Fibroids & Fertility
Q&A with Dr. Geronemus

Q: I am writing to you in regards to conceiving a third child with uterine fibroids. I have been blessed to give birth to two beautiful children. Will it be a problem to conceive naturally again? What are the risks to undergo IVF treatments?

A: Hello and thank you for your question.

The actual prevalence of uterine fibroids is unknown because the vast majority of women with uterine fibroids do not have any symptoms. It is estimated that 1 in 5 women of childbearing age have fibroids and around 50% of women by age 50 have fibroids.

Despite the fact that fibroids are very common in the general population it is estimated that only approximately 2% of infertility is caused by uterine fibroids. Knowing the precise location and size of the fibroids is very important when trying to evaluate a patient for potential fertility.

Fibroids that are in the uterine cavity (intracavitary), pushing on the lining of the uterine cavity (submucosal), or significantly distorting the uterine cavity (large intramural) have the greatest risk of decreasing the chances of a successful pregnancy. The best diagnostic tool to evaluate the exact location of the uterine fibroids and their effect on the uterine cavity is an MRI of the pelvis.

Fertility is multifactorial and many things have to be taken into consideration including a patient’s age and medical history. The fact that you have had two successful pregnancies is a reason to be optimistic. Additionally, any time there is an issue with fertility, the male partner also needs to be evaluated.

There are no large comprehensive studies comparing the chances of a successful pregnancy after Uterine Fibroid Embolization (UFE) versus other fibroid treatments. Most small studies did not account for differences it the patients’ ages and the fibroid sizes and location. These smaller studies often gave confusing and sometime conflicting results.

Because of this, while UFE is sometimes done in women who desire future fertility and also have other symptoms such as heavy menstrual periods, it is not commonly done as a primary treatment for infertility. This may change in the future after more research is done.

As to the specific risks involved with IVF it would be best to consult with a fertility specialist. There is no additional risk with IVF following UFE then there would be with a natural pregnancy following UFE. With uterine fibroids and any symptom, including infertility, every patient is different and a full in-person evaluation is the best way to find out what is best for you.

geronemus-headshot
Adam R. Geronemus, M.D.
Associate Director, The Fibroid Center
South Miami Hospital/Miami Cardiac & Vascular Institute
www.BaptistHealth.net/Fibroid

Important: This communication is for informational purposes only, and is not intended nor recommended as a substitute for medical advice, diagnosis or treatment—which should always involve a personal, office consultation. Always seek the in-person advice of a qualified physician regarding any medical questions or conditions. This communication is governed by the ask4UFE.com Terms of Use.

Transradial Uterine Fibroid Embolization Proves Safe and Effective for Women with Smaller Arteries
Alicia Armeli

wrist-image

New research published in the Journal of Vascular and Interventional Radiology showed that transradial uterine fibroid embolization (UFE)—a technique that allows doctors to treat fibroids from the radial artery in the wrist—is safe and effective in women with smaller arteries.1

“Transradial access UFE has been shown to be effective for patients with radial artery diameters that measure greater than 3 millimeters,” says Dr. Sammy Pham, MD, Diagnostic Radiologist at Harlem Hospital Center in New York, NY, and co-author of the study. “And yet, the average female radial artery is much smaller.”

To investigate, Dr. Pham and a team of interventional radiologists reviewed the medical records of 60 women who underwent transradial UFE between October 2013 and August 2015. All women had radial arteries that measured between 2 and 3 millimeters across.

Despite artery size, procedural outcomes showed transradial access to have a technical success rate of 100 percent with no major complications. Two minor adverse effects were reported and included bruising at the access site and temporary constriction of the radial artery, both of which were treated conservatively. After the procedure, the radial artery was seen to be normal in all patients, as well as upon discharge from the hospital and at a 5-week follow up. No further complications were reported.

Traditionally, interventional radiologists have used the femoral artery to perform UFE—a technique called transfemoral access. By making a small nick in the upper thigh, a thin tube called a catheter is threaded through the femoral artery and up into the uterine arteries that supply fibroids with blood. Tiny particles are then injected that block blood flow to the fibroids, causing them to shrink and symptoms to subside.

Instead of targeting the femoral artery, transradial access uses the radial artery in the wrist. In comparison to transfemoral access, research links transradial access to less bleeding at the puncture site, reduced hospital stay, and lower complication rates.2 After the procedure, patient comfort also improves with transradial access. As Dr. Pham points out, “a procedure performed at the wrist instead of the groin allows patients the freedom to move about without constraints, while also preserving their physical modesty.”

