Efficacy of pre-operative gonadotrophin hormone releasing analogues for women with uterine fibroids undergoing hysterectomy or myomectomy: a systematic review.

OBJECTIVE: To evaluate the role of pretreatment with gonadotrophin releasing hormone (GnRH) analogues (GnRHa) prior to surgery for women with uterine fibroids.
DESIGN: A systematic review was undertaken of all randomised controlled trials assessing the efficacy of GnRHa treatment prior to surgery (myomectomy or hysterectomy) in women with fibroids.
SETTING: Secondary care. Sample Premenopausal women with fibroids awaiting surgery attending hospitals or clinics.
METHODS: Electronic searches of Medline, EmBase, Current Contents, the Cochrane Library, National Research Register, NLM's Clinical Trials Register and the Cochrane group's Trials Register were performed, between 1980 and 2000. Twenty-six randomised controlled trials were identified that compared GnRHa with no treatment, placebo or other medical treatment. The quality of the trials was assessed and data were extracted independently by two of the reviewers. Statistical analysis was performed in Revman according to Cochrane guidelines and where possible outcomes were pooled in a meta-analysis. MAIN OUTCOME MEASURES: Pre-operative assessment (reduction in uterine and fibroid volume, change in haemoglobin and haematocrit, change in patient's symptoms), intra-operative assessment (duration of operation, blood loss, proportion with vertical incision, proportion undergoing vaginal rather than abdominal procedure, frequency of blood transfusions), post-operative assessment (complications, duration of hospital stay, recurrence of fibroids).
RESULTS: Pre- and post-operative haemoglobin and haematocrit were significantly improved by GnRHa therapy prior to surgery, and uterine volume, uterine gestational size and fibroid volume were all reduced. Pelvic symptoms were also reduced but some adverse events were more likely during GnRHa therapy. Hysterectomy appeared to be easier after pretreatment with GnRHa therapy; there was reduced operating time and a greater proportion of hysterectomy patients was able to have a vaginal rather than an abdominal procedure. Duration of hospital stay was also reduced. Blood loss and rate of vertical incisions were reduced for both myomectomy and hysterectomy. Evidence of increased risk of fibroid recurrence after GnRHa pretreatment in myomectomy patients was equivocal and few data were available to assess change in postoperative fertility.
CONCLUSIONS: The use of GnRHa for three to four months prior to fibroid surgery reduces both uterine volume and fibroid size. They are beneficial in the correction of pre-operative iron deficiency anaemia, if present, and reduce intra-operative blood loss. If uterine size is such that a midline incision is planned, this can be avoided in many women with the use of GnRHa. For women undergoing hysterectomy, a vaginal procedure is more likely following the use of these agents.