Medical Management of Leipmyomas-Emphasis for Different Geographical Regions

Abstract

Leiomyomas are the commonest benign tumours of uterus.Surgery is the most common mode of treatment of symptomatic fibroids.With the advent of minimally invasive intervenional procedures like uterine artery embolization(UAE),and focused ultrasound on MRI we got some lesser invasive techniques,although they have drawbacks regarding ovarian reserve etc for patients desiring fertility.InitiallyGnRH agonists like leuprolide acetate were the most effectivemedical agents introduced ,but their drawback was bone density demineralization,hot flushes on long term use besides cost.Selective progesterone receptor modulators gradually got introduced with initial trials with mifepristone(RU486),followed by asoprisnil,ulipristalacetate.Since mifepristone had antiglucocorticoid and androgen receptor activity it was not approved by FDA for license,while four PEARL trials have got completed for UPA acetate 5&10mg regarding safety and efficacy and intermittent therapy with 5mg got FDA approval in Europe and Canadabefore surgery.Further trials indicated it may be the future drug of choice for patients desiring fertility for longterm intermittent therapy and possibly avoiding surgery and its complications like adhesions,uterine scar and risk for rupture during pregnancy.However in countries where uripristal is not available still one is forced to use mifepristone .Detailed mechanism of all these drugs is discussed and a case report of a young unmarried girl with high BMI is reported where mifepristone intermittent was effective not only in relieving patients symptoms but effective in decreasing uterine and fibroid volume which highlights how in such young cases one can preserve future fertility without putting them at risk of surgery and sometimes myomectomy complications ending in hysterectomy.