These same benefits hold true even among high-risk patients. A 2016 study by Biederman, et al. showed transradial access to have a 100 percent technical success rate with zero complications among morbidly obese patients undergoing different vascular procedures—including UFE.3 Morbidly obese patients are more prone to complications; however, the authors concluded that vascular procedures using transradial access are a safe and viable option for these individuals.

Despite these benefits, working with smaller arteries can pose potential problems. On average, a woman’s radial artery measures about 2.4 millimeters across, which means there’s less space for a catheter to move smoothly through the artery during a procedure. Reduced space between a catheter and the radial artery wall can result in a vasospasm—or a sudden narrowing of the blood vessel. This can make placing a transradial catheter difficult.4

What’s more, less area between a catheter and the artery wall can slow blood flow around the catheter, putting a woman at a greater risk of forming a blood clot.4 However, Dr. Pham explains “Our study showed transradial UFE to have minimal complications and all patients in our study reported a substantial improvement in symptoms at follow-up visits.”

To achieve such results, Dr. Pham and his team take a number of precautions. “Having adequate planning and proper equipment is important even before starting a procedure,” Dr. Pham tells Ask4UFE. “Sufficient anti-clotting medication during the procedure and then using a radial compressive device around each patient’s wrist afterward will help minimize bleeding.”

Uterine fibroids affect up to 80 percent of women by age 50, with African American women most at risk.5 And while these noncancerous growths don’t usually cause a problem, up to 50 percent of women with fibroids will seek treatment for heavy painful periods and bulk symptoms like urinary incontinence.6

Regardless of the access point, UFE has a long-term symptom cure rate that hovers around 90 percent—a statistic studies show to remain stable for 11 years following the procedure. 7  Considered minimally invasive, UFE is a practical option for women who don’t want surgery and for those who desire to keep their reproductive organs intact.

“Transradial access is one more way interventional radiologists have improved the UFE experience,” Dr. Pham says. “Several patients in our hospital, along with studies looking at patient preference, have favored transradial access. But it should be noted that both access points have their advantages and disadvantages and both options should be offered to women seeking UFE.”

ABOUT THE AUTHOR   Alicia Armeli is a Health Freelance Writer, Registered Dietitian Nutritionist, and Certified Holistic Life Coach. She has master’s degrees in English Education and Nutrition. Through her writing, she empowers readers to live optimally by building awareness surrounding issues that impact health and wellbeing. In addition to writing, she enjoys singing, traveling abroad and volunteering in her community.

ABOUT THE DOCTOR  Sammy Pham, MD, is a Diagnostic Radiologist at Harlem Hospital Center in New York, NY. With clinical interests in Interventional Radiology and Interventional Oncology, Dr. Pham offers patients cutting edge procedures, ensuring the best patient care possible. 

REFERENCES

  1. Pham, S., Arampulikan, J., Ruiz, D., & Resnick, N. (2016). Safety and efficacy of transradial uterine fibroid embolization via small caliber arterial access. Journal of Vascular and Interventional Radiology, 27(3), S21. doi: http://dx.doi.org/10.1016/j.jvir.2015.12.067
  1. Posham, R., Biederman, D. M., Patel, R. S., Kim, E., Tabori, N. E., Nowakowski, F. S., Lookstein, R. A., Fischman, A. M. (2016). Transradial approach for noncoronary interventions: a single-center review of safety and feasibility in the first 1500 cases. Journal of Vascular and Interventional Radiology, 27(2), 159-166. doi: 10.1016/j.jvir.2015.10.026
  1. Biederman, D. M., Marinelli, B., O’Connor, P. J., Titano, J. J., Patel, R. S., Kim, E., Tabori, N. E., Nowakowski, F. S., Lookstein, R. A., & Fischman, A. M. (2016). Transradial access for visceral endovascular interventions in morbidly obese patients: safety and feasibility. The Journal of Vascular Access, 17(3), 256-260. doi: 10.5301/jva.5000530
  1. Caputo, R. P., Tremmel, J. A., Rao, S., Gilchrist, I.C., Pyne, C., Pancholy, S., Frasier, D., Gulati, R., Skelding, K., Bertrand, O., & Patel, T. (2011). Transradial arterial access for coronary and peripheral procedures: executive summary by the Transradial Committee of the SCAI. Catheterization and Cardiovascular Interventions, 78(6), 823-39. doi: 10.1002/ccd.23052
  1. US Department of Health and Human Services: Office on Women’s Health. (2015). Uterine Fibroids Fact Sheet. Retrieved August 7, 2016, from http://womenshealth.gov/publications/our-publications/fact-sheet/uterine-fibroids.html
  1. Soliman, A. M., Yang, H., Du, E. X., Kelkar, S. S., & Winkel, C. (2015). The direct and indirect costs of uterine fibroid tumors: a systematic review of the literature between 2000 and 2013. American Journal of Obstetrics and Gynecology, 213(2), 141-160. doi: 10.1016/j.ajog.2015.03.019
  1. McLucas, B., Voorhees Iii, W. D., & Elliott, S. (2015). Fertility after uterine artery embolization: a review. Minimally Invasive Therapy & Allied Technologies, 2, 1-7.
Fighting Fibroids with Estrogen Balancing Foods
Alicia Armeli

