Zoladex in the Management of Retained Products of Conception with Enhanced Myometrial Vascularity: A Case Series
Shanitha Fathima Sr *1, Zulqarnain Kazim Anjum 2
*Correspondence to: Shanitha Fathima Sr, Obstetrics and Gynaecology, Medcare Royal Speciality Hospital, Dubai, ARE.
© 2026 Shanitha Fathima Sr. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 18 May 2026
Published: 01 June 2026
DOI: https://doi.org/10.5281/zenodo.20729097
Abstract
Background: Abnormally adherent retained products of conception (RPOC) with enhanced myometrial vascularity (EMV) are very rare condition in the first trimester, but when associated with enhance myometrial vascularity (EMV), it causes abnormal uterine bleeding and can lead to major haemorrhage during evacuation and even emergency hysterectomy at the time of evacuation. It can mimic uterine arteriovenous malformations and gestational trophoblastic disease. This clinical condition is more common with history a prior repeat evacuation, multiple caesarean births, or other uterine surgeries like myomectomy. Hence, it's important that such cases should be referred to experienced specialists for evaluation and treatment. The presence of a focal hyperechoic mass in the endometrium with evidence of excessive vascularity noted in ultrasound with doppler imaging is the best for proper evaluation. We reviewed the pathophysiology, diagnosis and management strategies of RPOC with EMV highlighting the role of doppler ultrasound in diagnosis, conservative approaches and treatments which may include medical, hysteroscopic, laparoscopic removal of the retained tissue, uterine artery embolization or hysterectomy. Here we are introducing a medical treatment with inj. Zoladex (Goserlin) without or with surgical intervention only if required. Recently Zoladex, a GnRH agonist have been utilized to reduce endometrial vascularity and facilitate a safer treatment.
Objective: To evaluate the role of Zoladex in reducing vascularity and facilitating management of RPOC with EMV.
Methods: We present a series of 10 patients with RPOC and EMV managed with Zoladex.
Results-All patients showed significant reduction in vascularity, spontaneous resolution or expulsion of RPOC, except 2 cases which required hysteroscopic removal of the avascular remnant after the 1st cycle of zoladex. None experienced major hemorrhage or loss of fertility.
Conclusion: Zoldex may serve as a safe, non invasive alternative or adjunct in managing RPOC with EMV, especially in women desiring fertility preservation.
Categories: Obstetrics/Gynecology, Radiology, Anatomy.
Keywords: enhanced myometrial vascularity, goserlin, hypervascular rpoc, rpoc with emv, zoladex.
Introduction
RPOC with Enhanced Myometrial Vascularity (EMV) though rare is a high-risk condition exclusively seen in context of a recent pregnancy. It is typically secondary to RPOC in early postpartum period or following first trimester spontaneous miscarriage or termination of pregnancy. It is a a high-risk condition as surgical evacuation carries a substantial risk of haemorrhage. The reported incidence of this highly vascular variant is approximately 18% among all RPOC. it is usually diagnosed on transvaginal colour doppler ultrasound even though gold standard for distinction between AVM and EMV is digital subtraction angiography [1]. Ultrasound manifestations of EVMs include high velocity flow,low resistance index in tubular anechoic serpentine structures, increased myometrial thickening, heterogeneity, enlarged vessels in endometrium or myometrial mass [2]. Surgical treatment has a very high risk of massive haemorrhage during curettage or hysteroscopic resection. Hence medical therapy to reduce vascularity is preferred prior to surgery in stable patients.
Pathophysiology: Enhanced myometrial vascularity is a low resistance high velocity blood flow through modified peri trophoblastic spiral arteries. It can be seen in RPOC, Gestational trophoblastic disease (GTD) or placental site subinvolution [3].
Conservative management is preferred in asymptomatic cases and patients with minimal vaginal bleeding. Usually done by serial ultrasounds and beta hcg monitoring to assess the RPOC.
Conservative management include expectant management, medical therapy- administration of misoprostol, tranexamic acid and also GnRH agonists like Goserelin.
Surgical management includes simple D &C, Hysteroscopic resection, But it is estimated that nearly 20% of RPOC’s have increased vascularity and in such cases simple dilatation and curettage (D&C) may lead to massive haemorrhage.
Increased vascularity may indicate AVM which puts the patient at increased risk of life threatening intra? operative haemorrhage [4].
Hence in all cases of RPOC’s, vascularity should be evaluated with colour doppler prior to attempting dilatation and curettage to decide upon the accurate mode of management and avoid the complications of massive haemorrhage and hysterectomy.
Vascularity can be reduced with administration of methotrexate, GnRH agonists-zoladex, uterine artery embolization. Simple D and C in cases of hypervascular RPOC should be deferred until its vascularity is sufficiently reduced. Vascularity can be reduced with uterine artery embolization,This technique results in significant clinical improvement and averted many hysterectomies. This procedure is of short duration performed usually under conscious sedation where the branches of uterine artery are occluded using a variety of embolization substances. The most common embolization substances used for the management of post-partum haemorrhage or vaginal bleeding include gelfoam particles, coils or glue like n-butylcyanoacrylate.However, persistent symptoms after UAE occur in approximately 20% of patients who may require other procedures such as repeat embolization, myomectomy or hysterectomy [5].
