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Frauenheilkunde up2date 2016; 10(06): 487-505
DOI: 10.1055/s-0042-117550
Allgemeine Gynäkologie und gynäkologische Onkologie
Georg Thieme Verlag KG Stuttgart · New York

Myome – Entstehung, Diagnostik und Therapie

Johannes Schmid
,
Jelena Petresin
,
Andreas Müller
,
Alexander Boosz
Further Information

Publication History

Publication Date:
10 January 2017 (online)

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Kernaussagen

Epidemiologie

Myome sind die häufigsten soliden Tumoren der Frau. Sie sind meist hormonabhängig und durch ein gutartiges Wachstum charakterisiert. Bei ca. 20–40 % aller Frauen über 30 Jahre finden sich Myome des Uterus, die vor allem in der reproduktiven Lebensphase symptomatisch werden.

Symptomatik

Im Vordergrund stehen Blutungsstörungen, Schmerzen und Druckgefühl sowie Störungen im Rahmen der Reproduktion und Schwangerschaft. Letztere äußern sich in Aborten, Sterilität und dem vermehrten Auftreten von Komplikationen. Entscheidend ist die Lage und Größe der Myome, wobei vor allem submuköse und intramurale Myome eine Rolle zu spielen scheinen.

Diagnostik

Im Vordergrund stehen hier an erster Stelle die klinische Untersuchung und der Ultraschall als nicht invasive Untersuchungsmethoden. Das MRT oder CT sollte Sonderfällen vorbehalten bleiben.

Therapie

Die minimalinvasiven OP-Methoden, wie operative Hysteroskopie und Laparoskopie, sind die Methoden der Wahl zur organerhaltenden Resektion bzw. Enukleation von Myomen. Alternativ stehen die verschiedenen Hysterektomieverfahren bei abgeschlossener Familienplanung zur Verfügung.

Eine medikamentöse Therapieoption zur Beschwerdeverbesserung und präoperativen Myomverkleinerung stellt die Therapie mit Ulipristalacetat dar, die der Therapie mit GnRH-Agonisten überlegen ist. Die Therapie kann präoperativ zur OP-Vorbereitung erfolgen sowie als Langzeitintervalltherapie. Der Progesteronantagonist Mifepriston (RU 486) scheint ebenfalls in äquipotenter Weise eine Größenreduktion von Myomen zu verursachen, ist aber in Deutschland zu diesem Zweck nicht zugelassen. Die Embolisation der A. uterina sowie der hochintensive fokussierte Ultraschall sind für ausgewählte Patientinnen mit abgeschlossener Familienplanung und nach sorgfältiger Abwägung des Risikos und Nutzen eine Alternative. Zu beachten ist aber die relativ hohe Rate an sekundären operativen Eingriffen.

 

