Single or repeated gonadotropin-releasing hormone agonist treatment avoids hysterectomy in premenopausal women with large symptomatic fibroids with no effects on sexual function

AIM

The aim of our study was to explore the effects on symptoms and female sexual function of the medical management with gonadotropin-releasing hormone agonist (GnRHa) in women of more than 45 years old compared to surgical management.

METHODS

Women with symptomatic uterine fibroids were enrolled to participate to the present open-label study. We offered two different treatment options: medical with GnRHa for 6 months (group A) or hysterectomy (group B). The patients were reviewed in follow-up for 24 months. The impact of medical or surgical therapy on sexual life was evaluated.

RESULTS

No significant differences were found in population characteristics between the two groups. GnRHa treatment was efficient in reducing symptoms in 88% of patients but 22% of patients needed adjunctive cycles of medical therapy. After 24 months, 16% of the patients did not complete the study. The failure percentage of the medical treatment was 12%. No severe side-effects were recorded, and eight patients had reached menopause. No significant differences were observed in the Female Sexual Function Index score in each domain between the medical and surgical groups, with total scores of 18.94 ± 10.16 and 22.00 ± 8.86, respectively (mean ± standard deviation), and the prevalence of dysfunction was 12% and 22%, respectively, similar to the general population of the same age.

CONCLUSION

We found that medical therapy with GnRHa is a satisfactory alternative to surgery for fibroids in women of more than 45 years old.

Association of age at menarche with increasing number of fibroids in a cohort of women who underwent standardized ultrasound assessment

Age at menarche has been associated with several reproductive conditions, and frequencies differ by race. Racial disparities also impact fibroid risk. We comprehensively examined the relationship between age at menarche, fibroid characteristics, and race. Women were enrolled in Right From the Start (2001-2010), a multistate study that systematically screened for fibroids during very early pregnancy. Endovaginal ultrasounds were conducted, and fibroid presence, number, type, volume, and diameter were recorded according to standardized definitions. Generalized estimating equations adjusted for correlations within study site were used to estimate associations between age at menarche and fibroid status and to test for interactions with race. Of 5,023 participants, 11% had a fibroid. Seven percent underwent menarche before 11 years of age and 11% at 15 years or later. We did not observe interactions between age at menarche and race. A 1-year increase in age at menarche was inversely associated with fibroids (adjusted risk ratio = 0.87, 95% confidence interval: 0.82, 0.91). Early age at menarche had a similar positive association in individual analyses with fibroid size, type, and location but was stronger for multiple fibroids (adjusted risk ratio = 0.75, 95% confidence interval: 0.68, 0.83). Our findings confirm other reports of an association between age at menarche and fibroid development (regardless of characteristics), demonstrate no effect modification by race, and suggest a stronger association for women with multiple fibroids, possibly reflecting a stronger association for early-onset disease.

[Epidemiological profile of uterine fibroids in the region of Sidi Bel Abbes, Algeria]

Introduction

Les léiomyomes ou fibromyomes plus communément dénommés fibromes, sont les tumeurs les plus répandues du tractus génital féminin. Ils affectent 20 à 25% des femmes en activité génitale. Notre étude vise à élucider la réalité de ce type de pathologie dans la région de sidi bel Abbes, nord-ouest d'Algérie.

Méthodes

A travers une étude rétrospective allant du 1^er janvier 2008 au 1 mai 2011 portant sur les patientes opérées pour fibrome au sein de la maternité de Sidi Bel Abbes, nous avons relevé les particularités épidémiologiques et cliniques de cette pathologie.

Résultats

Au total 323 cas de fibromes ont été recensés. La tranche d'âge la plus touchée varie de 40 à 44 ans dans une fourchette d'âge comprise entre 20 et 74 ans. 37.83% des patientes étaient nullipares. Une prédominance des patientes dont l'âge de la ménarche est précoce, a été retenue (60.3%). 3% des femmes ont présenté un terrain familial prédisposant. La symptomatologie était dominée par les hémorragies génitales (35%). La majorité des patientes (51.70%) présentaient un utérus polymyomateux dont la localisation des fibromes était principalement corporéale (96%), sous séreuse (43%). Le traitement était conservateur dans 71.82% des cas.

Conclusion

Sur la base des résultats obtenus, la mise au point d'un programme national de sensibilisation et de dépistage précoce, s'impose

Abnormal uterine bleeding in midlife: The role of levonorgestrel intrauterine system

Abnormal uterine bleeding is a common gynecological complaint affecting 10-30% of women in midlife and constitute about one-third of all outpatient gynecological visits. It adversely affects the quality of woman's life and can lead to psychological, social, medical, and sexual problems and thus necessitating appropriate and adequate management. Different treatment modalities for such problems are available, yet the levonorgestrel intrauterine system (LNG-IUS) has recently provided a good treatment option effective in treating such complaints and at the same time, having a reliable contraceptive effect which is desired by such age group. For women in their reproductive years, the LNG-IUS has become one of the most acceptable medical treatments for menorrhagia, reducing referrals to specialists, and decreasing the recourse to operative treatments. It is easy to insert, has a sustained effect, cost-effective, and well tolerated besides providing reliable contraception.

