Internet Citation: They have not reviewed the report, except as given the opportunity to do so through the peer or public review mechanism. Many women have significant hot flashes while using GnRH agonists. Hysterectomy. No. The management of uterine fibroids also depends on the number, size and location of the fibroids. Medications include: Gonadotropin-releasing hormone (GnRH) agonists. Overdistension of the uterus (twins and fibroids); . MARIA SYL D. DE LA CRUZ, MD, AND EDWARD M. BUCHANAN, MD. We are moderately confident that the estimate of effect lies close to the true effect for this outcome. Review/update the Fibroids do not regrow after surgery, but new fibroids may develop. Many women who are told that hysterectomy is their only option can have an abdominal myomectomy instead. Your first appointment will likely be with either your primary care provider or a gynecologist. Uploaded by . It is likely that analyses will be combined using a Bayesian hierarchical mixed effects model. 13(14)-EHC 130-EF. Am J Obstet Gynecol. Expectant management is appropriate for women with asymptomatic uterine fibroids. Fibroids have a very typical appearance on an ultrasound, and because they're so common, they're almost always accurately diagnosed. Uterine leiomyomas. Does risk of cancer dissemination from morcellation differ by patient or fibroid characteristics (e.g., age; race/ethnicity; symptoms; menopausal status; imaging characteristics; vascular supply to fibroids; or number, size, type, location, or total volume of fibroids)? This input is intended to ensure that the key questions are specific and relevant. Discuss these with your doctor. 1. Uterine leiomyomas, or fibroids, are a major cause of abnormal uterine bleeding in women. You may want to consider the severity of your symptoms, your feelings about surgery, your plans for pregnancy and how close you are to menopause. Analysis of subgroups will be done formally, within a statistical model, or by stratifying results and organizing the report in such a way that end users are provided with overall outcomes data and information specific to subgroups defined by factors such as menopausal status or fibroid size that can be easily identified and stand alone as needed. Older women in or entering menopause may have a higher cancer risk, and women who are no longer concerned about preserving their fertility have additional treatment options for fibroids. Maintain frequent J Clin Epidemiol. We will use prespecified questions1 from Table 4 in "Assessing the Risk of Bias of Individual Studies in Systematic Reviews of Health Care Interventions"23 to assess risk of bias of randomized controlled trials. Grading the strength of a body of evidence when assessing health care interventions for the effective health care program of the Agency for Healthcare Research and Quality: An update. PMID: 11214143, Huyck KL, Panhuysen CI, Cuenco KT, et al. All myomectomies carry the risk of cutting into an undiagnosed cancer, but younger, premenopausal women generally have a lower risk of undiagnosed cancer than do older women. Develop early identification of the changes in skin integrity. Fibroids can range in size from small, pea-sized growths to large, round ones that may be more than 5 to 6 inches wide. Lancet. 4 Uterine artery embolization is a potential minimally . The search and selection literature sources may be refined following discussions with Technical Experts. The cause of fibroids is unknown. Acute Pain. Includes: possible causes, signs and . Table 2 includes the differential diagnosis of uterine masses.31, Treatment of uterine fibroids should be tailored to the size and location of the tumors; the patient's age, symptoms, desire to maintain fertility, and access to treatment; and the physician's experience 4,11 (Table 332 42 and Table 44,16,34,38,4044 ). CARE PLAN Patient: Doris Bowman Admitted on: 3/17/2021 Medical Diagnosis: Uterine leiomyomas (fibroids) Nursing Assessment Subjective: Patient states: "I just had surgery; it hurts in my belly." Patient states: "Pain level, It's pretty bad, I'd give it a 6" Objective : Vital Signs Heart rate: 95, Blood pressure: 118/67 mm Hg. Robotic myomectomy gives your surgeon a magnified, 3D view of your uterus, offering more precision, flexibility and dexterity than is possible using some other techniques. This content does not have an Arabic version. If that's the case for you, watchful waiting could be the best option. Recognize signs of impending rupture, immediately notify the physician, and call for assistance. Methods Guide for Effectiveness and Comparative Effectiveness Reviews. Telephone: (301) 427-1364, Powered by the Evidence-based Practice Centers, https://effectivehealthcare.ahrq.gov/products/uterine-fibroids/research-protocol, Comment on Key Questions and Draft Reports, 25 Years of the AHRQ Evidence-based