Why is hormonal treatment not effective for hydatidiform mole (molar pregnancy)?

From the Guidelines

Hormonal treatment is not used for molar pregnancy because it would be ineffective and potentially dangerous, and the primary treatment is surgical evacuation through dilation and curettage (D&C) as recommended by the ESMO clinical practice guidelines 1. The abnormal tissue in a molar pregnancy consists of proliferating trophoblastic cells that already produce high levels of human chorionic gonadotropin (hCG), and hormonal treatments would not stop this abnormal growth. Some key points to consider in the management of molar pregnancy include:

• Surgical evacuation through dilation and curettage (D&C) is the primary treatment for molar pregnancy, as it allows for the removal of the abnormal tissue and reduces the risk of complications 1.
• Hormonal medications could potentially stimulate further growth of the abnormal tissue or mask symptoms of persistent disease, making them an inappropriate treatment option for molar pregnancy.
• After surgical evacuation, patients require close monitoring of hCG levels to ensure complete resolution and detect any persistent gestational trophoblastic disease, as recommended by the ESMO clinical practice guidelines 1.
• If persistent disease is detected, chemotherapy (commonly methotrexate for low-risk disease or combination regimens for high-risk disease) is the appropriate treatment, not hormonal therapy, as it has been shown to be effective in treating gestational trophoblastic disease 1. The fundamental issue in molar pregnancy is the abnormal genetic composition of the conceptus, which leads to uncontrolled trophoblastic proliferation that cannot be corrected with hormonal interventions. Therefore, the use of hormonal treatment for molar pregnancy is not recommended due to its potential to cause harm and its lack of effectiveness in treating the underlying condition, and instead, surgical evacuation and close monitoring of hCG levels should be prioritized 1.

From the Research

Hormonal Treatment for Molar Pregnancy

• Hormonal treatment, such as oral contraceptives, is not recommended after a molar pregnancy due to the potential risk of persistent trophoblastic disease 2.
• The use of oral contraceptives after a molar pregnancy may increase the risk of gestational trophoblastic disease (GTD), with an odds ratio of 1.5 (95% CI, 1.1-2.1) 2.
• The risk of GTD increases with the duration of oral contraceptive use, with an odds ratio of 1.7 (95% CI 1.2-2.6) for users reporting more than 12 months of use 2.

Management of Molar Pregnancy

• Suction curettage is the preferred method of molar evacuation, regardless of uterine size, in patients who desire to preserve fertility 3.
• Prophylactic chemotherapy may be useful in the management of high-risk molar pregnancy, especially when hormonal follow-up is either unavailable or unreliable 3.
• Close surveillance with serial human chorionic gonadotropin (hCG) monitoring is essential to diagnose gestational trophoblastic neoplasia (GTN) and identify the need for chemotherapy 4, 5.

Treatment and Outcomes

• Most molar pregnancies are treated with dilation and curettage, but hysterectomy may be appropriate in select cases when future fertility is not desired 4.
• Cure rates for postmolar low-risk GTN approach 100%, and subsequent pregnancy outcomes for patients reflect those of the general population 4.
• All patients should be referred for psychologic support and expert level care 5.