Vitamin D3 inhibits expression and activities of matrix metalloproteinase-2 and -9 in human uterine fibroid cells

STUDY QUESTION

Can biologically active vitamin D3 [1,25(OH)₂D3] regulate the expression and activity of matrix metalloproteinases (MMPs) in human uterine fibroid cells?

SUMMARY ANSWER

1,25(OH)₂D3 effectively reduced the expression and activities of MMP-2 and MMP-9 in cultured human uterine fibroid cells.

WHAT IS KNOWN ALREADY

Uterine fibroids (leiomyoma) express higher levels of MMP activity than adjacent normal myometrium, and this is associated with uterine fibroid pathogenesis. However, it is unknown whether 1,25(OH)₂D3 can regulate the expression and activities of MMPs in human uterine fibroid cells.

STUDY DESIGN, SIZE, DURATION

Surgically removed fresh fibroid tissue was used to generate primary uterine fibroid cells.

PARTICIPANTS/MATERIALS, SETTING, METHODS

An immortalized human uterine fibroid cell line (HuLM) and/or primary human uterine fibroid cells isolated from fresh fibroid tissue were used to examine the expression of several MMPs, tissue inhibitors of metalloproteinases (TIMP) 1 and 2 and the activities of MMP-2 and MMP-9 after 1,25(OH)₂D3 treatment. Real-time PCR and western blots analyses were used to measure mRNA and protein expression of MMPs, respectively. Supernatant cell culture media were analyzed for MMP-2 and MMP-9 activities using a gelatin zymography assay.

MAIN RESULTS AND THE ROLE OF CHANCE

1-1000 nM 1,25(OH)₂D3 significantly reduced mRNA levels of MMP-2 and MMP-9 in HuLM cells in a concentration-dependent manner (P < 0.5 to P < 0.001). The mRNA levels of MMP-1, MMP-3, MMP-13 and MMP-14 in HuLM cells were also reduced by 1,25(OH)₂D3. 1,25(OH)₂D3 significantly reduced MMP-2 and MMP-9 protein levels in a concentration-dependent manner in both HuLM and primary uterine fibroid cells (P < 0.05 to P < 0.001). Moreover, 1,25(OH)₂D3 increased the mRNA levels of vitamin D receptor (VDR) and TIMP-2 in a concentration-dependent manner in HuLM cells (P < 0.05 to P < 0.01). 1,25(OH)₂D3 also significantly increased protein levels of VDR and TIMP-2 in all cell types tested (P < 0.05 to P < 0.001). Gelatin zymography revealed that pro-MMP-2, active MMP-2 and pro-MMP-9 were down-regulated by 1,25(OH)₂D3 in a concentration-dependent manner; however, the active MMP-9 was undetectable.

LIMITATIONS, REASONS FOR CAUTION

This study was performed using in vitro uterine fibroid cell cultures and the results were extrapolated to in vivo situation of uterine fibroids. Moreover, in this study the interaction of vitamin D3 with other regulators such as steroid hormone receptors was not explored.

WIDER IMPLICATIONS OF THE FINDINGS

This study reveals an important biological function of 1,25(OH)₂D3 in the regulation of expression and activities of MMP-2 and MMP-9. Thus, 1,25(OH)₂D3 might be a potential effective, safe non-surgical treatment option for human uterine fibroids.

Profibrotic interleukin-33 is correlated with uterine leiomyoma tumour burden

STUDY QUESTION

Are interleukin-33 (IL-33) serum levels higher in women with uterine leiomyoma compared with controls without leiomyoma?

SUMMARY ANSWER

Serum IL-33 is elevated in women with uterine leiomyoma and correlated with features of uterine leiomyoma tumour burden, namely fibroid number, size and weight.

WHAT IS KNOWN ALREADY

Uterine leiomyomas are the most common benign tumours in premenopausal women associated with major tissue fibrosis. IL-33 is a cytokine involved in fibrotic disorders. The potential role of IL-33 in leiomyoma has not been reported before.

STUDY DESIGN, SIZE, DURATION

This is a prospective laboratory study conducted in a tertiary-care university hospital between January 2005 and December 2010. We investigated non-pregnant, 42-year-old patients (n = 151) during surgery for a benign gynaecological condition.

PARTICIPANTS/MATERIALS, SETTING, METHODS

After complete surgical exploration of the abdominopelvic cavity, 59 women with histologically proved uterine leiomyoma and 92 leiomyoma-free control women were enrolled. Women with endometriosis or past history of ovarian malignancy and borderline tumours were not included. The control group included women with benign ovarian cysts, paratubal cysts or tubal defects without any evidence of uterine leiomyoma. For each patient, a structured questionnaire was completed during a face-to-face interview conducted by the surgeon during the month preceding surgery. Serum samples were obtained in the month preceding the surgical procedures according to the menstrual phase or hormonal therapy. IL-33 was measured in sera by enzyme-linked immunosorbent assay, and correlation of IL-33 concentration with the extent and severity of the disease was investigated.