Practice Center Program, http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm424443.htm, http://www.pcori.org/research-results/2014/comparing-options-management-patient-centered-results-uterine-fibroids-compare, Attention Deficit Hyperactivity Disorder: Diagnosis and Treatment in Children and Adolescents, Diagnostic Errors in the Emergency Department: A Systematic Review, Strategies for Patient, Family and Caregiver Engagement, Impact of Community Health Worker Certification on Workforce and Service Delivery for Asthma and Other Selected Chronic Diseases, Maternal and Fetal Effects of Mental Health Treatments in Pregnant and Breastfeeding Women: A Systematic Review of Pharmacological Interventions, U.S. Department of Health & Human Services, Women who are being treated for uterine fibroids (KQs 1-4). Medications called GnRH agonists treat fibroids by blocking the production of estrogen and progesterone, putting you into a temporary menopause-like state. Accessed May 1, 2019. Larger fibroids can cause you to experience a variety of symptoms, including: Excessive or painful bleeding during your period (menstruation). In this procedure, a thin tube called an endoscope is passed through the cervix and into the uterus. Although aetiology and natural history of the conditions are markedly different, symptoms can overlap and make differential diagnoses necessary, often using invasive methods such as laparoscopy. The Key Questions reflect the unmet need for a relevant synthesis of evidence from prospective randomized controlled trials on the relative benefits and harms of surgical, procedural, and medical interventions to manage uterine fibroids. Bleeding between your periods. Uterine fibroids: An update on current and emerging medical treatment options. Overview of treatment of uterine leiomyomas (fibroids). Uploaded by shiramu. Hartmann KE, et al. Philadelphia, Pa.: Elsevier; 2019. https://www.clinicalkey.com. Comparative effectiveness review no. We anticipate performing a meta-analysis to describe the effects of treatment decisions on outcomes including likelihood of maintaining fertility or needing additional treatment, including, ultimately, hysterectomy. Accessed April 24, 2019. But it's more likely with increasing weight or obesity and more likely with smaller rather than larger fibroids. Management of abnormal uterine bleeding. Feb 29, 2016. They can grow as a . Effective Health Care Program, Agency for Healthcare Research and Quality, Rockville, MD. We may limit the report of key findings from studies assessed as high risk of bias to summary tables. Many women who have uterine fibroids do not have symptoms. Acupuncture has shown promise for improving fibroid outcomes in small studies. If confirmation is needed, your doctor may order an ultrasound. There are several ways to reduce that risk, such as evaluating risk factors before surgery, morcellating the fibroid in a bag or expanding an incision to avoid morcellation. HHSA 290-2015-00003I from the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services. This surgery removes the uterus. We will carry out hand searches of the reference lists of recent systematic reviews or meta-analyses of therapies for uterine fibroids. information highlighted below and resubmit the form. Quantifying study-level heterogeneity via random effects is preferable to the use of an arbitrary variance cutoff value or statistical tests for heterogeneity, such as Q statistics or I2 scores. We will assess reporting bias of randomized controlled trials by examining outcomes of trials as reported in resources such as ClinicalTrials.gov to determine if prespecified outcomes are not reported in the published literature. If we are unable to resolve a discrepancy in the reporting of data from a publication we may contact study authors for additional information or clarification. We will upload the extracted data to the Systematic Review Data Repository (SRDR). The most common complication is postembolization syndrome, which is characterized by mild fever and pain, and vaginal expulsion of fibroids.63. We will also incorporate relevant, eligible studies identified by peer reviewers or public commenters. In: Endocrinology: Adult and Pediatric. 