Resolution of Uterine Arteriovenous Malformation and Maintenance of Reproduction in 20 Women Treated with a GnRH Agonist Concomitantly with an Aromatase Inhibitor and Tranexamic Acid

Danazol as a Treatment for Uterine Arteriovenous Malformation: A Case Report

Uterine arteriovenous malformation (AVM) is associated with a risk of massive uterine bleeding. Although uterine artery embolization remains the first-line treatment for AVM, there has been a recent exploration of pharmacological options. Danazol is known to reduce blood flow to the uterus; however, our understanding of its therapeutic efficacy for AVM remains limited. Herein, we present the results of danazol use in patients with uterine AVM. We retrospectively reviewed the medical records of patients who received danazol for the treatment of AVM between January 2013 and November 2022. The cohort comprised 10 patients who developed AVM after dilatation and curettage (D&C), abortion, or cesarean section. Danazol was administered twice daily at a total dose of 400 mg/day, and was employed for AVM treatment in hemodynamically stable patients who provided consent and were devoid of massive bleeding. Outpatient follow-ups (ultrasound measurements of AVM size and symptom assessment) were performed every 2 weeks. AVM was successfully treated with danazol in most patients with no adverse event. Eight postabortal patients had complete resolution of AVM after an average of 45 days (range 14-70 days). Of two patients who developed AVM after a cesarean section, one experienced AVM reduction, and the other developed massive bleeding, requiring emergency uterine artery embolization. In light of these outcomes, danazol can be potentially prioritized over uterine artery embolization in the treatment of AVM after abortion in hemodynamically stable patients.

Medical Management of Uterine Arteriovenous Malformation: A Case Series

BACKGROUND

There has been increasing interest in medical management of uterine Arteriovenous Malformations (AVMs) in hemodynamically stable patients as a means of decreasing the need for invasive treatment that may impact fertility.

CASES

Amongst six cases of sonographically diagnosed uterine AVM managed medically with combined oral contraceptive pills or medroxyprogesterone acetate, three experienced complete resolution and three experienced partial resolution. Amongst those with complete resolution, all had a subsequent pregnancy that had no complication attributable to previous AVM or medical therapy. Amongst those with partial resolution, one is currently pregnant, one remains on therapy, and one has discontinued treatment with resumption of normal menses.

CONCLUSION

Medical management is effective in completely or partially resolving uterine AVMs. Subsequent pregnancies in this population are feasible and are not at higher risk for perinatal complications.

Placental polyp with arteriovenous malformation treated with a gonadotoropin-releasing hormone antagonist

A 35-year-old woman (gravida 1, para 0) underwent termination of pregnancy (ToP) at 12 weeks of gestation. One month after ToP, she experienced significant vaginal bleeding and the mass with blood flow was identified on imaging. The presence of a placental polyp with arteriovenous malformation (AVM) was suspected on transvaginal sonography and MRI. Since the bleeding had ceased when she visited our hospital, we decided to treat the placental polyp with AVM with gonadotropin-releasing hormone (GnRH) antagonist therapy instead of surgery. Two months after GnRH antagonist treatment, the mass and blood flow in the uterus disappeared. Menstruation resumed 1 month after the completion of treatment. In our case, we were able to successfully treat placental polyps with AVM using GnRH antagonist therapy.

Medical treatment of uterine arteriovenous malformation: a systematic review and meta-analysis

OBJECTIVE

To quantify the efficacy of medical management of uterine arteriovenous malformation (AVM) and compare efficacy between different classes of medication. In addition, we evaluated for factors associated with treatment success and pregnancy outcomes after medical management.

DESIGN

Systematic review and meta-analysis.

SETTING

Not applicable.

PATIENT(S)

Thirty-two studies representing 121 premenopausal women with medically-treated uterine AVM were identified via database searches of MEDLINE, Embase, Web of Science, and cited references.

INTERVENTION(S)

Medical treatment with progestins, gonadotropin-releasing hormone agonists (GnRH-a), methotrexate, combined hormonal contraception , uterotonics, danazol, or combination of the above.

MAIN OUTCOME MEASURE(S)

Primary outcome of treatment success was defined as AVM resolution without subsequent procedural interventions. Secondary outcome was treatment complication (readmission or transfusion).

RESULT(S)

The overall success rate of medical management was 88% (106/121). After adjusting for clustering effects, success rates for progestin (82.5%; 95% confidence interval [CI], 70.1%-90.4%), GnRH-a (89.3%; 99% CI, 71.4%-96.5%) and methotrexate (90.0%; 99% CI, 55.8%-98.8%) were significantly different from the null hypothesis of 50% success. The agents with the lowest adjusted proportion of complications were progestins (10.0%; 99% CI, 3.3%-26.8%) and GnRH-a (10.7%; 99% CI, 3.5%-28.4%). No clinical factors were found to predict treatment success. Twenty-six subsequent pregnancies are described, with no reported recurrences of AVM.

CONCLUSION(S)

Medical management for uterine AVM is a reasonable approach in a well selected patient. These data should be interpreted in the context of significant publication bias.