MAIN RESULTS AND THE ROLE OF CHANCE

IL-33 was detected in 32 (54.2%) women with leiomyoma and 18 (19.6%) controls (P < 0.001). Serum IL-33 was higher in women with leiomyoma (median, 140.1 pg/ml; range, 7.5-2247.7) than in controls (median, 27.8 pg/ml; range, 7.5-71.6; P = 0.002). We found positive correlations between serum IL-33 concentration and leiomyoma features, such as fibroid weight (r = 0.630; P = 0.001) and size (r = 0.511; P = 0.018) and the number of fibroids (r = 0.503; P = 0.003).

LIMITATIONS, REASONS FOR CAUTION

There was a possible selection bias due to inclusion of only surgical patients. Therefore our control group consisted of women who underwent surgery for benign gynaecological conditions. This may lead to biases stemming from the fact that certain of these conditions, such as tubal infertility or ovarian cysts, might be associated with altered serum IL-33 levels.

WIDER IMPLICATIONS OF THE FINDINGS

We demonstrate for the first time that elevated serum IL-33 levels are associated with the existence of uterine leiomyoma. However, even if an association does not constitute proof of cause and effect, investigating the mechanisms that underlie fibrogenesis associated with leiomyomas is a step towards understanding this enigmatic disease. This study opens the doors to future, more mechanistics studies to establish the exact role of IL-33 in uterine leiomyomas pathogenesis.

STUDY FUNDING/COMPETING INTEREST(S)

No funding, no conflict of interest.

Fibroid tumors are not a risk factor for adverse outcomes in twin pregnancies

OBJECTIVE

Uterine fibroid tumors have been associated with adverse outcomes in singleton pregnancies. We aimed to estimate risk for adverse obstetric outcomes that are associated with fibroid tumors in twin pregnancies.

STUDY DESIGN

A retrospective cohort study of twin pregnancies with ≥1 fibroid tumor on second trimester ultrasound examination. Outcomes included small-for-gestational-age fetal growth, preterm delivery, preterm rupture of membranes, abruption, preeclampsia, and intrauterine fetal death. Univariable and multivariable analyses were used to evaluate the impact of fibroid tumors on outcomes in twin pregnancies compared with twin pregnancies without fibroid tumors.

RESULTS

Of 2378 nonanomalous twin pregnancies, 2.3% had fibroid tumors. Twin pregnancies with fibroid tumors were no more likely to have small-for-gestational-age growth (40.0% vs. 36.0%; adjusted odds ratio, 1.1; 95% confidence interval, 0.7-2.0) or preterm delivery at <34 weeks' gestation (25.0% vs. 24.0%; adjusted odds ratio, 1.0; 95% confidence interval, 0.5-1.9) than twin pregnancies without fibroid tumors. Other adverse outcomes were no more likely to occur in twin pregnancies with fibroid tumors than in twin pregnancies without fibroid tumors. Post hoc power calculations suggested >97% power to detect 2-fold differences in small for gestational age and preterm delivery at <34 weeks' gestation.

CONCLUSION

In contrast to data that suggest an increased risk for adverse outcomes in singleton pregnancies with fibroid tumors, twin pregnancies with fibroid tumors do not appear to be at increased risk for complications compared with those pregnancies without fibroid tumors.

An essential role of p27 downregulation in fenvalerate-induced cell growth in human uterine leiomyoma and smooth muscle cells

Previously, we reported that fenvalerate (Fen) promotes proliferation of human uterine leiomyoma (UtLM) cells by enhancing progression of cells from G(0)-G(1) to S phase through molecular mechanisms independent of estrogen receptor-α and -β. The cyclin-dependent kinase (CDK) inhibitor p27, which blocks G(1) to S phase transitions and is an important regulator of CDK2, is often decreased in hormonally regulated diseases, including uterine leiomyomas. Therefore, we were interested in whether Fen could regulate the expression of p27 and whether p27 might play a role in Fen-induced cell proliferation. Expression of p27 in Fen-treated UtLM and uterine smooth muscle cells (UtSMCs) was examined. We found that p27 mRNA was significantly downregulated and that protein levels were decreased in both cell types treated with 10 μM Fen for 24 h compared with respective controls. Overexpression of p27 in UtLM cells and UtSMCs using an adenovirus doxycycline (Dox)-regulated Tet-off system abrogated the proliferative effects of Fen, as evidenced by decreased total cell numbers and BrdU incorporation. Fen treatment increased CDK2 mRNA expression levels; however, overexpression of p27 also abolished this effect. In contrast, Dox treatment dramatically restored the above muted responses. Finally, we utilized siRNA to knock down p27 expression. After transfection, mRNA levels of p27 were downregulated in UtLM cells and UtSMCs and total cell numbers and BrdU incorporation increased significantly compared with nontransfected cells. Fen treatment in the presence of p27 silencing enhanced the increased cell counts and BrdU labeling in UtLM cells and UtSMCs. Taken together, these results indicate that p27 downregulation is critical for Fen-induced cell proliferation.

