The role of hormone therapy before hysteroscopic myomectomy

Abstract

This review analyzes the preoperative treatments used before hysteroscopic myomectomy, trying to identify the main indications for each option. Methods: a comprehensive search of several databases was conducted from inception up to May 2021. The searched databases were MEDLINE, In-Process & Other Non-Indexed Citations, Daily, Ovid EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus. The search strategy included the combinations of the following medical terms: Hysteroscopic myomectomy; Uterine fibroid, Hormonal therapy, preoperative. We selected clinical studies, systematic reviews, and meta-analyses in English to investigate hormone therapy before hysteroscopic myomectomy. We opted for a narrative synthesis of the results, summarizing the evidence provided by the most relevant studies to offer the reader a complete and synthetic overview of the topic. Findings in brief : The hormonal therapies preoperatively used to prepare the endometrium before a hysteroscopic procedure are gonadotropins releasing hormone (GnRH) analog, danazol, progestogen, and combined oral contraceptives. On the one hand, the efficacy of GnRH analogs and danazol administration before hysteroscopic surgery has been demonstrated by several studies, mainly related to the time of surgery and volume of distension medium absorbed. On the other hand, although the evidence is more limited, progestogens and combined hormonal contraceptives have proven a comparable efficacy in achieving adequate endometrial thinning. Conclusions: To date, no definitive data provide strong evidence towards one specific preoperative therapy before myomectomy hysteroscopy. Several variables should be considered using a specific medical therapy (including the different potential effects with a particular drug compared to the others in type 0, 1, or 2 myoma); this element further amplifies the heterogeneity of the available findings in the literature and does not allow to draw a firm conclusion about a best pharmacological management over the others.

Optimizing Operative Hysteroscopy in the Office Setting: Updated Techniques and Technology

“…Endometrial thickness affects visualization of the endometrial cavity and intracavitary pathology. 13 For this reason, timing the procedure to occur during the follicular phase of the menstrual cycle can be very helpful. When this is not feasible, or in patients without a regular cycle, medical treatment is targeted at altering sex hormone levels, which influence endometrial thickness.…”

“…When this is not feasible, or in patients without a regular cycle, medical treatment is targeted at altering sex hormone levels, which influence endometrial thickness. 13 Progestins have been studied for endometrial preparation and have been shown to induce endometrial atrophy and reduce operating time and bleeding during the procedure. 14 Another benefit noted was rapid resumption of menstruation, which can be beneficial to patients undergoing hysteroscopic myomectomy with the plan to conceive.…”

“…18 When considering the available evidence, it is not sufficient to support routine use of GnRH agonists before hysteroscopic myomectomy, especially in light of the profound vasomotor symptoms that may arise from use of this medication. 13 As outlined, many options exist for preoperative preparation of hysteroscopy. Although there are insufficient data to support one specific approach, providers can consider available strategies to meet the patient's needs and operative goals, weighing side effects, dosage, duration and costbenefits before procedures.…”

“…Endometrial thickness affects visualization of the endometrial cavity and intracavitary pathology 13. For this reason, timing the procedure to occur during the follicular phase of the menstrual cycle can be very helpful.…”

“…A meta-analysis looked specifically at 2 randomized controlled trials and found no significant operative benefit in terms of complete myoma resection, but did show shorter operative time and reduction in distension medium absorption in GnRH agonist groups 18. When considering the available evidence, it is not sufficient to support routine use of GnRH agonists before hysteroscopic myomectomy, especially in light of the profound vasomotor symptoms that may arise from use of this medication 13…”