Is the use of gonadotrophin-releasing hormone agonists facilitates vaginal hysterectomy in moderate enlarged uterus?

Introduction: Vaginal hysterectomy is considered to be the method of choice for removal of the uterus but most gynecologists still prefer the abdominal route for removal of benign large uteri >14 weeks. GnRH agonists such as goserelin can reduce uterine bulk by up to 60% and was initially used to convert a midline to Pfannenstiel incision in abdominal hysterectomy. The conversion of an abdominal to a potential vaginal hysterectomy by uterine size reduction would prove advantageous.Objective: To evaluate the efficacy of the preoperative administration of GnRH agonist for women with enlarged uteri without prolapse in order to facilitate vaginal hysterectomy; in comparison with patients with enlarged uteri who underwent to direct Total abdominal hysterectomy for a similar indication (i.e. Menorrhagia).Design: Prospective multicentre randomized controlled trialSetting: Tertiary Center HospitalsMethods: Women scheduled for hysterectomy for menorrhagia with non-prolapsing clinical uterine size of >14 weeks were offered an attempt for vaginal hysterectomy after pre-treatment with Goserelin for 3 months (Study group= 30). A group of women with comparable uterine size who underwent abdominal hysterectomy for similar indication served as (Control group=30). Pre- and postoperative data such as hemoglobin, myoma size, uterine weight, duration of procedure and complications, pain score, and length of hospital stay were collected prospectively.Results: Both groups had comparable preoperative hemoglobin, body mass index and subjective preoperative uterine bulk (16.7±2.4 vs16.9±2.2 weeks). The uterine weight was lower in the study group (507.6±211 g) compared to the control group (728.8±189 g), P<0.001.The subjective mean decrease in clinical uterine bulk was 20%. The duration of surgery was nearly twice as long in vaginal (123.3±34.9 min) compared to abdominal hysterectomy (73.9±23.9 min), P< 0.001, but analgesia use and the length of inpatient stay were lower in the study group (2.4±1 days) compared to control group (4.97±1.5 days), P<0.001. No significant difference between the two groups as regards the rate of occurrence of surgical complications.Conclusions: In women with >14 week size uteri, treatment with gonadotrophin agonists reduces uterine size sufficiently to allow safe vaginal hysterectomy. Although duration of surgery was longer, women who underwent vaginal hysterectomy required less analgesia and had shorter inpatient stay.