Laparoscopic myomectomy with uterine artery ligation: review article and comparative analysis

Uterine leiomyomas are one of the most common benign smooth muscle tumors in women, with a prevalence of 20 to 40% in women over the age of 35 years. Although many women are asymptomatic, problems such as bleeding, pelvic pain, and infertility may necessitate treatment. Laparoscopic myomectomy is one of the treatment options for myomas. The major concern of myomectomy either by open method or by laparoscopy is the bleeding encountered during the procedure. Most studies have aimed at ways of reducing blood loss during myomectomy. There are various ways in which bleeding during laparoscopic myomectomy can be reduced, the most reliable of which is ligation of the uterine vessels bilaterally. In this review we propose to discuss the benefits and possible disadvantages of ligating the uterine arteries bilaterally before performing laparoscopic myomectomy.

A novel saline infusion sonohysterography-based strain imaging approach for evaluation of uterine abnormalities in vivo: preliminary results

In this article, we demonstrate the feasibility of saline infusion sonohysterography-based strain imaging for the determination of stiffness variations in uterine masses in vivo. Strain images are estimated using a 2-dimensional multilevel hybrid algorithm developed for sector array ultrasound transducers. Coarse displacements are initially estimated using envelope echo signals, followed by a guided finer displacement estimation using window lengths on the order of 6 wavelengths and 7 A-lines on radiofrequency data. Strain images are obtained by estimating displacement slopes using least squares estimation. In this prospective study, we show that stiffer masses such as fibroids appear darker or as regions with low strain on strain images and are thus clearly differentiated when compared to normal uterine tissue. A high strain boundary around stiffer masses referred to as a "halo" due to increased slipping or sliding of the mass during the applied deformation is also visualized. Uterine polyps, on the other hand, are visualized as masses that are brighter or regions with high strain when compared to the background myometrium, indicating the presence of a softer mass. Axial strain images provide additional new information that may supplement current clinical B-mode imaging used for the diagnosis of uterine abnormalities. Our results show the feasibility of improving clinical diagnosis based on strain imaging.

The estimated annual cost of uterine leiomyomata in the United States

OBJECTIVE

The purpose of this study was to estimate the total annual societal cost of uterine fibroid tumors in the United States, based on direct and indirect costs that include associated obstetric complications.

STUDY DESIGN

A systematic review of the literature was conducted to estimate the number of women who seek treatment for symptomatic fibroid tumors annually, the costs of medical and surgical treatment, the amount of work time lost, and obstetric complications that are attributable to fibroid tumors. Total annual costs were converted to 2010 US dollars. A sensitivity analysis was performed.

RESULTS

The estimated annual direct costs (surgery, hospital admissions, outpatient visits, and medications) were $4.1-9.4 billion. Estimated lost work-hour costs ranged from $1.55-17.2 billion annually. Obstetric outcomes that were attributed to fibroid tumors resulted in a cost of $238 million to $7.76 billion annually. Uterine fibroid tumors were estimated to cost the United States $5.9-34.4 billion annually.

CONCLUSION

Obstetric complications that are associated with fibroid tumors contributed significantly to their economic burden. Lost work-hour costs may account for the largest proportion of societal costs because of fibroid tumors.

Leiomyoma-related hospitalization and surgery: prevalence and predicted growth based on population trends

OBJECTIVE

To estimate leiomyoma-related inpatient care in the United States for 2007 with predictions for the ensuing 40 years.

STUDY DESIGN

We used the 2007 Nationwide Inpatient Sample to estimate hospitalizations and inpatient surgeries for uterine leiomyoma in US women 15 to 54 years. We used the US Census Bureau population projections to predict leiomyoma-related inpatient care through 2050.

RESULTS

In 2007, 355,135 women were hospitalized for leiomyoma (rate = 42 per 10,000 women-years). Black women had increased rates of hospitalization, hysterectomy, and myomectomy (relative risk, 3.5, 2.4, 6.8, respectively) compared with white women. Leiomyoma-related hospitalizations are predicted to increase 23% (to 437,874) between 2007 and 2050, with 20% and 31% increases in leiomyoma-related hysterectomies and myomectomies.

CONCLUSION

Leiomyoma-related inpatient care and major surgery remains substantial despite advances in less invasive treatment options. Given population growth, the projected burden of leiomyoma-related inpatient care will increase significantly by 2050, differentially impacting black vs white women.