1998-2023 Mayo Foundation for Medical Education and Research (MFMER). The disposition of comments for systematic reviews and technical briefs will be published three months after the publication of the evidence report. There is some literature about the relationship of imaging findings and symptom profiles, but the correlation is not tight. An official website of the Department of Health & Human Services, Most women will develop one or more uterine fibroids (i.e., leiomyomata), benign smooth muscle tumors of the uterus, during their reproductive lifespan.1 In the United States, an estimated 26 million women between the ages of 15 and 50 have uterine fibroids.1-4 More than 15 million of them will experience associated symptoms or health concerns.5,6 A disproportionate number of black women are among those with symptoms in part due to earlier age at onset of fibroids with larger and more numerous tumors.1-3,7,8, The etiology of uterine fibroids is not well understood, and a variety of factors including race/ethnicity, parity, and age at menarche have been examined. After locating a fibroid, your doctor uses a specialized device to deploy several small needles into the fibroid. https://effectivehealthcare.ahrq.gov/topics/uterine-fibroids/research-2017. Uterine atony refers to the failure of the uterus to contract sufficiently during and after childbirth. It can occur during both vaginal and cesarean delivery . Author disclosure: No relevant financial affiliations. Management should be tailored to the size and location of fibroids; the patient's age, symptoms, desire to maintain fertility, and access to treatment; and the experience of the physician. We will retrieve and review all articles that meet our predetermined inclusion criteria from abstract screening or for which we have insufficient information to make a decision about eligibility. Most fibroids are benign i.e. The American College of Obstetricians and Gynecologists. Mayo Clinic on Incontinence - Mayo Clinic Press, NEW The Essential Diabetes Book - Mayo Clinic Press, NEW Ending the Opioid Crisis - Mayo Clinic Press, FREE Mayo Clinic Diet Assessment - Mayo Clinic Press, Mayo Clinic Health Letter - FREE book - Mayo Clinic Press, Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic School of Continuous Professional Development, Mayo Clinic School of Graduate Medical Education, Our caring team of Mayo Clinic experts can help you with your uterine fibroids-related health concerns, What are uterine fibroids? The Food and Drug Administration (FDA) advises against the use of a device to morcellate the tissue (power morcellator) for most women having fibroids removed through myomectomy or hysterectomy. Subgroup analysis may be used to evaluate the intervention trajectory in a defined subset of the participants in a trial, or in complementary subsets. A single copy of these materials may be reprinted for noncommercial personal use only. Risk of Injury. We will use multilevel models, which boost the power of the analysis by sharing strengths across subgroups for variables where it makes sense to do so, or subgroup analysis (with random effects meta-analysis) to explore heterogeneity if there are a sufficient number of studies. Antiprogestins*. Identification of Future Research Needs in the Comparative Management of Uterine Fibroid Disease. Get answers to the most frequently asked questions about uterine fibroids from Michelle Louie, M.D., a minimally invasive gynecologic surgeon at Mayo Clinic. We will use a date limit of 1985 for the search of indexed literature. It should now be feasible, and most informative to guiding care, to restrict a review to randomized clinical comparisons of effectiveness, including medical management versus surgical, rather than restricting comparisons only to abdominal hysterectomy. Because there is minimal concern for malignancy in women with asymptomatic fibroids, watchful waiting is preferred - for management.4 There are no studies that support - surveillance with imaging or repeat imaging in asymptomatic women with fibroids.4,11, Hormonal Contraceptives. Key Informants must disclose any financial conflicts of interest greater than $10,000 and any other relevant business or professional conflicts of interest. The forms used for the full-text screening level will include additional questions to identify studies that meet all the inclusion criteria. Accessed April 24, 2019. Kellerman RD, et al. Because of their unique clinical or content expertise, individuals are invited to serve as Technical Experts and those who present with potential conflicts may be retained. If you want to entertaining books, lots of novels, tale, jokes, and more fictions collections are after that launched, from Nursing Care Plan Uterine Fibroids Many physicists using number of factors are plagued homeopathy in all other treatment must aim to eliminate. There's no single best approach to uterine fibroid treatment many treatment options exist. Descent. NURSING-CARE-PLAN-2021 - Read online for free. Key Informants are the end users of research, including patients and caregivers, practicing clinicians, relevant professional and consumer organizations, purchasers of health care, and others with experience in making health care decisions. Therapeutics and Clinical Risk Management. Can treatment of uterine fibroids improve my fertility? The impact of race as a risk factor for symptom severity and age at diagnosis of uterine leiomyomata among affected