New Treatment Option for Large Uterine Fibroids May Preserve Fertility

The pretreatment of large fibroid tumors with gonadotropin-releasing hormone (GnRH) is safe and does not inhibit the use of uterine artery embolization (UAE), conclude the authors of a new study conducted in Korea.¹ This new finding offers women with large uterine fibroids a new nonsurgical treatment choice that can replace hysterectomy.

Of 40 patients who had fibroid tumors that were 10 centimeters or larger, 28 patients had UAE without pretreatment with GnRH, and 12 patients received GnRH 1 to 5 times before undergoing UAE. Three months after UAE, the necrosis of the large fibroids and their volume were assessed with an MRI scan for all patients.

After UAE, complete necrosis of the large fibroids occurred in 39 (97.5%) of 40 patients. The one patient who had incomplete necrosis did not receive GnRH. The fibroids of patients who received pretreatment with GnRH shrunk an average of 36.3%. Furthermore, the patients who received GnRH had higher mean volume reduction rates of the predominant fibroids and the uterus after UAE than patient who did not receive GnRH (56.5% and 50.8% vs 35.1% and 34.9%, respectively).

Offering UAE to women with large fibroids has been a source of disagreement in the medical community because of concerns about an increased risk of infection or sepsis, explained Man Deuk Kim, MD, PhD, lead author of the study. The results of this study, however, showed that pretreatment with GnRH shrunk the tumors by 36.3% and reduced complications. Four patients who participated in the study had grade D complications that required at least 48 hours of hospitalization, but none of them were in the GnRH group.

Another source of concern is the limitations and adverse effects of GnRH agonists. GnRH agonists, such as leuprolide, are costly, injectable drugs that can cause the following adverse effects: hot flushes, night sweats, vaginal dryness, weight gain, and depression.² Depending on which GnRH is used, some adverse effects may persist even after the drug has been discontinued. Also, although GnRH can shrink fibroids, the fibroids will regrow once GnRH is discontinued, so UAE or surgery should be performed soon after GnRH pretreatment.

Kim acknowledged that GnRH agonist treatment can cause sudden temporary narrowing of the uterine artery. This potential effect does not prevent performing UAE, however. “Interventional radiologists may be unfamiliar with prescribing GnRH, but our study encourages them to consider GnRH as a pretreatment for patients with large fibroids who want to avoid surgery,” said Kim. For patients who want to preserve their fertility by avoiding a hysterectomy, this treatment option should be considered.

Pertinent Points:
- Pretreating large uterine fibroids with gonadotropin-releasing hormone (GnRH) before uterine artery embolization is a safe and effective nonsurgical approach that can replace hysterectomy.
- The use of GnRH before uterine artery embolization was associated with a 36.3% mean volume reduction rate of fibroids with a pretreatment diameter of 10 centimeters or larger.

References:

1. Kim MD, Lee M, Lee MS, et al. Uterine artery embolization of large fibroids: comparative study of procedure with and without pretreatment gonadotropin-releasing hormone agonists. Am J Roentgenol. 2012;199:441-446.
2. Uterine fibroids and hysterectomy: medications. Available at: http://www.umm.edu/patiented/articles/what_medications_used_uterine_fibroids_000073_8.htm. Accessed September 25, 2012.