Uterine Fibroids and Transcervical Resection of Myoma (TCRM)

Uterine fibroids are very common, affecting more than 60% of women aged 45 and older. Submucous fibroids can cause heavy menstrual bleeding (HMB), dysmenorrhea, and fertility problems. Transcervical resection of myoma (TCRM) is a widely implemented treatment, particularly for FIGO PALM-COEIN classification type 0, 1, and 2 fibroids. TCRM seems to be safe and effective for reducing HMB in qualitative studies, with only a small percentage of patients needing repeat surgery (approximately 4% after 2–3 years and less than 10% after 5 years).

Furthermore, HMB can cause anemia and iron deficiency. The presence of submucous fibroids and the amount of protrusion is also related to anemia and (lower) Hb level, although no significant relation to Pictorial Blood Assessment Chart (PBAC) score and anemia or Hb level was found. PBAC is a validated measurement instrument to quantify menstrual blood loss, where women score the number of pads or tampons used during their period and the degree to which those were stained with blood. A PBAC score of more than 150 indicates HMB. The uterine fibroid symptom and quality of life questionnaire (UFSQOL) was developed for assessing other fibroid-related symptoms and health-related quality of life in women with uterine fibroids. UFSQOL scores have been reported to improve after TCRM.

The aim of this study by A.L. Keizer et al. was to quantify the effect of TCRM on HMB and health-related quality of life in patients with submucous fibroids, using PBAC, UFS-QOL, and Hb level. In women with submucous fibroids, HMB measured by PBAC decreased significantly 6 months after TCRM compared to baseline. Symptom severity scores were significantly lower and health-related quality of life scores were higher 6 months after TCRM.

A prospective cohort study was conducted in three teaching hospitals and two academic hospitals in the Netherlands. Patients with HMB (PBAC score > 150) and submucous fibroids (type 0, 1, 2, 3, 4, and hybrid type 2–5) scheduled for TCRM were eligible. At baseline and 3 months after TCRM, a Trans Vaginal Ultrasound (TVU) was performed and an Hb sample was taken. Patients filled out the Pictorial Blood Assessment Chart (PBAC) and the Uterine Fibroid Symptom and Quality of Life (UFS-QOL) questionnaire at baseline and up to 6 months after surgery. Primary outcome was improvement in PBAC score 6 months after surgery. Secondary outcomes were improvement in PBAC score and Hb level 3 months after surgery and UFS-QOL scores 3 and 6 months after surgery.

126 patients were included and 104 were operated. PBAC were obtained from 98 patients. Six months after surgery, 56.6% of patients went from HMB to normal menstrual bleeding (PBAC < 150). A significant reduction in median PBAC scores of 427 (IQR 198 – 1392) (p<.0001) was found (86% improvement). UFS-QOL scores were obtained from 91 patients. Symptom severity improved from a median of 54 on a scale of 100 (IQR 44–66) at baseline to 22 (IQR 9–41) after 6 months (p<.0001) (59% improvement). Health-related quality of life (HRQOL) improved from a median score of 44 on a scale of 100 (IQR 33–62) to 89 (IQR 67–97) 6 months after surgery (p<.0001) (102% improvement).

In women with submucous fibroids, HMB measured by PBAC decreased significantly 6 months after TCRM compared to baseline. Symptom severity scores were significantly lower and health-related quality of life scores were higher 6 months after TCRM. A trend towards a decrease of anemia after surgery was found. Linear regression analysis demonstrated that higher age, black ethnicity, and larger fibroid volume at baseline were associated with a larger improvement for changes in PBAC score, in UFS-QOL score, and in Hb level, respectively.

In this study, authors proved that TCRM reduces post-operative PBAC scores, severity of other fibroid-related symptoms, and improves health-related Quality of Life in patients with submucous fibroids. This is valuable information for decision-making in the treatment of fibroid-induced HMB for both clinicians and patients.

Source: A.L. Keizer et al.; European Journal of Obstetrics & Gynecology and Reproductive Biology 274 (2022) 128–135