Uterine artery embolization: a safe and effective, minimally invasive, uterine-sparing treatment option for symptomatic fibroids

Leiomyomas (or fibroids) are exceedingly common lesions. The indications to initiate treatment are based on the symptoms that can arise from their presence. In general, medical therapy should be considered the first line of treatment. Currently, the treatment of fibroids is in evolution. Since uterine artery embolization (UAE) was first described by Ravina et al in 1995, it has been shown to be a safe, efficacious, and cost-effective alternative to traditional surgical options, with data from long-term studies now available. Appropriate patient evaluation and selection are vital; the ideal candidate is one who is premenopausal, has symptomatic fibroids resistant to medical therapy, no longer desires fertility, and wishes to maintain her uterus. Uterine artery embolization is primarily an angiographic procedure, but periprocedural clinical management is critical for patient satisfaction. This article discusses the various embolic materials that are commonly used and available for UAE; understanding the technical nuances is critical for long-term success.

Uterine Artery Embolization in the Management of Symptomatic Uterine Fibroids: An Overview of Complications and Follow-up

Uterine artery embolization (UAE) evolved as a treatment for symptomatic uterine fibroids in the early 1990s, after initially being used as a temporizing measure prior to hysterectomy or myomectomy. Since that time, over 100,000 UAEs have been performed. Technical success rates have been quoted ranging from 94 to 99%. The overall incidence of major complications associated with the procedure is low, the majority of which can be prevented. Knowledge of the potential complications and the measures that can be taken to avoid these complications is essential. Furthermore, because UAE is a relatively new procedure, no standardized recommendations for patient follow-up exist. Common practice for patient follow-up includes both clinic visits at increasing time intervals postprocedure, as well as telephone follow-up, and imaging follow-up when necessary. As symptomatic improvement is subjective, some institutions have developed standardized questionnaires to better assess patient improvement postprocedure. Aggressive pain control is a crucial component of follow-up, as uncontrolled pain can result in readmission and patient dissatisfaction.

Magnetic resonance-guided focused ultrasound for uterine fibroids

Uterine fibroids are an important problem for women of reproductive age. Although hysterectomy has been the traditional treatment for fibroids, many women are interested in a less invasive therapy. Magnetic resonance-guided focused ultrasound (MRgFUS) is a new technique for treating a variety of solid tumors. It has been tested and approved by the U.S. Food & Drug Administration (FDA) for the treatment of uterine fibroids. The procedure is completely noninvasive. It is performed as an outpatient procedure and the patient can resume her normal activities the day following the procedure. Techniques of treatment of uterine fibroids are still being refined, but significant progress has been made in understanding some of the challenges for this new technology. Some fibroids are more responsive to the focused ultrasound; some fibroids are more resistant. Not all women are candidates for this procedure. Absolute contraindications include bowel that is in the path of the ultrasound beam, or surgical scars in the beam pathway. The procedure of MRgFUS is feasible, safe and becoming increasingly popular. Questions still remain particularly the use of this technique for patients desiring fertility, and what will be the long-term results.

Uterine artery embolization for treatment of symptomatic fibroids

Over the past decade, uterine artery embolization (UAE) has become a popular alternative treatment for women with symptomatic fibroids who desire uterine preservation and/or the avoidance of surgical intervention. In this article, the history of UAE, preprocedure patient evaluation and patient selection, procedure technique, and expected UAE outcomes are reviewed.

Uterine leiomyomata in a cohort of Great Lakes sport fish consumers

Diet and endocrine disrupting persistent organic pollutants (POPs) have been associated with gynecologic conditions including uterine leiomyomata (UL), endometriosis, and ovarian cysts. Great Lakes sport fish consumption is a source of exposure to POPs such as p,p'-diphenyldichloroethene (DDE) and polychlorinated biphenyls (PCBs). This study was designed to examine retrospectively the effects Great Lakes sport fish consumption on the incidence of UL and to examine the effects of DDE and PCB serum levels on prevalent UL in women participating in the Great Lakes Fish Consumption Study. We hypothesized that associations of exposures with UL would be modified by breastfeeding status. Years of sport fish consumption, demographic, health, and reproductive data were assessed by survey. In a subgroup, serum was collected and tested for DDE and PCB levels. Effects of years of Great Lakes sport fish and sport fish consumption were modeled using time-dependent Cox proportional hazards regression and effects of POP exposures on UL were modeled using multiple logistic regression. Years of sport fish consumption were associated with UL, with an incidence rate ratio of 1.2 (95% CI 1.0-1.3) for each 10-year increment of fish consumption. Summary measures of POP exposures in the overall group were not associated with UL. In the subgroup of women who never breastfed and in whom PCB measurements were available, however, UL was significantly associated with PCBs and groupings of estrogenic, antiestrogenic, and dioxin-like PCBs. These findings support the possibility that PCB exposures from fish consumption may increase the risk of UL and highlight the importance of additional studies exploring biologic pathways by which they could be acting.

Efficacy and tolerability of CDB-2914 treatment for symptomatic uterine fibroids: a randomized, double-blind, placebo-controlled, phase IIb study

OBJECTIVE

To evaluate the efficacy and tolerability of the P receptor modulator CDB-2914 (Ulipristal, CDB).

DESIGN

Randomized, placebo-controlled double-blind clinical trial.

SETTING

Clinical research center.

PATIENT(S)

Premenopausal women with symptomatic uterine fibroids.

