Goserelin therapy before surgery for uterine fibroids

Uterine fibroids: an update on current and emerging medical treatment options

Uterine fibroids are the most common gynecological disorder, classically requiring surgery when symptomatic. Although attempts at finding a nonsurgical cure date back to centuries, it is only around the middle of the last century that serious attempts at a medical treatment were carried out. Initially, both progestins and estrogen–progestin combinations have been utilized, although proof of their usefulness is lacking. A major step forward was achieved when peptide analogs of the GnRH were introduced, first those with superagonist properties and subsequently those acting as antagonists. Initially, the latter produced side effects preventing their routine utilization; eventually, this problem was overcome following the synthesis of cetrorelix. Because both types of analogs produce hypoestrogenism, their use is limited to a maximum of 6 months and, for this reason, today they are utilized as an adjuvant treatment before surgery with overall good results. Over the last decade, new, nonpeptidic, orally active GnRH-receptor blockers have also been synthesized. One of them, Elagolix, is in the early stages of testing in women with fibroids. Another fundamental development has been the utilization of the so-called selective progesterone receptor modulators, sometimes referred to as “antiprogestins”. The first such compound to be applied to the long-term treatment of fibroids was Mifepristone; today, this compound is mostly used outside of Western Countries, where the substance of choice is Ulipristal acetate. Large clinical trials have proven the effectiveness of Ulipristal in the long-term medical therapy of fibroids, although some caution must be exercised because of the rare occurrence of liver complications. All selective progesterone receptor modulators produce unique endometrial changes that are today considered benign, reversible, and without negative consequences. In conclusion, long-term medical treatment of fibroids seems possible today, especially in premenopausal women.

Experience with a gonadotrophin-releasing hormone agonist prior to myomectomy--comparison of twice- vs thrice-monthly doses and a control group

The aim of this randomised prospective study was to investigate the impact of preoperative gonadotrophin-releasing hormone agonist (GnRHa) compared with a control group with myomectomy. A total of 36 women (n = 36, group 1) with fibroids were randomised to receive either two monthly doses (n = 18/36, group 1a) or three monthly doses of goserelin (n = 18/36, group 1b) prior to myomectomy. The 32 women who received no treatment (group 2) comprised the controls. All patients had similar demographic features. There were no significant differences among the three groups with respect to: (1) mean intraoperative blood loss; (2) preoperative and postoperative blood transfusion or (3) length of hospital stay. The only advantage of administering GnRHa prior to myomectomy for symptomatic fibroids in our population was a higher haemoglobin level prior to surgery among the women who received three doses of the drug.

Gonadotropin releasing hormone agonists: Expanding vistas

Gonadotropin-releasing hormone (GnRH) agonists are derived from native GnRH by amino acid substitution which yields the agonist resistant to degradation and increases its half-life. The hypogonadotropic hypogonadal state produced by GnRH agonists has been often dubbed as "pseudomenopause" or "medical oophorectomy," which are both misnomers. GnRH analogues (GnRH-a) work by temporarily "switching off" the ovaries. Ovaries can be "switched off" for the therapy and therapeutic trial of many conditions which include but are not limited to subfertility, endometriosis, adenomyosis, uterine leiomyomas, precocious puberty, premenstrual dysphoric disorder, chronic pelvic pain, or the prevention of menstrual bleeding in special clinical situations. Rapidly expanding vistas of usage of GnRH agonists encompass use in sex reassignment of male to female transsexuals, management of final height in cases of congenital adrenal hyperplasia, and preserving ovarian function in women undergoing cytotoxic chemotherapy. Hypogonadic side effects caused by the use of GnRH agonists can be tackled with use of "add-back" therapy. Goserelin, leuprolide, and nafarelin are commonly used in clinical practice. GnRH-a have provided us a powerful therapeutic approach to the treatment of numerous conditions in reproductive medicine. Recent synthesis of GnRH antagonists with a better tolerability profile may open new avenues for both research and clinical applications. All stakeholders who are partners in women's healthcare need to join hands to spread awareness so that these drugs can be used to realize their full potential.

Human myometrium and leiomyomas express gonadotropin-releasing hormone 2 and gonadotropin-releasing hormone 2 receptor

OBJECTIVE

To determine the presence or absence of a second form of GnRH (GnRH2) and corresponding receptor (GnRHR2) in human uterine myometrium and leiomyomata.

DESIGN

Evaluation of human leiomyoma and patient-matched myometrium of differential mRNA and protein expression of GnRH2 and GnRHR2.

SETTING

University hospital.

PATIENT(S)

Eight women undergoing medically indicated hysterectomy for symptomatic fibroids.

INTERVENTION(S)

Microarray analysis, reverse-transcriptase polymerase chain reaction (RT-PCR), real-time RT-PCR, and immunohistochemistry.

MAIN OUTCOME MEASURE(S)

Expression of mRNA and protein in leiomyoma and patient-matched myometrium.

RESULT(S)

Microarray analysis demonstrated expression, and we confirmed the findings by RT-PCR. Real-time RT-PCR demonstrated equivalent expression of the genes in leiomyoma compared with patient-matched myometrium (0.99-fold for GnRH2 and 1.28-fold for GnRHR2). Immunohistochemistry confirmed the expression of GnRH2 protein in both leiomyoma and myometrium.

CONCLUSION(S)

A second form of GnRH and corresponding receptor exists in the fibroid and myometrium. We speculate that an autocrine loop exists. Our findings provide further evidence that GnRH agonists may interact directly with GnRH receptors present in uterine fibroids.