sisters. Scribd is the world's largest social reading and publishing site. 10(14)-EHC063-EF. 3rd ed. the unsubscribe link in the e-mail. AHRQ Publication No. Comparing Options for Management: Patient-Centered Results for Uterine Fibroids (COMPARE-UF). Fibroids in the uterine cavity can cause miscarriage or make it more difficult to get pregnant. Why I'm Offering DMPA to Patients With Uterine Fibroids; Recommendations. The exact cause of uterine fibroids is still not known. Myoma are very small in size: on average 0.3-0.4 cm. Best Practice and Research: Clinical Obstetrics and Gynaecology. Aromatase inhibitors (e.g., letrozole [Femara], anastrozole [Arimidex], fadrozole [not available in the United States]) block the synthesis of estrogen. Because appointments can be brief, it's a good idea to prepare for your appointment. Further studies are needed on fertility outcomes after uterine artery embolization so that patients can be counseled appropriately. Morcellation should not be used in women with suspected or known uterine cancer. During hysteroscopy, a thin, lighted instrument (hysteroscope) provides a view of the inside of the uterus. For all procedures except hysterectomy, seedlings tiny tumors that your doctor doesn't detect during surgery could eventually grow and cause symptoms that warrant treatment. July 2001, Wegienka G, Baird DD, Hertz-Picciotto I, et al. https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Gynecologic-Practice/Uterine-Morcellation-for-Presumed-Leiomyomas. Nursing Care Plan for Uterine Fibroids (Myoma) Apr 29, 2015. uterine fibroids features, types, diagnosis, mangement. The draft Key Questions were posted for public comments (6/23/15 7/13/15). A doctor or technician moves the ultrasound device (transducer) over your abdomen . Technical Experts constitute a multi-disciplinary group of clinical, content, and methodological experts who provide input in defining populations, interventions, comparisons, or outcomes and identify particular studies or databases to search. Fibroids can cause abnormal uterine bleeding, pelvic pressure, bowel dysfunction, urinary frequency and urgency, urinary retention, low back pain, constipation, and dyspareunia. We have no evidence, we are unable to estimate an effect, or we have no confidence in the estimate of effect for this outcome. The EPC will complete a disposition of all peer review comments. PMID: 17012456, Cardozo ER, Clark AD, Banks NK, et al. Are the fibroids located on the inside or outside of my uterus? Uterine fibroids are frequently found incidentally during a routine pelvic exam. 2014:P20-575. A Win for Women With Symptomatic Uterine Fibroids; 2001/viewarticle/981231. Total abdominal hysterectomy bilateral salpingo-oophorectomy (TAHBSO) is the removal of the entire uterus, the ovaries, fallopian tubes, and the cervix. 2015;372:1646. It is defined as excessive menstrual bleeding with a loss of more than 80ml of blood per month. Uterine fibroids, or leiomyomas, are the most common . Factors like genetics, abnormalities in the blood vessel or vascular system, hormones and other growth factors play an [] We will use the criteria and established tools described in the Methods Guide for Effectiveness and Comparative Effectiveness Reviews.23 Two senior investigators will assess each included study independently. We will record exclusion codes in an EndNote (Thomson Reuters, New York, NY) bibliographic database and will compile a list of excluded papers and exclusion reasons in the report. PMID: 15738025, Laughlin SK, Baird DD, Savitz DA, et al. Ultrasonography is the recommended initial imaging modality for diagnosis of uterine fibroids. Also, some procedures such as laparoscopic or robotic myomectomy, radiofrequency ablation, or MRI-guided focused ultrasound surgery (FUS) may only treat some of the fibroids present at the time of treatment. Advertising revenue supports our not-for-profit mission. We collected a list of outcomes from a prior review of relevant studies and prioritized that list to establish a core minimum set of outcomes for quantitative analyses. During hysterosonography (his-tur-o-suh-NOG-ruh-fee), a care provider uses a thin, flexible tube (catheter) to inject salt water (saline) into the hollow part of the uterus. Lyceum-Northwestern . Uterine fibroids or leiomyomata are the most common benign tumor affecting women. AskMayoExpert. Diagnosis/definition: Uterine fibroids are the most common benign gynecologic tumors Fibroids can grow on the inside of the uterus, within the muscle wall of the uterus, or on the outer surface of the uterus. If you have symptoms of uterine fibroids, your doctor may order these tests: Ultrasound. Using both instruments provides your doctor with two views of a uterine fibroid, allowing for more-thorough treatment than would be possible with just one view. This comment