Appraisal of current uterine fibroid management guidelines

A study published in the BJOG: An International Journal of Obstetrics and Gynaecology reports a need for high-quality fibroid management and treatment guidelines.

The study, conducted in London, United Kingdom, gathered national and international guidelines for diagnosis and treatment of uterine fibroids and assessed quality using the Appraisal of Guidelines for Research and Evaluation II. Three reviewers were responsible for the independent appraisal of the included guidelines and 939 titles and abstracts were screened, with a total of 9 guidelines being selected.

There was consensus across guidelines regarding only 3 areas: 1) asymptomatic women with fibroids are best managed expectantly; 2) gonadotrophin-releasing hormone treatment is effective at improving blood levels preoperatively in women with anemia; 3) hysteroscopic myomectomy should be considered firstline treatment for management of symptomatic submucosal fibroids.

Otherwise, the recommendation content between guidelines varied or was inconsistently reported. For example, in 1 guideline, pregnant women with fibroids required increased monitoring, while in another guideline, they did not unless they were symptomatic. Researchers looked at assessment of fibroids, medical treatment, and surgical treatment when assessing for consistency of recommendations.

Most of the guidelines, 8 of 9, used methodology that described a systematic database search.The number of supporting citations ranged from 6 to 204. Only 25.3% of recommendations were developed using good-quality evidence. The number of Cochrane systematic reviews cited in each guideline ranged from 0 to 7 and the number of randomized controlled trials cited per guideline ranged from 0 to 25. 27.7% of guideline recommendations were based only on expert opinion or clinical consensus rather than evidence.

Researchers concluded that in this study, no published uterine fibroid practice guideline was considered high-quality. Seventy-eight percent of the guidelines scored as being low-quality. There was suboptimal transparency regarding the systematic review strategies used, tools to evaluate the evidence quality were inconsistently used, discussion of the barriers to guideline application was limited and none of the guidelines demonstrated an involvement of patients with fibroids as the primary stakeholders in the guideline development process.

The scope of guideline content varied. For example, 1 guideline was limited to the discussion of submucosal fibroids, while other guidelines discussed uterine fibroids in the context of fertility. Because of these inconsistencies, there are several contrasting recommendations that do not allow for comparison across the guidelines. The scope of each guideline limits discussion of the number of different treatments available.

From this study, many research questions remain unanswered. There is a lack of evidence regarding long-term treatment outcomes and it is still not fully understood how certain fibroid characteristics, such as size and number, affect clinical outcomes. The optimal perioperative therapy to assist in improving operative outcomes has not yet been determined.

The authors suggest that future guideline development for uterine fibroids should be evidence-based with stronger research methodology, which will allow for validity of recommendations and the ability to cross compare guidelines. The current guidelines and their lack of cohesive recommendations could contribute to suboptimal clinical care and inconsistencies in assessment and management of fibroids among clinicians.

Reference

  1. Amoah A, Joseph N, Reap S, Quinn S. Appraisal of national and international uterine fibroid management guidelines: a systematic review. [published online ahead of print, 2021 Sep 30]. BJOG. 2022; 129(3): 356-364. doi: 10.1111/1471-0528.16928.