Mechanism of LHRH analogue action in uterine fibroids. Comparison of ovarian cyst formation in women using the levonorgestrel-releasing intrauterine system vs. hysterectomy. Role of goserelin-depot in the clinical management of uterine fibroids. Effects of the position of fibroids on fertility. Reducing blood loss at myomectomy with use of a gelatin-thrombin matrix hemostatic sealant. Randomised comparison of uterine artery embolisation (UAE) with surgical treatment in patients with symptomatic uterine fibroids (REST trial): 5-year results. Uterine fibroid embolization versus myomectomy in women wishing to preserve fertility: preliminary results of a randomized controlled trial. Identifying the indications for laparoscopically assisted vaginal hysterectomy: a prospective, randomised comparison with abdominal hysterectomy in patients with symptomatic uterine fibroids. Effect of mifepristone for symptomatic leiomyomata on quality of life and uterine size: a randomized controlled trial. Treatment with the gonadotrophin releasing hormone-agonist goserelin before hysterectomy for uterine fibroids. The place of Zoladex in deferred surgery for uterine fibroids. Zoladex Myoma Study Group.
Luteinising hormone-releasing hormone analogues have been found to reduce the size of uterine fibroids. Further studies are required to determine their exact mechanism of action. However, they are known to induce hypo-oestrogenism, which leads to reduction in uterine arterial blood flow, one mechanism by which reduction of fibroid size is thought to occur. To analyze the effect of the levonorgestrel-releasing intrauterine system (LNG-IUS) on ovarian cyst formation, endometrial thickness and the size of uterus and uterine fibroids by ultrasonography.
                This was a prospective, randomized trial comparing the LNG-IUS and hysterectomy in 236 women (age range 35-49 years) referred for menorrhagia. Transvaginal ultrasound examination was used to study the presence of ovarian cysts, uterine size, endometrial thickness, and the size of the uterus and uterine fibroids during a 12-month follow-up period.
                At baseline examination, 12 ovarian cysts were detected, eight in the LNG-IUS group and four in the hysterectomy group. During the follow-up period, 14 new cysts had emerged at 6 months and 14 new cysts had emerged at 12 months in the LNG-IUS group, whereas the corresponding figures in the hysterectomy group were three and eight, respectively. All but one of the 14 new cysts (94.1%) detected at 6 months in the LNG-IUS group resolved spontaneously, whereas two out of the eight cysts detected at the baseline examination persisted for 12 months. Three cysts were removed at operation. The relative risk of the occurrence of ovarian cysts was significantly higher in women with LNG-IUS, compared with women who underwent hysterectomy. LNG-IUS did not affect the size of the uterus or uterine fibroids, but it was associated with a decrease in endometrial thickness. The occurrence of cysts did not correlate with age or follicle stimulating hormone levels, but a weak positive correlation between the occurrence of cysts and the presence of irregular bleeding was observed.
                LNG-IUS use in the treatment of menorrhagia was associated with the development of ovarian cysts, but these were symptomless and showed a high rate of spontaneous resolution. LNG-IUS did not affect the size of the uterus or the size of uterine fibroids, but decreased the thickness of the endometrium. On 30 women suffering from uterine fibroids, the monthly subcutaneous administration of goserelin depot (3.6 mg) for 6 (n = 22) or 12 months (n = 8) induced an about 50% shrinkage of uterus and fibroid volume, and within 3 months, an increase in the haematocrit value, with no metabolic side effects or detectable bone demineralization, evaluated by single photon absortiometry at distal radius. Both uterine and fibroid volumes reversed to pretreatment values after 3 months of goserelin depot withdrawal. In comparison with untreated subjects, on another 10 patients a three month administration of goserelin depot reduced the loss of blood during the surgical removal of the uterus or fibroids. Present data indicate that goserelin depot is effective and relatively safe in the medical management of uterine fibroids. Although, goserelin depot cannot yet be proposed as a definite medical therapy, it may represent a useful instrument in the presurgical management of uterine fibroids. This prospective, controlled study was performed in order to evaluate whether the location of uterine fibroids may influence reproductive function in women and whether removal of the fibroid prior to conception may improve pregnancy rate and pregnancy maintenance. We examined 181 women affected by uterine fibroids who had been trying to conceive for at least 1 year without success. The main outcome measures were the pregnancy rate and the miscarriage rate. Among the patients who underwent myomectomy, the pregnancy rates obtained were 43.3% in cases of submucosal, 56.5% in cases of intramural, 40.0% in cases of submucosal-intramural and 35.5% in cases of intramural-subserosal uterine fibroids, respectively. Among the patients who did not undergo surgical treatment, the pregnancy rates obtained were 27.2% in women with submucosal, 41.0% in women with intramural, 15.0% in women with submucosal-intramural and 21.43% in women with intramural-subserosal uterine fibroids, respectively. Although the results were not statistically significant in the group of women with intramural and intramural-subserosal fibroids, this study confirms the important role of the position of the uterine fibroid in infertility as well as the importance of fibroids removal before the achievement of a pregnancy, to improve both the chances of fertilization and pregnancy maintenance. To evaluate the hemostatic efficacy and handling of gelatin-thrombin matrix in abdominal myomectomy.
