Therefore, for women who are mildly or moderately symptomatic with fibroids, watchful waiting may allow treatment to be deferred, perhaps indefinitely. As women approach menopause, watchful waiting may be considered, because there is limited time to develop new symptoms and after menopause, bleeding stops and fibroids decrease in size (19). Although not specifically studied, the incidence of hysterectomy for fibroids declines considerably after menopause, suggesting that there is a significant decline in symptoms.
Nonsteroidal anti-inﬂammatory drugs (NSAIDs) were not shown to be effective for the treatment of menorrhagia in women with fibroids. A placebo-controlled, double-blind study of 25 women with menorrhagia, 11 of whom also had fibroids, found a 36% decrease in blood loss among women with idiopathic menorrhagia, but no decrease in women with fibroids. No other studies examined this treatment (86).
Treatment with GnRH-a decreases uterine volume, fibroid volume, and bleeding. However, the benefits of GnRH-a are limited by side effects and risks associated with long-term use (87,88). Monthly GnRH-a given for 6 months reduced fibroid volume by 30% and total uterine volume by 35% (87). Reduction in uterine size occurs mostly within the first 3 months of treatment (88). Menorrhagia responds well to GnRH-a; 37 of 38 women had resolution by 6 months. Following discontinuation of GnRH-a, menses returns in 4 to 8 weeks and uterine size returns to pretreatment levels within 4 to 6 months (89). In this study 64% of women remained asymptomatic 8 to 12 months after treatment.
Side effects occur in 95% of women treated with GnRH-a (89). Seventy-eight percent experience hot ﬂushes, 32% vaginal dryness, and 55% have transient frontal headaches. However, during 6 months of treatment only 8% of women discontinued GnRH-a because of the side effects. Arthralgia, myalgia, insomnia, edema, emotional lability, depression, and decreased libido are reported. The hypoestrogenic state induced by GnRH-a causes significant bone loss after 6 months of therapy (90).
In an effort to reduce side effects, inhibit bone loss, and allow longer-term use of GnRH-a, low doses of estrogen and progestins may be added while continuing GnRH-a. However, a study of long-term use of GnRH-a over 6 years found a wide range of reduction in bone density among women and no difference in bone loss between groups given estrogen and progestin versus those treated with GnRH-a alone (91).
Gonadotropin-Releasing Hormone Agonist as Temporary Treatment for Perimenopausal Women
Women in late perimenopause who are symptomatic from uterine fibroids may consider short-term use of GnRH-a. Thirty-four perimenopausal women with symptomatic fibroids were treated with GnRH-a for 6 months, 12 of whom required repeat treatment 6 months after discontinuation of the medication (92). Thirty-one women avoided surgery; 15 of the women went into natural menopause. Although not specifically studied, add-back therapy might be considered in this setting.
Gonadotropin-Releasing The immediate suppression of endogenous GnRH by daily subcutaneous injection of the GnRH
Hormone Antagonist antagonist ganirelix results in a 29% reduction in fibroid volume within 3 weeks (93). Treatment is accompanied by hypoestrogenic symptoms. When long-acting compounds are available, a GnRH antagonist might be considered for medical treatment prior to surgery.