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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.
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.
Cochrane Database Syst Rev. 2017 Nov 15
Preoperative medical therapy before surgery for uterine fibroids
Lethaby A et al.
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