Comparing Perioperative Outcomes of Uterine Artery Embolization and Hysterectomy in Insurer and Demographically Diverse Populations: A Retrospective, Multi-Center Database Study

INTRODUCTION

Past studies comparing perioperative outcomes of hysterectomy (HYST) and uterine artery embolization (UAE) do not control for demographically and insurer diverse populations. This study sought to identify the 30‑day readmission, 15‑day complication, and minimum 1‑year surveillance reintervention rates of diverse, propensity matched patients undergoing UAE or HYST for uterine leiomyoma.

METHODS

Adults from the New York's Statewide Planning and Research Cooperative System (SPARCS) database 2009‑2013 who underwent HYST or UAE for uterine leiomyoma were retrospectively reviewed and 1:1 propensity matched. Univariate analysis compared demographics, complications, readmissions, and reintervention rates. Binary logistic and linear regression models identified independent predictors of outcomes.

RESULTS

A total of 682 patients were identified, where the number (n) of patients in each cohort was n=341, HYST, and n=341, UAE. Significance levels are shown with p values. No significant differences were identified between HYST and UAE demographics, complication (2.60% HYST vs 2.90% UAE, p=0.816) or readmission rates (3.20% HYST vs 3.80% UAE, p=0.678); 0.30% of UAE patients had a reintervention UAE and 2.90% of UAE patients had reintervention hysterectomy. HYST patients had a significantly longer average length of stay (2.59 days HYST vs 1.63 days UAE, p<0.001). The Deyo-Charlson (Deyo) comorbidity score positively predicted any complication with odds ratio=34.262, 95% confidence interval [4.938, 237.725], and p<0.001, but did not predict readmissions.

CONCLUSION

HYST patients had significantly longer hospital stays. UAE and HYST had comparable readmission and complication rates. The Deyo comorbidity score was a significant predictor of any complication. This study supports the safety and efficacy of UAE when compared to HYST in demographic and insurer diverse populations.

Liver function, tolerability and satisfaction during treatment with ulipristal acetate in women with fibroids: a single center experience

The aim of the study was to evaluate liver function in women treated with ulipristal acetate (UPA) and to assess the tolerability and satisfaction during treatment. This Cross-sectional study included women with symptomatic uterine fibroids subjected to one or more 3-month treatment courses of 5 mg UPA daily. Following European Medical Agency's prescriptions, women were asked about symptoms potentially related to liver damage and had blood tests done, to assess serum levels of aspartate aminotransferase (AST) and alanine aminotransferase (ALT). Data on side effects, tolerability and satisfaction with the therapy were obtained during a phone interview. A total of 162 women completed the study with a mean treatment duration of 1.8 ± 0.9 cycles. No increased AST and ALT serum levels were detected and no woman reported symptoms suggestive of liver injury. The majority of women reported improvement of fibroids-related symptoms and a high degree of satisfaction with treatment. More than half of women had side effects, in most cases not as severe as to discontinue therapy. Ulipristal acetate did not worsen liver function or cause severe organ injury and showed high tolerability and satisfaction profiles. Therefore, we believe that it can still be considered a valuable option in the treatment of uterine fibroids.

Short-term quality of life after myomectomy for uterine fibroids from the COMPARE-UF Fibroid Registry

BACKGROUND

Uterine fibroids may decrease quality of life in a significant proportion of affected women. Myomectomy offers a uterine-sparing treatment option for patients with uterine fibroids that can be performed abdominally, laparoscopically (with or without robotic assistance), and hysteroscopically. Quality of life information using validated measures for different myomectomy routes, especially hysteroscopic myomectomy, is limited.

OBJECTIVE

To compare women's perception of their short-term health-related quality of life measures and reported time to return to usual activities and return to work for different routes of myomectomy.

MATERIALS AND METHODS

Comparing Options for Management: Patient-centered Results for Uterine Fibroids (COMPARE-UF) is a prospective nationwide fibroid registry that enrolled premenopausal women seeking treatment for uterine fibroids at 8 clinical sites. For this analysis, we included women undergoing hysteroscopic, abdominal, or laparoscopic myomectomy who completed the postprocedure questionnaire scheduled between 6 and 12 weeks after surgery. Health-related quality of life outcomes, such as pain, anxiety, and return to usual activitie, were assessed for each route. The hysteroscopic myomectomy group had large differences in demographics, fibroid number, and uterine size compared to the other groups; thus, a direct comparison of quality of life measures was performed only for abdominal and laparoscopic approaches after propensity weighting. Propensity weighting was done using 24 variables that included demographics, quality of life baseline measures, and fibroid and uterine measurements.

