ABSTRACT
Uterine leiomyoma is the most common tumor of the female genital tract and is clinically detectable in 20-50% of women under the age of 50 years. Its incidence is particularly high in the last decade of reproductive activity.1'3 Uterine leiomyomata appears to be more frequent in black women,4 nulliparous women, overweight women, and in women with a positive family history, while oral contraception, smoking, and multiparity may have a protective effect.5,6
Uterine leiomyoma is composed of proliferat ing smooth muscle cells and a conjunctive stroma. Several theories have been advanced to explain its development. Cytologic abnormali ties found in spindle cells point to a monoclonal origin.7 The presence of steroid receptors and their modulators suggests hormonal involve ment, possibly mediated by growth factors or cytokines.8,9 Various pathways have been impli cated in the development and regulation of leiomyomata, including extracellular matrix modulation10 and angiogenic factors.11,12
Uterine leiomyoma is frequently asymptomatic but can be a source of menorrhagia, compression of adjacent organs, pelvic pain, and infertility. The clinical manifestations depend on the location, size, and number of leiomyomata. Treatment is unnecessary when leiomyomata are asympto
matic. The indications of myomectomy in infer tile women are controversial, particularly in the case of subserosal or intramural leiomyomata without distortion of the uterine cavity.1,2,13,14
For women who do not wish to preserve their fertility, the classical surgical treatment for symptomatic leiomyomata is hysterectomy. In France about 72,000 hysterectomies are per formed annually, uterine leiomyomata being the causal factor in one-third of cases. About 80,000 hysterectomies are performed annually in the United Kingdom15 and over 600,000 in the United States.16 This treatment is effective and offers a significant improvement in quality of life, with no risk of recurrence and an acceptable complication rate.1 However, previous overuse of hysterectomy, together with the growing number of women who wish to keep their uterus for reasons other than childbearing, has prompted the development of alternative, con servative treatments. Uterus-sparing surgery is possible because leiomyoma is a benign tumor and the risk of uterine sarcoma is low (2-3 cases per thousand).13 This chapter will only deal with conservative surgery based on myomectomy, by means of laparotomy, laparoscopy, or the vaginal route. Alternative therapies such as medical shrinkage, embolization, and hysteroscopic myomectomy are examined in other chapters.
