Medical Management of Fibroids, IVF, INFERTILITY , USP OF FIBROIDS ,

1. Medical Management of
Fibroids
Dr. Sharda Jain
Dr. Jyoti Agarwal
Dr. Jyoti Bhaskar

2. OUR TEAM

3. U.S.P. of Fibroids
Benign uterine fibroids are the most
common pelvic tumor in women
---occur in 20 to 50 % of women .
-- ESTIMATED LIFETIME RISK
-- 70 percent In white women
--- 80 percent in black women.

4. Uterine sarcoma is malignant
form -- very rare
(3 to 7 per 100,000 )
with a poor prognosis.
Uterine Sarcoma

5. Majority of fibroids in women’s life,
remain asymptomatic but some
present with
Abnormal uterine bleeding (AUB)
INFERTILITY ,
PELVIC PAIN
PRESSURE SYMPTOMS.

6. International Federation of Gynecology
and Obstetrics (FIGO) classification of
fibroids
Submucous 0 Pedunculated intracavitatory
1 < 50% intramural
2 > 50 % intramural
Others 3 Contacts endometrium, 100 % intramural
4 Intramural
5 Subserous >50 % intramural
6 Subserous < 50 % intramural
7 Subserous peduculated
8 Others (specify, e.g. cervical , parasitic)

7. Infertility
Most Gynaecologists feel that R/O
fibroids is going to improve fertility but
this is not TRUE.
Surgery wrongly done-- can cause
adhesions, distortion of tubo ovarian
relationship, blockage of tubes & then
only treatment left is I.V.F.

8. Prophylactic therapy to avoid potential
future complications from fibroids is
NOT recommended except.
women with significant submucous
fibroids who are contemplating
pregnancy.
PROPHYLACTIC Treatment of
fibroids .

9. PROPHYLACTIC Treatment of
fibroids .
women with ureteral compression
leading to moderate or severe
hydronephrosis. In these women,
prophylactic treatment may prevent
miscarriage or urinary tract
obstruction.

10. Relief of symptoms (eg, heavy bleeding, pain,
pressure ) is the major goal in management of
fibroids .
The type and timing of any intervention should be
individualized, based upon factors.
•TYPE AND SEVERITY OF SYMPTOMS,
•SIZE OF THE FIBROID,
• LOCATION OF THE FIBROID,
• PATIENT AGE,
• REPRODUCTION PLAN
• OBSTETRICAL HISTORY.
Symptomatic fibroids

11. Medical Management of Fibroids
with Bleeding
 Medical therapy provides adequate symptom
relief in some women, primarily in situations
where bleeding is the dominant or only
symptom.
 In general, 75 percent of women get some
improvement over one year of therapy, but
long-term failure rates are higher.

12. Same medical management
of fibroids is effective
with pressure symptoms
as well
Medical Management of
Fibroids
with Pressure symptoms

13. Hormonal Therapy
COMBINED OCP and progestational agents
are commonalty used in the treatment of
HEAVY MENSTRUAL PERIOD
Women with heavy menstrual bleeding
associated with fibroids Do Respond to OCP
therapy.
It should be tried before invasive therapy.
The mechanism of action is via endometrial
atrophy.

14. Progestational agents
There are NO DATA to show the
effectiveness of progestin only
contraceptive is specifically USEFUL for
treatment of symptomatic fibroids.
They can be considered for treatment of
MILD SYMPTOMS, especially for women
who need CONTRACEPTION.

15. Levonorgesrel-releasing
intrauterine system (IUS )
Effective
Observational studies and systematic
reviews have shown a reduction in
uterine volume and bleeding, and an
increase in hematocrit after
placement of this IUS the device

16. It is widely used for control of heavy menstrual
bleeding and now approved by the US Food and
Drug administration (FDA) for this indication .
A second advantage of this treatment is that it
provides contraception for women who do not
desire pregnancy.
Levonorgesrel-releasing
intrauterine system (IUS )
(Effective)

17. Gonadotropine releasing hormone
agonists (GnRH agonist )
GnRH agonist are the most effective medical
therapy for uterine fibroids.
First used by Filicouri in 1983.
These drugs work by initially increasing the
release of gonadotropine, followed by
desensitization and down regulation to a
Hypo gonadotropic - hypo gonadal state that
clinically resembles menopause.