In our study we used Zoladex 3.6 mg single dose for 1 month duration.GnRH agonists, like Zoladex (Goserlin-3.6 mg depot) suppress ovarian hormone production creating a hypoestrogenic state, which result in inducing endometrial atrophy and reducing uterine perfusion, regression of neovascularisation and shrinkage of retained placental tissue. This effect may facilitate spontaneous resolution of RPOC or make subsequent surgery safer.
Case Presentation
In our study we report a series of 15 patients (2021 - 2025) referred as a case of RPOC with enhanced myometrial vascularity.
All of the patients presented with prolonged bleeding with intermittent heavy bleeding. All of them were vitally stable. Each patient was evaluated with serum beta hcg and transvaginal ultrasound with doppler.
Standard regimen used was goserlin 3.6 mg SC, single dose. Follow up of all the patients were done every 2 weeks using serum beta hcg, transvaginal ultrasound with doppler for monitoring vascularity, endometrial thickness and size of residual mass.
In our study, we found decreased bleeding, marked reduction in vascularity and shrinkage of RPOC with spontaneous expulsion in 13 cases and in 2 cases remnant avascular tissues of small size around 1 cm was noted. For both the cases hysteroscopic resection was done. Serum beta hcg levels reflected the activity of RPOC and was used to monitor progress of treatment.
Out of 15 patients treated, 9 patients subsequently achieved pregnancy. complete resolution was confirmed by transvaginal ultrasound and serum beta hcg evaluation. No significant side effects were noted in any of the patients.
Discussion
RPOC had been the leading cause of post abortal or postpartum haemorrhage. In the acute setting, patients may experience abnormal uterine bleeding, hemorrhage, pelvic pain, or infection. Long-term complications include intrauterine adhesions, menstrual irregularities, new onset pelvic pain, infertility, recurrent pregnancy loss, and abnormal placentation in subsequent pregnancies. Most of surgical treatments without prior preoperative treatment for decreasing vascularity had ended up with severe intraoperative haemorrhage necessitating interventions including emergency hysterectomy, uterine artery embolization (UAE) and blood transfusion [6,7,8]. Although UAE prior to surgery has been associated with better results, the potential adverse effect on consequent pregnancy remains unclear. Hence no effective conservative treatment strategy has been established till date.
The present study shows that conservative management of RPOC with increased vascularity using Gnrh agonist, goserlin helps in remarkable decrease in vascularity decreasing the risk of massive haemorrhage and less invasive treatment for patients who are hemodynamically stable.
In our study, all patients presented with prolonged bleeding per vaginum with intermittent heavy bleeding and spotting in between. Around 60% patients had spontaneous miscarriage and the rest 40% presented with similar symptoms of heavy bleeding on and off after undergoing dilatation and evacuation of products of conception.
Our study showed that conservative management with Goserlin 3.6 mg, single dose, caused reduction in amount of bleeding, marked reduction in vascularity , shrinkage of RPOC and spontaneous expulsion without any need for surgical intervention except in 2 cases where hysteroscopic resection done to remove the avascularised and shrinked RPOC. With single dose use of Goserlin 3.6 mg , side effects were minimal and transient. Hence for stable patients with hypervascular RPOC, Goserlin is a preferrable treatment by itself and also it helps preperation in decreasing vasularity prior to surgical treatment like hysteroscopic resection and D&E . Uterine artery embolization is a better option for unstable patient, hysteroscopic removal for low vascular RPOC and D&E for less vascular RPOC. Zoladex is a very effective conservative medical treatment for hyper vascular RPOC and it helps in marked reduction in vascularity leading to spontaneous expulsion. It is highly effectively in reducing severe intraoperative haemorrhage during surgical treatments like D&C and hysteroscopic resection reducing the need for interventions including emergency hysterectomy, uterine artery embolisation (UAE) and blood transfusion.
Conclusions
This study was done on a group of referred patients to our tertiary centre. Unprepared intrauterine manipulation in the presence of RPOCs with rich blood flow might lead to uncontrollable massive bleeding, potentially requiring an undesired hysterectomy or UAE to preserve the uterus as a safer alternative.Our study demonstrated the effectiveness of Zoladex in the treatment of stable patients with hyper vascular retained products of conception. This conservative therapy appeared to be well effective in reducing the vascularity, avoiding massive haemorrhage during surgery and preservation of fertility in all the 15 patients treated. Further large sample studies are needed to establish long term outcomes and to establish a standard approach.
Additional Information
Author Contributions
All authors have reviewed the final version to be published and agreed to be accountable for all aspects of the work.
Concept and design: Shanitha Fathima Sr., Zulqarnain Kazim Anjum Acquisition, analysis, or interpretation of data: Shanitha Fathima Sr. Drafting of the manuscript: Shanitha Fathima Sr.
Critical review of the manuscript for important intellectual content: Shanitha Fathima Sr.
Supervision: Shanitha Fathima Sr.
Disclosures
Human subjects: Informed consent for treatment and open access publication was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.
References