Goserelin (Zoladex) in the treatment of fibroids

Preoperative medical therapy before surgery for uterine fibroids

BACKGROUND

Uterine fibroids occur in up to 40% of women aged over 35 years. Some are asymptomatic, but up to 50% cause symptoms that warrant therapy. Symptoms include anaemia caused by heavy menstrual bleeding, pelvic pain, dysmenorrhoea, infertility and low quality of life. Surgery is the first choice of treatment. In recent years, medical therapies have been used before surgery to improve intraoperative and postoperative outcomes. However, such therapies tend to be expensive.Fibroid growth is stimulated by oestrogen. Gonadotropin-hormone releasing analogues (GnRHa) induce a state of hypo-oestrogenism that shrinks fibroids , but has unacceptable side effects if used long-term. Other potential hormonal treatments, include progestins and selective progesterone-receptor modulators (SPRMs).This is an update of a Cochrane Review published in 2000 and 2001; the scope has been broadened to include all preoperative medical treatments.

OBJECTIVES

To assess the effectiveness and safety of medical treatments prior to surgery for uterine fibroids.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility Group specialised register, CENTRAL, MEDLINE, Embase, PsycINFO and CINAHL in June 2017. We also searched trials registers (ClinicalTrials.com; WHO ICTRP), theses and dissertations and the grey literature, handsearched reference lists of retrieved articles and contacted pharmaceutical companies for additional trials.

SELECTION CRITERIA

We included randomised comparisons of medical therapy versus placebo, no treatment, or other medical therapy before surgery, myomectomy, hysterectomy or endometrial resection, for uterine fibroids.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

We included a total of 38 RCTs (3623 women); 19 studies compared GnRHa to no pretreatment (n = 19), placebo (n = 8), other medical pretreatments (progestin, SPRMs, selective oestrogen receptor modulators (SERMs), dopamine agonists, oestrogen receptor antagonists) (n = 7), and four compared SPRMs with placebo. Most results provided low-quality evidence due to limitations in study design (poor reporting of randomisation procedures, lack of blinding), imprecision and inconsistency. GnRHa versus no treatment or placebo GnRHa treatments were associated with reductions in both uterine (MD -175 mL, 95% CI -219.0 to -131.7; 13 studies; 858 participants; I² = 67%; low-quality evidence) and fibroid volume (heterogeneous studies, MD 5.7 mL to 155.4 mL), and increased preoperative haemoglobin (MD 0.88 g/dL, 95% CI 0.7 to 1.1; 10 studies; 834 participants; I² = 0%; moderate-quality evidence), at the expense of a greater likelihood of adverse events, particularly hot flushes (OR 7.68, 95% CI 4.6 to 13.0; 6 studies; 877 participants; I² = 46%; moderate-quality evidence).Duration of hysterectomy surgery was reduced among women who received GnRHa treatment (-9.59 minutes, 95% CI 15.9 to -3.28; 6 studies; 617 participants; I² = 57%; low-quality evidence) and there was less blood loss (heterogeneous studies, MD 25 mL to 148 mL), fewer blood transfusions (OR 0.54, 95% CI 0.3 to 1.0; 6 studies; 601 participants; I² = 0%; moderate-quality evidence), and fewer postoperative complications (OR 0.54, 95% CI 0.3 to 0.9; 7 studies; 772 participants; I² = 28%; low-quality evidence).GnRHa appeared to reduce intraoperative blood loss during myomectomy (MD 22 mL to 157 mL). There was no clear evidence of a difference among groups for other primary outcomes after myomectomy: duration of surgery (studies too heterogeneous for pooling), blood transfusions (OR 0.85, 95% CI 0.3 to 2.8; 4 studies; 121 participants; I² = 0%; low-quality evidence) or postoperative complications (OR 1.07, 95% CI 0.43 to 2.64; I² = 0%; 5 studies; 190 participants; low-quality evidence). No suitable data were available for analysis of preoperative bleeding. GnRHa versus other medical therapies GnRHa was associated with a greater reduction in uterine volume (-47% with GnRHa compared to -20% and -22% with 5 mg and 10 mg ulipristal acetate) but was more likely to cause hot flushes (OR 12.3, 95% CI 4.04 to 37.48; 5 studies; 183 participants; I² = 61%; low-quality evidence) compared with ulipristal acetate. There was no clear evidence of a difference in bleeding reduction (ulipristal acetate 5 mg: OR 0.71, 95% CI 0.3 to 1.7; 1 study; 199 participants; moderate-quality evidence; ulipristal acetate 10 mg: OR 0.39, 95% CI 0.1 to 1.1; 1 study; 203 participants; moderate-quality evidence) or haemoglobin levels (MD -0.2, 95% CI -0.6 to 0.2; 188 participants; moderate-quality evidence).There was no clear evidence of a difference in fibroid volume between GnRHa and cabergoline (MD 12.71 mL, 95% CI -5.9 to 31.3; 2 studies; 110 participants; I² = 0%; low-quality evidence).The included studies did not report usable data for any other primary outcomes. SPRMs versus placebo SPRMs (mifepristone, CDB-2914, ulipristal acetate and asoprisnil) were associated with greater reductions in uterine or fibroid volume than placebo (studies too heterogeneous to pool) and increased preoperative haemoglobin levels (MD 0.93 g/dL, 0.5 to 1.4; 2 studies; 173 participants; I² = 0%; high-quality evidence). Ulipristal acetate and asoprisnil were also associated with greater reductions in bleeding before surgery (ulipristal acetate 5 mg: OR 41.41, 95% CI 15.3 to 112.4; 1 study; 143 participants; low-quality evidence; ulipristal acetate 10 mg: OR 78.83, 95% CI 24.0 to 258.7; 1 study; 146 participants; low-quality evidence; asoprisnil: MD -166.9 mL; 95% CI -277.6 to -56.2; 1 study; 22 participants; low-quality evidence). There was no evidence of differences in preoperative complications. No other primary outcomes were measured.