 

fighting-fibroids-estrogen

Uterine fibroids—common benign tumors that grow in the wall of the uterus—are most common during a woman’s 30s and 40s, usually until she reaches menopause. This unmistakable pattern is suspected to parallel estrogen levels that rise prior to menopause but then taper off. Excess estrogen circulating in the body may also play a role in uterine fibroid growth.

To naturally manage hormone levels, women are encouraged to swap out processed foods for whole foods that may help balance estrogen levels and inhibit tumor growth. Calcium-D-glucarate, a naturally-occurring mineral in several fruits and vegetables, has been found to aid in ridding the body of excess estrogen.

The body detoxifies excess hormones by first metabolizing them in the liver and then excreting them through the feces or urine.

According to a 2016 paper published by Kunc, Gabrych, and Witkowski, certain gut bacteria make an enzyme called β‐glucuronidase that can inhibit this detox process.1 The authors explain that at high levels, β‐glucuronidase makes the body hold on to excess hormones—reabsorbing them back into the body instead of excreting them—causing estrogen levels to rise. High levels of β‐glucuronidase have been linked with a greater risk of estrogen-dependent cancers.1

Supplementation with calcium-D-glucarate has been seen to weaken β‐glucuronidase activity, in turn helping the body excrete more estrogen.1 High fiber diets, like vegetarian, have also been seen to reduce β‐glucuronidase in the feces—which results in more estrogen being excreted and less circulating in the body.1

As with any treatment, supplementing with calcium-D-glucarate should always first be discussed with a doctor. This helpful mineral can be found in fiber-rich foods such as oranges, grapefruits, apples, and cruciferous vegetables like broccoli, kale, and cabbage. Incorporating these foods into your everyday meals and snacks can be an easy way to help balance hormones and naturally fight fibroids.

ABOUT THE AUTHOR   Alicia Armeli is a Health Freelance Writer, Registered Dietitian Nutritionist, and Certified Holistic Life Coach. She has master’s degrees in English Education and Nutrition. Through her writing, she empowers readers to live optimally by building awareness surrounding issues that impact health and wellbeing. In addition to writing, she enjoys singing, traveling abroad and volunteering in her community.

REFERENCES

  1. Kunc, M., Gabrych, A., & Witkowski, J. M. (2016). Microbiome impact on metabolism and function of sex, thyroid, growth and parathyroid hormones. Acta Biochimica Polonica. 63(2): 189-201. doi: 10.18388/abp.2015_1093

Uterine Artery Embolization May Offer Relief to Women with Adenomyosis
By Alicia Armeli

Adenomyosis

A widely estimated 5 to 70 percent of women have adenomyosis (ad-uh-no-my-oh-sis)—a common gynecological condition that causes the lining of the uterus to grow into the uterine wall.1 Although the majority of women with this condition experience no symptoms at all, about one-third suffers from symptoms like heavy periods, pelvic pain, and urinary frequency.2

Given the nature of the disease, hysterectomy is currently considered the only definitive treatment for this condition. Because of this, researchers continue to search for an effective minimally invasive option to offer women, including uterine artery embolization (UAE).

“Although UAE is commonly known as a treatment for uterine fibroids, it can also be used to treat adenomyosis,” explains Dr. Richard Shlansky-Goldberg, MD, Interventional Radiologist and Professor of Radiology, Obstetrics and Gynecology, and Surgery at the Hospital of the University of Pennsylvania in Philadelphia. “Medical therapy is an option, as is hysterectomy—but not every woman wants hormones or surgery, which makes UAE a viable alternative.”