RESULTS

A total of 1206 women from 8 COMPARE-UF sites underwent myomectomy (338 hysteroscopic, 519 laparoscopic, and 349 abdominal). All women had substantial improvement in short-term health-related quality of life and symptom severity scores, which was not different among groups. Average symptom severity scores decreased about 30 points in each group. Return to usual activities averaged 0 days (interquartile range, 0-14 days) for hysteroscopic myomectomy, 21 days (interquartile range, 14-28 days) for laparoscopic myomectomy, and 28 days (interquartile range, 14-35 days) for abdominal myomectomy. After propensity adjustment, quality of life outcomes in the laparoscopic and abdominal myomectomy groups were similar except for more anxiety in the laparoscopic myomectomy group and slightly more pain in the abdominal myomectomy group. After propensity weighting, return to usual activities favored laparoscopic compared to abdominal procedures; median time was the same at 21 days, but the highest quartile of women in the abdominal group needed an additional week of recovery (interquartile range,14.0-28.0 for laparoscopic versus 14.0-35.0 for abdominal, P < .01). Time to return to work was also longer in the abdominal arm (median, 22 days; interquartile range, 14-40 days, versus median, 42; interquartile range, 27-56).

CONCLUSION

Women who underwent myomectomy had substantial improvement in health-related quality of life, regardless of route of myomectomy. After propensity weighting, abdominal myomectomy was associated with a nearly 2-week longer time to return to work than laparoscopic myomectomy.

Comparison of Clinical Symptoms of Assumed vs. Actual Uterine Fibroids - Symptoms Described by Patients and Ultrasound Findings

Purpose How many women assume that they have fibroids but are found not to have fibroids on ultrasound examination? How severe are the physical symptoms reported by these women compared to the symptoms reported by women with actual uterine fibroids? Are the symptoms more severe if the patient believes that she has at least one relatively large (dominant) fibroid or more than 3 fibroids?

Material and Methods A total of 1548 patients completed an anonymous questionnaire in which they were asked about the number of their fibroids, dysmenorrhea and premenstrual symptoms, dyspareunia and bleeding disorders (using a numerical analog scale between 0 – 10). The questionnaire was administered in a hospital-based fibroid clinic. The information provided by the patients was then compared with transvaginal or abdominal ultrasound findings. The symptoms reported by women with and without fibroid(s) were compared.

Results 1045 out of 1548 patients fulfilled the studyʼs inclusion criteria. Contrary to the information they provided, no fibroid(s) were detected in 6% (62 of 1045 patients) of patients on ultrasound examination. Of these women, 87% had dysmenorrhea, 79% had premenstrual pain and 57% reported dyspareunia. The severity of the symptoms was found not to be associated with the assumed size or number of fibroid(s). There was no significant difference in the pain reported by women without and by women with fibroids. Reporting a feeling of strong pressure on the bladder (OR: 1.18) or abdomen (OR: 1.12) or constipation (OR: 1.16) increased the likelihood of detecting a fibroid on ultrasound investigation.

Conclusions The presence of manifest symptoms (dysmenorrhea, dyspareunia, premenstrual pain, bleeding disorders) does not allow conclusions to be made about the number or size of fibroids or about which therapy is indicated. Even an erroneous assumption about the presence of fibroids may result in patients experiencing symptoms.

Laparoscopic Myomectomy

Laparoscopic myomectomy is minimally invasive treatment for patients suffering from fibroids, especially those wishing to maintain their fertility sparing potential. While this surgery requires intensive training in surgical skills such as intracorporeal suturing and specimen extraction, patients can also expect less adhesion and a quick return to normal activity. This surgery can be broken into three stages, each presenting its own specific and unique challenges—enucleation, reapproximation of the myoma bed, and specimen extraction. To prepare for the broad spectrum of cases where the size and number of fibroids can differ greatly, we have mastered several techniques for each stage of the procedure. To keep the surgery safe, we train for unexpected scenarios by practicing minimally invasive repair and reconstruction techniques. By following basic tenets and understanding the laparoscopic anatomy, we define the targets and boundaries of our dissection to ensure completeness. In this paper, techniques for the enucleation, reapproximation, and extraction will be presented in detail.

