The Management of Uterine Leiomyomas

doi:10.1016/S1701-2163(15)30338-8

Journal of Obstetrics and Gynaecology Canada

Volume 37, Issue 2, February 2015, Pages 157-178

https://doi.org/10.1016/S1701-2163(15)30338-8 Get rights and content

Abstract

Objectives

The aim of this guideline is to provide clinicians with an understanding of the pathophysiology, prevalence, and clinical significance of myomata and the best evidence available on treatment modalities.

Options

The areas of clinical practice considered in formulating this guideline were assessment, medical treatments, conservative treatments of myolysis, selective uterine artery occlusion, and surgical alternatives including myomectomy and hysterectomy. The risk-to-benefit ratio must be examined individually by the woman and her health care provider.

Outcomes

Implementation of this guideline should optimize the decision-making process of women and their health care providers in proceeding with further investigation or therapy for uterine leiomyomas, having considered the disease process and available treatment options, and reviewed the risks and anticipated benefits.

Evidence

Published literature was retrieved through searches of PubMed, CINAHL, and Cochrane Systematic Reviews in February 2013, using appropriate controlled vocabulary (uterine fibroids, myoma, leiomyoma, myomectomy, myolysis, heavy menstrual bleeding, and menorrhagia) and key words (myoma, leiomyoma, fibroid, myomectomy, uterine artery embolization, hysterectomy, heavy menstrual bleeding, menorrhagia). The reference lists of articles identified were also searched for other relevant publications. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date limits but results were limited to English or French language materials. Searches were updated on a regular basis and incorporated in the guideline to January 2014. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, and national and international medical specialty societies.

Benefits, Harms, and Costs

The majority of fibroids are asymptomatic and require no intervention or further investigations. For symptomatic fibroids such as those causing menstrual abnormalities (e.g. heavy, irregular, and prolonged uterine bleeding), iron defficiency anemia, or bulk symptoms (e.g., pelvic pressure/pain, obstructive symptoms), hysterectomy is a definitive solution. However, it is not the preferred solution for women who wish to preserve fertility and/or their uterus. The selected treatment should be directed towards an improvement in symptomatology and quality of life. The cost of the therapy to the health care system and to women with fibroids must be interpreted in the context of the cost of untreated disease conditions and the cost of ongoing or repeat investigative or treatment modalities.

Values

The quality of evidence in this document was rated using the criteria described in the Report of the Caadian Task Force on Preventive Health Care (Table 1).

Summary Statements

1.
Uterine fibroids are common, appearing in 70% of women by age 50; the 20% to 50% that are symptomatic have considerable social and economic impact in Canada. (II-3)
2.
The presence of uterine fibroids can lead to a variety of clinical challenges. (III)
3.
Concern about possible complications related to fibroids in pregnancy is not an indication for myomectomy except in women who have had a previous pregnancy with complications related to these fibroids. (III)
4.
Women who have fibroids detected in pregnancy may require additional maternal and fetal surveillance. (II-2)
5.
Effective medical treatments for women with abnormal uterine bleeding associated with uterine fibroids include the levonorgestrel intrauterine system, (I) gonadotropin-releasing hormone analogues, (I) selective progesterone receptor modulators, (I) oral contraceptives, (II-2) progestins, (II-2) and danazol. (II-2)
6.
Effective medical treatments for women with bulk symptoms associated with fibroids include selective progesterone receptor modulators and gonadotropin-releasing hormone analogues. (I)
7.
Hysterectomy is the most effective treatment for symptomatic uterine fibroids. (III)
8.
Myomectomy is an option for women who wish to preserve their uterus or enhance fertility, but carries the potential for further intervention. (II-2)
9.
Of the conservative interventional treatments currently available, uterine artery embolization has the longest track record and has been shown to be effective in properly selected patients. (II-3)
10.
Newer focused energy delivery methods are promising but lack long-term data. (III)