AUTHORS' CONCLUSIONS

A rationale for the use of preoperative medical therapy before surgery for fibroids is to make surgery easier. There is clear evidence that preoperative GnRHa reduces uterine and fibroid volume, and increases preoperative haemoglobin levels, although GnRHa increases the incidence of hot flushes. During hysterectomy, blood loss, operation time and complication rates were also reduced. Evidence suggests that ulipristal acetate may offer similar advantages (reduced fibroid volume and fibroid-related bleeding and increased haemoglobin levels) although replication of these studies is advised before firm conclusions can be made. Future research should focus on cost-effectiveness and distinguish between groups of women with fibroids who would most benefit.

GnRH analogues in the treatment of fibroids

Uterine fibroids are estimated to affect up to 25% of women of reproductive age and are a common cause of morbidity, being associated with menstrual dysfunction, iron deficiency anaemia, pregnancy wastage and subfertility. Their pathogenesis remains unknown but their association with ovarian function and oestrogen production is undisputed and supported by their occurrence only after puberty and the shrinkage observed after the menopause. This oestrogen dependency has recently been exploited therapeutically through investigation of the use of agents that induce a hypo-oestrogenic state, the gonadotrophin-releasing hormone (GnRH) or luteinizing hormone-releasing hormone (LHRH) analogues.

Efficacy of pre-operative gonadotrophin hormone releasing analogues for women with uterine fibroids undergoing hysterectomy or myomectomy: a systematic review

OBJECTIVE

To evaluate the role of pretreatment with gonadotrophin releasing hormone (GnRH) analogues (GnRHa) prior to surgery for women with uterine fibroids.

DESIGN

A systematic review was undertaken of all randomised controlled trials assessing the efficacy of GnRHa treatment prior to surgery (myomectomy or hysterectomy) in women with fibroids.