  • Literatur

  • 1 Robboy SJ, Bentley RC, Butnor K et al. Pathology and pathophysiology of uterine smooth-muscle tumors. Environ Health Perspect 2000; 108: 779-784
    CrossrefGoogle Scholar
  • 2 Cramer SF, Patel A. The frequency of uterine leiomyomas. Am J Clin Pathol 1990; 94: 435-438
    CrossrefGoogle Scholar
  • 3 AQUA: Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen GmbH. Bundesauswertung zum Verfahrensjahr 2012 15/1, Gynäkologische Operationen; 2013. Im Internet: http://www.sgg.de/downloads/Bundesauswertungen/2012/bu_Gesamt_15N1-GYN-OP_2012.pdf Stand: 11.02.2016
    Google Scholar
  • 4 Flake PG. Etiology and pathogenesis of uterine leiomyomas: a review. Environ Health Perspect 2003; 111: 1037-1054
    CrossrefGoogle Scholar
  • 5 Ross RK, Pike MC, Vessey MP et al. Risk factors for uterine fibroids: reduced risk associated with oral contraceptives. Br Med J (Clin Res Ed) 1986; 293: 359-362
    CrossrefGoogle Scholar
  • 6 Chiaffarino F, Parazzini F, La Vecchia C et al. Use of oral contraceptives and uterine fibroids: results from a case-control study. Br J Obstet Gynaecol 1999; 106: 857-860
    CrossrefGoogle Scholar
  • 7 Deligdisch L. Hormonal pathology of the endometrium. Mod Pathol 2000; 13: 285-294
    CrossrefGoogle Scholar
  • 8 Walker CL. Role of hormonal and reproductive factors in the etiology and treatment of uterine leiomyoma. Recent Prog Horm Res 2002; 57: 277-294
    CrossrefGoogle Scholar
  • 9 Townsend DE, Sparkes RS, Baluda MC et al. Unicellular histogenesis of uterine leiomyomas as determined by electrophoresis by glucose-6-phosphate dehydrogenase. Am J Obstet Gynecol 1970; 15: 1168-1173
    Google Scholar
  • 10 Stewart EA. Uterine fibroids. Lancet 2001; 357: 293-298
    CrossrefGoogle Scholar
  • 11 Friedman AJ, Barbieri RL, Doubilet PM et al. A randomized, double-blind trial of a gonadotropin releasing-hormone agonist (leuprolide) with or without medroxyprogesterone acetate in the treatment of leiomyomata uteri. Fertil Steril 1988; 49: 404-409
    Google Scholar
  • 12 Brandon DD, Bethea CL, Strawn EY et al. Progesterone receptor messenger ribonucleic acid and protein are overexpressed in human uterine leiomyomas. Am J Obstet Gynecol 1993; 169: 78-85
    CrossrefGoogle Scholar
  • 13 Segaloff A, Weed JC, Sternberg WH et al. The progesterone therapy of human uterine leiomyomas. J Clin Endocrinol Metab 1949; 9: 1273-1291
    CrossrefGoogle Scholar
  • 14 Murphy AA, Kettel LM, Morales AJ et al. Regression of uterine leiomyomata in response to the antiprogesterone RU 486. J Clin Endocrinol Metab 1993; 76: 513-517
    CrossrefGoogle Scholar
  • 15 Carr BR, Marshburn PB, Weatherall PT et al. An evaluation of the effect of gonadotropin-releasing hormone analogs and medroxyprogesterone acetate on uterine leiomyomata volume by magnetic resonance imaging: a prospective, randomized, double blind, placebo-controlled, crossover trial. J Clin Endocrinol Metab 1993; 76: 1217-1223
    CrossrefGoogle Scholar
  • 16 Friedman AJ, Daly M, Juneau-Norcross M et al. Long-term medical therapy for leiomyomata uteri: a prospective, randomized study of leuprolide acetate depot plus either oestrogen-progestin or progestin ‘add-back’ for 2 years. Hum Reprod 1994; 9: 1618-1625
    CrossrefGoogle Scholar
  • 17 Rein MS. Advances in uterine leiomyoma research: the progesterone hypothesis. Environ Health Perspect 2000; 108: 791-793
    CrossrefGoogle Scholar
  • 18 Ligon AH, Morton CC. Genetics of uterine leiomyomata. Genes Chromosomes Cancer 2000; 28: 235-245
    CrossrefPubMedGoogle Scholar
  • 19 National Collaborating Centre for Womenʼs and Childrenʼs Health. National Institute for Clinical Excellence. Fertility: Assessment and Treatment for People with Fertility Problems. London: RCOG Press; 2004