Recommendations

1.
Women with asymptomatic fibroids should be reassured that there is no evidence to substantiate major concern about malignancy and that hysterectomy is not indicated. (III-D)
2.
Treatment of women with uterine leiomyomas must be individualized based on symptomatology, size and location of fibroids, age, need and desire of the patient to preserve fertility or the uterus, the availability of therapy, and the experience of the therapist. (III-B)
3.
In women who do not wish to preserve fertility and/or their uterus and who have been counselled regarding the alternatives and risks, hysterectomy by the least invasive approach possible may be offered as the definitive treatment for symptomatic uterine fibroids and is associated with a high level of satisfaction. (II-2A)
4.
Hysteroscopic myomectomy should be considered first-line conservative surgical therapy for the management of symptomatic intracavitary fibroids. (II-3A)
5.
Surgical planning for myomectomy should be based on mapping the location, size, and number of fibroids with the help of appropriate imaging. (III-A)
6.
When morcellation is necessary to remove the specimen, the patient should be informed about possible risks and complications, including the fact that in rare cases fibroid(s) may contain unexpected malignancy and that laparoscopic power morcellation may spread the cancer, potentially worsening their prognosis. (III-B)
7.
Anemia should be corrected prior to proceeding with elective surgery. (II-2A) Selective progesterone receptor modulators and gonadotropin-releasing hormone analogues are effective at correcting anemia and should be considered preoperatively in anemic patients. (I-A)
8.
Use of vasopressin, bupivacaine and epinephrine, misoprostol, peri-cervical tourniquet, or gelatin-thrombin matrix reduce blood loss at myomectomy and should be considered. (I-A)
9.
Uterine artery occlusion by embolization or surgical methods may be offered to selected women with symptomatic uterine fibroids who wish to preserve their uterus. Women choosing uterine artery occlusion for the treatment of fibroids should be counselled regarding possible risks, including the likelihood that fecundity and pregnancy may be impacted. (II-3A)
10.
In women who present with acute uterine bleeding associated with uterine fibroids, conservative management with estrogens, selective progesterone receptor modulators, antifibrinolytics, Foley catheter tamponade, and/or operative hysteroscopic intervention may be considered, but hysterectomy may become necessary in some cases. In centres where available, intervention by uterine artery embolization may be considered. (III-B)

Section snippets

Clinical Importance of Uterine Fibroids

The terms fibroid, myoma, and leiomyoma are synonymous and are the commonest gynaecological tumours, with a prevalence of 70% to 80% in women who have reached the age of 50.¹ In 95 061 US nurses, aged 25 to 44 years, the incidence was 8.9/1000 for white women and 30.9/1000 for black women.² The prevalence increases with age, peaking in women in their 40s. A hysterectomy study has found leiomyomas in 77% of uterine specimens.³

In many women, myomas may be asymptomatic and are diagnosed

MEDICAL MANAGEMENT

Until recently, medical management options for uterine leiomyomas have been of limited value because of their moderate efficacy and/or associated adverse effects. Novel therapies at the receptor and gene levels have emerged or are undergoing investigation and may eventually offer better long-term management options.⁵⁸

Because estrogen upregulation of both ERs and PRs during the follicular phase is followed by progesterone-induced mitogenesis during the luteal phase, all hormonal therapies to

Hysterectomy

In women who have completed childbearing, hysterectomy is indicated as a permanent solution for symptomatic leiomyomas. The only indications for hysterectomy in a woman with completely asymptomatic fibroids are enlarging fibroids after menopause without HRT, which raises concerns of leiomyosarcoma, even though it remains very rare. 91., 92. Women with asymptomatic fibroids should be reassured that there is no evidence to substantiate concern about malignancy, and that hysterectomy is not

Uterine Artery Embolization

An SOGC clinical practice guideline on UAE has been published,¹⁷⁸ and an up-to-date-review of UAE to treat uterine fibroids is included in the upcoming SOGC guideline.¹⁹ UAE is a procedure carried out by interventional radiologists and consists of injecting an occluding agent into one or both uterine arteries. First described in 1995, it has become one of the most common alternative conservative therapies offered to women with sympotomatic uterine fibroids. The procedure is minimally invasive

Acute Uterine Bleeding

Acute uterine bleeding unrelated to pregnancy has been defined as that which is sufficient in volume, in the opinion of the treating clinician, to require urgent or emergent intervention.¹⁹⁰ Women with fibroids may present with acute intraperitoneal or vaginal hemorrhage, which can become life-threatening on rare occasions. Since acute uterine bleeding may or may not be associated with leiomyomas, the approach to investigation and treatment should be the same.⁴⁵