Caesarean section in women following an abdominal myomectomy: a choice or a need?

Delivery options following both open and laparoscopic myomectomy remains a controversial topic and opinions vary between obstetricians and gynaecologists. The historical advice of planned caesarean section before 39-weeks persists despite the movement towards the minimal access approach for myomectomy. The main concern remains the small, but potentially catastrophic risk of uterine rupture. Unfortunately, there remains a paucity of data assessing factors that can affect the uterine integrity following laparoscopic myomectomy, such as number, size and type of fibroids, uterine cavity breach and electro-cautery usage. Despite this, the cited 1% overall risk of rupture following myomectomy is similar to the quoted risk following trial of labour after caesarean section, and a successful and safe vaginal delivery can be achieved in as high as 90%. Patient choice and informed consent are essential in the holistic approach to managing these women and safely supporting their delivery choices.

A High-Intensity Focused Ultrasound Surgery Theater Design in a Private Clinic

Noninvasive high-intensity focused ultrasound (HIFU) surgery has become a popular surgical treatment for fibroids, adenomyosis, and various gynecological diseases in China and many countries. While traditional theater designs in hospitals are standardized and easily available for reference, an outpatient HIFU theater design is not yet available in the literature or is nonexistent. The authors presented the design and setup of an ultrasound-guided HIFU center in Hong Kong and listed the space and safety requirements and special features of their HIFU theater. Despite its limited space, the HIFU surgery center has made available a nursing station, a changing room, and an observation/recovery room. A room for learning HIFU treatment and viewing is also available without any intrusion of patient's privacy during treatment. The article concluded that because the space requirements for a HIFU theater were much reduced, the cost of the HIFU theater setup would be much cost-effective. Finally, its relaxing lighting environment was totally different and impossible to be installed in a traditional operating theater in a hospital.

Treatment of symptomatic fibroid disease using uterine fibroid embolisation: An Australian perspective

Uterine leiomyomata (fibroids) are symptomatic in up to 35% of women and treatment can be a costly burden to the individual and society. Options for treatment range from non-hormonal, hormonal, minimally invasive, to surgery. While symptoms from smaller fibroids may respond to simple treatment, those with larger fibroids or with a large volume of disease require a more definitive option. Surgery (hysterectomy or myomectomy) are both well-established treatment modalities with good clinical outcomes. Since the 1990s, uterine fibroid embolisation has emerged as a less invasive option for women than for surgical techniques, while level 1 evidence shows that in the short to mid-term, there is a similar improvement in symptom-related quality of life outcomes to surgery, but with reduced hospital stay and reduced cost. However, in the longer term there may be a need for further treatment or retreatment in some patients compared with surgery. Since its introduction, uptake of this procedure in Australia has been low relative to surgical options. This manuscript reviews the current literature surrounding treatment, along with the trends in uptake of embolisation by Australian women, places this in context of current guidelines from major societies, and encourages gynaecologists and interventional radiologists to be aware of the advantages and limitations of embolisation.

Putative human myometrial and fibroid stem-like cells have mesenchymal stem cell and endometrial stromal cell properties

STUDY QUESTION

Can endometrial stromal stem/progenitor cell markers, SUSD2 and CD146/CD140b, enrich for human myometrial and fibroid stem/progenitor cells?

SUMMARY ANSWER

SUSD2 enriches for myometrial and fibroid cells that have mesenchymal stem cell (MSC) characteristics and can also be induced to decidualise.

WHAT IS KNOWN ALREADY

Mesenchymal stem-like cells have been separately characterised in the endometrial stroma and myometrium and may contribute to diseases in their respective tissues.

STUDY DESIGN, SIZE, DURATION

Normal myometrium, fibroids and endometrium were collected from hysterectomies with informed consent. Primary cells or tissues were used from at least three patient samples for each experiment.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Flow cytometry, immunohistochemistry and immunofluorescence were used to characterise tissues. In vitro colony formation in normoxic and hypoxic conditions, MSC lineage differentiation (osteogenic and adipogenic) and decidualisation were used to assess stem cell activity. Xenotransplantation into immunocompromised mice was used to determine in vivo stem-like activity. Endpoint measures included quantitative PCR, colony formation, trichrome, Oil Red O and alkaline phosphatase activity staining.

