A 35-year-old woman with a 9 cm subserosal uterine fibroid is to undergo myomectomy. Preoperative gonadotropin-releasing hormone (GnRH) agonist therapy was administered for 3 months. Which is the primary unintended consequence of preoperative GnRH agonist use that can complicate intraoperative myomectomy?

• A GnRH agonists cause vascular proliferation within the fibroid, increasing intraoperative hemorrhage
• B GnRH agonists convert subserosal to intramural fibroids, requiring different surgical approach
• C GnRH agonists cause post-treatment estrogen rebound that may increase fibroid vascularity for 6 weeks post-treatment
• D GnRH agonists cause fibroid softening and loss of tissue planes, making complete enucleation more difficult and increasing risk of incomplete removal ✓

Explanation

Preoperative GnRH agonist therapy for 3 months reduces fibroid volume by 30–50% and decreases intraoperative blood loss. However, it causes fibroid softening and degenerative changes that make tissue planes between the fibroid and myometrium less distinct, complicating enucleation and potentially leaving behind fibroid remnants that can regrow. Surgeons experienced in GnRH agonist pre-treatment find enucleation planes harder to identify. Additionally, GnRH agonists can mask smaller satellite fibroids (reduced size makes them impalpable), leading to incomplete removal and higher recurrence rates. For these reasons, some surgeons use GnRH agonists selectively (large fibroids, anemia correction) rather than routinely.

Reference: Shaw's Textbook of Gynaecology, 17th ed.

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Written and medically reviewed by the StethoPrep medical team.