did not require changes to the Key Questions as literature addressing Key Question 1 would include benefits of morcellation. The Complete list of NANDA Nursing Diagnosis for 2012-2014 with 16 new diagnoses. A fibroid specialist will be able to tell you what options are possible based on the size, number and location of the fibroids and your treatment goals. We will use the search strategies presented in Tables A-3 and A-4 of the Appendix. View Abnormal UTERINE ACTIVITY.pptx from NURSING DIAGNOSIS at University of Nairobi. urinary elimination related to uterine fibroids, impaired physical mobility nursing care plan, nursing care plans for a urinary tract . PMID: 18823754, Viswanathan M, Ansari MT, Berkman ND, et al. Large fibroids may cause infertility by preventing a fertilised egg from implanting in the womb or blocking the fallopian tubes, although this is rare. If you have symptoms of uterine fibroids, your doctor may order these tests: Ultrasound. There are some small studies looking into possible dietary and environmental factors that may promote fibroid growth. Ongoing observational studies such as COMPARE21 will provide data about sequencing of treatments when completed. Minor changes included the addition of fibroid type and location as a characteristic of interest in Key Question 2 and Key Question 4. Laparoscopic or robotic myomectomy. Though hysterectomy and myomectomy by a variety of routes are frequently used, perhaps with insufficient consideration of alternative treatment prior to surgery,16 the range of fibroid-specific treatments including interventions like extended medical management with ulipristal acetate, magnetic resonance image-guided focused ultrasound (MRgFUS), uterine artery embolization, radiofrequency volumetric thermal ablation, and techniques for myolysis are increasingly generating comparative effectiveness data7,9 as is the clinical trials literature about improving bleeding symptoms.17 Furthermore, as the literature evolves, including larger studies of stronger design with longer followup, a clearer picture of anticipated outcomes is likely to emerge. For example, oral contraceptives can help control menstrual bleeding, but they don't reduce fibroid size. The final search strategies will be peer reviewed by an independent information specialist. With laparoscopic radiofrequency ablation (Acessa), also called Lap-RFA, your doctor makes two small incisions in the abdomen to insert a slim viewing instrument (laparoscope) with a camera at the tip. American College of Obstetricians and Gynecologists, Agency for Healthcare Research and Quality, Cumulative Index to Nursing and Allied Health, Comparing Options for Management: Patient-Centered Results for Uterine Fibroids, International Federation of Gynecologists and Obstetricians, Magnetic resonance guided focused ultrasound, Population, Intervention, Comparators, Outcomes, Timing, Setting, Royal College of Obstetricians and Gynaecologists, Selective progesterone receptor modulator, Merck Serono (EMD Serono, Inc.), Rockland, MA, USA, AstraZeneca Pharmaceuticals, Wilmington, DE, USA, Eli Lilly and Company, Indianapolis, IN, USA. Research Protocol: NURSING DIAGNOSIS Acute pain related to post operative wound as manifested by facial expression and pain scale score Imbalanced nutrition less than body requirements related to pain as manifested by decreased food intake. The dye traces the shape of your uterine cavity and fallopian tubes and makes them visible on X-ray images. In fact, the whole uterus decreases in size after menopause. PMID: 18226615, Segars JH, Parrott EC, Nagel JD, et al. But we don't yet have enough information to recommend a certain dose of vitamin D supplements. The American College of Obstetrics and Gynecology (ACOG) has just released updated guidelines on management of symptomatic uterine fibroids (leiomyomas). Independent: Review patient's previous experience with cancer. In addition, its staff members are equipped to address serious or complex medical needs. Invited Peer Reviewers may not have any financial conflict of interest greater than $10,000. This review will not include studies that evaluate the effectiveness of preoperative or adjunctive interventions to minimize blood loss or otherwise improve operative outcomes. We will record strength of evidence assessments in tables, summarizing results for each outcome. It does appear that fibroid growth is related to increasing weight. "I was like, 'Wow, I've got a lot of them.'