Uterine leiomyomas are common and life-altering for many women. Despite a wide range of symptoms, varying characteristics of the uterus and the leiomyomas themselves, and many alternatives, hysterectomy accounts for almost three fourths of all surgical therapy, yet there is increasing evidence for a variety of procedural therapies for symptomatic leiomyomas and a new generation of medical therapies under development. With increasing evidence of long-term risk from hysterectomy and new data regarding leiomyoma biology, individualized medical approaches to leiomyomas are likely in the near future. Key biological attributes that influence this disease process are common driver mutations and the new appreciation of the interaction of smooth muscle cells and fibroblasts. Additionally, the interaction between cell types and steroid hormone responsiveness likely plays a role in pathogenesis that can be leveraged in individualized therapy. However, given the independent clonal nature of leiomyomas within the same uterus, moving in the direction of biopsies for individual leiomyomas to understand the biology is unlikely to be fruitful. Use of advanced imaging will likely continue to evolve not only to accurately predict malignant disease, including sarcomas, but to predict leiomyoma subtypes, response to therapy, or both. We predict the continued evolution of therapy from excisional or interventional therapies to medical therapies and ultimately prediction of at-risk individuals. Ideally, individualized therapies will offer primary prevention for women at high risk of leiomyomas and secondary prevention after initial treatment.
Newly understood leiomyoma biology raises the possibility for innovative individualized leiomyoma care; innovative diagnostic techniques will be required to correlate leiomyoma subtype with therapeutic response.
Divisions of Gynecology and Reproductive Endocrinology and Infertility, Department of Obstetrics & Gynecology, and the Department of Surgery, Mayo Clinic, Rochester, Minnesota.
Corresponding author: Shannon K. Laughlin-Tommaso, MD, MPH, Division of Gynecology, Department of Obstetrics and Gynecology, 200 First Street SW, Rochester, MN 55905; email: email@example.com.
Supported by grant number P50HS023418 from the Agency for Healthcare Research and Quality.
Financial Disclosure Dr. Laughlin-Tommaso received personal fees from Allergan and grants from Halt Medical outside the submitted work. Dr. Stewart received personal fees from AbbVie, Allergan, Astellas, Bayer, GlaxoSmithKline, Gynesonics, Myovant, and Welltwigs outside the submitted work.
Continuing medical education for this article is available at http://links.lww.com/AOG/B129.
Each author has indicted that she has met the journal's requirements for authorship.