Delayed treatment for uterine fibroids during the COVID‐19 pandemic

Dear Dr Papageorghiou, We thank Odejinmi et al. for their interest in our publication ‘Care for uterine fibroids: another casualty of the COVID pandemic’.1 The authors state that the management of such patients during the coronavirus disease 2019 (COVID19) pandemic differed between countries.2 In our study we analysed comprehensive data from all hospitals in France providing gynaecological care.1 Although we agree that differences by country are likely, best practice guidelines are relatively similar in most Western countries, particularly regarding the priority of surgery or embolisation, both of which occur primarily in hospital.3– 5 Aside from the factors that we focused on, additional factors may explain the poor management of patients with fibroids. In addition to ulipristal acetate, oral progestins and gonadotropinreleasing hormone (GnRH) antagonists are also commonly used in the management of uterine fibroids responsible for bleeding. Although not positively confirmed, these two treatments may have been used to postpone hospital treatment. GnRH antagonists were not even available then. However, this does not significantly alter our reasoning. These treatments are not recommended for the longterm management of uterine fibroids.3,4 In addition to serious (but rare) side effects, progestins can cause fibroid growth, and their prescription for fibroidrelated bleeding is limited to 3 months.5 GnRH agonists only have the effect of suspending symptoms, with a recurrence of symptoms and regrowth when the treatment is stopped, and have side effects that prevent their longterm use. By limiting access to health facilities, the lockdowns had negative effects on women with this pathology, which is consistent with our findings. Regarding confounding factors, women with uterine fibroids may be more likely to belong to ethnic minorities, which are in turn associated with the likelihood of contracting COVID19. However, hospital care in France is fully covered by social security, and emergency departments are well distributed throughout the country. Therefore, women have no financial barriers to hospital care, regardless of socioeconomic status, but during the pandemic, admission was only offered in major emergencies, regardless of COVID19 status. Is poor patient management a result of the lack of guidance? In France, evidencebased guidelines for the management of myomas from the French College of Gynaecologists and Obstetricians, published in 2011, are widely used.5 More importantly, our study sought to document the effect of the change in patient management before and during the pandemic. As patient care management varied during the pandemic, we considered the four pandemic periods. We then estimated the difference in management during these periods compared with the 2019 baseline year. The results indicate that most women did not receive hospital care if their condition was not an emergency.1 We presume some women received medical consultations outside the hospital setting, which were almost exclusively virtual consultations during lockdown.6 The increase in anaemia and transfusion rates during and after lockdown suggest that the delay in treatment led to worsening symptoms. Similarly, the increased rates of emergency admissions compared with 2019 suggest that had these patients been managed as usual, they would not require emergency treatment.