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Medical Management

Medical Management

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Although curative treatment of fibroids relies on surgical therapies, medical treatments are considered the first-line treatment to reduce the symptoms, avoid or delay surgery. Medical therapy may also play a role as a temporizing measure for symptomatic women approaching menopause who wish to avoid surgical intervention. For women requiring surgery, medical therapy may be administered preoperatively to minimize bleeding and thereby improve preoperative hemoglobin levels, or to decrease the leiomyoma size in preparation for a minimally invasive surgical approach.
The medical management of leiomyomas should aim to improve a patient's quality of life by reducing signs and symptoms, while also minimizing side effects. However, the adverse effects associated with prolonged medical therapies limit the duration of their use. In addition, a rebound increase in the size of the leiomyomas can be observed after discontinuing hormonal medical therapy.

Every woman with fibroid doesn’t need treatment. The management of small, asymptomatic myomas is judicious observation. When the tumor is first discovered, it is appropriate to perform a pelvic ultrasound at 6-month intervals to determine the rate of growth. Medical management can be Hormonal and Non hormonal treatment depending on the symptoms and severity.

Hormonal Medical Management

The rationale for hormonal medical management is drawn from research demonstrating the increased expression of estrogen and progesterone receptors in leiomyoma cells relative to a normal myometrium. Moreover, studies have demonstrated that the ovarian steroids estradiol and progesterone stimulate fibroid growth. This has led to the advent of various forms of hormonal medical management to block the stimulatory effects of ovarian steroids, decrease fibroid growth, and alleviate symptoms in women with leiomyomas.

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a). Combination oral contraceptive pills

To date, combination oral contraceptives (COCs) are one of the most commonly prescribed therapies in the management of women with abnormal uterine bleeding, despite their limited efficacy in the management of leiomyoma-related uterine bleeding. As myoma(fibroid) growth is stimulated by both estrogens and progestins, COC use should not be expected to provide symptomatic relief in terms of reducing the myoma volume. In the short term, COCs can be used to improve heavy menstrual bleeding associated with fibroids. overall, they have no effect on decreasing leiomyoma volume or uterine size. The advantages of COCs are the ease of accessibility, oral administration, low cost, and minimal side-effect profile. However, generally, COCs are not recommended for the treatment of abnormal uterine bleeding or bulk symptoms associated with leiomyomas.

b). GnRH Agonists

GnRH agonists acts by reducing the circulating steroid hormone (Estrogen&Progesterone) levels, induce a so-called “pseudo menopause state,” and therefore reduce fibroid size. For >25 years, GnRH agonists have been studied for the treatment of symptomatic leiomyomas, and the therapeutic benefits are notable. Within the first 3-6 months of treatment, most women show a 30-40% reduction in fibroid volume and significant improvement of their symptoms, while being allowed the option for fertility preservation. Due to the side effects it’s not recommended for long term usage

Disadvantages/Side Effects: The most commonly reported side effects of GnRH agonists are related to the hypoestrogenic state inducedresulting in distressing hot flushes, mood changes, and vaginal dryness. In addition, the hypoestrogenic state leads to bone demineralization, resulting in decreased bone mineral density (BMD) increasing the risk of bone fracture.

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c). Levonorgestrel intrauterine system

In 2009, the FDA approved the levonorgestrel-intrauterine system (LNG-IUS) to treat heavy menstrual bleeding in women who opt for an intrauterine device for contraception. Although numerous studies indicate improvement in menstrual bleeding and hemoglobin levels when used in women with leiomyomas, they do not demonstrate an appreciable change in fibroid size. Once inserted, the LNG-IUS is effective for up to 5 years, thus potentially providing women with a long-term treatment option. Because it is not administered systemically, minimal side effects are reported.

d) Selective Progesterone Receptor Modulators

Selective progesterone receptor modulators (SPRMs) have tissue-specific effects at progesterone receptors (PRs).

Ulipristal acetate

Ulipristal acetate, a selective progesterone receptor modulator (SPRM), has emerged as an effective medication in decreasing menstrual blood loss and myoma size when used in the short term.Ulipristal acetate reduces the size of uterine fibroids in women who have not yet started menopause by blocking the effects of progesterone. It is used by some women for as long as 3 months before surgical fibroid removal; other women take the drug in repeated courses, with time off between courses.
But In early February 2018, the The European Medicines Agencyconcluded that there is a risk for rare but serious liver injury with ulipristal acetate for the treatment of uterine fibroids, and measures were implemented to minimize the risk.Many countries have Suspended the usage of ulipristal acetate for uterine fibroids after theEuropean Medicines Agencyreview of liver injury risk.

Nonhormonal Medical Management

a). Tranexamic acid

Tranexamic acid was approved by the FDA in 2009, and it is used globally for the treatment of heavy menstrual bleeding in women with and without fibroids.

b). Nonsteroidal anti-inflammatory drugs (NSAIDs)

Several studies have demonstrated that NSAIDs are effective in reducing menstrual blood loss. Patients treated with NSAIDs showed a 30% reduction of menstrual blood loss. This class of drugs appears to be effective only for symptom relief, without affecting fibroid size or uterine volume. However, NSAIDs may also be beneficial in controlling anemia and pain associated with menses. They may also serve as an alternative when hormones are not well tolerated by the patient

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