Whether it’s utilized to treat fibroids or adenomyosis, UAE’s technique remains the same. By injecting particles into the uterine arteries and blocking blood flow to the troublesome areas—like when embolizing fibroids—interventional radiologists can target the affected tissue, depriving it of oxygenated blood, causing it to die and symptoms to subside.

To test the effectiveness of the UAE procedure, Dr. M. D. Kim, MD, from Yonsei University College of Medicine in Seoul, Korea, and a team of researchers examined the outcomes of 50 women who underwent UAE for symptomatic adenomyosis.1 The team observed rates of affected tissue death and symptom recurrence 18 to 48 months following the procedure.

The results published in the Journal of Vascular and Interventional Radiology showed that symptoms returned in almost one-fourth of the patients treated. The researchers found that when less than 34 percent of the targeted uterine tissue was killed, symptoms were more likely to come back in comparison to cases where more tissue could be treated.

These results show that treating adenomyosis with UAE won’t offer the same results as when using it to treat fibroids. “The problem with adenomyosis is that it isn’t abnormal tissue growing—like we see with fibroids,” Dr. Shlansky-Goldberg emphasizes. “It’s normal tissue growing in an abnormal place, which can be more difficult to treat, especially if it fills the majority of the uterus.”

Long-term success rates following UAE for fibroid treatment average around 90 percent, whereas rates for complete symptom resolution after treatment of adenomyosis—although mixed—can run a little over 55 percent after only two years. 2,3

To improve UAE outcomes when treating adenomyosis, researchers are trying different methods in hopes of getting better results. A small study testing the “1-2-3 Protocol” of embolization—a technique that involves the use of small, normal and larger size particles during a single procedure—resulted in complete necrosis, or death of affected uterine tissue, in 80 percent of patients with no reported symptom recurrence after following up for 18 months.2

And yet, interventional radiologists are wary of procedures that use smaller than normal size particles due to the risk of more pain after the procedure, injury to the uterine wall, or wasting away of the uterine lining—which could result in infertility.2

With mixed success rates, some women may need to look for additional treatments in order to have long-term relief. This could mean a second round of UAE.

“If a woman still experiences symptoms immediately after a UAE procedure that has successfully blocked all sources of blood flow to the affected tissue, a second round probably won’t improve her condition,” Dr. Shlansky-Goldberg clarifies. “But if symptoms recur after a few years, it would make sense to take another look. Blood vessels have a way of making new pathways that could redirect blood to affected uterine tissue, causing symptoms to come back.”

Although more studies are needed to solidify its long-term efficacy, UAE is a short-term treatment option for women with adenomyosis. “When it comes to the traditional adenomyosis treatment options available, women are often stuck between a rock and a hard place, especially if they don’t want a hysterectomy,” Dr. Shlansky-Goldberg tells Ask4UFE. “UAE’s success rates may be lower, but it still can help to improve their symptoms.”

ABOUT THE AUTHOR   Alicia Armeli is a Health Freelance Writer, Registered Dietitian Nutritionist, and Certified Holistic Life Coach. She has master’s degrees in English Education and Nutrition. Through her writing, she empowers readers to live optimally by building awareness surrounding issues that impact health and wellbeing. In addition to writing, she enjoys singing, traveling abroad and volunteering in her community. She is a paid consultant of Merit.

ABOUT THE DOCTOR  Richard Shlansky-Goldberg, MD, is an interventional radiologist and professor of Radiology, Obstetrics and Gynecology, and Surgery at the Hospital of the University of Pennsylvania in Philadelphia. Recognized by Best Doctors in America, as Castle Connolly’s America’s Top Doctors, and showcased in Philadelphia Magazine’s Top Docs issue—Dr. Shlansky-Goldberg specializes in helping women with uterine fibroids find relief. Collaborating with the department of obstetrics and gynecology at the University of Pennsylvania allows him to ensure every woman knows and understands all her treatment options, ensuring the best patient care possible. 