    Google Scholar
  • 20 Bhave Chittawar P, Franik S, Pouwer AW et al. Minimally invasive surgical techniques versus open myomectomy for uterine fibroids. Cochrane Database Syst Rev 2014; (10) CD004638
    Google Scholar
  • 21 Donnez J, Jadoul P. What are the implications of myomas on fertility?. Hum Reprod 2002; 17: 1424-1430
    CrossrefGoogle Scholar
  • 22 Grigorieva V, Chen-Mok M, Tarasova M et al. Use of a levonorgestrel-releasing intrauterine system to treat bleeding related to uterine leiomyomas. Fertil Steril 2003; 79: 1194-1198
    CrossrefGoogle Scholar
  • 23 Magalhães J, Aldrighi JM, de Lima GR. Uterine volume and menstrual patterns in users of the levonorgestrel-releasing intrauterine system with idiopathic menorrhagia or menorrhagia due to leiomyomas. Contraception 2007; 75: 193-198
    CrossrefGoogle Scholar
  • 24 Zapata LB, Whiteman MK, Tepper NK et al. Intrauterine device use among women with uterine fibroids: a systematic review. Contraception 2010; 82: 41-55
    CrossrefGoogle Scholar
  • 25 Engman M, Granberg S, Williams AR et al. Mifepristone for treatment of uterine leiomyoma. A prospective randomized placebo controlled trial. Hum Reprod 2009; 24: 1870-1879
    CrossrefGoogle Scholar
  • 26 Fiscella K, Eisinger SH, Meldrum S et al. Effect of mifepristone for symptomatic leiomyomata on quality of life and uterine size: a randomized controlled trial. Obstet Gynecol 2006; 108: 1381-1387
    CrossrefGoogle Scholar
  • 27 Mavrelos D, Ben-Nagi J, Davies A et al. The value of pre-operative treatment with GnRH analogues in women with submucous fibroids: a double-blind, placebo controlled randomized trial. Hum Reprod 2010; 25: 2264-2269
    CrossrefPubMedGoogle Scholar
  • 28 Matchar DB, Myers ER, Barber MW et al. Management of uterine fibroids. Evid Rep Technol Assess (Summary) 2001; 34: 1-6
    Google Scholar
  • 29 Donnez J, Tomaszewski J, Vázquez F et al. Ulipristal acetate versus leuprolide acetate for uterine fibroids. N Engl J Med 2012; 366: 421-432
    CrossrefGoogle Scholar
  • 30 Donnez J, Tatarchuk TF, Bouchard P et al. Ulipristal acetate versus placebo for fibroid treatment before surgery. N Engl J Med 2012; 366: 409-420
    CrossrefGoogle Scholar
  • 31 Donnez J, Vázquez F, Tomaszewski J et al. PEARL III and PEARL III Extension Study Group. Long-term treatment of uterine fibroids with ulipristal acetate. Fertil Steril 2014; 101: 1565-1573
    CrossrefGoogle Scholar
  • 32 Jirecek S, Lee A, Pavo I et al. Raloxifene prevents the growth of uterine leiomyomas in premenopausal women. Fertil Steril 2004; 81: 132-136
    CrossrefGoogle Scholar
  • 33 Palomba S, Russo T, Orio F et al. Effectiveness of combined GnRH analogue plus raloxifene administration in the treatment of uterine leiomyomas: a prospective, randomized, single-blind, placebo-controlled clinical trial. Hum Reprod 2002; 17: 3213-3219
    CrossrefGoogle Scholar
  • 34 Palomba S, Orio S, Morelli M et al. Raloxifene administration in premenopausal women with uterine leiomyomas: a pilot study. J Clin Endocrinol Metab 2002; 87: 3603-3608
    CrossrefGoogle Scholar
  • 35 Hilário SG, Bozzini N, Borsari R et al. Action of aromatase inhibitor for treatment of uterine leiomyoma in perimenopausal patients. Fertil Steril 2009; 91: 240-243
    CrossrefGoogle Scholar
  • 36 Parsanezhad ME, Azmoon M, Alborzi S et al. A randomized, controlled clinical trial comparing the effects of aromatase inhibitor (letrozole) and gonadotropin-releasing hormone agonist (triptorelin) on uterine leiomyoma volume and hormonal status. Fertil Steril 2010; 93: 192-198
    CrossrefGoogle Scholar
  • 37 ACOG Committee on Practice Bulletins-Gynecology. ACOG practice bulletin: surgical alternatives to hysterectomy in the management of leiomyomas. Int J Gynaecol Obstet 2001; 73: 285-294
