When is treatment with hormones considered?

GnRH analogues are artificially produced hormones. They inhibit the production of estrogen in the ovaries. Because estrogen makes it easier for fibroids to grow, using GnRH analogues can temporarily slow their growth or cause them to shrink in size. GnRH analogues are usually injected under the skin or into muscle tissue once a month. They are also available in the form of depot (slow-release) injections that last for three months, and a nasal spray for daily use.

GnRH analogues aren't suitable for long-term use because of their side effects. They can increase the risk of osteoporosis (loss of bone mass) if they are used for longer than about one year. They also reduce the body’s production of estrogen so much that it isn't possible to get pregnant while using them. When treatment with GnRH analogues is stopped, the ovaries start functioning normally again and estrogen levels return to normal. Then it's possible to get pregnant again.

During this treatment, it's important to have the size of the fibroids checked by a doctor and keep an eye on whether your symptoms change. This also includes watching for side effects, because estrogen deficiency may cause problems.

GnRH analogues make fibroids stop growing or shrink, which may reduce menstrual bleeding and period pain. The treatment can improve anemia, which lowers risks during surgery. But not all women benefit from these hormones: About half don’t notice any improvement in their symptoms.

GnRH analogues are usually only used for less than six months. The goal is often to shrink the fibroids before a planned surgical procedure. If the fibroids are smaller, then the cuts made during surgery to remove them can be smaller too. There is also less blood loss, and complications are less common than with larger fibroids.

Whether GnRH analogues are suitable depends on the type of fibroids and the planned surgical procedure. Studies show that they have benefits when used before myomectomy (removal of the fibroids) and hysterectomy (removal of the womb). GnRH analogues don't have any advantages if fibroids located directly under the lining of the womb are removed during hysteroscopy (use of a narrow telescope to see inside the womb).

GnRH analogues often cause side effects that are very similar to problems associated with menopause. Over half of all women who use them experience hot flashes, sweating, headaches or vaginal infections.

Hormonal intrauterine devices are inserted into the womb (uterus) and can remain there for up to five years. Also known as hormonal coils, they are normally used for contraception. They contain artificial hormones called progestins, which are similar to the female sex hormone progesterone. Progesterone prevents the lining of the womb from getting thicker during the menstrual cycle. Hormonal IUDs continuously release progestins, which also prevent the lining of the womb from building up.

Hormonal IUDs are only suitable for treating fibroids that aren’t too big. If the fibroids change the shape of the womb, it might not be possible to insert an IUD. And because they have a contraceptive effect, IUDs are also not a good idea for women who would like to become pregnant.

IUDs can’t reduce the size of the fibroids, so they won’t relieve symptoms like pain and cramps. But because the artificial hormones stop the lining of the womb from building up, they can help to lower the amount of blood lost during menstruation and help prevent anemia. People who have anemia usually feel tired and beat.

It can help to keep a diary when starting treatment so that you can keep track of things like how often you still have heavy periods, whether other symptoms improve or whether you experience any side effects. These notes can help your doctor to assess how effective the hormonal IUD is.

Hormonal IUDs may cause various side effects, including acne, spotting (vaginal bleeding between periods), mood swings and breast tenderness. These kinds of side effects are usually more common during the first few months of treatment than later on. Overall, they affect about 1 to 10 out of 100 women who use hormonal IUDs. These IUDs are rejected by the body in about the same number of women. Using a hormonal IUD carries a certain risk: It is estimated that they cause damage to the womb in up to 1 out of 1,000 women.

Birth control pills contain either a combination of the hormones estrogen and progestin (combination pill), or only progestin (mini pill). Both kinds can reduce menstrual bleeding, making them an option for women whose main symptom is heavy periods. Uninterrupted use of the combination birth control pill usually causes menstrual periods to stop completely over time. Because using the pill in this way – with only rare breaks or none at all – hasn’t been approved in Germany, it is considered to be “off-label” use. This means that some health insurers may not cover the costs.

The pill may cause side effects such as water retention, headaches and breast tenderness. It can also increase the risk of blood clots (thrombosis), especially in older women and women who smoke. It's not clear how well the pill relieves fibroid symptoms, or how it compares to other treatments. There generally isn’t enough good-quality research on using birth control pills to treat fibroid symptoms.

Ulipristal acetate (trade name: Esmya) is best known as being the drug used in the “morning after pill.” These pills can be taken after unprotected sex to prevent an unwanted pregnancy. Ulipristal acetate has also been approved at a lower dose for the treatment of uterine fibroids. It is the only selective progesterone receptor modulator (SPRM) that has been approved for this purpose in Germany. It blocks the effect of the female sex hormone progesterone. Like estrogen, progesterone promotes the growth of fibroids.

Ulipristal acetate can be used as a long-term treatment, but it is no longer used in preparation for surgery. It is only prescribed for women who are not yet going through menopause, and those who can't have surgery or for whom surgery wasn't successful. Like GnRH analogues, it can shrink fibroids and reduce menstrual bleeding. It is taken as tablets for up to three months. After that the treatment needs to be stopped for at least one month. If the symptoms don't go away, you can take ulipristal acetate again after the break – but only for up to three months at a time, with a one-month break between the treatments. Ulipristal acetate is only available on prescription.

The possible side effects include hot flashes and abdominal pain. Hot flashes are more likely when taking GnRH analogues, though. In very rare cases it may cause liver damage, so certain precautions must be taken before the treatment. Your liver function is tested, for instance.