INTERVENTION(S)

Once-daily oral CDB (10 or 20 mg) or placebo (PLC) for 12 weeks (treatment 1). A second 3-month treatment with CDB (treatment 2) was offered. A computer-generated blocked randomization was used.

MAIN OUTCOME MEASURE(S)

Magnetic resonance imaging (MRI)-determined total fibroid volume (TFV) change was the primary outcome; amenorrhea and quality of life (QOL) were secondary end points.

RESULT(S)

Treatment 1 TFV increased 7% in the PLC group, but decreased 17% and 24% in the CDB10 and CDB20 groups. The TFV decreased further in treatment 2 (-11%). Amenorrhea occurred in 20/26 women taking CDB and none on PLC. Ovulation resumed after CDB. Hemoglobin improved only with CDB (11.9 ± 1.5 to 12.9 ± 1.0 g/dL) as did the Fibroid QOL Questionnaire symptom severity, energy/mood, and concern subscores, and overall QOL scores. The CDB was well tolerated, with no serious adverse events. Adverse events were unchanged during treatments.

CONCLUSION(S)

Administration of CDB-2914 for 3-6 months controls bleeding, reduces fibroid size, and improves QOL.

Using laser diodes for the removal of a lesion of the oral mucosa. Case report

AIM.: Describe a clinical case of a voluminous asymptomatic fibromatosis lesion present on the cheek mucosa and evaluate the healing of the site after removal of the lesion with use of the laser diode. METHODS.: It was decided to use laser diodes to affect the mucous membrane and remove the lesion without the use of local anesthetic infiltration. The protocol used includes a 300-micron fiber and the emission of continuous light of 1.5 Watt with a range of wave of 940 nm. RESULTS.: THE PROVEN BENEFITS OF USING LASER DIODES FOR MINOR SURGERY ARE: drastic reduction of intraoperative bleeding and in the hours after the surgerywill restrict the swellingbetter and faster healing with no scarring and better cosmetic resultdoes not require suturesreducing the operating time thanks to no need for anesthetic infiltrationin most cases totally absent or less post-operative pain on the surgical site. CONCLUSIONS.: The laser diodes give a significant contribution to improving the surgical treatment of tumors of the oral cavity infact during the surgery reduce bleeding and surgical time, while in the process of healing by reduce swelling and post-operative pain and better results appearance without scarring.

Pregnancy after uterine arterial embolization

OBJECTIVE

To evaluate pregnancy outcomes, complications and neonatal outcomes in women who had previously undergone uterine arterial embolization.

METHODS

A retrospective study of 187 patients treated with uterine arterial embolization for symptomatic uterine fibroids between 2005-2008 was performed. Uterine arterial embolization was performed using polyvinyl alcohol particles (500-900 mm in diameter). Pregnancies were identified using screening questionnaires and the study database.

RESULTS

There were 15 spontaneous pregnancies. Of these, 12.5% were miscarriages (n = 2), and 87.5% were successful live births (n = 14). The gestation time for the pregnancies with successful live births ranged from 36 to 39.2 weeks. The mean time between embolization and conception was 23.8 months (range, 5-54). One of the pregnancies resulted in twins. The newborn weights (n = 14) ranged from 2.260 to 3.605 kg (mean, 3.072 kg). One (7.1%) was considered to have a low birth weight (2.260 kg). There were two cases of placenta accreta (12.5%, treated with hysterectomy in one case [6.3%]), one case of premature rupture of the membranes (PRM) (6.3%), and one case of preeclampsia (6.3%). All of the patients were delivered via Cesarean section.

CONCLUSION

In this study, there was an increased risk of Cesarean delivery. There were no other major obstetric risks, suggesting that pregnancy after uterine arterial embolization is possible without significant morbidity or mortality.

Magnetic resonance-guided focused ultrasound surgery (MRgFUS) treatment for uterine fibroids

Magnetic Resonance-guided focused Ultrasound Surgery (MRgFUS) is gaining popularity as an alternative to medical and surgical interventions in the management of symptomatic uterine fibroids. Studies have shown that it is an effective non-invasive treatment with minimal associated risks as compared to myomectomy and hysterectomy. MRgFUS can be offered to a majority of patients suffering from symptomatic uterine fibroids. It has been suggested that the use of broader inclusion criteria as well as the mitigation techniques makes it possible to offer MRgFUS to a much larger subset of patients than previously believed. This paper will describe how MRgFUS treatment for uterine fibroids is performed at the University of Malaya Medical Centre, Kuala Lumpur, Malaysia.

Risk factors for surgically removed fibroids in a large cohort of teachers

OBJECTIVE

To describe reproductive and lifestyle correlates of surgically confirmed fibroids.

DESIGN

Prospective cohort study.

SETTING

The California Teachers Study, an ongoing prospective study of more than 133,000 female teachers and school administrators identified through the California State Teachers Retirement System.