Laparoscopic myomectomy for symptomatic uterine myomas

OBJECTIVE

To evaluate the safety, efficacy, and techniques of laparoscopic myomectomy as treatment for symptomatic uterine myomas.

DESIGN

Medline literature review and cross-reference of published data.

RESULTS

Results from randomized trials and clinical series have shown that laparoscopic myomectomy provides the advantages of shorter hospitalization, faster recovery, fewer adhesions, and less blood loss than abdominal myomectomy when performed by skilled surgeons. Improvements in surgical instruments and techniques allows for safe removal and multilayer myometrial repair of multiple large intramural myomas. Randomized trials support the use of absorbable adhesion barriers to reduce adhesions, but there is no apparent benefit of presurgical use of GnRH agonists. Pregnancy outcomes have been good, and the risk of uterine rupture is very low when the myometrium is repaired appropriately.

CONCLUSION(S)

Advances in surgical instruments and techniques are expanding the role of laparoscopic myomectomy in well-selected individuals. Meticulous repair of the myometrium is essential for women considering pregnancy after laparoscopic myomectomy to minimize the risk of uterine rupture. Laparoscopic myomectomy is an appropriate alternative to abdominal myomectomy, hysterectomy, and uterine artery embolization for some women.

GnRH Agonist Treatment before Total Laparoscopic Hysterectomy for Large Uteri

STUDY OBJECTIVE

To evaluate whether uterine shrinkage induced by gonadotropin-releasing hormone (GnRH) agonists in women with a large uterus (>14 wks) may facilitate total laparoscopic hysterectomy.

DESIGN

Randomized, prospective study (Canadian Task Force classification I).

SETTING

University-affiliated hospital.

PATIENTS

Sixty-two women with symptomatic uterine myomas (size 16-20 wks).

INTERVENTIONS

Total laparoscopic hysterectomy for benign pathology.

MEASUREMENTS AND MAIN RESULTS

Before surgery, women were assigned, at a ratio of 1:1 by random selection, to receive injections of triptorelin depot 11.25 mg 3 months before surgery (group A) or no treatment (group B). Uterine volume, mean operating time, uterine weight, drop in hemoglobin, intraoperative complications, conversions to laparotomy, and hospital stay were recorded. Triptorelin decreased uterine volume, calculated by ultrasonography, by 26.5% in group A, whereas the volume remained unchanged in group B. Statistical differences were found between groups concerning uterine weight, operating time, and drop in hemoglobin level. Three patients in group B were converted to laparotomy because of uterine size.

CONCLUSION

In women with a large uterus, a 3-month preoperative course of GnRH may facilitate laparoscopic hysterectomy, decreasing uterine size, operating time, and blood loss.

Etiology and pathogenesis of uterine leiomyomas: a review

Uterine leiomyomas, or fibroids, represent a major public health problem. It is believed that these tumors develop in the majority of American women and become symptomatic in one-third of these women. They are the most frequent indication for hysterectomy in the United States. Although the initiator or initiators of fibroids are unknown, several predisposing factors have been identified, including age (late reproductive years), African-American ethnicity, nulliparity, and obesity. Nonrandom cytogenetic abnormalities have been found in about 40% of tumors examined. Estrogen and progesterone are recognized as promoters of tumor growth, and the potential role of environmental estrogens has only recently been explored. Growth factors with mitogenic activity, such as transforming growth factor- (subscript)3(/subscript), basic fibroblast growth factor, epidermal growth factor, and insulin-like growth factor-I, are elevated in fibroids and may be the effectors of estrogen and progesterone promotion. These data offer clues to the etiology and pathogenesis of this common condition, which we have analyzed and summarized in this review.

Immunohistochemical detection of insulin-like growth factor type I receptor and uterine volume changes in gonadotropin-releasing hormone analog-treated uterine leiomyomas

OBJECTIVE

This study was undertaken to assess the relationship between insulin-like growth factor (IGF) type I receptor (IGF-I-R) expression in uterine leiomyomas after gonadotropin-releasing hormone (GnRH) analog administration and modifications in uterine size.

STUDY DESIGN

Forty-six women with menorrhagia for uterine leiomyomatosis were treated monthly with leuprolide acetate depot 3.75 mg before undergoing surgery. The uterine volume before and after therapy was assessed by transabdominal ultrasonography. Immunohistochemical detection of IGF-I-R was performed on leiomyoma tissue samples. The relationship between IGF-I-R levels and uterine volume changes was analyzed.

RESULTS

Uterine volume decreased after therapy. Patients with a lower immunohistochemical expression of IGF-I-R showed a larger decrease in uterine size.

CONCLUSION

The shrinkage in uterine volume induced by GnRH analogs seems to be related to the observed reduction in IGF-I-R levels. So, the IGF-I/IGF-I-R system might be involved in leiomyoma growth, and the pharmacologic action of GnRH analogs on uterine leiomyomas might also be related to the effects on IGF-I-R expression.