Endometrial biopsy and

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To compare surgeon responses regarding their surgical plan before and after receiving a patient-specific three-dimensional (3D)-printed model of a patient’s multifibroid uterus created from their magnetic resonance imaging.
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To provide evidence-based recommendations for the management of chronic pelvic pain in females.
This guideline is specific to pelvic pain in adolescent and adult females and excluded literature that looked at pelvic pain in males. It also did not address genital pain.
The intent is to benefit patients with chronic pelvic pain by providing an evidence-based approach to management. Access to certain interventions such as physiotherapy and psychological treatments, and to interdisciplinary care overall, may be limited by costs and service availability.
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Family physicians, gynaecologists, urologists, pain specialists, physiotherapists, and mental health professionals.
Management of chronic pelvic pain should consider multifactorial contributors, including underlying central sensitization/nociplastic pain, and employ an interdisciplinary biopsychosocial approach that includes pain education, physiotherapy, and psychological & medical treatments.
- 1.
  Chronic pelvic pain is a common condition that can cause severe distress and considerable burden on the person affected as well as the health care system (high).
- 2.
  Etiology of chronic pelvic pain can be multifactorial and involve gynaecologic, urologic, gastrointestinal, myofascial/musculoskeletal, neuropathic, and psychosocial contributors as well as alterations in the central nervous system (high).
- 3.
  When pain becomes persistent and unresponsive to standard treatments, there is likely altered pain processing at the level of the central nervous system called central sensitization/nociplastic pain (moderate).
- 4.
  The therapeutic relationship between pain patients and their health care providers can impact their satisfaction with care and health outcomes (moderate).
- 5.
  Possible gynaecologic contributors to chronic pelvic pain include dysmenorrhea, endometriosis, adenomyosis, vulvodynia, and pelvic venous disorders (moderate).
- 6.
  Painful bladder syndrome and irritable bowel syndrome are chronic overlapping pain conditions that are common in the pelvic pain population and can be diagnosed based on clinical history (high).
- 7.
  Pelvic floor myofascial dysfunction is a frequent source of pain in women with chronic pelvic pain (high).
- 8.
  Myofascial abdominal pain, pelvic girdle pain, low back pain, referred hip pain, joint hypermobility, and postural imbalances may contribute to chronic pelvic pain (Moderate).
- 9.
  Pain, tingling, numbness following a dermatome may be suggestive of entrapment neuropathy (moderate).
- 10.
  Pain-specific psychosocial factors, such as pain catastrophizing and fear avoidance, and mental health conditions, including depression, anxiety, insomnia, and active trauma symptoms, contribute to perpetuating and intensifying chronic pelvic pain (moderate).
- 11.
  The presence of cutaneous allodynia, hyperalgesia, pelvic floor tenderness, and/or chronic overlapping pain conditions are suggestive of central sensitization/nociplastic pain (moderate).
- 12.
  Interdisciplinary management that includes psychological, physiotherapy, and medical treatment and is based on a biopsychosocial model offers more comprehensive and effective care than stand-alone treatments for individuals with chronic pelvic pain (moderate).
- 1.
  Health care providers should have a systematic approach to identify and address nociceptive stimuli initiating and perpetuating pain, as well as clinical findings suggestive of central sensitization/nociplastic pain (strong, moderate).
- 2.
  Pelvic ultrasound should be offered as a low-cost investigation to identify some pelvic pathologies that may contribute to chronic pelvic pain (strong, moderate).
- 3.
  In the absence of studies specific to chronic pelvic pain, management interventions deemed effective for generalized chronic pain may be used for chronic pelvic pain when a centralized process is suspected (conditional, low).
- 4.
  Pain neuroscience education should be included as an important component of chronic pain management (strong, moderate).
- 5.
  Lifestyle changes including dietary modifications, exercise, and smoking cessation may be offered as part of chronic pain management (conditional, low).
- 6.
  Physiotherapy assessment and treatment should be offered for chronic pelvic pain management (strong, high).
- 7.
  Psychological treatments that should be included in management of chronic pain are cognitive behavioural therapy (strong, high), acceptance and commitment therapy (strong, high), and mindfulness meditation (conditional, moderate).
- 8.
  For insomnia symptoms, cognitive behavioural therapy for insomnia is the initial treatment of choice and is safer than prolonged use of sleeping medications (strong, high).
- 9.
  Nonsteroidal anti-inflammatory drugs should be recommended for the treatment of dysmenorrhea (strong, moderate), but are of unclear effectiveness for non-menstrual chronic pelvic pain (conditional, low).
- 10.
  Opioid medications are not recommended for long-term management of chronic pelvic pain (strong, moderate).
- 11.
  Tricyclic antidepressants should be considered for neuropathic pelvic pain (moderate, strong), painful bladder syndrome (conditional, moderate), and irritable bowel syndrome (strong, moderate).
- 12.