PATIENT(S)

California Teachers Study cohort members, reporting no previous history of fibroids, were ascertained prospectively for surgical diagnosis of fibroids using hospital patient discharge records.

MAIN OUTCOME MEASURE(S)

Multivariable Cox proportional hazards regression methods were used to assess the association of self-reported menstrual, reproductive, and lifestyle characteristics with fibroids, using ages at the start and end of follow-up (in months) to define time on study. Hazard rate ratios, presented as relative risks (RR) with 95% confidence intervals (CI), were estimated.

RESULT(S)

The strongest risk factor we identified was African-American race/ethnicity, as compared to non-Latina white women. We observed a reduced risk of fibroids for postmenopausal women in comparison to premenopausal women, but use of hormone replacement therapies (regardless of formulation) were associated with an increased risk. Other risk factors included race, a family history of fibroids, being overweight, and drinking alcohol, Smoking and diabetes were associated with a decreased risk of fibroids.

CONCLUSION(S)

These observations provide a more detailed epidemiologic profile of women with surgically managed fibroids.

Laparoscopic management of large myomas

The objective of this article is to review the different techniques that have been adopted for removal of large myomas laparoscopically. We have also quoted literature about the impact of myomas on Pregnancy and obstetrical outcome and the effect of laparoscopic myomectomy on the same. Technical modifications to remove large myomas have been described along with methods to reduce intraoperative bleeding. This comprehensive review describes all possibilities of laparoscopic myomectomy irrespective of size, site and number.

The impact of race as a risk factor for symptom severity and age at diagnosis of uterine leiomyomata among affected sisters

OBJECTIVE

The objective of the study was to identify risk factors for uterine leiomyomata (UL) in a racially diverse population of women with a family history of UL, and to evaluate their contribution to disease severity and age at diagnosis.

STUDY DESIGN

We collected and analyzed epidemiologic data from 285 sister pairs diagnosed with UL. Risk factors for UL-related outcomes were compared among black (n = 73) and white (n = 212) sister pairs using univariate and multivariate regression models.

RESULTS

Black women reported an average age at diagnosis of 5.3 years younger (SE, 1.1; P < .001) and were more likely to report severe disease (odds ratio, 5.22; 95% confidence interval, 1.99-13.7, P < .001) than white women of similar socioeconomic status.

CONCLUSION

Self-reported race is a significant factor in the severity of UL among women with a family history of UL. Differences in disease presentation between races likely reflect underlying genetic heterogeneity. The affected sister-pair study design can address both epidemiological and genetic hypotheses about UL.

MR imaging-guided interventions in the genitourinary tract: an evolving concept

MR imaging-guided interventions are well established in routine patient care in many parts of the world. There are many approaches, depending on magnet design and clinical need, based on MR imaging providing excellent inherent tissue contrast without ionizing radiation risk for patients. MR imaging-guided minimally invasive therapeutic procedures have advantages over conventional surgical procedures. In the genitourinary tract, MR imaging guidance has a role in tumor detection, localization, and staging and can provide accurate image guidance for minimally invasive procedures. The advent of molecular and metabolic imaging and use of higher strength magnets likely will improve diagnostic accuracy and allow targeted therapy to maximize disease control and minimize side effects.

Aromatase excess in cancers of breast, endometrium and ovary

Pathogenesis and growth of three common women's cancers (breast, endometrium and ovary) are linked to estrogen. A single gene encodes the key enzyme for estrogen biosynthesis named aromatase, inhibition of which effectively eliminates estrogen production in the entire body. Aromatase inhibitors successfully treat breast cancer, whereas their roles in endometrial and ovarian cancers are less clear. Ovary, testis, adipose tissue, skin, hypothalamus and placenta express aromatase normally, whereas breast, endometrial and ovarian cancers overexpress aromatase and produce local estrogen exerting paracrine and intracrine effects. Tissue-specific promoters distributed over a 93-kb regulatory region upstream of a common coding region alternatively control aromatase expression. A distinct set of transcription factors regulates each promoter in a signaling pathway- and tissue-specific manner. In cancers of breast, endometrium and ovary, aromatase expression is primarly regulated by increased activity of the proximally located promoter I.3/II region. Promoters I.3 and II lie 215 bp from each other and are coordinately stimulated by PGE(2) via a cAMP-PKA-dependent pathway. In breast adipose fibroblasts exposed to PGE(2) secreted by malignant epithelial cells, PKC is also activated, and this potentiates cAMP-PKA-dependent induction of aromatase. Thus, inflammatory substances such as PGE(2) may play important roles in inducing local production of estrogen that promotes tumor growth.