MAIN RESULTS AND THE ROLE OF CHANCE

CD146+CD140b+ and/or SUSD2+ myometrial and fibroid cells were located in the perivascular region and formed more colonies in vitro compared to control cells and differentiated down adipogenic and osteogenic mesenchymal lineages in vitro. SUSD2+ myometrial cells had greater in vitro decidualisation potential, and SUSD2+ fibroid cells formed larger tumours in vivo compared to control cells.

LARGE-SCALE DATA

N/A.

LIMITATIONS, REASONS FOR CAUTION

Markers used in this study enrich for cells with stem/progenitor cell activity; however, they do not distinguish stem from progenitor cells. SUSD2+ myometrial cells express markers of decidualisation when treated in vitro, but in vivo assays are needed to fully demonstration their ability to decidualise.

WIDER IMPLICATIONS OF THE FINDINGS

These results suggest a possible common MSC for the endometrial stroma and myometrium, which could be the tumour-initiating cell for uterine fibroids.

STUDY FUNDING/COMPETING INTEREST(S)

These studies were supported by NIH grants to JMT (R01OD012206) and to ALP (F32HD081856). The authors certify that we have no conflicts of interest to disclose.

Vitamin D, reproductive disorders and assisted reproduction: evidences and perspectives

Vitamin D is an important nutrient involved in many fundamental health outcomes. However, its influence on female reproductive function remains ambiguous. Cholecalciferol seems to have a role in the reproductive processes and in the patients affected by polycystic ovary syndrome, endometriosis, uterine myomas and premature ovarian failure. Moreover, it may play an important role in the assisted reproductive techniques, given that it is capable of influencing oocyte quality, but also an adequate preparation of the endometrium for embryonic implantation. Although promising, available evidence is based on a limited number of in vitro, in vivo and clinical studies. We provide an overview of the association between vitamin D and female infertility reporting the most recent data published in the literature. Nevertheless, properly randomised clinical trials are mandatory to achieve more conclusive results about the promising role of vitamin D in the management of female assisted reproduction.

Uterine fibroid management: Today and tomorrow

Current treatments for fibroids are mainly surgical and expensive, so alternatives need to be found. It is, therefore, vital to develop and evaluate alternatives to surgical procedures, especially when fertility preservation is the goal. Selective progesterone receptor modulators (SPRMs) are synthetic compounds that have either an agonistic or antagonistic impact on target tissues determined by their binding to progesterone receptors. Their mixed activity depends on recruitment of cofactors that regulate transcription along so-called genomic pathways, as well as nongenomic interactions with other signaling pathways. There is no doubt that surgery remains indicated in some instances, but we must now establish whether use of SPRMs (notably ulipristal acetate) allows less invasive surgery or even complete avoidance of surgery. Long-term intermittent administration of ulipristal acetate will undoubtedly change our approach to the management of uterine fibroids according to the International Federation of Gynecology and Obstetrics classification, which provides a comprehensive basis for different treatment options. When considering less invasive techniques (uterus-sparing options like myomectomy), the choice is guided by the size, number and location of fibroids, as well as the personal experience of the gynecologist and available equipment. There is now a growing body of evidence pointing to the crucial role of progesterone pathways in the pathophysiology of uterine fibroids. SPRMs should, therefore, be considered an alternative to surgical therapy, or at least an adjunct to surgery, as illustrated in the algorithms. © 2019 Japan Society of Obstetrics and Gynecology.

The Use of Ulipristal Acetate (Esmya) Prior to Laparoscopic Myomectomy: Help or Hindrance?

Introduction:

The aim of this study was to assess the operative effects, both positive and negative, of pretreatment with ulipristal acetate (UPA) on laparoscopic myomectomy.

Materials and Methods:

We conducted a retrospective analysis of prospectively collected data from patients who underwent a laparoscopic myomectomy over a 2-year period.