REFERENCES

  1. Bae, S. H., Kim, M. D., Kim, G. M., Lee, S. J., Park, S. I., Won, J. Y., & Lee do, Y. (2015). Uterine artery embolization for adenomyosis: percentage of necrosis predicts midterm clinical recurrence. Journal of Vascular and Interventional Radiology, 26(9): 1290-1296. doi: 10.1016/j.jvir.2015.04.026
  2. Kim, M. D., Kim, Y. M., Kim, H. C., Cho, J. H., Kang, H. G., Lee, C., Kim, H. J., & Lee, J. T. (2011). Uterine artery embolization for symptomatic adenomyosis: a new technical development of the 1-2-3 protocol and predictive factors of MR imaging affecting outcomes. Journal of Vascular and Interventional Radiology, 22(4): 497-502. doi: 10.1016/j.jvir.2011.01.426
  3. McLucas, B., Voorhees Iii, W. D., & Elliott, S. (2015). Fertility after uterine artery embolization: a review. Minimally Invasive Therapy & Allied Technologies, 2: 1-7.
Pharmaceuticals for Fibroids 101
Alicia Armeli

pharmaceuticals-fibroids-101

Statistics show 30 to 50 percent of women with uterine fibroids will seek treatment for heavy periods, pelvic pain, and bulk symptoms like urinary frequency.1

To avoid surgery, many of these women will explore pharmaceuticals as their first line of defense. Categorized into two groups, the following medications have been shown to help ease fibroid-related discomfort, either by managing symptoms or reducing fibroid size.

Therapies That Manage Symptoms

 Non-Hormonal

  • An option to control pain and heavy bleeding is Non-Steroidal Anti-Inflammatory Drugs (NSAIDs). Ibuprofen—a frequently used NSAID—works by balancing hormones in the uterus, decreasing menstrual bleeding by as much as 40 percent.2 Gastrointestinal discomfort such as gas, stomach pain, and diarrhea are common side effects.3 Other more serious complications like stomach ulcers and worsening of asthma have been reported.2
  • Tranexamic acid, also known as Lysteda, is an antifibrinolytic agent used to control heavy bleeding. Taken on heavy flow days, antifibrinolytic medication slows the breakdown of blood in the uterine lining, thereby preventing heavy bleeding. Research has shown tranexamic acid to reduce menstrual blood loss by 40 percent.2 Side effects when taking tranexamic acid are mild and usually related to menstruation, such as back pain, headache, and fatigue.4 In rare cases, tranexamic acid breaks down fibroid tissue, potentially causing a low-grade fever and pelvic pain.5
  • Because menstrual blood loss can be severe, anemia is often a complication of fibroids. Iron and vitamin B12 are commonly prescribed supplements to support blood health and to treat anemia.6 

Hormonal

  • Hormonal contraceptives that contain both estrogen and progestin work by preventing ovulation and thinning the uterine lining. Research published in the American Journal of Obstetrics and Gynecology showed a significant reduction in menstrual bleeding among women using the birth control pill, the vaginal ring, or the transdermal patch.2 What’s more, these methods were seen to ease pelvic pain—especially when used continuously over time.2 Mild side effects can include nausea, headache, spotting, weight gain, and breast tenderness.2 Oral contraceptives that contain drosperinone could increase the risk for developing deep vein thrombosis (DVT)—a potentially life-threatening condition where blood clots form in the legs.7 Stroke and heart attack have also been reported.2
  • The Levonorgestrel-Releasing Intrauterine System (LNG-IUS) is a type of IUD that works by gradually releasing progestin to the uterine lining. Effective for 5 years, clinical studies have shown the LNG-IUS to reduce menstrual bleeding by 86 percent after 3 months and 97 percent after 1 year.2 Women with fibroids can use the LNG-IUS—if their fibroids don’t change the shape of the uterine cavity. A paper investigating LNG-IUS safety and efficacy published in the International Journal of Women’s Health reported that fibroids distorting the uterine cavity made inserting the device difficult and also increased the risk of it coming out of place.8 Overall, women using the LNG-IUS reported being satisfied, despite possible side effects like cramping, spotting, and discomfort during insertion.2,8
  • Danazol is a synthetic female steroid that thins the uterine lining and decreases menstrual bleeding by preventing the secretion of follicle-stimulating hormone (FSH) and luteinizing hormone (LH). This therapy option has been seen to reduce blood loss by up to 80 percent.2 However, because danazol also incites weak male hormonal activity, unpleasant side effects like acne, weight gain, and mild cases of facial hair have been reported.2