18. Most women will develop amenorrhea,
 Improvement in anemia is bonus.
There is significant reduction (35 to 60 percent) in
uterine size within three months of initiating this
therapy.
 However, there is rapid resumption of menses and
pretreatment uterine volume after discontinuation
of GnRH agonists(short lasting effect).
GnRH Agonist

19. Hypo estrogenic side effects on long term treatment
is a big draw back.
A RULE OF THUMB for women with endometriosis is
that approximately 6 percent of bone is lost over 12
months of therapy and 3 percent is regained
following the cessation of therapy.
GnRH – Agonist

20. The side effects of long - term GNRH
agonist administration can be minimized
during therapy by giving ADD - BACK
THERAPY with low dose estrogen -
progestin after the initial phase of down
regulation.
GnRH – agonist

21. Low dose estrogen - progestin therapy, such as
used for menopausal harmone replacement
therapy i.e. 0.625 mg of conjugated estrogen
and 2.5 of medroxy progesterone acetate or 5
mg norethindrone acetate)
Maintains amenorrhea and the reduction in
uterine volume, while preventing significant
hypo estrogenic side effects.
What is this add back therapy to
prevent osteoporosis ??

22. Can OCP be given as add bad
therapy to prevent
osteoporosis ??
“No”
Using OCP as add- back
therapy for fibroids is not
indicated.

23. Preoperative GnRH analogs
use is not recommended
before myomectomy except in
cases of severe anaemia

24. GnRH - antagonist
The advantage of antagonists over
agonists is the rapid onset of
clinical effects without the
characteristic initial flareup
observed with GNRH agonist
treatment

25. GnRH - antagonist
However, in the United States these
agents are marketed at doses used for
ovulation induction and long-acting
preparations are not available .
Thus , treatment of fibroids is
cumbersome due to the need for daily
injections.

26. Progesterone receptor modulators - drugs that
modulate progesterone are increasingly used for
medical treatment of fibroids. However, they not yet
approved by the US Food and Drug Administration
(FDA).
They have the advantage of oral administration and
minimal symptomatic side effects. The major
concern is whether there are endometrial effects
with long - term use.
Progesterone Receptor
modulator (PRM)

27. Ulipristal acetate is a progesterone
receptor modulator (PRM) that Inhibits
Ovulation, but has little impact on serum
estradiol levels. The drug is approved for
three months of preoperative therapy
outside USA.
Ulipristal Acetate
Fertil. Steril 2014,101;1565

28. Ulipristal Acetate
Ulipristal acetate (oral, 5 mg or 10 mg
once daily for 13 weeks ) was compared
with placebo in one randomized trial of
242 women with menorrhagia
Fibroid – associated anemia improved,
and uterus size decreased.
Fertil. Steril 2014,101;1565

29. Mifepristone (RU - 486) is the most widely
studied Progesterone Receptor Modulator
and reduces uterine volume by 25 to 75
percent in women with fibroids, which is
comparable to the reduction observed
with GnRH agonists.
Re growth occurs slowly following
cessation of the drug.
Mifepristone ( Ru- 486)

30. Raloxifene - The efficacy of
selective estrogen receptor
modulators for treatment of
fibroids is unclear.
Raloxifene

31. Danazol and gestrinone which are
potent Androgenic steroids may be an
effective treatment of fibroids
 symptoms in some women are
associated with severe androgenic
side effects.
Danazol & Gestrinone

32. Nonsteroidal
antiinflammatory drugs
Nonsteroidal antiinflammatory drugs (NSAIDs)
have not been extensively studied in
fibroids – related menorrhagia.
NSAIDs do not appear to reduce blood loss in
women with fibroids but provide relief in
painful periods.

33. Antifibrinolytic agents
Antifibrinolytic agents, which are
useful in the treatment of
idiopathic menorrhagia, have not
been well studied in fibroids –
related menorrhagia.

34. Conclusion
Most common pelvic tumor.
All fibroids are not symptomatic still
fibroids are blamed for infertility,
abnormal bleeding, lower abdomen
pain etc.

35. Conclusion
Medical treatment of fibroids does not
improve fertility
Medical treatment fibroids causing heavy
periods & presser symptoms is effective
but still evolving.
Preoperative GnRH anologs use is not
recommended except in cases severe
anemia

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OPTION
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