Results:

A total of 62 patients were included, of which 10 received a 3-month preoperative course of UPA, and 52 patients received no pretreatment. There was no statistically significant difference between the two groups (no pretreatment vs. UPA pretreatment) with regard to blood loss (214.4 [±214.96] vs. 160 [±51.64], P = 0.432), operating time (111.64 [±41.8] vs. 117.5 [±50.4], P = 0.694), and duration of inpatient stay (1.27 [±0.56] vs. 1.11 [±0.33], P = 0.419). There were no complications in either group. In 100% of cases with UPA pretreatment, a distortion of the fibroid capsule with a more technically challenging dissection was noted, compared to 0% in the no pretreatment group. This anatomical distortion may result in more cases of incomplete resection and a potentially higher risk of recurrence.

Conclusion:

We conclude that UPA confers no operative benefits and should be used with caution in the presurgical treatment of fibroids. The use of UPA may indeed result in a more technically difficult myomectomy with distorted cleavage planes and carry a potential risk of incomplete resection.

Adlay (Coix lachryma-jobi L. var. ma-yuen Stapf.) Hull Extract and Active Compounds Inhibit Proliferation of Primary Human Leiomyoma Cells and Protect against Sexual Hormone-Induced Mice Smooth Muscle Hyperproliferation

Uterine leiomyomas, also known as fibroids, are benign neoplasms of the uterus and have a high incidence rate in women of reproductive age. Hysterectomy or myomectomy is the initial treatment, but fibroids will recur if the patient is still exposed to similar risk factors. Therefore, developing new therapeutic strategies are urgently necessary. In this study, the anti-proliferation effects of each fraction of adlay seeds were evaluated in uterine leiomyomas, and we identified the potential phytochemical compounds. We found that the ethyl acetate fraction of adlay hull (AHE-ea) appeared to be highly efficient in the anti-proliferation of rat uterine leiomyoma ELT3 cells and primary human uterine leiomyoma (hUL) cells. The proliferation of primary human normal uterine smooth muscle (UtSMC) and normal uterine myometrial (hUM) cells were also suppressed by AHE-ea. Two phytosterols, stigmasterol and β-sitosterol, were identified from AHE-ea fraction. Mice treated with AHE-ea and stigmasterol alone demonstrated reduced diethylstilbestrol/medroxyprogesterone 17-acetate (DES/MPA)-induced uterine myometrial hyperplasia, which is the critical step for the development of leiomyoma. Taken together, our results suggest that the AHE-ea fraction could be considered as a natural plant-based medicine in the prevention or treatment of uterine leiomyoma growth.

Multiparametric MRI Characterization of Funaki Types of Uterine Fibroids Considered for MR-Guided High-Intensity Focused Ultrasound (MR-HIFU) Therapy

RATIONALE AND OBJECTIVES

To compare quantitative multiparametric magnetic resonance imaging (mpMRI) data of symptomatic uterine fibroids being considered for MR-guided high-intensity focused ultrasound ablation with fibroid characterization based on the Funaki Classification scheme.

MATERIALS AND METHODS

This was a prospective, Institutional Review Board -approved, Health Insurance Portability, and Accountability Act-compliant study. Informed consent was obtained. From December 2013 to April 2015, 48 women with symptomatic fibroids underwent screening with mpMRI protocol including sagittal/axial T2-weighted fast spin-echo, sagittal diffusion-weighted, and sagittal dynamic contrast-enhanced 3D T1-weighted gradient echo imaging on a 3T magnet. All fibroids were assigned Funaki type 1, 2, or 3 based on T2-weighted imaging. Differences in size, perfusion, and diffusion/intravoxel incoherent motion parameters among the three Funaki types were determined using linear mixed model. A logistic regression analysis was performed to select the best model in predicting type 3 fibroids.

RESULTS

A total of 100 fibroids were assessed (20 type 1, 66 type 2, and 14 type 3). Apparent diffusion coefficient and D of type 3 fibroids were significantly higher than those of type 1 (P < 0.0001, P < 0.0001) and 2 fibroids (P = 0.004, P < 0.0001) respectively. Transfer constant of type 3 fibroids was significantly higher than type 1 (P = 0.0357), but not than type 2 (P = 0.0752). A cutoff value of D = 1 × 10^-3 mm²/s offers an accuracy, sensitivity, and specificity of 76%, 71%, and 77%, respectively, for the diagnosis of Funaki 3 fibroids.

