Uterine Fibroids Associated With Infertility
Uterine Fibroids Associated With Infertility
There are several options for the medical management of uterine myomas. Currently, the only US FDA approved medical treatments for symptomatic fibroids are GnRH analog (leuprolide acetate) and levonorgestrel-containing intrauterine device (Mirena®, Bayer AG, Berlin, Germany). Leuprolide has been approved for decreasing the size of fibroids, while Mirena is approved for the treatment of heavy menses, not necessarily related to fibroids. Several other medications are currently undergoing clinical trials, many of which appear to have potential for the treatment of uterine myomas. These include ulipristal acetate, proellex, mifepristone, asoprisnil, aromatase inhibitors, pirfenidone and epigallocatechin gallate. Ulipristal, a selective progesterone-receptor modulator, in particular has shown promise. Recent studies by Donnez et al. have shown a reduction in bleeding and fibroid size with ulipristal versus placebo, as well as non-inferiority compared with leuprolide. Additionally, ulipristal was shown to be less likely to cause hot flashes in study subjects than leuprolide acetate.
However, while these options for the medical management of uterine myomas exist, in general they are not appropriate in the setting of desired fertility. Leuprolide and Mirena delay the ability to pursue attempts at conception, and the medications currently under clinical investigations have yet to be thoroughly studied in patients pursuing pregnancy. Perhaps the only exception is the use of a brief course of GnRH analog, which may help correct preoperative anemia if the patient is experiencing heavy bleeding. Further details on medical management of fibroids are outside the scope of this review.
Medical Management
There are several options for the medical management of uterine myomas. Currently, the only US FDA approved medical treatments for symptomatic fibroids are GnRH analog (leuprolide acetate) and levonorgestrel-containing intrauterine device (Mirena®, Bayer AG, Berlin, Germany). Leuprolide has been approved for decreasing the size of fibroids, while Mirena is approved for the treatment of heavy menses, not necessarily related to fibroids. Several other medications are currently undergoing clinical trials, many of which appear to have potential for the treatment of uterine myomas. These include ulipristal acetate, proellex, mifepristone, asoprisnil, aromatase inhibitors, pirfenidone and epigallocatechin gallate. Ulipristal, a selective progesterone-receptor modulator, in particular has shown promise. Recent studies by Donnez et al. have shown a reduction in bleeding and fibroid size with ulipristal versus placebo, as well as non-inferiority compared with leuprolide. Additionally, ulipristal was shown to be less likely to cause hot flashes in study subjects than leuprolide acetate.
However, while these options for the medical management of uterine myomas exist, in general they are not appropriate in the setting of desired fertility. Leuprolide and Mirena delay the ability to pursue attempts at conception, and the medications currently under clinical investigations have yet to be thoroughly studied in patients pursuing pregnancy. Perhaps the only exception is the use of a brief course of GnRH analog, which may help correct preoperative anemia if the patient is experiencing heavy bleeding. Further details on medical management of fibroids are outside the scope of this review.