Ultrasound interstitial thermal therapy (USITT) for the treatment of uterine myomas

Uterine myomas (fibroids) are the most common pelvic tumors occurring in women, and are the leading cause of hysterectomy. Symptoms can be severe, and traditional treatments involve either surgical removal of the uterus (hysterectomy), or the fibroids (myomectomy). Interstitial ultrasound technologies have demonstrated potential for hyperthermia and high temperature thermal therapy in the treatment of benign and malignant tumors. These ultrasound devices offer favorable energy penetration allowing large volumes of tissue to be treated in short periods of time, as well as axial and angular control of heating to conform thermal treatment to a targeted tissue, while protecting surrounding tissues from thermal damage. The goal of this project is to evaluate interstitial ultrasound for controlled thermal coagulation of fibroids. Multi-element applicators were fabricated using tubular transducers, some of which were sectored to produce 180° directional heating patterns, and integrated with water cooling. Human uterine fibroids were obtained after routine myomectomies, and instrumented with thermocouples spaced at 0.5, 1.0, 1.5, 2.0, 2.5 and 3.0 cm from the applicator. Power levels ranging from 8-15 W per element were applied for up to 15 minute heating periods. Results demonstrated that therapeutic temperatures >50° C and cytotoxic thermal doses (t43) extended beyond 2 cm radially from the applicator (>4 cm diameter). It is anticipated that this system will make a significant contribution toward the treatment of uterine fibroids.

Degenerated uterine fibroid mimicking hydrometra: fallacy in CT

Fibroids are the commonest uterine neoplasms, occurring in 20% - 30% of women of reproductive age. In women who have pelvic masses of unknown cause, unusual manifestations of fibroids such as necrosis or degeneration may simulate a carcinoma or hydrometra resulting in problems with image interpretation. We report a case of an unsuspected large degenerated uterine fibroid in a lady mistakenly diagnosed as hydrometra on computed tomography scanning.

Uterine leiomyomas and their effect on in vitro fertilization outcome: a retrospective study

PURPOSE

The effect of uterine leiomyomas on the outcome of in vitro fertilization (IVF) treatment has been controversial. This study was undertaken to clarify influence of fibroids on IVF success, in a large population with age and other potential confounding variables controlled for in the analysis.

METHODS

A population of 141 patients with and 406 without leiomyomata undergoing their first IVF cycle was studied.

RESULTS

The association between uterine leiomyomas and assisted reproduction treatment outcome was not statistically significant (OR = 0.73, 95% CI: 0.49-1.19, p = 0.21) after controlling for age and other risk factors. Also, fibroids neither affected the risk of spontaneous abortion (OR = 1.06, 95% CI: 0.44-2.60) nor the risk of ectopic pregnancy (OR = 0.78, 95% CI: 0.08-8.02). Location of fibroids (intramural vs. submucosal/subserosal) and their size had no significant effect on pregnancy outcome.

CONCLUSIONS

Results from our analyses indicated that in vitro fertilization outcome was not affected by the presence of uterine leiomyomas. Therefore, in patients with normal uterine cavities and fibroids less than a certain size (i.e., < 7 cm), undergoing myomectomies as a prerequisite for assisted reproduction treatment is seriously questionable.

Combining myoma coagulation with endometrial ablation/resection reduces subsequent surgery rates

BACKGROUND

This study compares results of endometrial ablation alone and in combination with myoma coagulation. Subsequent surgery rates were 38% for ablation alone and 12% for combined therapy.

OBJECTIVE

The purpose of this study was to compare hysterectomy rates following various surgical procedures to treat profuse uterine bleeding as well as myomatous uteri.

STUDY DESIGN

This is a descriptive study of women who underwent endometrial ablation alone, endometrial ablation with myoma coagulation, or endometrial resection with myoma coagulation to treat profuse uterine bleeding as well as myomatous uterus. From 1986 to 1995, the author performed 52 endometrial ablation procedures; 88 myoma coagulation and endometrial ablation procedures; and 28 myoma coagulations with resection of submucous myomas in patients who were subsequently available for follow-up. Patients were followed up for up to ten years.

RESULTS

Of the patients undergoing ablation alone, 20 (38%) of 52 required a second surgery for continued symptoms during a mean follow-up of 47 months. Five of these patients (9.6%) underwent hysterectomy. Of the patients who underwent endometrial ablation plus myoma coagulation (myolysis), 11 (12.5%) of 88 required a repeat surgical procedure during a mean follow-up of 25 months. Five of these patients (5.7%) underwent hysterectomy. Volumetric measurements revealed an average reduction in fibroid volume of 54.5% in this patient group following treatment with a gonadotropin-releasing hormone (GnRH) agonist and combined myoma coagulation and endometrial ablation surgery. Of the 28 patients who underwent myoma coagulation plus resection, five (18%) required a repeat procedure. Of these five, one (4%) required hysterectomy. Fibroid volume in this group was reduced by a mean of 72.6% following administration of a GnRH agonist and combined laparoscopic and hysteroscopic surgery as described. The rate of reoperation was significantly lower among patients receiving endometrial ablation with myoma lysis with or without resection compared with those undergoing endometrial ablation alone (P<0.01).

CONCLUSIONS

Myoma coagulation (myolysis), when combined with endometrial ablation among women with symptomatic fibroids and bleeding, reduces all subsequent surgery rates compared with endometrial ablation alone. Myolysis with endometrial resection also results in a reduced need for hysterectomy.