CONCLUSION

mpMRI-derived quantitative parameters may enable a more objective selection of patients prior to MR-guided high-intensity focused ultrasound therapy.

Creation and Piloting of a Model for Simulating a Minimally Invasive Myomectomy

Introduction: In the era of mandatory work hour restrictions for residency programs, the opportunity for mastery of complex surgical skills in the operating room (OR) has been compromised. All the while, gynecologic surgical techniques have continued to expand. Surgical simulation offers an adjuvant modality for helping young surgeons hone their surgical techniques. We sought to design, construct, and pilot a model for simulating a minimally invasive myomectomy procedure for the purpose of resident training. We undertook a preliminary evaluation of the model’s validity.

Methods: Gynecologic surgical simulation models were constructed from polyvinyl alcohol poured into 3D-printed injection molds. A total of 12 laparoscopic and 12 robot-assisted simulated myomectomies were performed using the models. Face and content validity were evaluated with post-simulation questionnaires. Construct validity was assessed by comparing procedural metrics (time to completion and estimated blood loss) between residents and attending surgeons.

Results: In the post-simulation survey, the majority of attending surgeons agreed the model was realistic (83.3%) and included the critical steps of a myomectomy (87.5%). Most residents agreed they would feel more prepared for a myomectomy if they practiced on the model beforehand (87.5%) and the majority of attending surgeons agreed they would feel comfortable giving a resident more operative autonomy if the resident had previously completed the simulation (71.4%). Procedural metrics were not significantly associated with expertise level.

Conclusion: We were able to successfully create a model for simulating a minimally invasive myomectomy. Initial simulations using the model were well received by participants. Further development and investigation of the model will be pursued to determine if this is a valid and useful tool for teaching and practicing a minimally invasive myomectomy.

Uterine artery embolization in the treatment of symptomatic fibroids - state of the art 2018

Uterine fibroids are considered to be the most common benign tumours in females. The vast majority of these tumours are incidental findings and do not require any treatment. Symptomatic fibroids, with ailments such as abnormal uterine bleeding, dysmenorrhoea, pelvic pain, impaired urination, bowel dysfunction, infertility, and recurrent pregnancy loss, are indicated for medical treatment. Surgery remains a first-line treatment of symptomatic uterine fibroids; however, minimally invasive techniques and pharmacological management have become more available and popular. Among minimally invasive techniques uterine artery embolization (UAE) is the most well-established uterine preserving treatment. UAE was first introduced in obstetrics and gynaecology in 1987 and since then many studies have shown the safety and efficacy of UAE in fibroid treatment with low rates of complications. In this review we present a novel approach to UAE, which reflects the current state of knowledge based on recent clinical trials and long-term post-procedural follow-up.

Uterine structural abnormality and intrauterine device malposition: analysis of ultrasonographic and demographic variables of 517 patients

BACKGROUND

Intrauterine devices are currently one of the leading forms of reversible contraception in the world. However, in approximately 10-25% of women, intrauterine devices can become malpositioned, leading to consequences including pain, bleeding, as well as possible decreased contraceptive efficacy.

OBJECTIVE

We sought to determine whether certain reproductive and uterine characteristics are associated with an increased risk of intrauterine device malposition. We hypothesized that anatomical characteristics such as the presence of any uterine anomalies, particularly congenital anomalies and fibroids that may lead to cavitary distortion, would be associated with a higher incidence of intrauterine device malposition.

MATERIALS AND METHODS

We conducted a retrospective case-control study in an academic medical center. All patients presenting for scheduled ultrasound appointments for gynecologic indication between June 2004 and February 2016 were included (1,253 ultrasound reports identified). Of these, 236 demonstrated malpositioned intrauterine devices. With a control group of 281 patients with normal intrauterine device location, a total of 517 patients were included in the study. Transabdominal and transvaginal ultrasounds were performed followed by 3-dimensional rendering (as per our institution's protocol for patients with intrauterine devices) using Voluson 730 and Voluson E8 ultrasound machines. Demographic and reproductive characteristics, indication for ultrasound, intrauterine device, and uterine characteristics were all extrapolated from the electronic medical record. χ² Tests were performed for categorical variables. Generalized linear models for Poisson distributed variables, and multiple logistic regression were used to ascertain significant independent predictors of IUD malposition. Ninety-five percent confidence intervals and effect sizes were calculated, and P < .05 was considered statistically significant.

