Why do doctors prescribe dydrogesterone (a progestogen) to women of reproductive age with a history of uterine fibroids after a myomectomy?

Why Dydrogesterone is Prescribed After Myomectomy

Dydrogesterone is not routinely recommended or supported by current evidence-based guidelines after myomectomy. The available high-quality guidelines from the American College of Radiology (2024) and Environmental Health Perspectives (2000) do not mention progestogen therapy, including dydrogesterone, as part of standard post-myomectomy management 1.

Standard Post-Myomectomy Recommendations

The evidence-based post-myomectomy care focuses on:

• Waiting 2-3 months before attempting pregnancy to allow uterine incisions to heal and minimize risk of myometrial scar disruption during pregnancy, based on clinical experience with Cesarean section scars 1
• Adhesion prevention strategies including minimizing surgical trauma, confining incisions to the anterior uterine surface, and using adhesion barriers (oxidized regenerated cellulose, hyaluronic acid/carboxymethylcellulose combinations) 1
• Monitoring for complications including postoperative adhesions, which occur in approximately 21.57% of cases and can affect fertility 2

Why Progestogens Are Not Standard Post-Myomectomy Therapy

Progestogens, including dydrogesterone, lack evidence for preventing fibroid recurrence or improving surgical outcomes after myomectomy. The French guidelines (2012) indicate that progestogens are used for managing abnormal uterine bleeding in women with fibroids who have NOT undergone surgery, not as post-operative therapy 3.

Key Evidence Gaps:

• No guideline recommends hormonal suppression after myomectomy for adhesion prevention 1
• GnRH agonists are used preoperatively to reduce fibroid size and correct anemia before surgery, not postoperatively 1, 4
• Combined hormonal contraceptives show mixed evidence for fibroid growth, with studies showing reduced, similar, or even increased risk 4

When Hormonal Therapy IS Indicated Post-Myomectomy

The only scenario where hormonal therapy might be considered is for contraception during the 2-3 month healing period before attempting pregnancy, though this is not explicitly stated in guidelines 1.

Common Clinical Practice vs. Evidence

Some physicians may prescribe dydrogesterone post-myomectomy based on:

• Theoretical concern about estrogen-driven fibroid regrowth, though this lacks supporting evidence 1, 3
• Confusion with preoperative medical management, where GnRH agonists (not progestogens) are used to shrink fibroids before surgery 1, 4
• Local practice patterns not supported by international guidelines 5

What Should Actually Be Done Post-Myomectomy

Focus on evidence-based postoperative care:

• Delay pregnancy attempts for 2-3 months to allow incision healing 1
• Consider hysteroscopy at 3 months to diagnose and treat intrauterine adhesions early, especially in patients desiring fertility 2
• Monitor for complications including fever (38% incidence), wound infection (5%), and adhesion formation (21.57%) 5, 2
• Counsel patients about uterine rupture risk in future pregnancies, particularly with deep myometrial incisions 1

If hormonal management is needed for symptom control (not fibroid prevention), appropriate options include:

• Levonorgestrel-releasing intrauterine device for abnormal bleeding 3
• Combined oral contraceptives for contraception during healing period (though evidence for fibroid effect is mixed) 4, 3
• GnRH antagonists with add-back therapy if significant symptoms persist, though this suppresses fertility 4