REVIEW QUESTION

Does hormonal treatment before uterine fibroid surgery improve outcomes?

TYPE OF REVIEW

A systematic review of 38 randomized controlled trials (RCTs).

RELEVANCE FOR NURSING

Uterine fibroids are benign smooth muscle tumors that occur in up to 40% of women over 35 years of age. For some, these are asymptomatic and do not require treatment, but up to 50% of women with fibroids may experience heavy menstrual bleeding (leading to anemia), dysmenorrhea, infertility, and low quality of life. For these women, the first-choice intervention is surgery. Recently, preoperative medical therapies have been used to improve intra- and postoperative outcomes. Because fibroid growth is stimulated by estrogen, these therapies include a gonadotropin-hormone releasing analogue (GnRHa), which offsets the estrogen, causing a decrease in uterine and fibroid size, and reducing the difficulty of the surgery and the risk of bleeding. Other potential hormonal therapies include progestins, dopamine agonists, and selective progesterone receptor modulators (SPRMs). These therapies are only for short-term use, however, because of their potential adverse effects, including bone loss, and their high cost.

CHARACTERISTICS OF THE EVIDENCE

This review included all RCTs available before June 2017 that met the inclusion criteria (a comparison of medical therapies versus placebo or no treatment given before surgery for uterine fibroids). Surgeries included myomectomy (removal of fibroids from the uterus), hysterectomy, or endometrial resection. A total of 38 RCTs involving 3,623 women were included, of which 14 were wholly or partially funded by pharmaceutical companies. Therefore, it is not possible to state if conflict of interest influenced the results.

Trials that used GnRHa treatment showed a reduction in both fibroid and uterine size and an increase in preoperative hemoglobin levels. During hysterectomy, there was less blood loss (and therefore fewer blood transfusions) and less time in surgery (an average reduction of 14 minutes); there were also fewer postoperative complications. During myomectomy, however, these positive results were not replicated; although patients did experience less intraoperative blood loss. Women taking GnRHa, however, reported a greater likelihood of hot flushes. Those given the SPRM ulipristal acetate had similar results.

BEST PRACTICE RECOMMENDATIONS

This review suggests that the use of GnRHa and SPRM therapies prior to surgery for uterine fibroids is beneficial, as they can reduce the complexity of the surgical procedure, lessen blood loss, and decrease the incidence of anemia. The improvement of surgical outcomes is important as it reduces the risk of potential complications, which can be debilitating and even fatal, improving recovery time and the need for prolonged hospital stay.

RESEARCH RECOMMENDATIONS

The use of GnRHa and SPRM therapies prior to surgery requires further investigation on a larger scale. Because ulipristal acetate is currently under review by the European Medicines Agency, which has recommended not starting new regimens and performing at least monthly liver function tests on current patients, further research is required to establish the role of these therapies in improving the outcomes of women treated for uterine fibroids. The fact that some women who received a GnRHa had an increased frequency of hot flushes also requires further investigation, as the study sizes were small. Further research should also identify which women would benefit most from these therapies because of their high cost.

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