Preoperative Hormonal Treatment Before Laparoscopic Approach for Uterine Fibroids: Do We Need It?

We recently have read the narrative review by Mar ın-Buck et al. [1], describing the most recent advances in minimally invasive approaches for performing myomectomy. Overall, asymptomatic women affected by small fibroids may benefit from expectant management, particularly those approaching menopause. Although hysterectomy and myomectomy have been the traditional gold standard curative therapies for symptomatic fibroids, not all women wish to undergo a surgery, and some may have an elevated risk of surgical complications. However, in the last years, the number of the gynecological surgical laparoscopic procedure has sharply increased, and, today, they peak 80% of all gynecological procedures. With particular regard to myomectomy, it has been demonstrated that when compared with traditional laparotomic or mini-laparotomic techniques, laparoscopic approach tends to improve intraoperative blood loss, postoperative hemoglobin drop, postoperative pain and length of hospitalization [2]. We would focus the attention on the preoperative medical treatment options for treating uterine fibroids, topic which the authors briefly discussed in this interesting overview of the literature [1]. In general, surgical management for uterine fibroids can be directly performed in women having adequate hemoglobin levels; otherwise, in case of anemia, preoperative menstrual suppression and iron supplementation may be advisable in order to improve the outcomes of surgery. In fact, laparoscopic myomectomy can be complicated by extensive peri-operative bleeding; therefore, blood transfusions and eventually reoperation may be necessary for treating some patients, especially if they had previous low levels of hemoglobin. Preoperative hormonal therapy for uterine fibroids aims to correct preoperative anemia, decreasing uterine abnormal bleeding related to their presence and to decrease intraoperative blood loss, reducing fibroid vascularization and volume [3]. The preoperative hormonal therapy may be advantageous in all women undergoing laparoscopic myomectomy but particularly in those patients affected by large and/or multiple fibroids, which likely have a higher risk of intraoperative blood loss. Obviously, better postsurgical levels of hemoglobin can allow for a quicker return to social activities, among which work. Moreover, a decrease in myoma volume due to the use of a preoperative drug may theoretically allow the performance of less invasive surgical procedures; for example, in case of large uteri requiring morcellation for laparoscopic abdominal or vaginal removal, a decrease of uterine size can reduce the need of an eventual intrabdominal morcellation. Until now, the most investigated preoperative hormonal options for uterine fibroids have been gonadotropin releasing hormone analogs (GnRHas) and selective progesterone receptor modulator (SPRMs). The choice of most appropriate therapy should consider the characteristic of myomas (size, location and number), efficacy and safety profiles of each drug, route of administration as well as preference of both patients and surgeons. Nevertheless, we have to consider that all these preoperative drugs share some potential drawbacks such as cost, delay in the surgical approach, additional consultations, and onset of drug-related adverse events.