    CrossrefGoogle Scholar
  • 38 Parker WH. Uterine myomas: management. Fertil Steril 2007; 88: 255-271
    CrossrefGoogle Scholar
  • 39 Fernandez H, Sefrioui O, Virelizier C et al. Hysteroscopic resection of submucosal myomas in patients with infertility. Hum Reprod 2001; 16: 1489-1492
    CrossrefGoogle Scholar
  • 40 Pritts EA, Parker WH, Olive DL. Fibroids and infertility: an updated systematic review of the evidence. Fertil Steril 2009; 91: 1215-1223
    CrossrefGoogle Scholar
  • 41 Dessolle L, Soriano D, Poncelet C et al. Determinants of pregnancy rate and obstetric outcome after laparoscopic myomectomy for infertility. Fertil Steril 2001; 76: 370-374
    CrossrefGoogle Scholar
  • 42 Li TC, Mortimer R, Cooke ID. Myomectomy: a retrospective study to examine reproductive performance before and after surgery. Hum Reprod 1999; 14: 1735-1740
    CrossrefGoogle Scholar
  • 43 Campo S, Garcea N. Laparoscopic myomectomy in premenopausal women with and without preoperative treatment using gonadotropin-releasing hormone analogues. Hum Reprod 1999; 14: 44-48
    CrossrefGoogle Scholar
  • 44 Ahmad G, OʼFlynn H, Hindocha A et al. Barrier agents for adhesion prevention after gynaecological surgery. Cochrane Database Syst Rev 2015; (4) CD000475
    Google Scholar
  • 45 Nieboer TE, Johnson N, Lethaby A et al. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev 2009; (3) CD003677
    Google Scholar
  • 46 Lethaby A, Mukhopadhyay A, Naik R. Total versus subtotal hysterectomy for benign gynaecological conditions. Cochrane Database Syst Rev 2012; (4) CD004993
    Google Scholar
  • 47 Boosz A, Lermann J, Mehlhorn G et al. Comparison of re-operation rates and complication rates after total laparoscopic hysterectomy (TLH) and laparoscopy-assisted supracervical hysterectomy (LASH). Eur J Obstet Gynecol Reprod Biol 2011; 158: 269-273
    CrossrefGoogle Scholar
  • 48 Mueller A, Boosz A, Koch M et al. The Hohl instrument for optimizing total laparoscopic hysterectomy: results of more than 500 procedures in a university training center. Arch Gynecol Obstet 2012; 285: 123-127
    CrossrefGoogle Scholar
  • 49 Food and Drugs Administration. Laparoscopic uterine power morcellation in hysterectomy and myomectomy: FDA safety communication. Im Internet: http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm393576.htm Stand: 12.12.2016
    Google Scholar
  • 50 Beckmann MW, Juhasz-Böss I, Denschlag D et al. Surgical methods for the treatment of uterine fibroids – risk of uterine sarcoma and problems of morcellation: Position paper of the DGGG. Geburtsh Frauenheilkd 2015; 75: 148-164
    Article in Thieme ConnectGoogle Scholar
  • 51 Pritts EA, Vanness DJ, Berek JS et al. The prevalence of occult leiomyosarcoma at surgery for presumed uterine fibroids: a meta-analysis. Gynecol Surg 2015; 12: 165-177
    CrossrefGoogle Scholar
  • 52 Barakat EE, Bedaiwy MA, Zimberg S et al. Robotic-assisted, laparoscopic, and abdominal myomectomy: a comparison of surgical outcomes. Obstet Gynecol 2011; 117: 256-265
    CrossrefGoogle Scholar
  • 53 Mueller A, Oppelt P, Ackermann S et al. The Hohl Instrument for optimizing total laparoscopic hysterectomy procedures. J Minim Invasive Gynecol 2005; 12: 432-435
    CrossrefGoogle Scholar
  • 54 Thiel F, Renner S, Oppelt P et al. Establishment of total laparoscopic hysterectomy (TLH) in a university gynecology department: results of the first 100 operations. Geburtsh Frauenheilk 2006; 66: 665-669
    Article in Thieme ConnectGoogle Scholar
  • 55 Spies JB, Spector A, Roth AR et al. Complications after uterine artery embolization for leiomyomas. Obstet Gynecol 2002; 100: 873-880
    CrossrefGoogle Scholar
