Preoperative medical therapy before surgery for uterine fibroids

Uterine fibroids are the prolonged menstrual cycles, occurred in almost 40% women's aged over 35. Various hormonal treatments include Gonadotropin-hormone releasing analogs (GnRHa), progestins and selective progesterone-receptor modulators (SPRMs) are recommend for uterine fibroids. This Cochrane review assessed all the preoperative medical treatments and provided clear evidence that preoperative GnRHa reduces uterine and fibroid volume.

A total of 40% females over 35 age exhibits the cases of uterine fibroids; out of which some are asymptomatic, but up to 50% produce symptoms that required the treatment. Due to heavy menstrual bleeding, dysmenorrhoea, low quality of life, pelvic pain, and infertility symptoms like anaemia occurred. First preference to manage this severe condition is surgery. These days, specific medical therapies have been introduced before the surgery to enhance the intraoperative and postoperative results. But the cost of these therapies is very high.

The oestrogen stimulates the fibroid growth. Therefore, gonadotropin-hormone releasing analogues (GnRHa) are used to cause a hypo-oestrogenism state which causes shrinkage of fibroids, however, has intolerable side effects if taken for long-term. Progestins and selective progesterone receptor modulators (SPRMs) are some other hormonal therapies options which can be used for such issues. This analysis involved the assessment of medical treatments' safety and efficacy which introduce before surgery to treat uterine fibroids.

The  PsycINFO, CENTRAL, Embase, CINAHL, MEDLINE, Cochrane Gynaecology and Fertility Group specialised register were searched in June 2017 for data collection. The dissertations and the grey literature, trials registers, hand-searched reference lists of retrieved articles and contacted pharmaceutical companies for additional trials were also analysed for further information.

A total of 38 RCTs (3623 women) comprised 19 studies compared GnRHa to other medical pretreatments (selective oestrogen receptor modulators (SERMs),  oestrogen receptor antagonists, dopamine agonists, progestin, SPRMs), no pretreatment, placebo and four compared SPRMs with placebo. Low-quality evidence was noticed due to inconsistency, limitations in study design and imprecision.

GnRHa versus no treatment or placebo:

Increased preoperative haemoglobin with decreased uterine and fibroid volume was found among patients treated with GnRHa than placebo at the cost of a higher likelihood of adverse events, especially hot flushes. The women who took GnRHa therapy exhibited a reduced duration of hysterectomy surgery with fewer blood transfusions and postoperative complications with reduced blood loss during myomectomy. No evidence was found regarding the difference in groups for other primary results following myomectomy: blood transfusion, postoperative complications, or duration of surgery. Also, no cases of preoperative bleeding found.

GnRHa versus other medical therapies:

GnRHa group exhibited a more significant decrease in uterine volume but with complications like hot flushes compared with ulipristal acetate. No evidence was found regarding the difference in haemoglobin levels or bleeding reduction. Also, no evidence was seen that showing the difference in fibroid volume between cabergoline and GnRHa. No usable data was found from the selected studies regarding other primary outcomes.

SPRMs versus placebo SPRMs:

SPRMs like Ulipristal acetate, Asoprisnil, Mifepristone, and CDB-2914 showed a significant decrease in fibroid or uterine volume and increased preoperative haemoglobin levels than placebo. The Asoprisnil and Ulipristal acetate also exhibited larger reductions in bleeding before surgery. No evidence regarding differences in preoperative complications and other primary results was noticed.

The use of preoperative medical therapy prior to surgery for fibroids is to perform surgery easier. Clear evidence present that preoperative GnRHa increases preoperative haemoglobin levels decreases uterine and fibroid volume along with side effect like hot flushes. The rate of complications, blood loss and operative time also reduced during the hysterectomy. Evidence proposes that ulipristal acetate may provide the same benefits; however, replication of these studies is suggested prior to making firm conclusions. Further analyses are required that should be focused on cost-effectiveness and distinguish between groups of women with fibroids who would most benefit.