RESULTS

In this study, we found a cumulative IUD malposition rate of 19%. In patients with malpositioned intrauterine devices, there was increased incidence of retroflexed uterine positions (7.6% vs 1.8%, P = .001), and all uterine anomalies (this includes septate and bicornuate uteri and fibroids, 31.9% vs 23.5%, P = .02) compared with controls. The anterior midline uterine position was more commonly noted in controls (28.5% vs 11%, P < .001). A higher total number of fibroids was noted in the malpositioned group (3.7 vs 1.8, P = .01); however, fibroid size was not statistically significant. In particular, there was an increased incidence of submucosal fibroids in women with malpositioned intrauterine devices (P = .01). Multivariable logistic regression revealed that anterior midline position (odds ratio [OR], 0.33; 95% confidence interval [CI], 0.20-0.57) and absence of uterine anomalies (OR, 0.59; 95% CI, 0.38-0.93) were factors associated with a lower risk of IUD malposition; whereas vaginal bleeding (OR, 2.25; 95% CI, 1.38-3.67), pain (OR, 2.85; 95% CI, 1.84-4.44), or missing IUD strings at time of presentation (OR, 3.58; 95% CI, 1.88-6.82) were associated with an increased risk of malposition.

CONCLUSION

Retroflexed uterine positions and all uterine malformations are associated with higher incidence of malpositioned intrauterine devices. Presence of increased number of fibroids and specifically submucosal fibroids showed a positive association with intrauterine device malposition, as did symptoms of bleeding, pain, and missing IUD strings at time of presentation. These findings pertain to women presenting for gynecologic ultrasound evaluation and may not be generalizable to all women with IUDs.

Relation between hysterectomy, oophorectomy and the risk of incident differentiated thyroid cancer: The E3N cohort

BACKGROUND

Thyroid cancers are threefold more frequent in women than in men. A role of reproductive or hormonal factors has been suggested but with contradictory results. We investigated potential associations between history of hysterectomy, with or without oophorectomy, and history of benign gynaecological disease (uterine fibroids, endometriosis) and the incidence of differentiated thyroid cancer, in a large French prospective cohort.

METHODS

A total of 89 340 women from the E3N cohort were followed up between 1990 and 2012. Gynaecological diseases treated by surgery were self-reported. Thyroid cancers were validated by histological reports. Time-dependent covariates included smoking status, BMI and history of benign thyroid disease. Cox proportional hazard models with age as timescale were used to estimate Hazard Ratios (HR) and 95% confidence intervals (CI).

RESULTS

A total of 412 cases of thyroid cancer were diagnosed during follow-up. A history of hysterectomy was associated with an increased risk of differentiated thyroid cancer (adjusted HR=2.05; 95%CI: 1.65-2.55). The association was not altered after further adjustment for reproductive factors. Endometriosis, uterine polyps, ovarian cysts and oophorectomy without hysterectomy were not associated with the risk of thyroid cancer. A history of fibroids was also significantly related to the risk of thyroid cancer over the follow-up period (adjusted HR=1.91; 95%CI: 1.50-2.44) and the increased risk persisted after adjustment for history of hysterectomy.

CONCLUSIONS

Women who had either a history of fibroids or hysterectomy had an increased risk of differentiated thyroid cancer. These findings suggest shared biological mechanisms between fibroids and thyroid cancer, which deserve to be further dissected.

Uterine Fibroids and the Risk of Cardiovascular Disease in the Coronary Artery Risk Development in Young Adult Women's Study

BACKGROUND

Uterine fibroids, the most common reproductive tract tumor in women, have been associated with hypertension and atherosclerotic cardiovascular disease (CVD). Prior studies of fibroids and CVD have examined the subset of women with symptomatic fibroids who undergo hysterectomy, itself a risk factor for CVD. We aimed to study the risk of subclinical CVD, as determined by coronary artery calcification (CAC), carotid intima media thickness (CIMT), and left ventricular (LV) mass, in women with ultrasound-diagnosed uterine fibroids.