Expression of Bcl-2, Bcl-x, Mcl-1, Bax and Bak in human uterine leiomyomas and myometrium during the menstrual cycle and after menopause

To investigate the expression of Bcl-2, Bcl-x, Mcl-1, Bax and Bak proteins in human uterine leiomyomas and homologous myometrium during the menstrual cycle and after menopause. The expression of Bcl-2, Bcl-x, Mcl-1, Bax and Bak in leiomyomas (n=24) and myometrial samples (n=22) from women with leiomyomas was measured by immunohistochemistry and Western blot. Measured by immunohistochemistry, a significant difference between leiomyomas and myometrium was observed only for the Bax protein, in tissues obtained from women in the secretory phase of the menstrual cycle. The Bcl-2 staining was more abundant in leiomyomas than in myometrium only in tissues obtained in the proliferative phase of the cycle. Bcl-2 was more abundant in leiomyomas from women of fertile age than in leiomyomas from menopausal women. No significant differences were observed for the Bcl-x or Bak proteins, whereas the Mcl-1 protein was significantly less abundant in secretory phase leiomyomas than in leiomyomas from menopausal women. Western blot analysis based on pools of tissue extracts from the different groups essentially confirmed the data obtained by immunohistochemistry. Bcl-2 family proteins are expressed in leiomyomas and myometrium in different phases related to and influenced by gonadal steroids. These proteins are suggested to interact with each other in the regulation of programmed cell death, apoptosis, but their specific role in growth control of uterine leiomyomas remains to be investigated.

Uterine leiomyomas: histopathologic features, MR imaging findings, differential diagnosis, and treatment

Leiomyomas are the most common uterine neoplasm and are composed of smooth muscle with varying amounts of fibrous connective tissue. As leiomyomas enlarge, they may outgrow their blood supply, resulting in various types of degeneration: hyaline or myxoid degeneration, calcification, cystic degeneration, and red degeneration. Leiomyomas are classified as submucosal, intramural, or subserosal; the latter may become pedunculated and simulate ovarian neoplasms. Although most leiomyomas are asymptomatic, patients may present with abnormal uterine bleeding, pressure on adjacent organs, pain, infertility, or a palpable abdominalpelvic mass. Magnetic resonance (MR) imaging is the most accurate imaging technique for detection and localization of leiomyomas. On T2-weighted images, nondegenerated leiomyomas appear as well-circumscribed masses of decreased signal intensity; however, cellular leiomyomas can have relatively higher signal intensity on T2-weighted images and demonstrate enhancement on contrast material-enhanced images. Degenerated leiomyomas have variable appearances on T2-weighted images and contrast-enhanced images. The differential diagnosis of leiomyomas includes adenomyosis, solid adnexal mass, focal myometrial contraction, and uterine leiomyosarcoma. For patients with symptoms, medical or surgical treatment may be indicated. MR imaging also has a role in treatment of leiomyomas by assisting in surgical planning and monitoring the response to medical therapy.

Screening for endometrial cancer in asymptomatic postmenopausal women with conventional and colour Doppler sonography

OBJECTIVE

To evaluate endometrial thickness and uterine arterial flow measurement as predictors of endometrial cancer.

DESIGN

Prospective study among a cohort of women invited to age-adjusted, population-based breast cancer screening by mammography.

SETTING

City of Turku, Finland.

POPULATION

1074 postmenopausal women aged 57-61 years (mean 59 years).

METHODS

Conventional and colour Doppler sonography. Endometrial biopsy was taken when the endometrial thickness (double layer) was > or = 4.0 mm, if the uterine artery pulsatility index was < or = 1.0 or if there was a fluid accumulation in the endometrial cavity.

MAIN OUTCOME MEASURES

Detection of endometrial cancer in endometrial biopsy. Record linkage with the files of the Finnish Cancer Registry three and a half years after the first ultrasound examination. Major statistical results are based on the analysis of variance and logistic regression models.

RESULTS

An endometrial biopsy was taken from 291 women (27%). One woman had endometrial tuberculosis, three an endometrial polyp, 16 endometrial hyperplasia, three endometrial carcinoma (Stage Ib), and one had cervical carcinoma (Stage Ib). One woman was diagnosed as having endometrial cancer Stage Ib two and a half years after screening; she had refused further examination after a positive screen. A second endometrial cancer (Stage Ib) was diagnosed three years after a negative screening result.

CONCLUSION

Transvaginal sonography is confirmed to have a very high sensitivity for the detection of early endometrial carcinoma, but the specificity remains low. If endometrial cancer is to be detected at an early stage, further examinations should be carried out when the endometrial thickness is > or = 4.0 mm, especially when the woman has risk factors such as obesity, late menopause or current use of hormonal replacement therapy. Doppler sonography does not improve the detection of premalignant and malignant endometrial lesions compared with normal ultrasound.

Treatment with a gonadotrophin releasing hormone agonist before hysterectomy for leiomyomas: results of a multicentre, randomised controlled trial

OBJECTIVES

To ascertain whether uterine shrinkage induced by a gonadotrophin releasing hormone agonist before hysterectomy for fibroids increases the possibility of a vaginal procedure.

DESIGN

A multicentre, prospective, randomised, controlled study.

PARTICIPANTS

One hundred and twenty-seven premenopausal women with a uterine volume of 12 to 16 gestational weeks.

INTERVENTIONS

Twelve weeks of triptorelin depot treatment before hysterectomy or immediate surgery.

MAIN OUTCOME MEASURES

Number of vaginal and abdominal hysterectomies, operating time, blood loss, degree of difficulty of the procedure, perioperative serum haemoglobin and haematocrit levels, hospital stay, and patients' overall satisfaction with treatment.

