GnRH agonists and uterine leiomyomas.

Gonadotrophin-releasing hormone (GnRH) agonists are widely used in the treatment of women with symptomatic leiomyomas. The effectiveness of this treatment, as far as symptoms are concerned, is well established, and in recent years many studies have contributed to defining the optimal role for GnRH agonists. Side-effects and health risks prohibit the long-term use of these compounds. The combined use of high-dose agonists and steroids in the so-called 'add back' schedules reduces many of the disadvantages of the monotherapy. However, it is still an expensive alternative when compared with definitive surgery, and therefore should only be used in women who insist on preservation of the uterus. Low-dose agonist therapy ('draw back') has not yet been proven to be suitable for clinical application. The use of GnRH agonists and steroids in sequential schedules seems to result in a loss of both the volume reduction as well as the reduction in clinical symptoms. The use of GnRH agonists prior to myoma surgery should not become a routine measure and should be limited to cases where the size of the uterus is > 600 ml. Hysterectomy should only be preceded by GnRH agonist treatment if uterine volume decrease is expected to facilitate either the abdominal or vaginal procedure. For both operative procedures the presence of myoma-related anaemia is an indication for pretreatment. The use of GnRH agonists before endoscopic surgery is widely accepted on the basis of assumptional advantages; however, definite proof of these advantages is not yet available.