LHRH analogues and fibroids--potential for longer-term use

Tamoxifen and the female genital tract

Ugwumadu AHN, Carmichael P, Neven P. Tamoxifen and the female genital tract. Int J Gynecol Cancer 1998; 8: 6-15. Tamoxifen was originally developed by Imperial Chemical Industries (England) (ICI) in 1966 as an anti-estrogenic contraceptive. Ironically, it found a role in the treatment of anovulatory infertility, but its most important application to date is in adjuvant hormonotherapy for breast cancer. Tamoxifen has a complex and poorly understood mix of estrogenic and anti-estrogenic properties with variable and contrasting effects on hormone-sensitive target tissues, such as the endometrium. This article reviews the gynecologic lesions associated with tamoxifen therapy and discusses the merits and acceptability of endometrial surveillance tests and the role of progestogens.

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.

Uterine leiomyomata and endometrial proliferation in postmenopausal women treated with the anti-oestrogen tamoxifen

Two cases of fibroid growth and endometrial proliferation in postmenopausal women on tamoxifen (anti-oestrogen) therapy for breast cancer are described. Oestrogen in association with growth factors may control fibroid growth and differentiation. The possible mechanisms and consequences of tamoxifen-induced fibroid growth are discussed. Oestrogen responsive tissues demonstrate a differential and contrasting response to tamoxifen and caution should be exercised in the expansion of its clinical application. Women on long-term tamoxifen therapy may benefit from ultrasound surveillance of their uterus and endometrium, with biopsy in suspicious cases, as there is a paucity of data on malignant transformation of these benign lesions induced by tamoxifen therapy.