RESULTS

After randomisation, four women withdrew from the study, leaving 60 women in the triptorelin arm and 63 in the immediate surgery arm. At baseline evaluation a vaginal hysterectomy was indicated in seven women allocated to pre-operative medical therapy (12%), and in 10 of those allocated to immediate surgery (16%). Clinical assessment after the 12-week GnRH agonist course showed that abdominal hysterectomy was no longer indicated in 25/53 women (47%) as a vaginal procedure appeared appropriate. Thus the overall rate of indication for a vaginal procedure in the pre-operative medical treatment arm was 32/60 cases (53%), with a between-group difference of 37% (95% CI, 26% to 51%; chi2(1) = 19.18, P < 0.0001; OR 6.06; 95% CI, 2.60 to 14.10). Pre- and post-operative serum haemoglobin and haematocrit levels were significantly higher in the GnRH agonist than in the immediate surgery arm. No appreciable difference was observed between the groups in the other intra- and post-operative variables, including patients' satisfaction.

CONCLUSIONS

Pre-operative GnRH agonist therapy increased the rate of vaginal hysterectomy in selected women with fibroids and uterine volume of 12 to 16 gestational weeks.

Endoscopic treatment of uterine fibroids

Endoscopic surgery is able to replace most abdominal operations in the surgical treatment of uterine leiomyomas. The use of gonadotrophin hormone-releasing hormone analogues, arterial embolization, hysteroscopy, new techniques of morcellation, laparo-vaginal gasless laparoscopy and laparoscopic mini-laparotomy have enabled the avoidance of laparotomy incisions in most patients. The previous disadvantages of laparoscopy, namely a prolonged operating time, excessive bleeding and inadequate closure, have been overcome. Case and controlled studies have demonstrated the effectiveness of endoscopy in fibroid treatment. The surgical techniques require advanced endoscopic training.

Steroidal and nonsteroidal "add-back" therapy: extending safety and efficacy of gonadotropin-releasing hormone agonists in the gynecologic patient

OBJECTIVE

To assess the efficacy of various steroidal and nonsteroidal add-back regimes in ameliorating hypoestrogenic side effects of long-term GnRH agonist (GnRH-a) therapy in gynecologic patients.

DESIGN

English language literature review.

PATIENTS

Gynecologic patients administered GnRH-a as therapy for ovarian hyperandrogenism, premenstrual syndrome, dysfunctional uterine bleeding, uterine leiomyomata, and symptomatic endometriosis.

INTERVENTIONS

Steroidal and nonsteroidal add-back regimes including estrogens with progestins, progestins alone, and progestins with organic bisphosphonates in combination with various GnRH-a for > or = 6 months of therapy.

MAIN OUTCOME MEASURES

Vasomotor symptoms, bone density changes, lipid profiles, alterations in presenting symptoms, and disease state.

RESULTS

Estrogens in combination with progestins were efficacious as add-back in the management of ovarian hyperandrogenic states, dysfunctional uterine bleeding, premenstrual syndrome, and leiomyomata. Medroxyprogesterone acetate alone is ineffective as add-back for treatment of endometriosis or leiomyomata. Norethindrone is effective as add-back in the management of endometriosis but not leiomyomata, although high doses alter lipid profiles in an undesirable fashion. Organic bisphosphonates show great promise in preserving bone density without other untoward effects.

CONCLUSIONS

No single add-back regime is appropriate for all gynecologic indications for GnRH-a. Ideal protocols preserve the efficacy of agonists while suppressing associated vasomotor symptoms and bone density loss.

Alternative treatment

Alternatives to endometrial ablation include re-education of the 20% or more women complaining of menorrhagia whose blood loss is normal, less than 35 ml, and the use of an increasing variety of drugs to find an effective regime with minimal side effects. Endometrial resection is an effective treatment, particularly in the short term. Laparoscopic and vaginal hysterectomy have advantages over endometrial resection in the long term, avoiding failure and retreatment for menorrhagia. Hysteroscopic, laparoscopic and open myomectomy are more suitable in treating fibroids of significant size, although these techniques may be used with endometrial resection to avoid hysterectomy. Myoma reduction may become a less morbid alternative to myomectomy.

Prediction of histopathologic features and proliferative activity of uterine leiomyoma by magnetic resonance imaging prior to GnRH analogue therapy: correlation between T2-weighted images and effect of GnRH analogue

To predict the histological features and proliferative activity of leiomyomas and to evaluate the effect of GnRH analogues (GnRHa) by MR images, the correlation between MR images and histopathologic findings was studied on 137 leiomyomatous nodules from 79 patients. The correlation among cellularity, proliferative activity and MR images was studied on sections of 42 leiomyomatous, nodules stained with hematoxylin-eosin and immunohistochemistry for proliferating cell nuclear antigen. The utility of MR imaging in assessing response to therapy with a GnRHa (buserelin 900 micrograms/day, intranasal for 16 weeks) was studied on 62 leiomyomatous nodules from 29 patients. On T2-weighted MR images, we encountered five major images. According to the increase of signal intensity relative to that of the myometrium and/or the endometrium, the images were classified as Type 1, Type 2, Type 3, Type 4, and Type 5. Histopathologically, the majority of Type 1, Type 2 and Type 3 images had features of typical leiomyoma. Almost all cellular leiomyomas and bizarre leiomyomas had Type 4 images. Variable degenerative features were observed in the nodules with Type 5 images. According to the increase of signal intensity, leiomyomas had a tendency to show a high degree of both cellularity and proliferative activity. Moreover, the reduction rate of leiomyomatous nodules after GnRHa therapy correlated with the tumor signal intensity on T2-weighted images before therapy. The reduction rate was the lowest in Type 1 images (20.9%) and the highest in Type 4 images (50.7%). These results suggest that increased the signal intensity on T2-weighted MR images correlates with the cellularity and proliferative activity of leiomyomas, and with tumor response to GnRHa treatment. MR imaging enables quantitative monitoring of GnRHa therapy in patients with leiomyomatous nodules, and allows us to predict the histopathology, cellularity, proliferative activity, and shrinkage rate of nodules before GnRHa treatment.