SETTING

Secondary care. Sample Premenopausal women with fibroids awaiting surgery attending hospitals or clinics.

METHODS

Electronic searches of Medline, EmBase, Current Contents, the Cochrane Library, National Research Register, NLM's Clinical Trials Register and the Cochrane group's Trials Register were performed, between 1980 and 2000. Twenty-six randomised controlled trials were identified that compared GnRHa with no treatment, placebo or other medical treatment. The quality of the trials was assessed and data were extracted independently by two of the reviewers. Statistical analysis was performed in Revman according to Cochrane guidelines and where possible outcomes were pooled in a meta-analysis.

MAIN OUTCOME MEASURES

Pre-operative assessment (reduction in uterine and fibroid volume, change in haemoglobin and haematocrit, change in patient's symptoms), intra-operative assessment (duration of operation, blood loss, proportion with vertical incision, proportion undergoing vaginal rather than abdominal procedure, frequency of blood transfusions), post-operative assessment (complications, duration of hospital stay, recurrence of fibroids).

RESULTS

Pre- and post-operative haemoglobin and haematocrit were significantly improved by GnRHa therapy prior to surgery, and uterine volume, uterine gestational size and fibroid volume were all reduced. Pelvic symptoms were also reduced but some adverse events were more likely during GnRHa therapy. Hysterectomy appeared to be easier after pretreatment with GnRHa therapy; there was reduced operating time and a greater proportion of hysterectomy patients was able to have a vaginal rather than an abdominal procedure. Duration of hospital stay was also reduced. Blood loss and rate of vertical incisions were reduced for both myomectomy and hysterectomy. Evidence of increased risk of fibroid recurrence after GnRHa pretreatment in myomectomy patients was equivocal and few data were available to assess change in postoperative fertility.

CONCLUSIONS

The use of GnRHa for three to four months prior to fibroid surgery reduces both uterine volume and fibroid size. They are beneficial in the correction of pre-operative iron deficiency anaemia, if present, and reduce intra-operative blood loss. If uterine size is such that a midline incision is planned, this can be avoided in many women with the use of GnRHa. For women undergoing hysterectomy, a vaginal procedure is more likely following the use of these agents.

Pre-operative GnRH analogue therapy before hysterectomy or myomectomy for uterine fibroids

BACKGROUND

Uterine fibroids, smooth muscle tumours of the uterus, are found in at least 25 to 35% of women over the age of 35 years. Although some of these tumours are asymptomatic, up to 50% cause symptoms severe enough to warrant therapy and surgery is the standard treatment. Fibroid growth is stimulated by oestrogen and gonadotropin releasing hormone agonists (GnRHa) which induce a state of hypoestrogenism have been investigated as a potential treatment. GnRHa treatment causes fibroids to shrink but cannot be used long term because of unacceptable symptoms and bone loss. Therefore, GnRHa may be useful pre-operatively both to reduce fibroid and uterine volume and control bleeding.

OBJECTIVES

The objective of this review is to evaluate the role of pre-treatment with gonadotropin releasing hormone (GnRH) analogues prior to a major surgical procedure, either hysterectomy or myomectomy, for uterine fibroids.

SEARCH STRATEGY

Electronic searches for relevant randomised controlled trials of the Cochrane Menstrual Disorders and Subfertility Group Register of Trials, MEDLINE, EMBASE, the National Research Register, the National Library of Medicine's Clinical Trials Register and Current Contents were performed. Attempts were also made to identify published trials from citation lists of review articles and direct contact with drug companies for unpublished trials. In most cases, the first author of each included trial was contacted for additional information. The search was updated in October 2000.

SELECTION CRITERIA

The inclusion criteria were randomised comparisons of GnRH analogue treatment versus placebo, no treatment, or other medical therapy prior to surgery, either myomectomy or hysterectomy, for uterine fibroids.