                Prospective and randomized trial.
                University teaching hospital.
                Women (n = 50) with uterine fibroids with a uterine size equivalent to > or =16 weeks gestation.
                Gelatin-thrombin matrix (FloSeal Matrix; Baxter Healthcare Corp., Fremont, CA) was delivered to the site of the uterine bleeding during myomectomy.
                Patient age, parity, number of myomas, operative time, blood loss, transfusion, intraoperative and postoperative complications, and length of hospitalization were evaluated.
                The average blood loss during surgery was 80 +/- 25.5 mL for the FloSeal group and 625 +/- 120.5 mL for the control group. Intraoperative blood transfusion was necessary in five patients from the control group. Postoperative blood loss was 25 +/- 5 mL for the FloSeal group and 250 +/- 75 mL for the control group. Length of the postoperative hospital stay was 2.5 +/- 1.2 days for FloSeal group and 4.5 +/- 1.3 for the control group. No major immediate or delayed complications were observed in either group.
                Reductions in hemorrhage in FloSeal-treated women undergoing a myomectomy are encouraging, and provide evidence for the ability of gelatin-thrombin matrix to reduce blood loss when applied immediately and directly to bleeding uterine tissue. To compare the long-term results of uterine artery embolisation (UAE) with surgery for women with symptomatic uterine fibroids.
                Pragmatic, open, multicentre, randomised trial.
                Twenty-seven participating UK secondary care centres.
                Women aged ≥18 years with symptomatic fibroids who were considered to justify surgical treatment.
                In total, 157 women were randomised (in a 2:1 ratio): 106 to UAE and 51 to surgery (hysterectomy 42; myomectomy nine).
                Quality of life at 5 years, as assessed by the Short Form General Health Survey (SF-36). Secondary measures included complications, adverse events and the need for further intervention.
                There were no significant differences between groups in any of the eight components of the SF-36 scores at 5 years (minimum P = 0.45). Symptom score reduction and patient satisfaction with either treatment was very high, with no group difference. Rates of adverse events were similar in both groups (19% embolization and 25% surgery; P = 0.40). The 5-year intervention rate for treatment failure or complications was 32% (UAE arm) and 4% (surgery arm), respectively. The initial cost benefit of UAE over surgery at 12 months was substantially reduced because of subsequent interventions, with treatments being cost neutral at 5 years.
                We have found that UAE is a satisfactory alternative to surgery for fibroids. The less invasive nature of UAE needs to be balanced against the need for re-intervention in almost a third of patients. The choice should lie with the informed patient.
                © 2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology © 2011 RCOG. To compare the clinical results of surgical and endovascular treatment of uterine myomas in young women.
                In a university-affiliated, tertiary care center a prospective trial was conducted. Sixty-three women, wishing to retain fertility, with intramural fibroid(s) larger than 4 cm, were randomly selected either for uterine artery embolization or myomectomy. Invasiveness, efficacy, and complications of both procedures were compared.
                Thirty embolizations and 33 myomectomies (15 laparoscopic, 18 open) were performed. The mean follow-up was 17 months. In embolized patients, there was a significantly shorter procedure length (p<0.0001), hospital stay (p<0.001) and disability period (p<0.0001), lower CRP (p<0.001) and higher hemoglobin (p<0.0001) concentrations the 2nd day after procedure. But there was a higher incidence of re-interventions (p<0.01) and a lower rate of total symptomatic relief (p<0.1). The groups did not significantly differ in: technical success rate, febrile morbidity, FSH levels 6 months after the procedure, and complication rates.