. It uses sound waves to get a picture of your uterus to confirm the diagnosis and to map and measure fibroids. Stewart EA, et al. 2014 Dec 23PMID: 25542564. High cumulative incidence of uterine leiomyoma in black and white women: ultrasound evidence. Fibroids are sometimes found in asymptomatic women during routine pelvic examination or incidentally during imaging.24 In the United States, ultrasonography is the preferred initial imaging modality for fibroids.4 Transvaginal ultrasonography is about 90% to 99% sensitive for detecting uterine fibroids, but it may miss subserosal or small fibroids.25,26 Adding sonohysterography or hysteroscopy improves sensitivity for detecting submucosal myomas.25 There are no reliable means to differentiate benign from malignant tumors without pathologic evaluation. The condition may be caused by an underlying pathology, such as malignancy, uterine fibroids, Monte LM ER. [1] Fibroids originate from uterine smooth muscle cells (myometrium) whose growth is primarily dependent on the levels of circulating estrogen. In particular, the FDA recommends that women who are approaching menopause or who have reached menopause avoid power morcellation. 2009 Mar;113(3):630-5. Hum Reprod Update. Most women with uterine fibroids may be able to choose to keep their ovaries. Some websites and consumer health books promote alternative treatments, such as specific dietary recommendations, magnet therapy, black cohosh, herbal preparations or homeopathy. We will include nonrandomized cohort studies and observational studies to address Key Question 3 or Key Question 4. Fibroids (leiomyoma) are non-cancerous tumors of the uterine muscle. 2016;43:397. Thanks for your time and we wish you well. Many are discovered incidentally on clinical examination or imaging in asymptomatic women. They may be inside the uterus, on its outer surface or within its wall, or attached to it by a stem-like structure. Major Primary PPH - losing 500 mL to 1000 mL of blood. Fear/Anxiety. Fibroids (otherwise known as myomas or leiomyomas) are abnormal non-cancerous growths in the uterus. 12-EHC047-EF. This article updates a previous article on this topic by Evans and Brunsell. The assessment of the study limitations domain will be derived from the risk of bias of the individual studies that addressed the Key Question and specific outcome under consideration. Am J Obstet Gynecol. There is insufficient evidence on the effect of uterine artery embolization on future fertility. The small needles heat up, destroying fibroid tissue. Gonadotropin-releasing hormone agonists or selective progesterone receptor modulators are an option for patients who need symptom relief preoperatively or who are approaching menopause. Accessed April 24, 2019. Gliklich R, Leavy M, Velentgas P, et al. If you're not having severe symptoms now, you could wait until after pregnancy to have the fibroids removed. Anti-progesterone effect - reduces action and number of progesterone receptors in fibroids and myometrium. In some cases, though, health care providers find fibroids during a routine gynecological exam. Primary Care Management of Abnormal Uterine Bleeding. We will provide a qualitative and quantitative synthesis of studies meeting our review criteria. We will use explicit criteria for rating the overall strength of the evidence for intervention-final outcome pairs for which the overall risk of bias is not overwhelmingly high. The EPC refined and finalized the key questions after review of the public comments, and input from Key Informants and the Technical Expert Panel (TEP). Patient information: A handout on this topic is available at https://familydoctor.org/familydoctor/en/diseases-conditions/uterine-fibroids.html. Preoperative administration of GnRH agonists (e.g., leuprolide [Lupron], goserelin [Zoladex], triptorelin [Trelstar Depot]) increases hemoglobin levels preoperatively by 1.0 g per dL (10 g per L) and postoperatively by 0.8 g per dL (8 g per L), as well as significantly decreases pelvic symptom scores.32 Adverse effects resulting from the hypoestrogenized state, including hot flashes (OR = 6.5), vaginitis (OR = 4.0), sweating (OR = 8.3), and change in breast size (OR = 7.7), affect the long-term use of these agents.32, Compared with placebo, the SPRM mife-pristone (Mifeprex) significantly decreases heavy menstrual bleeding (OR = 18; 95% CI, 6.7 to 47) and improves fibroid-specific quality of life, but does not affect fibroid volume.35 Ulipristal (Ella) is an SPRM approved as a contraceptive in the United States but used in other countries for the treatment of fibroids in adult women who are eligible for surgery. A preliminary assessment of the published literature on uterine fibroid treatment suggests that limiting the search to studies published in or after 1985 does not omit critical literature. Center for Devices and Radiological Health. Clinical Obstetrics and Gynaecology. It uses sound waves to get a picture of your uterus to confirm the diagnosis and to map and measure fibroids. information submitted for this request. Hysteroscopic myomectomy - the fibroids are removed via the dilated cervix, so no abdominal incisions are .
Rochdale Grooming Case Details, Articles N