Principal Director & Unit Head, Obstetrics and Gynaecology, Max Hospital, Gurugram
Part 5 of 9 in Benign Growth in Uterus Causing Gynaecological Problems
Medical Management: Painkillers, Progesterone and GnRH Agonists
August 25, 2024
Medical management is appropriate for smaller fibroids not distorting the uterine cavity, particularly when surgery isn't immediately wanted or needed. Painkillers and oral contraceptive pills are first-line for pain and bleeding control.
Tranexamic acid and progesterone
Asked directly whether tranexamic acid reduces fibroid size, Dr. Lal was clear it does not: it works by promoting clot formation to reduce heavy bleeding, not by shrinking the fibroid itself. Progesterone hormone therapy does reduce fibroid size, but only by around 20%, so it's reserved for patients with heavy bleeding who are waiting for surgery or unable to have it, not used routinely in asymptomatic patients.
GnRH agonists and when medication has a real role
GnRH agonists such as leuprolide and goserelin, both used in India, can reduce fibroid size by 40-50%, with the two options largely interchangeable and center-dependent. Medical management overall works best in three situations: a submucosal-cavity-sparing fibroid causing bleeding, a peri-menopausal patient likely to see the fibroid shrink naturally after menopause, and a patient trying to conceive where shrinking the fibroid first with a GnRH agonist for six to nine months can improve the chance of pregnancy before deciding on surgery. Used long-term, though, medication isn't the answer, since GnRH-induced shrinkage reverses within six months to a year of stopping the drug.
This article is based on a Jivo Masterclass session conducted by Dr. Suman Lal, Principal Director & Unit Head, Obstetrics and Gynaecology, Max Hospital, Gurugram. The article has been summarised with the assistance of an AI tool from the original masterclass recording. Watch the full Masterclass recording
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This guide is based on a live Jivo Masterclass: Dr. Suman Lal taught doctors across Africa on August 25, 2024.
FROM THE LIVE Q&A
Moderator
How far can progesterone hormone reduce the size of a fibroid?
Dr. Suman Lal
Progesterone reduces fibroid size by only around 20%. It's given to women waiting for surgery or unable to have surgery who have heavy bleeding, not routinely to patients without symptoms.
Frequently Asked Questions
What is the management of fibroids using medication without surgery, and what are the possibilities?▼
If bleeding is heavy and the fibroid isn't inside the cavity, medical management with painkillers, oral contraceptive pills, and GnRH agonist injections is possible. GnRH injections reduce fibroid size but the effect reverses within six months to a year of stopping, so medical management is generally a one-to-two year bridge, not a permanent solution, and is most useful pre-menopause, pre-surgery, or pre-pregnancy attempts.
What is the role of the gonadotropin agonists used in India, Lupron and Goserelin?▼
Both are effective at reducing fibroid size, by around 40-50%. Different centres use different ones, but either can be used.
Do you suggest that a scan measuring a 5cm fibroid should be surgically removed?▼
Not automatically. If the 5cm fibroid is inside the uterus causing heavy bleeding or obstruction, yes. If it's outside the uterus and not causing any problem, there's no need to operate. If it's in the muscle layer and the patient is trying to conceive or undergo IVF, removal is often needed. Symptoms, location and fertility goals all have to be weighed together, not size alone.
What is the relationship between fibroids and menstrual pain?▼
A fibroid inside the uterine cavity acts like a foreign body. When menstrual contractions begin, the uterus tries to expel the fibroid the same way labour contractions try to expel a baby, causing cramping. An intramural fibroid also increases the uterus's surface area, independently increasing both pain and bleeding.
What is the fate of myoma nuclei after embolization, and why is it contraindicated in women wishing to conceive in the future?▼
Embolization blocks the artery supplying the uterus, so blood flow to the entire uterus decreases, not just to the fibroid. That reduced blood flow is exactly why the procedure is contraindicated for women planning pregnancy afterward, since it can compromise the nutrition and growth of a future baby. For these patients, myomectomy (surgical removal) is the right choice instead.
Does tranexamic acid shrink fibroids?▼
No. It promotes clot formation to reduce heavy bleeding but does not reduce fibroid size.
How much can GnRH agonists shrink a fibroid?▼
By around 40-50%. Leuprolide and goserelin are both used in India and are largely interchangeable, though the effect reverses within six months to a year of stopping treatment.
In This Series: Benign Growth in Uterus Causing Gynaecological Problems
- 1.Uterine Fibroids
- 2.What Are Uterine Fibroids? Risk Factors and Symptoms
- 3.Diagnosing and Classifying Fibroids by Location
- 4.Fibroids, Fertility, Pregnancy Risk and Menstrual Pain
- 5.Medical Management: Painkillers, Progesterone and GnRH Agonists
- 6.Uterine Artery Embolization: When It Works and When It's Contraindicated
- 7.Surgical Removal: Hysteroscopic, Laparoscopic and Robotic Myomectomy
- 8.Beyond Fibroids: PCOS, Endometriosis and Infertility
- 9.Preventing Adhesions After Myomectomy: What Actually Works