Therapies That Reduce Fibroid Size

  • Gonadotropin-Releasing Hormone agonists (GnRH-a) are medications that inhibit the body’s production of FSH and LH hormones. Subsequently, the ovaries stop producing estrogen, putting the body in a medically induced postmenopausal state. The absence of female hormones causes fibroids to shrink by 30 to 60 percent.2 Because long-term use is linked to bone loss, GnRH-a is commonly taken for no more than three to six months—unless small doses of estrogen and progestin are added back to protect bone density.9 Given its limited use, GnRH-a is often prescribed to stop heavy bleeding for a short period of time before menopause or to shrink fibroids before surgical removal.10 Menopausal symptoms like hot flashes, vaginal dryness, and depression have been reported side effects.2 Once the medication is discontinued, menstruation resumes and fibroids grow back.

Numerous other drugs, such as selective progesterone receptor modulators and aromatase inhibitors, are currently being studied for their efficacy; however, more research is needed.11

Although not curative, medical therapy is a noninvasive treatment option that can effectively manage fibroid symptoms, potentially making a woman’s need for surgery obsolete. It’s important to work with a gynecologist to find which regimen is best for you.

ABOUT THE AUTHOR   Alicia Armeli is a Health Freelance Writer, Registered Dietitian Nutritionist, and Certified Holistic Life Coach. She has master’s degrees in English Education and Nutrition. Through her writing, she empowers readers to live optimally by building awareness surrounding issues that impact health and wellbeing. In addition to writing, she enjoys singing, traveling abroad and volunteering within her community.

 REFERENCES

  1. Soliman, A. M., Yang, H., Du, E. X., Kelkar, S. S., & Winkel, C. (2015). The direct and indirect costs of uterine fibroid tumors: a systematic review of the literature between 2000 and 2013. American Journal of Obstetrics and Gynecology, 213(2): 141-160. doi: 10.1016/j.ajog.2015.03.019
  1. Bradley, L. D., & Gueye, N. A. (2016). The medical management of abnormal uterine bleeding in reproductive-aged women. American Journal of Obstetrics and Gynecology, 214(1): 31-44. doi: 10.1016/j.ajog.2015.07.044
  1. Cleveland Clinic. (2016). Drugs, Devices & Supplements. Retrieved Aug 1, 2016, from http://my.clevelandclinic.org/health/drugs_devices_supplements/hic_Non-Steroidal_Anti-Inflammatory_Medicines_NSAIDs
  1. US National Library of Medicine. (2014). Tranexamic Acid. Retrieved July 31, 2016, from https://medlineplus.gov/druginfo/meds/a612021.html
  1. Ip, P. P., Lam, K. W., Cheung, C. L., Yeung, M. C., Pun, T. C., Chan, Q. K., & Cheung, A. N. (2007). Tranexamic acid-associated necrosis and intralesional thrombosis of uterine leiomyomas: a clinicopathologic study of 147 cases emphasizing the importance of drug-induced necrosis and early infarcts in leiomyomas. The American Journal of Surgical Pathology, 31(8): 1215-1224.
  1. UterineFibroids.org. (2015). Oral Treatment Options for Uterine Fibroid Treatment. Retrieved July 30, 2016, from http://www.uterine-fibroids.org/oral-treatments.html
  1. US National Library of Medicine. (2015). Estrogen and Progestin (Oral Contraceptives). Retrieved July 31, 2016, from https://medlineplus.gov/druginfo/meds/a601050.html?
  1. Bednarek, P. H., & Jensen, J. T. (2009). Safety, efficacy and patient acceptability of the contraceptive and non-contraceptive uses of the LNG-IUS. International Journal of Women’s Health, 1: 45-58.
  1. UpToDate. (2016). Patient Information: Uterine Fibroids (Beyond the Basics). Retrieved Aug 1, 2016, from http://www.uptodate.com/contents/uterine-fibroids-beyond-the-basics
  1. University of Wisconsin-Madison School of Medicine and Public Health. (2016). Uterine Fibroids: Should I Use GnRH-A Therapy?. Retrieved August 1, 2016, from http://www.uwhealth.org/health/topic/decisionpoint/uterine-fibroids-should-i-use-gnrh-a-therapy/tv7259.html
  1. Song, H., Lu, D., Navaratnam, K., & Shi, G. (2013). Aromatase inhibitors for uterine fibroids. The Cochrane Database Systematic Reviews, (10): CD009505. doi: 10.1002/14651858.CD009505.pub2