Effects of two different doses of leuprolide acetate depot on uterine cavity area in patients with uterine leiomyomata

OBJECTIVE

To compare the effects of two different doses of a monthly depot injection of a GnRH agonist (GnRH-a) on uterine cavity area in patients with uterine leiomyomata.

DESIGN

Prospective, randomized study.

SETTING

Hospital department of obstetrics and gynecology.

PATIENTS

Thirty-six premenopausal women, 25 to 52 years of age, with uterine leiomyomata.

INTERVENTION

Leuprolide acetate (LA) depot, 1.88 or 3.75 mg, was administered SC every 4 weeks for 24 weeks.

MAIN OUTCOME MEASURE

Uterine cavity area before and after treatment was assessed by hysterosalpingography.

RESULTS

The 1.88- and 3.75-mg LA depots significantly reduced uterine cavity area by 40.8% and 40.2%, respectively. No significant difference was observed between the two groups.

CONCLUSION

Monthly injection of 1.88 or 3.75 mg LA depots appears to reduce uterine cavity area to a similar extent in patients with uterine leiomyomata.

The effect of gynecological risk factors on lumbar and femoral bone mineral density in peri- and postmenopausal women

The relationship between gynecological history and bone mineral density (BMD) of the lumbar spine and femoral neck was studied in 3126 perimenopausal women. The study population was a random, stratified sample of participants, selected from the Kuopio Osteoporosis Study, which consisted primarily of all 14,220 women aged 47-56 years in Kuopio Province in 1989. After exclusion of 1521 women reporting past or present hormonal replacement therapy (HRT), 1605 women formed the final study population. Present HRT users had significantly higher lumbar BMD but not femoral BMD, than non-hormone users. Postmenopausal status, late menarche, and bilateral oophorectomy were risk factors for low BMD. Protective factors against low BMD were increased body weight, increased number of pregnancies, as well as hysterectomy without bilateral oophorectomy. The majority (43.8%) of these operations had been performed due to the presence of leiomyomas. No significant correlation was found between nulliparity, breast-feeding or amenorrhea before the age of 30 and BMD. In the multiple regression analysis, gynecological variables could account for only 18.4-26.8% of the variance in BMD, while time since last periods, age, age at menarche, weight and hysterectomy were the most significant variables. We conclude that reproductive history gives rise to some special risk groups, to whom BMD measurements and osteoporosis prevention efforts should be directed. However, it is impossible to predict BMD by gynecological characteristics.

Laparoscopic myomectomy. Operative procedure and results

Myomectomy was performed by laparoscopy in 102 patients, according to a precise technique using the monopolar hook for the uterine incision and intraperitoneal sutures. Myomas were mostly removed through the suprapubic puncture site after fragmentation or by colpotomy. Conversion to laparotomy during the laparoscopic procedure was necessary in 2 cases. No complications were observed. A second-look laparoscopy was performed in 17 cases. Postoperative adhesions were noted in 2 cases. In our experience, operative laparoscopy has several advantages over laparotomy and the risk of complications is low in selected cases.

Treatment of submucous fibroids, and outcome of assisted conception

STUDY OBJECTIVE

To determine the effect of hysteroscopic resection and goserelin in the treatment of submucous fibroids, and their significance in assisted conception.

DESIGN

Patients with history of subfertility and previous failed attempts at assisted conception were examined by transvaginal sonography before further attempts at assisted conception. Those diagnosed as having submucous fibroids were treated with goserelin injections, hysteroscopic resection, or a combination of both. Saline sonohysterography was performed whenever the submucous nature of the fibroid was unclear.

SETTING

The Churchill Clinic Fertility and IVF Centre, London, United Kingdom

PATIENTS

One hundred women being treated for subfertility over a period of 2 years. Twenty-seven had submucous fibroids diagnosed by transvaginal sonography, and a comparable group of 73 had a normal uterine cavity.

INTERVENTIONS

Three doses of goserelin 3.6 mg subcutaneously at 4-week intervals were given, followed by hysteroscopic resection of the submucous part of fibroids if the fibroids remained submucous. Three patients had hysteroscopic resection without goserelin, as the fibroids were resectable when they were diagnosed. All patients underwent assisted conception within 3 months unless they conceived spontaneously in the interim.

MEASUREMENTS AND MAIN RESULTS

The pregnancy rate in patients with normal uterine cavity was 26%/embryo transfer, and 15.8% of these ended in a miscarriage. The pregnancy rate was significantly higher (p >0.02) in the study group after treatment of submucous fibroids (48.2%/embryo transfer), and the miscarriage rate of 23.1% was not significantly different.

CONCLUSIONS

Submucous fibroids are a significant cause of subfertility. A combination of goserelin injections and hysteroscopic resection significantly improves pregnancy rates without increasing the miscarriage rate.