  Serotonin and norepinephrine reuptake inhibitors such as duloxetine (conditional, moderate) and venlafaxine (conditional, low) may be considered in chronic pain management.
- 13.
  Clinicians should consider alternative treatment options to gabapentin for the management of chronic pelvic pain without gynaecologic pathology; however, gabapentin may be an option in cases of neuropathic pain (strong, moderate).
- 14.
  There is currently insufficient evidence to recommend cannabinoids for chronic pelvic pain management (conditional, low).
- 15.
  Progestogens and gonadotropin-releasing hormone agonists or antagonists should be considered in the management of chronic pelvic pain, especially in the presence of cyclical exacerbation or endometriosis (strong, moderate).
- 16.
  Surgery for chronic pelvic pain may be offered after pain beliefs and treatment expectations are explored and with counselling about the rationale for surgery, the uncertainty of the evidence surrounding outcomes, and the possibility that pain could be unchanged or worse post-operatively (strong, moderate).
- 17.
  Targeted therapies such as trigger point injections and nerve blocks can be considered in specific clinical circumstances, if there is no response to modalities with higher evidence (good practice point, low).
- 18.
  Botox injection of the pelvic floor muscles may be considered in the presence of persistent spasm that has not responded to pelvic physiotherapy interventions (conditional, low).
- 19.
  Acupuncture may be considered as a complementary modality for chronic pelvic pain (conditional, low).
- 20.
  There is a need in Canada for more publicly funded programs where health care providers work together in an interdisciplinary approach to treat chronic pelvic pain (strong, moderate).
Directive clinique n<sup>o</sup> 445: Gestion de la douleur pelvienne chronique
2024, Journal of Obstetrics and Gynaecology Canada
Fournir des recommandations fondées sur des données probantes pour la gestion de la douleur pelvienne chronique.
Cette directive porte sur la douleur pelvienne chez les adolescentes et les femmes adultes et n’aborde pas la douleur génitale. La littérature sur la douleur pelvienne chez les hommes a été exclue de toute analyse.
L’intention de cette directive est de profiter aux patientes atteintes de douleur pelvienne chronique en fournissant des stratégies de prise en charge fondées sur des données probantes. L’accès à certaines interventions, comme la physiothérapie et la psychothérapie, et aux soins interdisciplinaires en général peut être limité par les coûts et la disponibilité des services.
Des recherches ont été effectuées dans les bases de données Medline et Cochrane afin de recenser les articles en anglais publiés entre 1990 et 2020 concernant la douleur pelvienne chronique, dont le diagnostic, les états douloureux concomitants, la sensibilisation centrale, la prise en charge, les médicaments, la chirurgie, la physiothérapie, la psychothérapie, les traitements complémentaires et alternatifs ainsi que les soins multidisciplinaires et interdisciplinaires. Le comité a passé la littérature et les données disponibles en revue, et les membres ont élaboré les recommandations par consensus. Seuls les articles en anglais portant sur des sujets de sexe féminin ont été analysés.
Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique GRADE (Grading of Recommendations, Assessment, Development, and Evaluation). Voir l’annexe A (tableau A1 pour les définitions et tableau A2 pour l’interprétation des recommandations fortes et faibles).
Médecins de famille, gynécologues, urologues, spécialistes en gestion de la douleur, physiothérapeutes et professionnels de la santé mentale.
La gestion de la douleur pelvienne chronique doit prendre en compte les multiples facteurs de contribution et nécessite une approche biopsychosociale interdisciplinaire impliquant éducation, physiothérapie, psychothérapie et pharmacothérapie.
- 1.
  La douleur pelvienne chronique est un problème fréquent qui peut causer une profonde détresse et imposer un important fardeau à la personne atteinte et au système de santé (élevée).
- 2.
  L’étiologie de la douleur pelvienne chronique peut être multifactorielle et impliquer des facteurs de contribution gynécologiques, urologiques, gastro-intestinaux, myofasciaux, musculosquelettiques, neuropathiques et psychosociaux, de même qu’une altération du système nerveux central (élevée).
- 3.
  Lorsque la douleur devient persistante et réfractaire aux traitements standards, il est susceptible d’y avoir un trouble de modulation de la douleur au niveau du système nerveux central, à savoir la sensibilisation centrale ou la douleur nociplastique (moyenne).
- 4.
  La relation thérapeutique entre la patiente atteinte de douleur chronique et son professionnel traitant peut avoir un effet sur son degré de satisfaction des soins et ses résultats cliniques (moyenne).
- 5.
  Les facteurs de contribution gynécologiques pouvant être impliqués dans la douleur pelvienne chronique sont la dysménorrhée, l’endométriose, l’adénomyose, la vulvodynie et les troubles veineux pelviens (moyenne).
- 6.
  Le syndrome de la douleur vésicale et le syndrome du côlon irritable sont des états douloureux concomitants fréquents dans la population atteinte de douleur pelvienne et peuvent être diagnostiqués d’après l’histoire clinique (élevée).
- 7.
  La dysfonction myofasciale du plancher pelvien est une source de douleur fréquemment observée chez les femmes atteintes de douleur pelvienne chronique (élevée).
- 8.
  La douleur myofasciale abdominale, la douleur de la ceinture pelvienne, la lombalgie, la douleur projetée de la hanche, l’hypermobilité articulaire et les déséquilibres posturaux peuvent contribuer à la douleur pelvienne chronique (moyenne).
