Uterine fibroids are the most common benign tumours of the female reproductive tract. On the basis of their location, they can be divided into submucous, intramural or subserosal. Fibroids tend to grow in an estrogenic environment as evidenced by the reduction in size during menopause or in a medically induced hypoestrogenic state, such as with Gonadotrophin Releasing Hormone (GnRH) analogue therapy. Hysterectomy remains the only method of definitive treatment for symptomatic fibroids. However, conservative treatment may be desirable in many instances, chief among which would be the maintenance of child-bearing capability. Other reasons for keeping one’s uterus include better sexual functioning and avoidance of surgery, whether by choice or clinical reasoning.
This conservatism has lead to a proliferation of less invasive methods pursuing management of fibroids without recourse to surgery. Medical therapy provides only temporary relief of variable duration with repeat treatments a nuisance. Amongst the various radiological interventions, uterine artery embolization is an effective procedure, though not an ideal solution if future fertility is desired.(1) Hysteroscopic resection is quite feasible for treatment of submucosal fibroids, and the subject of our current attention.
Whether surgical or otherwise, all these methods can be hampered by complications such as bleeding, obstructed views and inadequate resection during the procedure. In order to minimize these risks, shrinking the fibroids to a more manageable size prior to the procedure offers a logical and practical proposition. GnRH analogue therapy has been advocated as a means to this end for some time now. Advantages of such pretreatment include reduction of fibroid size, bleeding and operating time and visual improvement during the procedure. Disadvantages, it has been said, include non-identification of tumour and tumour recurrence post-procedure. Many investigations in the past have set out to settle this issue once and for all but no definitive data has yet emerged.
The latest study to address this issue involved 47 reproductive-aged women with symptomatic submucosal fibroids randomly assigned to receive 3 months of depot goserelin or placebo injections prior to hysteroscopic resection (2). Sample size was calculated on the basis of an expected complete resection rate of about 50% without pretreatment and an improvement in resection rate to 92% with use of GnRH analogue. The primary outcome measure was the rate of complete resection of the fibroids.
Baseline characteristics and the number and size of submucous fibroids were well balanced in the study groups. Overall, 75% of the women had complete fibroid resection; this frequency was similar in both groups. Fibroid size and degree of intramural involvement were negatively associated with the frequency of successful complete resection. The duration of the procedure, the amount of distention fluid used, and the complication rates (excessive fluid deficit, bleeding, and perforation) were similar in the 2 groups. A similar proportion of women reported symptom improvement, and the need for second surgeries was not different between the 2 groups. On the basis of their findings, Mavrelos and colleagues concluded that preoperative use of GnRH analogues does not improve the outcome of hysteroscopic resection of submucous fibroids.
Evaluation of the outcomes of such trials requires the consideration of many factors. Although the study design seems sturdy, the number of patients involved in this case is not life-defining. A much larger number is required to provide significance. Surgical expertise plays an important part and a fairly high complete resection rate in the placebo arm might reflect the presumed above-average experience of the single surgeon involved. Results might differ with less experienced surgeons or in patients who truly benefit from GnRH analogue pretreatment. Since this study only evaluated women with submucous fibroids, the results obviously cannot be applied to fibroids of other persuasions. Thus, although this study did not find a benefit with GnRH therapy prior to hysteroscopic fibroid resection, use of this therapy should still be considered on an individual basis.
References
1. Freed MM, Spies JB. Uterine artery embolization for fibroids: a review of current outcomes. Semin Reprod Med. 2010;28:235-241.
2. Marvelos D, Ben-Nagi J, Davies A et al. The Value of Pre-operative Treatment With GnRH Analogues in Women With Submucous Fibroids: A Double-Blind, Placebo-Controlled Randomized Trial. Hum Reprod. 2010;25:2264-2269
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