  • 56 Stroszczynski C, Degenhart C. Uterusmyomembolisation und fokussierter Ultraschall: Stand 2013. Gynäkologe 2014; 47: 19-25
    CrossrefGoogle Scholar
  • 57 Tropeano G, Di Stasi C, Amoroso S et al. Long-term effects of uterine fibroid embolization on ovarian reserve: a prospective cohort study. Fertil Steril 2010; 94: 2296-2300
    CrossrefGoogle Scholar
  • 58 Froeling V, Meckelburg K, Schreiter NF et al. Outcome of uterine artery embolization versus MR-guided high-intensity focused ultrasound treatment for uterine fibroids: long-term results. Eur J Radiol 2013; 82: 2265-2269
    CrossrefGoogle Scholar
  • 59 Gupta JK, Sinha A, Lumsden MA et al. Uterine artery embolization for symptomatic uterine fibroids. Cochrane Database Syst Rev 2014; (12) CD005073
    Google Scholar
  • 60 Müller A, Thiel F, Binder H et al. Myome – Teil 1. Geburtsh Frauenheilk 2004; 64: R230-R243
    Google Scholar
  • 61 Müller A, Thiel F, Binder H et al. Myome – Teil 2. Geburtsh Frauenheilk 2004; 64: R245-R260
    Article in Thieme ConnectGoogle Scholar
  • 62 Committee on Gynecologic Practice, American College of Obstetricians and Gynecologists. ACOG Committee Opinion. Uterine artery embolization. Obstet Gynecol 2004; 103: 403-404
    CrossrefGoogle Scholar
  • 63 213. Stellungnahme der Deutschen Gesellschaft für Gynäkologie und Geburtshilfe (DGGG) zur Uterusarterienembolisation (UAE) zur Myombehandlung – Ergebnisse des 5. Radiologisch-gynäkologischen Expertentreffens. Im Internet: http://www.dggg.de/fileadmin/documents/stellungnahmen/aktuell/2015/213_Stellungnahme_UAE_zur_Myombehandlung1.pdf Stand: 01.12.2016
    Google Scholar
  • 64 David M, Kröncke T. Uterine fibroid embolisation – Potential impact on fertility and pregnancy outcome. Geburtsh Frauenheilk 2013; 73: 247-255
    Article in Thieme ConnectGoogle Scholar
  • 65 Ruhnke H, Eckey T, Bohlmann MK et al. MR-guided HIFU treatment of symptomatic uterine fibroids using novel feedback-regulated volumetric ablation: effectiveness and clinical practice. Fortschr Röntgenstr 2013; 185: 983-991
    Article in Thieme ConnectGoogle Scholar
  • 66 Toro JR, Travis LB, Wu HJ et al. Incidence patterns of soft tissue sarcomas, regardless of primary site, in the surveillance, epidemiology and end results program, 1978-2001: An analysis of 26,758 cases. Int J Cancer 2006; 119: 2922-2930
    CrossrefGoogle Scholar
  • 67 Hosh M, Antar S, Nazzal A et al. Uterine sarcoma: analysis of 13,089 cases based on surveillance, epidemiology, and end results database. Int J Gynecol Cancer 2016; 26: 1098
    CrossrefGoogle Scholar
  • 68 Amant F, Coosemans A, Debiec-Rychter M. Clinical management of uterine sarcomas. Lancet Oncol 2009; 10: 1188-1198
    CrossrefGoogle Scholar
  • 69 Goto A, Takeuchi S, Sugimura K et al. Usefulness of Gd-DTPA contrast-enhanced dynamic MRI and serum determination of LDH and its isozymes in the differential diagnosis of leiomyosarcoma from degenerated leiomyoma of the uterus. Int J Gynecol Cancer 2002; 12: 354-361
    CrossrefGoogle Scholar
  • 70 Parker WH, Fu YS, Berek JS. Uterine sarcoma in patients operated on for presumed leiomyoma and rapidly growing leiomyoma. Obstet Gynecol 1994; 83: 414-418
    PubMedGoogle Scholar
  • 71 Koo YJ, Lee JK, Lee YK et al. Pregnancy outcomes and risk factors for uterine rupture after laparoscopic myomectomy: a single-center experience and literature review. J Minimally Invasive Gynecol 2015; 22: 1022-1028
    Google Scholar
  • 72 Dubuisson JB, Fauconnier A, Deffarges JV et al. Pregnancy outcome and deliveries following laparoscopic myomectomy. Hum Reprod 2000; 15: 869-873
    CrossrefGoogle Scholar
  • 73 Müller A, Thiel FC, Renner SP et al. Hysterectomy – a comparison of approaches. Dtsch Arztebl Int 2010; 107: 353-359
    Google Scholar