                Although the reproductive outcomes of uterine artery embolization and myomectomy cannot be evaluated at the moment, our first results indicate that both methods are clinically successful in the majority of cases and are not connected with significant number of serious complications. To compare laparoscopically assisted vaginal hysterectomy (LAVH) and total abdominal hysterectomy (TAH) in patients with uterine fibroids.
                A prospective randomised study.
                The San Paolo Hospital, Milan.
                Sixty-two patients, who were not suitable for a vaginal hysterectomy, requiring treatment for uterine fibroids.
                Randomisation between LAVH and TAH. Comparison of outcomes on the whole series, patients with uteri < or = 500 g (Group 1) and patients with uteri > 500 g (Group 2).
                To establish operating time, blood loss, complications, febrile morbidity, analgesics administration and hospital stay for both treatment approaches.
                Median uterine weight was 400 g in both LAVH and TAH group. Median operating time was longer for LAVH (135 min compared with 120 min for TAH; P = 0.001), but patients undergoing LAVH had less analgesics administration (23% compared with 77%, P < 0.001) and a shorter median hospital stay (3.8 compared with 5.8 days; P < 0.001). LAVH, when compared with TAH in the two weight subgroups, required a significantly longer operating time only in Group 2, significantly reduced analgesics administration only in Group 1, and significantly reduced hospital stay in both groups. Conversions of LAVH to laparotomy were significantly more frequent in Group 2 (3/11) than in Group 1 (0/20) (P = 0.04).
                Compared with TAH, LAVH has advantages in removing uteri weighing < or = 500 g, with comparable operating time, less post-operative pain and shorter recovery. Among uteri weighing > 500 g LAVH showed a shorter recovery, but longer operating time than TAH and a 27% rate of conversion to laparotomy. To assess the effect of low-dose mifepristone on quality of life, pain, bleeding, and uterine size among women with symptomatic leiomyomata.
                Forty-two women with symptomatic uterine leiomyomata and uterine volume of 160 mL or more were randomized to mifepristone, 5 mg daily, or placebo for 26 weeks. Quality of life (Uterine Fibroid Symptoms Quality of Life Questionnaire and Medical Outcomes Study 36-Item Short Form survey) and uterine and leiomyoma size (ultrasonography) were assessed at baseline, and at 1 month, 3 months, and 6 months of treatment. Bleeding (daily logs and pictorial charts) and pain (McGill Pain Questionnaire) were assessed monthly. Endometrial pathology was assessed at baseline and 6 months.
                Forty-two women were randomized; 37 women completed all 6 months. Women randomized to mifepristone showed an improvement in leiomyoma-specific quality of life. Forty-one percent became amenorrheic, rates of anemia improved, and adjusted uterine size was reduced by 47%. Compared with the placebo group, improvements in these outcomes in the treatment group were significantly greater (P<.05 to .001). There were no significant differences in adverse effects between the groups. No endometrial hyperplasia was noted in any participant.
                Low-dose mifepristone improves leiomyoma-specific quality of life and reduces leiomyoma size among women with symptomatic leiomyomata.
                ClinicalTrials.gov www.clinicaltrials.gov NCT00133705
                I. 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.
                Randomised placebo-controlled study.
                Patients were recruited from the gynaecological outpatient departments from hospitals in Edinburgh, Glasgow and Newcastle.
                Seventy-one premenopausal women with uterine leiomyomata who were on the waiting list for hysterectomy.
                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.
                Haemoglobin concentrations at recruitment, at operation and post-operatively, pre-operative symptoms, operative difficulty and blood loss and post-operative complications.
                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.
                This study demonstrates the benefits of goserelin in women having total abdominal hysterectomy for uterine leiomyomata. Two hundred and forty-seven patients with uterine fibroids were randomized to surgery alone or 3 months' Zoladex (Zeneca, Macclesfield, Ches., UK) followed by surgery. Zoladex significantly reduced uterine and fibroid volumes (p = 0.0001). There was a significantly (p = 0.002) greater mean rise in haemoglobin from entry to preoperation in the Zoladex group (1 g/dl) compared with the surgery-alone group (0.3 g/dl) as well as a tendency towards easier surgery, and reduced operative blood loss. Zoladex-treated patients had a significantly (p = 0.016) shorter hospital stay and pelvic pain and abdominal pressure symptoms were significantly (p < 0.0001) reduced in this group. Zoladex was well tolerated.
There is no consistent evidence from the limited number of studies that SERMs reduce the size of fibroids or improve clinical outcomes. Further studies are required to establish evidence of benefit of SERMs in treating women with uterine fibroids. This updated review did not find any new study for inclusion.