Treatment with the gonadotrophin releasing hormone-agonist goserelin before hysterectomy for uterine fibroids

OBJECTIVE

To investigate the effect of the gonadotrophin releasing hormone (GnRH)-agonist goserelin, given by monthly subcutaneous injection for three months prior to total abdominal hysterectomy for uterine leiomyomata, on the pre-operative symptoms, difficulty of operation and operative blood loss.

DESIGN

Randomised placebo-controlled study.

SETTING

Patients were recruited from the gynaecological outpatient departments from hospitals in Edinburgh, Glasgow and Newcastle.

SUBJECTS

Seventy-one premenopausal women with uterine leiomyomata who were on the waiting list for hysterectomy.

INTERVENTIONS

After the presence of leiomyomata was confirmed using ultrasonography, the women were randomised to receive either the GnRH-agonist goserelin by monthly subcutaneous injection or a sham injection for three months prior to operation. At the monthly visits, patients were asked about treatment related symptoms, fibroid related symptoms, and their bleeding patterns. Blood was taken for haematological assessment.

MAIN OUTCOME MEASURES

Haemoglobin concentrations at recruitment, at operation and post-operatively, pre-operative symptoms, operative difficulty and blood loss and post-operative complications.

RESULTS

Treatment with goserelin induced amenorrhoea in over 80% of the women, and this was associated with a significant rise in haemoglobin level. At the time of operation, fibroid related symptoms were less in the goserelin group than in the placebo group. The hysterectomy was technically easier and the median (range) operative blood loss was significantly lower in the goserelin group compared with the placebo group (187 (60-600) ml vs 308 (118-1000) ml respectively; P < 0.05, Wilcoxon signed rank test). There was no difference between the two groups in the duration of hospital stay or the frequency of post-operative complications. The fibroids were smaller at the time of operation in the goserelin group, and more women treated with goserelin were able to have their operations through a transverse incision.

CONCLUSIONS

This study demonstrates the benefits of goserelin in women having total abdominal hysterectomy for uterine leiomyomata.

Steroid receptor binding and messenger RNA expression in fibroids from untreated and gonadotrophin-releasing hormone agonist pretreated women

OBJECTIVE

The hypothesis of this study was that oestrogen may play a role in fibroid growth and that a lack of oestrogen may be the reason for gonadotrophin-releasing hormone agonist (GnRHa) induced fibroid shrinkage. Therefore our aims were (1) to investigate oestrogen receptor (ER) and progesterone receptor (PR) binding in fibroids and myometrium from untreated women and in fibroids from GnRHa pretreated women, (2) to evaluate the mRNA expression of ER and PR in these tissues, and (3) to examine whether a correlation existed between receptor binding and mRNA expression for ER and PR.

DESIGN

Cytosolic ER and PR binding was assessed by the dextran-coated charcoal technique and ER and PR mRNA expression was assessed using Northern blots of total RNA.

PATIENTS

Fibroid and corresponding myometrial specimens were obtained from 20 women undergoing hysterectomy while fibroid specimens only were obtained from 10 women undergoing myomectomy after at least 3 months pretreatment with GnRHa.

RESULTS

We found that (1) ER binding was twice and PR binding was three times as great in fibroid as in myometrium and that there was no difference in binding for either receptor between fibroids from untreated and GnRHa pretreated women, (2) ER and PR mRNA abundances were similar in fibroids and myometrium from untreated women and in fibroids from untreated and GnRHa pretreated women, and (3) ER binding and ER mRNA abundance in both groups of fibroids and myometrium were independent of each other, but there was a positive correlation between PR binding and PR mRNA abundance in untreated fibroids and myometrium but not in GnRHa pretreated tumours.

CONCLUSIONS

We conclude that (1) both oestrogen and progesterone may contribute to fibroid growth because of increased receptor binding in fibroids compared with myometrium and (2) in GnRHa treated women, fibroids may shrink because of a lowered circulating oestradiol level rather than because of a change in steroid receptor binding.

GnRH agonist analogs and hysteroscopic resection of myomas

OBJECTIVES

The purpose of this study was to evaluate the effects of pretreatment with GnRH analogs and hysteroscopic resection of submucous myomas previously deemed to be contraindicated for this approach.

METHODS

Twenty-five patients were included in this study. Patients were assessed by ultrasonography and diagnostic hysteroscopy. They were treated with depot GnRH analogs for 3 months and then scheduled for hysteroscopic surgery.

RESULTS

After GnRH therapy the diameter was 61 +/- 10% of the initial diameter. In one patient, therapy was almost ineffective. Hysteroscopic surgery was possible in all 25 patients. Seven patients presented an intramural myoma that was not possible to remove entirely during the first attempt. After dessication and 2 supplementary months of GnRH analog therapy, a second surgical attempt was successful in complete removal of the tumor in all except one case. In one patient hysterectomy 15 days after hysteroscopic surgery was necessary for incoercible bleeding due to a deep adenomiosis.

CONCLUSIONS

A combined medical and surgical approach seems to reduce the limit of hysteroscopic surgery and avoid open myomectomy or hysterectomy in a well selected group of patients.

