Treat each recurrent episode as an episode of uncomplicated infection
●Treat each recurrent episode with longer duration of therapy (eg, topical azole for 7 to
14 days or fluconazole 150 mg orally on day 1, day 4, and day 7)
●The Infectious Diseases Society of America (IDSA) recommends 10 to 14 days of
induction therapy with a topical or oral azole, followed byfluconazole 150 mg once per
week for six months (clotrimazole 200 mg vaginal cream twice weekly is a nonoral
alternative
INTRODUCTION — Trichomoniasis is caused by
the protozoan Trichomonas vaginalis.
It is the most common non-viral sexually
transmitted disease (STD) worldwide.
Women are affected more often than men.
Trichomoniasis is one of the three major causes of
vaginal complaints among reproductive aged
women, along with bacterial vaginosis and
candida vulvovaginitis [1], and a cause of
urethritis in men; however, the infection is often
asymptomatic
CLINICAL FEATURES
Women
In women, trichomoniasis ranges from an asymptomatic carrier state to an acute, severe
inflammatory disease.
As many as 50 percent of infected women are asymptomatic, although many of these
women eventually become symptomatic. Asymptomatic carriage can persist for
prolonged periods of time (at least three months), thus it is often not possible to
ascertain when or from whom the infection was acquired .
Vaginitis — Common signs and symptoms of acute infection include a purulent,
malodorous, thin discharge associated with burning, pruritus, dysuria, frequency, lower
abdominal pain, or dyspareunia. Symptoms may be worse during menstruation.
Postcoital bleeding can occur.
Physical examination often reveals erythema of the vulva and vaginal mucosa. The
classically described green-yellow, frothy, malodorous discharge occurs in 10 to 30
percent of symptomatic women. Punctate hemorrhages may be visible on the vagina
and cervix ("strawberry cervix" in 2 percent of cases).
In chronic infection, signs and symptoms are milder and may include pruritus and
dyspareunia, with scanty vaginal secretion.
Men — In men, T. vaginalis infection is asymptomatic in over
three-quarters of cases and often transient (spontaneous
resolution within 10 days)
However, untreated infection can persist for months .
Symptoms, when present, are the same as those for urethritis
from any cause and consist of a clear or mucopurulent urethral
discharge and/or dysuria.
They may also have mild pruritus or burning sensation in the
penis after sexual intercourse
CONSEQUENCES
Women — Untreated trichomonal vaginitis may
progress to urethritis or cystitis. In addition, T. vaginalis
has been associated with a range of adverse
reproductive health outcomes, including cervical
neoplasia ,posthysterectomy cuff cellulitis or abscess
,atypical pelvic inflammatory disease in women infected
with HIV ,and infertility .It may also increase women's
susceptibility to HIV-1 infection by up to two-fold.
Men — T. Vaginalis in men has been associated with
prostatitis, balanoposthitis, epididymitis, infertility, and
prostate cancer
DIAGNOSIS
Women — The diagnosis of trichomonas is based on
laboratory testing (motile trichomonads on wet mount,
positive culture, positive nucleic acid amplification test, or
positive rapid antigen or nucleic acid probe test).
As with other types of vaginitis, none of the clinical features
of trichomoniasis is sufficiently sensitive or specific to allow a
diagnosis based upon signs and symptoms alone
TREATMENT
Treatment is indicated for both symptomatic and asymptomatic
women and men.
Treatment reduces the prevalence of T. vaginalis carriage in the population,
relieves symptoms, and reduces the risk of sequelae
(including acquisition/transmission of human immunodeficiency virus [HIV]).
The 5-nitroimidazole drugs (metronidazole or tinidazole) are the only
class of drugs that provide curative therapy of trichomoniasis.
Patients should be instructed to avoid intercourse until they and their partners
have completed treatment and are asymptomatic, which generally takes about
a week.
Clinicians should also screen the patient for other STDs when she presents
with trichomoniasis
Nonpregnant women
5-nitroimidazole drugs — The 5-nitroimidazole drugs
(metronidazole or tinidazole) are the only class of drugs that provide curative
therapy of trichomoniasis.
