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Evidence summaries

Preoperative Medical Therapy Before Surgery for Uterine Fibroids

In women with uterine fibroids, preoperative GnRH analoges or selective progesterone-receptor modulators like ulipristal acetate may reduce uterine and fibroid volume, blood loss and postoperative morbidity and increase preoperative haemoglobin levels compared with no treatment, although at the cost of adverse events. Level of evidence: "C"

Comment: The quality of evidence is downgraded by study limitations (unclear allocation concealment and blinding in half of the studies) and publication bias (mostly commercially funded studies).

Summary

A Cochrane review [Abstract] 1 included 38 studies with a total of 3623 subjects. GnRH analoges (GnRHa) treatments were associated with reductions in both uterine and fibroid volume, and increased preoperative haemoglobin, at the expense of a greater likelihood of adverse events, particularly hot flushes T1.Duration of hysterectomy surgery was reduced among women who received GnRHa treatment (-9.59 minutes, 95% CI 15.9 to -3.28; 6 studies, n=617) and there was less blood loss, fewer blood transfusions, and fewer postoperative complications T1.Selective progesterone-receptor modulators (SPRMs) (mifepristone, CDB-2914, ulipristal acetate and asoprisnil) were associated with greater reductions in uterine or fibroid volume than placebo and increased preoperative haemoglobin levels. Ulipristal acetate and asoprisnil were also associated with greater reductions in bleeding before surgery T2. There was no evidence of differences in preoperative complications or in severe adverse events.

GnRHa treatment versus placebo or no pretreatment for uterine fibroids

OutcomeRelative effect (95% CI)Assumed risk - Control -Placebo or no treatmentCorresponding risk - Intervention - GnRHa pretreatment (95% CI)No of Participants (studies) Quality of evidence
Uterine volume (mL) (mean, preoperative)-255 mL to 920 mL175.34 mL lower (219.04 mL to 131.65 mL lower)858 (13) Low
Haemoglobin (g/dL) (mean, preoperative)-10.9 g/dL to 13.4 g/dL0.88 mL higher (0.68 mL to 1.08L higher)834 (10) Low
Adverse eventsOR 2.78 (1.77 to 4.36)608 per 1000812 per 1000 (733 to 871)755 (4) Moderate
Blood transfusions before hysterectomyOR 0.54 (0.29 to 1.01)115 per 100066 per 1000 (36 to 116)601 (6) Moderate
Hysterectomy: Postoperative morbidityOR 0.54 (0.32 to 0.91)239 per 1000145 per 1000 (91 to 222)772 (7) Low
Blood transfusions before myomectomyOR 0.85 (0.26 to 2.75)194 per 1000170 per 1000 (59 to 398)121 (4) Low
Myomectomy: Postoperative morbidityOR 1.07 (0.43 to 2.64)188 per 1000199 per 1000 (91 to 379)190 (5) Low

Selective progesterone-receptor modulators (SPRM) compared to placebo for uterine fibroids

OutcomeRelative effect (95% CI)Assumed risk - Control - PlaceboCorresponding risk - Intervention - SPRM (95% CI)No of Participants (studies) Quality of evidence
Preoperative haemoglobin (g/dL, mean)-12.2 to 12.60.93 higher (0.52 to 1.35 higher)173 (2) High
Preoperative bleeding: (PBAC < 75) ulipristal acetate 5 mgOR 41.41 (15.26 to 112.38)188 per 1000906 per 1000 (779 to 963)143 (1) Low
Preoperative bleeding: Reduction in menstrual bleeding (PBAC < 75) ulipristal acetate 10 mgOR 78.83 (24.02 to 258.74)83 per 1000877 per 1000 (685 to 959)146 (1) Low

Clinical comments

Note

Date of latest search: 2018-02-07

    References

    • Lethaby A, Puscasiu L, Vollenhoven B. Preoperative medical therapy before surgery for uterine fibroids. Cochrane Database Syst Rev 2017;(11):CD000547. [PubMed]

Primary/Secondary Keywords