The histopathology of uterine leiomyomas following treatment with gonadotropin-releasing hormone analogues

Gonadotropin-releasing hormone analogues (GnRH agonists) cause pituitary desensitization by downregulation of GnRH receptors, decrease gonadal steroid production, and reduce uterine volume in women with leiomyomas. The purpose of this study was to examine the morphologic changes in uterine leiomyomas associated with GnRH agonist treatment. The study group consisted of 33 patients (mean age, 36.9 years) who presented with infertility, dysmenorrhea, and/or menorrhagia, and who were treated with a GnRH agonist prior to surgery. A control group consisted of 44 premenopausal patients (mean age, 41.5 years) with similar symptomatology who underwent resection of leiomyomas only. In neither group was there any history of recent pregnancy, uterine surgery, or hormone replacement therapy. Microscopic review of all cases was performed without knowledge of the therapeutic history. No differences with respect to mitotic activity, fibrosis, edema, or vascular changes were detected. There is a suggestion that leiomyomas subjected to preoperative GnRH agonist treatment showed increased cellularity (P = .04); necrosis (P < .001) was associated with preoperative GnRH agonist treatment. The reduction of leiomyoma size during GnRH agonist therapy may be due to both ischemic injury and cellular atrophy. Although necrosis of leiomyomas is associated with GnRH agonist treatment, the lack of significant pleomorphism or mitotic activity distinguishes these altered leiomyomas from leiomyosarcomas.

Long-term effects of hormone replacement therapy on the uterus and on uterine circulation

OBJECTIVE

Our purpose was to study the effects of postmenopausal hormone replacement therapy on the uterus and uterine circulation.

STUDY DESIGN

The study population consisted of 432 women, 58 to 59 years of age. Color Doppler ultrasonography with a transvaginal probe was used to measure the size of the uterus and the uterine artery pulsatility index.

RESULTS

The mean endometrial thickness in group 1 (controls without hormone replacement therapy) was significantly thinner compared with group 2 hormone replacement therapy and with group 3 after discontinuance of hormone replacement therapy. The mean uterine artery pulsatility index was lower both in group 2 and 3 compared with group 1. When hormone replacement therapy was initiated 2 to 10 years after menopause, the endometrial thickness did not differ from that among those who had started hormone replacement therapy earlier, but the pulsatility index was significantly higher. There was positive correlation between the size of the uterus and the pulsatility index in group 1, but the correlation was negative in group 2. In general, the duration of hormone replacement therapy had no effect on the pulsatility index. Estrogen users had a significantly thicker endometrium compared with estrogen-progestogen users. The pulsatility index was highest in the estrogen users with progestogen added every month.

CONCLUSION

The duration, onset of treatment in relation to menopause, discontinuance of hormone replacement therapy, and mode of treatment modify both the normal postmenopausal endometrial thickness and the uterine vascular resistance.

Efficacy of a low-dose leuprolide acetate depot in the treatment of uterine leiomyomata in Japanese women

OBJECTIVE

To compare the efficacy of two different doses, 1.88 mg and 3.75 mg, of a monthly depot injection of a gonadotropin-releasing hormone agonist (GnRH-a) in the treatment of uterine leiomyomata.

DESIGN

A prospective randomized study.

SETTING

Hospital department of gynecology and obstetrics.

PATIENTS

Forty-one premenopausal Japanese women, 25 to 53 years of age, with uterine leiomyomata.

INTERVENTIONS

Depot type of GnRH-a, leuprolide acetate (LA) 1.88 mg or 3.75 mg was administered subcutaneously every 4 weeks for 24 weeks.

MAIN OUTCOME MEASURES

Efficacy of treatment was assessed in terms of uterine volume, serum levels of estradiol (E2), luteinizing hormone (LH), follicle-stimulating hormone (FSH), and adverse symptoms during treatment.

RESULTS

In both groups, a significant reduction in uterine volume, 52% in 1.88 mg group and 47% in 3.75 mg group, was obtained at week 24, with near maximal reduction (41%, 45%) apparent by 12 weeks. No significant difference was observed between the groups in percent uterine volume reduction at each treatment week. Both groups showed significant and equal suppression of serum levels of E2, LH, and FSH. In addition, the incidence of adverse symptoms was not significantly different between the two groups.

CONCLUSIONS

Monthly injection of 1.88 mg or 3.75 mg LA depot has equivalent treatment efficacy in reducing uterine volume. Twelve weeks of treatment is enough to obtain near maximal reduction.

Treatment of uterine fibroids: current findings with gonadotropin-releasing hormone agonists

The gonadotropin-releasing hormone agonists have potential benefit as presurgical adjuncts in the management of uterine leiomyomas or fibroids. Uterine fibroids contain estrogen receptors and are responsive to therapeutic hormonal manipulation; gonadotropin-releasing hormone agonists are effective by inducing a state of hypoestrogenism. Clinical trials with gonadotropin-releasing hormone agonists consistently have demonstrated efficacy for decreasing both myoma size and uterine volume. The advantages of the preoperative use of gonadotropin-releasing hormone agonists include a reduction in uterine and myoma size and vascularity and potentially improved operative technique and uterine cavity integrity. Ongoing clinical trials will be needed to confirm the role of gonadotropin-releasing hormone agonists in the treatment of uterine fibroids.

Myomectomy by laparoscopy: a preliminary report of 43 cases

OBJECTIVE

To evaluate the technique and short-term results of intraperitoneal (IP) myomectomies.

DESIGN

From January 1, 1990, to March 1, 1991, IP myomectomies were performed in all cases in which it appeared feasible.

SETTING

This study was conducted in a tertiary care center, the Port-Royal University Hospital.