We recommend treatment with a single 2 gram oral dose of
either tinidazole or metronidazole (ie, four 500 mg tablets)
An alternative multidose regimen is metronidazole 500 mg orally twice a day for
seven days
Oral is preferred to vaginal therapy since systemic administration achieves
higher drug levels and therapeutic drug levels in the urethra and periurethral
glands, which serve as endogenous reservoirs of organisms that can cause
recurrence
Patients should be advised to not consume alcohol for 24 hours
after metronidazole treatment and for 72 hours after tinidazole treatment
because of the possibility of a disulfiram-like (Antabuse effect) reaction
Allergy to 5-nitroimidazole drugs — Given the low efficacy
of any drug other than the 5-nitroimidazole drugs (see '5nitroimidazole drugs' above), we suggest patients with
allergies to metronidazole or tinidazole be referred for
desensitization rather than using an alternative class of drugs
Follow-up — Follow-up is unnecessary for women who
become asymptomatic after treatment or who were initially
asymptomatic, given the high efficacy of 5-nitroimidazole
drugs
Sex partners — Treatment of sex partners is indicated
because maximal cure rates in infected women are achieved
when their sexual partners are treated simultaneousl
Pregnant women
Symptomatic pregnant women — Metronidazole is the drug of
choice for treatment of symptomatic trichomoniasis in pregnancy. Some
clinicians avoid its use in the first trimester because it crosses the placenta,
thus there is a potential for teratogenicity. The drug is mutagenic in bacteria
and carcinogenic in mice; however, these effects have never been observed
in humans.
Asymptomatic pregnant women — We suggest not treating
asymptomatic infections during pregnancy because randomized trials have
found that it does not prevent, and in some trials even increased, the risk of
preterm delivery
Sex partners — Treatment of sexual partners is indicated. In cases where
an asymptomatic pregnant woman is not treated, reinfection of the treated
partner can be minimized by avoidance of sexual intercourse or use of
condoms
Uterine fibroids
Common
25-30% of women over 35
Often asymtomatic
Incidentally detected on pelvic ultrasound
Symptoms related to fibroids:
menorrhagia
irregular menstruation (only for submucosal
fibroids)
urinary (frequency, retention) 
abdominal distention

How to follow up asymptomatic fibroids?
Ultrasound?
Usually no needed
Check symptoms and uterine size clinically every 6
months or ask patient to return if symptomatic
Post-myomectomy follow up:
fibroids can recur after myomectomy 
advice for pregnancy? 
When?
Caesarean delivery needed? ◦
Asymptomatic women
●We suggest expectant management of asymptomatic women, except in
the case of a woman with moderate or severe hydronephrosis or a
woman with a hysteroscopically-resectable submucous leiomyoma who
is
pursuing pregnancy .
Postmenopausal women
●In
the absence of postmenopausal hormonal therapy, leiomyomas
generally become smaller and asymptomatic in postmenopausal women;
therefore, intervention is not usually indicated.
We suggest evaluation to exclude sarcoma in a postmenopausal woman
with a new or enlarging pelvic mass .The incidence of sarcoma is 1 to 2
percent in women with a new or enlarging pelvic mass, abnormal uterine
bleeding, and pelvic pain.
Submucosal leiomyomas
●We recommend hysteroscopic myomectomy for women
with appropriate submucosal leiomyomas that are
symptomatic (eg, bleeding, miscarriage).This procedure
allows future childbearing, usually without compromising
the integrity of the myometrium, but is also an appropriate
option in women who have completed childbearing since it
is minimally invasive.
Abdominal myomectomy is performed in women with
significant symptoms and a submucous leiomyoma(s) not
amenable to hysteroscopic resection.
Premenopausal women
Women who desire fertility
●We recommend abdominal myomectomy for
treatment of symptomatic intramural and subserosal
leiomyomas in women who wish to preserve their
childbearing potential and who have no major
contraindications to a surgical approach.
Hysteroscopic myomectomy is the preferred approach to
submucosal leiomyomas.
.
Laparoscopic myomectomy is an option for women
with a uterus less than 17 weeks' size or with a small
number of subserosal or intramural leiomyomas. Future
childbearing is possible; however, the integrity of the
uterine incision during pregnancy has not been evaluated
adequately and may be inferior to abdominal
myomectomy.
Due to reports of uterine rupture in pregnancy
following some laparoscopic myomectomies, surgeons
should discuss the risks and benefits of each option with
patients, including possible risk of uterine rupture, as
well as provide information regarding their experience
with laparoscopic suturing.
Women who do not desire fertility
●Hysterectomy
is the definitive procedure for relief of
symptoms and prevention of recurrent leiomyoma-related
problems.
We suggest use of GnRH agonists prior to a potentially
complicated hysterectomy (or myomectomy) if the surgeon
feels reduction in uterine/myoma volume will significantly
facilitate the procedure or if there is significant anemia which
has not responded to iron therapy.
●For women with abnormal uterine bleeding related to
leiomyomas who wish to undergo the least invasive
procedure, we suggest a trial of placement of a
levonorgestrel-releasing intrauterine contraception over
other drug therapies .
●Several
more invasive options, both surgical and using
interventional radiology, are available to symptomatic
women (bleeding, pain, pressure) who have completed
childbearing but wish to retain their uterus. There is no
high quality evidence to recommend one procedure
over another.
Since fertility and pregnancy outcome may be adversely
affected after many of these procedures, we suggest not
performing these procedures (other than myomectomy)
for women wishing to optimize future pregnancy.