Management of the symptomatic fibroid in women older than 40 years of age. Hysterectomy or myomectomy?

Although complications resulting from a myomectomy are infrequent, the overall risk is probably greater than a hysterectomy. The effect of hysterectomy on the specific women is difficult to quantify, however. Supracervical hysterectomy is a reasonable alternative in the woman with a normal cervix. Moreover, repeated laparotomies are not particularly advisable. In a woman who has previously undergone a myomectomy and has had a recurrent symptomatic myomatous uterus, the decision must be made either to proceed with a repeat myomectomy or to perform a hysterectomy. The chance of successfully achieving a pregnancy after a second myomectomy may be less favorable than after a primary myomectomy. A myomectomy can be a difficult and often time-consuming procedure. With meticulous attention to technique, however, the procedure can be accomplished safely and effectively with relatively ensured hemostasis and minimal blood loss. A myomectomy affords the option of preserving the uterus in those patients with symptomatic uterine myomata who desire to preserve their reproductive organs. However, careful assessment with meticulous counseling of the patient is essential. The potential option for a hysterectomy must always be preserved. Hysteroscopic resection of submucous myomata with endometrial ablation has become the technique of preference in many cases. At the moment, abdominal myomectomy is the preferred technique for the removal of intramural and subserosal myomata. For the present, laparoscopic myomectomy must be viewed as being of very limited acceptability.