PATIENTS, PARTICIPANTS

Among 49 consecutive patients with interstitial or subserous myomas, 6 patients with voluminous, multiple myomas had laparotomies. Intraperitoneal myomectomy was performed in 43 patients. The indication for laparoscopy was a pelvic mass in 29 cases, infertility in 13, and severe endometriosis in 1 case.

INTERVENTIONS

Thermocoagulation or monopolar coagulation was used for the uterine incision. Myometrium and serosa were sutured in 23 of 43 patients. Myomas were removed through the suprapubic puncture site after fragmentation of large myomas.

MAIN OUTCOME MEASURE(S)

We evaluated the length of the procedures, blood loss, and postoperative course.

RESULTS

Ninety-two myomas were removed laparoscopically. No complication was observed.

CONCLUSIONS

In selected cases, IP myomectomy appears to be a safe technique with the advantages of laparoscopic surgery.

Endometrial ablation for the treatment of menorrhagia: a comparison of patients with normal, enlarged, and fibroid uteri

One hundred sixty-one patients underwent endometrial ablation with the Nd:YAG laser for the treatment of refractory menorrhagia. Patients were divided into one of three groups: those with a normal-sized uterus; those with an enlarged uterus (greater than 10 cm); and those with uterine fibroids, which had been documented clinically, ultrasonographically, or by a combination of hysteroscopy and laparoscopy or by one or the other. All patients were considered candidates for hysterectomy. Both preoperatively and postoperatively, patients monitored their menstrual cycles and evaluated their flow according to predetermined categories of amenorrhea, light flow, normal flow, heavy flow, and severe flow. After treatment, 68% of patients with normal-sized uterus and 91% of patients with an enlarged uterus (greater than 10 cm) and 88% of patients with uterine fibroids became amenorrheic or had light flow. None of the patients in this last group have had to undergo hysterectomy. This study indicates that the patient with an enlarged or fibroid uterus may not have contraindications for endometrial ablation. Endometrial ablation may be effective in at least temporarily controlling bleeding in those patients with enlarged or myomatous uterus.

Efficacy and safety considerations in women with uterine leiomyomas treated with gonadotropin-releasing hormone agonists: the estrogen threshold hypothesis

Gonadotropin-releasing hormone agonists induce a reversible hypogonadotropic hypogonadal environment. Leiomyomas are common, estrogen-sensitive, benign neoplasms that decrease in size by 40% to 50% during gonadotropin-releasing hormone agonist treatment. During gonadotropin-releasing hormone agonist therapy most women are amenorrheic. After discontinuation of gonadotropin-releasing hormone agonist treatment, uterine and myoma size increase and a return to pretreatment menstrual patterns often occurs. Concerns about the safety of long-term hypoestrogenism have made long-term gonadotropin-releasing hormone agonist administration an undesirable treatment strategy. This article focuses on the use of gonadotropin-releasing hormone agonists as preoperative therapy in selected women undergoing hysterectomy or myomectomy and the combination of a gonadotropin-releasing hormone agonist with estrogen-progestin "add-back" treatment as a potential long-term medical therapy for women with symptomatic leiomyomas. Finally, an estrogen threshold hypothesis to assess the effects of circulating estrogen concentrations on different tissues, is presented.

Treatment with GnRH agonists before myomectomy and the risk of short-term myoma recurrence

Twenty-four women with symptomatic multiple uterine myomas were allocated randomly to treatment with buserelin, 1200 micrograms/day intranasally, for 3 months followed by myomectomy (n = 8) or to immediate myomectomy (n = 16). Pre-operative treatment with buserelin reduced the mean uterine volume from 432 (SD 165) to 242 (SD 82) ml (P less than 0.01) but intra-operative blood loss and postoperative morbidity were not significantly less in this group. Six months after operation, pelvic examination was normal in all the patients. However, ultrasonography with transvaginal probe demonstrated the presence of myomas of less than 1.5 cm in five women (63%) treated pre-operatively with the analogue and in two women (13%) who underwent immediate surgery (P less than 0.05). Induction of a period of hypo-oestrogenism before myomectomy seems to favour short-term recurrence of uterine myomas, limiting the efficacy of surgery.

Fibroids and menorrhagia

Fibroids are an important cause of menorrhagia, resistant to conventional methods of medical treatment. The mechanism of their effect on menstrual blood loss is poorly understood but may involve abnormalities of local venous drainage, enlargement of the uterine cavity and abnormalities in prostaglandin production. Their cause remains unknown although it has long been assumed that they are oestrogen-dependent. In the past, study of their aetiology, prevention and treatment has received scant attention. Recent developments including measurement of tissue receptors for steroids and growth factors, non-invasive methods of monitoring fibroid growth and the use of LHRH agonists have enabled further study of their nature and of their response to therapy although much work remains to be done. The majority of women with uterine fibroids associated with menorrhagia are treated by hysterectomy although developments in endoscopic surgery have enabled a more conservative approach in some circumstances. LHRH agonists are the only medical agents which cause substantial shrinkage of fibroids although regression is not permanent. These agents are of value in short-term relief of symptoms and are likely to be a useful adjunct to surgery by reducing both uterine volume and bloodflow. However, because of the consequences of prolonged ovarian suppression, they are not suitable for long-term use unless there are medical contraindications to surgery. It remains to be seen whether their use in low-dose regimens or in combination with other agents will provide a successful, safe and cost-effective alternative to hysterectomy in women whose primary problem is heavy menstrual loss. They do however offer a means of conserving reproductive function in women wishing to retain this option.