Increasing Awareness of the Role of GnRH Pre-Treatment for Fibroids

Fibroids are benign tumours or growths of the uterus (myomas or leiomyomas) which are very common in women of reproductive age and tend to reduce in size after the menopause. They usually do not require treatment unless they cause symptoms. Symptoms of fibroids include prolonged heavy periods, abdominal distention, lower abdominal discomfort, or pain. Fibroids may cause pressure on other structures leading to such symptoms as urinary frequency and constipation.

Fibroids may be associated with infertility but many women with fibroids can conceive without difficulty. During pregnancy the fibroids enlarge and sometimes undergo degeneration leading to pain.

Women may present with symptoms and the diagnosis is confirmed by clinical examination and ultrasound scan. Fibroids often do not require treatment, as they are typically not symptomatic and shrink and disappear over time. Abdominal examination may reveal a mass arising from the pelvis and a vaginal examination may reveal an enlarged uterus, but the diagnosis is usually confirmed by a pelvic ultrasound scan.

Treatment of fibroids include analgesia and tranexamic acid for relatively mild symptoms. Surgery with myomectomy or hysterectomy in more troublesome or persistent symptoms. Such surgery may be undertaken by laparotomy (open surgery) or laparoscopically. Sub-mucus fibroids may also be treated by transcervical hysteroscopic resection

There are three main types of fibroids:

Intramural Fibroids – develop in the muscle wall of the womb. Subserosal Fibroids – develop outside the wall of the uterus into the pelvis. Submucosal Fibroids – develop in the muscle layer beneath the uterus’ inner lining and grow into the cavity of the uterus.

Treatment Gonadotropin-releasing hormone analogue (GnRH), such as goserelin or leuprolide acetate cause down regulation of the pituitary and supress ovarian function, which leads to reduced oestradiol secretion and shrinkage of the fibroids but also results in menopausal symptoms such as hot flushes, night sweats or mood changes. The effect of GnRH on fibroids is temporary and they will regrow once treatment is discontinued, furthermore long-term use of GnRH analogues will also result in osteoporosis. Prolonged treatment with GnRH is therefore not appropriate, however pre-treatment prior to surgery may be helpful as it will shrink fibroids thus facilitating surgery and may reduce the risk of bleeding during the procedure.

A Cochrane review on the use of preoperative medical therapy before surgery for fibroids, confirmed that pre-operative treatment with GnRH analogues increases the preoperative blood count (haemoglobin), resulting in a reduction of fibroid volume, reduced blood loss during the procedure and fewer post operative complications. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD000547.pub2/full

Case Studies:

Case Study 1

A myomectomy (a procedure with far less impact than a hysterectomy which is accompanied with fewer complications and a faster recovery time) was performed to remove a fibroid responsible for enlarging the uterus, in favour of a hysterectomy. Unfortunately, during the myomectomy procedure there was excessive bleeding due to difficulties in removing the fibroid, leading to the procedure being halted, and abandoned. This is a recognised complication of this procedure, but a retrospective review of the case, found that as the fibroids were over 5cm, pre-surgical treatment with a gonadotrophin-releasing hormone analogue (GnRH) would have successfully shrunk the fibroid, meaning surgery would have had a better chance of success.

Fortunately, the patient in this case did not come to any significant harm as a result of the bleeding complication that arose. However, this case demonstrates the importance of considering GnRH treatment to shrink and help relieve symptoms prior to the patient undergoing surgery, especially where uterine fibroids are causing an enlarged or distorted uterus.

Case Study 2

A patient underwent a hysteroscopic resection to remove a fibroid due to causing menorrhagia symptoms (menstrual bleeding that lasts more than 7 days). Whilst the operation was the appropriate course of action, the fibroid it was not possible to remove the fibroid in its entirety as the patient suffered heavy bleeding, a recognised complication of this procedure. The patient was managed appropriately, however, her symptoms did not fully resolve.

Retrospective review of the case demonstrated that whilst the patient was offered alternative options, such as a Mirena Coil (Intrauterine System (IUS)) prior to surgery to relieve her symptoms, GnRH was not considered by the treating clinician.

Case Study 3

The patient attended the Trust to undergo laparoscopic hysterectomy and bilateral salpingo-oophorectomy to for the treatment of a large pair of fibroids and endometriosis.

Initially, the patient was offered treatment with Esmya (an ulipristal acetate, alternative to GnRH) to reduce the size of the fibroids prior to the definitive surgery. However, the Esmya was appropriately halted due to the patient suffering side effects, but the patient was not offered a GnRH analogue

The surgery went ahead, without further pre-treatment.

A retrospective review discovered that the surgeon should have picked up on this omission, explaining to the patient the risks/benefits of proceeding without taking GnRH beforehand.

Recommendations to Improve Patient Safety and Clinical Standards:

  • GnRH analogues should always be considered prior to fibroid removal surgery. A discussion between the clinician and patient concerning the risks and benefits of taking GnRH analogues prior to surgery should take place.

  • If a GnRH analogue is halted, an alternative should be offered prior to surgery.

  • Gynaecological Surgeons should remain aware of the courses of treatments available for heavy menstrual bleeding women with fibroids:

  • Pre-treatment with GnRH should be considered before hysterectomy and myomectomy if the fibroids are causing an enlarged or distorted uterus.

  • https://www.nice.org.uk/guidance/ng88/chapter/Recommendations