- 9.
  La douleur, les picotements et les engourdissements suivant un dermatome peuvent indiquer une neuropathie canalaire (moyenne).
- 10.
  Certains facteurs psychosociaux spécifiques à la douleur contribuent à perpétuer et intensifier la douleur pelvienne chronique, par exemple la dramatisation de la douleur, les comportements de peur-évitement et les troubles de santé mentale, tels que la dépression, l’anxiété, l’insomnie et les symptômes de traumatisme actif (moyenne).
- 11.
  La présence d’allodynie cutanée, d’hyperalgésie, de sensibilité du plancher pelvien et/ou d’états douloureux chroniques concomitants évoque la sensibilisation centrale ou la douleur nociplastique (moyenne).
- 12.
  La prise en charge interdisciplinaire impliquant les sphères psychologique, physiothérapique et pharmacologique et reposant sur un modèle biopsychosocial donne une stratégie de soins plus globale et efficace que les traitements indépendants chez les personnes atteintes de douleur pelvienne chronique (moyenne).
- 1.
  Les professionnels de la santé doivent adopter une approche systématique pour reconnaître et atténuer les stimuli nociceptifs qui déclenchent et perpétuent la douleur ainsi que les observations cliniques évoquant la sensibilisation centrale ou la douleur nociplastique (forte, moyenne).
- 2.
  L’échographie pelvienne est un examen peu coûteux à proposer pour détecter certaines pathologies pelviennes pouvant contribuer à la douleur pelvienne chronique (forte, moyenne).
- 3.
  En l’absence d’études portant spécifiquement sur la douleur pelvienne chronique, les interventions de prise en charge jugées efficaces pour la douleur chronique généralisée sont des options envisageables pour le traitement de la douleur pelvienne chronique lorsque la douleur nociplastique est soupçonnée (conditionnelle, faible).
- 4.
  L’éducation sur la neurophysiologie de la douleur doit être une composante importante de la prise en charge de la douleur pelvienne chronique (forte, moyenne).
- 5.
  Les changements au mode de vie, dont les modifications alimentaires, l’exercice et l’abandon du tabagisme, peuvent être proposés dans la prise en charge de la douleur chronique (conditionnelle, faible).
- 6.
  Il y a lieu de proposer une évaluation et des traitements en physiothérapie pour la gestion de la douleur pelvienne chronique (forte, élevée).
- 7.
  Les options de psychothérapie envisageables dans la prise en charge de la douleur chronique sont la thérapie cognitivo-comportementale (forte, élevée), la thérapie d’acceptation et d’engagement (forte, élevée) et la méditation pleine conscience (conditionnelle, moyenne).
- 8.
  Pour traiter les symptômes d’insomnie, la thérapie cognitivo-comportementale de l’insomnie est le traitement initial de référence et s’avère plus sécuritaire que l’utilisation prolongée de somnifères (forte, élevée).
- 9.
  Il y a lieu de recommander les anti-inflammatoires non stéroïdiens pour le traitement de la dysménorrhée (forte, moyenne), mais leur efficacité dans la gestion de la douleur pelvienne chronique non menstruelle demeure incertaine (conditionnelle, faible).
- 10.
  Les opioïdes ne sont pas recommandés pour le traitement à long terme de la douleur pelvienne chronique (forte, moyenne).
- 11.
  Les antidépresseurs tricycliques sont à envisager pour la gestion de la douleur pelvienne neuropathique (moyenne, forte), du syndrome de la douleur vésicale (conditionnelle, moyenne) ou du syndrome du côlon irritable (forte, moyenne).
- 12.
  Les inhibiteurs de la recapture de la sérotonine et de la noradrénaline tels que la duloxetine (conditionnelle, moyenne) et la venlafaxine (conditionnelle, faible) sont envisageables pour la gestion de la douleur chronique.
- 13.
  Il y a lieu d’envisager des traitements de remplacement de la gabapentine pour la gestion de la douleur pelvienne chronique sans composante gynécologique, mais elle peut être utilisée en cas de douleur neuropathique (forte, moyenne).
- 14.
  Les données probantes actuelles sont insuffisantes pour recommander les cannabinoïdes pour la gestion de la douleur pelvienne chronique (conditionnelle, faible).
- 15.
  Il y a lieu d’envisager l’usage de progestatifs et d’agonistes ou antagonistes de la gonadolibérine pour la gestion de la douleur pelvienne chronique, surtout en cas d’exacerbation clinique ou d’endométriose (forte, moyenne).
- 16.
  Une fois que les croyances relatives à la douleur et les attentes thérapeutiques ont été explorées, la chirurgie peut être proposée avec un accompagnement qui aborde le raisonnement de l’intervention, l’incertitude des données entourant les résultats et la possibilité que la douleur demeure inchangée ou s’aggrave après l’intervention (forte, moyenne).
- 17.
  Les traitements ciblés, comme les infiltrations de point gâchette et les blocs nerveux, sont envisageables dans certaines situations cliniques bien précises en cas de douleur réfractaire aux modes de traitement étayés par de meilleures données probantes (bonne pratique, faible).
- 18.
  L’injection de toxine botulinique dans les muscles du plancher pelvien peut être envisagée en cas de spasmes persistants réfractaires aux interventions de rééducation pelvi-périnéale (conditionnelle, faible).
- 19.
  L’acupuncture est envisageable comme option de traitement complémentaire de la douleur pelvienne chronique (conditionnelle, faible).
- 20.
  Il existe un besoin au Canada de créer un plus grand nombrede programmes publics où des professionnels de la santé travaillent ensemble selon une approche interdisciplinaire pour la prise en charge de la douleur pelvienne chronique (forte, moyenne).