DATA COLLECTION AND ANALYSIS

Twenty-six RCTs were identified that fulfilled the inclusion criteria for this review. The reviewers extracted the data independently and odds ratios for dichotomous outcomes and weighted mean differences for continuous outcomes were estimated from the data of fourteen trials where GnRH analogue treatment was compared with no pre-treatment and six trials where GnRH analogue treatment was compared with placebo. Three trials are awaiting assessment because the data were not in a suitable form for extraction or they are awaiting translation. Two trials have been excluded because the data were not in a suitable form for extraction and the authors were not able to provide additional information. One RCT compared GnRHa pre-treatment with lynestrenol pre-treatment. Results from pre-operative outcomes were combined for both types of surgery but results from intra- and post-operative outcomes were reported separately for myomectomy and hysterectomy. Subgroup analysis was performed according to type of control group, no pre-treatment or placebo, and for some outcomes there were additional subgroup analyses according to size of the uterus in gestational weeks.

MAIN RESULTS

Pre- and post-operative haemoglobin (Hb) and haematocrit (HCT) were significantly improved by GnRH analogue therapy prior to surgery, and uterine volume, uterine gestational size and fibroid volume were all reduced. Pelvic symptoms were also reduced but some adverse events were more likely during GnRH analogue therapy. Hysterectomy appeared to be easier after pre-treatment with GnRH analogue therapy; there was reduced operating time and a greater proportion of hysterectomy patients were able to have a vaginal rather than an abdominal procedure. Duration of hospital stay was also reduced. Blood loss and rate of vertical incisions were reduced for both myomectomy and hysterectomy. Evidence of increased risk of fibroid recurrence after GnRH analogue pre-treatment in myomectomy patients was equivocal and few data were available to assess change in post-operative fertility. Lynestrenol did not offer any advantage over GnRH analogue therapy before fibroid surgery. The increased costs associated with GnRH analogue therapy were not assessed.

REVIEWER'S CONCLUSIONS

The use of GnRH analogues for 3 to 4 months prior to fibroid surgery reduce both uterine volume and fibroid size. They are beneficial in the correction of pre-operative iron deficiency anaemia, if present, and reduce intra-operative blood loss. If uterine size is such that a mid-line incision is planned, this can be avoided in many women with the use of GnRH analogues. For patients undergoing hysterectomy, a vaginal procedure is more likely following the use of these agents.

Uterine myomas: treatment options

Myomas (also called fibroids) are the most common solid pelvic tumors. Treatment options for myomas include medical and surgical management. The goals of medical management are to shrink the myoma and reduce its blood supply. Surgical interventions include therapies for women who wish to preserve fertility or retain their uterus. Newer treatment options include myomectomy achieved through an abdominal, laparoscopic, or hysteroscopic approach. Nurses assess and counsel women regarding treatment options.

Gonadotrophin hormone-releasing hormone analogue treatment of fibroids

Gonadotrophin hormone-releasing hormone analogue (GnRHa) therapy can induce a reduction in fibroid volume by up to 50% over a period of 3 months treatment. This effect may be beneficial in selected patients, prior to open or endoscopic myomectomy, to aid the surgical procedure by improving vision because of reduced blood loss and reduced uterine artery blood flow. Symptoms of excessive menstrual bleeding, pelvic pain and dysmenorrhoea will also be controlled. Long-term administration of GnRHa requires the use of concomitant add-back therapy, the optimal combination investigated to date being an oestrogen-progestogen continuous combined preparation.

Treatment of fibromas

This study defines the current modes of treatment of patients with uterine fibromas with a review of the literature. Progesterone treatments appear to be principally used in cases of minor functional symptomatology and we discuss recent studies of mifepristone. GnRH agonists are particularly effective in preoperative treatment for conservative surgery. The indications and results of hysteroscopic resection and laparoscopic myomectomy are compared to those of classic myomectomy and hysterectomy. The indications for myolysis are discussed.

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.

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.