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: This clinical practice guideline has been prepared by the Uterine Leiomyomas Working Group, reviewed by the Clinical Practice Gynaecology, Reproductive Endocrinology & Infertility, and Family Physician Advisory Committees, and approved by the Executive and Board of the Society of Obstetricians and Gynaecologists of Canada.

: Disclosure statements have been received from all contributors.

: The literature searches and bibliographic support for this guideline were undertaken by Becky Skidmore, Medical Reserch Analyst, Society of Obstetricians and Gynaecologists of Canada.

: This document reflects emerging clinical and scientific advances on the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate amendments to these opinions. They should be well documented if modified at the local level. None of these contents may be reproduced in any form without prior written permission of the SOGC.

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SOGC CLINICAL PRACTICE GUIDELINEThe Management of Uterine Leiomyomas

Abstract

Objectives

Options

Outcomes

Evidence

Benefits, Harms, and Costs

Values

Summary Statements

Recommendations

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MEDICAL MANAGEMENT

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Uterine Artery Embolization

Acute Uterine Bleeding

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J Vasc Interv Radiol

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Maturitas

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Contraception

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Eur J Obstet Gynecol Reprod Biol

Fertil Steril

Int J Gynaecol Obstet

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Am J Obstet Gynecol

Obstet Gynecol

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SOGC CLINICAL PRACTICE GUIDELINE
The Management of Uterine Leiomyomas