MATERIALS AND METHODS

Participants were 972 women from the Coronary Artery Risk Development in Young Adults (CARDIA) study, a cohort recruited in 1985-1986. CARDIA screened black and white women aged 35-49 years by ultrasound for fibroids at 16 years of follow-up (2002-2004). Demographics and CVD risk factors were collected in 2000-2001 at 15 years of follow-up (baseline for this analysis). Women were tested at years 15, 20, and 25 for CAC, at year 20 for CIMT, and at year 25 for echocardiographic LV mass. Multivariable logistic regression was used to estimate the odds of CAC, CIMT, and LV mass.

RESULTS

Fifty-two percent of women had fibroids (61.7% in black, 38.3% in white women). Most CVD risk factors were more common in women with fibroids. Adjusted odds of subclinical CVD, such as elevated CIMT and elevated LV mass, were not different for women with fibroids compared with those without (CIMT odds ratio [OR] = 1.03; confidence interval [95% CI] 0.7-1.5 and LV mass OR = 1.14; 95% CI 0.77-1.68), when adjusted for confounders.

CONCLUSIONS

Although women with fibroids had more CVD risk factors, presence of fibroids was not associated with subclinical CVD.

Perinatal outcomes of women undergoing cesarean delivery after prior myomectomy

Background: The American College of Obstetricians and Gynecologists recommends that women who have had a prior myomectomy that entered the endometrial cavity undergo cesarean delivery in order to avoid the possible complication of uterine rupture. Women with prior myomectomies may also have intraabdominal adhesions, complicating future surgery and if myomas remain after myomectomy, they may have more bleeding complications during their subsequent pregnancies.Objectives: The purpose of this study was to evaluate maternal and neonatal outcomes after prior myomectomy in women undergoing planned cesarean delivery.Study design: We conducted a retrospective cohort study using the Maternal Fetal Medicine Units Cesarean Registry database comparing women undergoing a cesarean delivery with a history of prior myomectomy to women undergoing a cesarean delivery without a history of a prior myomectomy. Inclusion criteria were singleton gestations at term undergoing planned cesarean delivery. Exclusion criteria were stillbirth, cesarean delivery indication for nonreassuring fetal heart rate, macrosomia, abruption, previa or women undergoing planned trial of labor after cesarean. Primary outcome was incidence of blood transfusion. Maternal and neonatal outcomes were compared secondarily. Logistic regression was used to adjust for confounders.Results: The entire study population included 73,257 deliveries; 34,002 women met inclusion criteria, of which 367 had a prior myomectomy and 33,635 were controls. The demographics, which varied by maternal age, race and number of prior cesareans were adjusted for when calculating maternal outcomes. The rate of intraoperative transfusion in the prior myomectomy group was 1.4% (5/367) compared to 0.4% (131/33,635) in the control group (aOR 2.8; 95% CI 1.15-6.79). The prior myomectomy group had a higher incidence of postpartum transfusion rate (2.5%, 9/367) compared to the control group (1.2%, 416/33,635) (aOR 2.03; 1.06-3.92), uterotonic usage (5.4%, 20/367) compared to the control group (3.5%, 1165/33,635; aOR 1.57; 95% CI 1.01-2.45), bowel injury (0.5%, 2/367) compared to the control group (0.0%, 14/33,635; aOR 8.13; 95% CI 2.05-32.28) and cesarean hysterectomy (1.4%, 5/367) compared to the control group (77/33,635; aOR 3.43; 95% CI 1.32-8.91). Neonatal outcomes were not different between groups.Conclusion: Prior myomectomy in women with term, singleton gestations undergoing planned cesarean delivery was associated with an 180% increased risk of intraoperative transfusion compared to the control group. We also found that women in the myomectomy group are 57% more likely to use uterotonics, 713% more likely to experience a bowel injury, 243% more likely to undergo a cesarean hysterectomy, and 227% more likely to need a classical uterine incision during delivery. Neonatal morbidity was not statistically different between the groups.

Results of an internal audit on the survival of patients with uterine sarcoma

Objective:

In the last 5 years there has been much discussion about the surgical procedure for uterine fibroids, and essentially, also uterine sarcoma. Still there exists no reliable presurgical diagnostic tool to differentiate between benign fibroids and uterine sarcomas. The aim of this study was to confirm the suspected association between intraoperative spread of tumor by morcellation and impaired outcomes in patients with sarcoma.

Material and Methods:

After the local ethics commission positively reviewed the study protocol, the oncologic database of our university hospital was retrospectively reviewed for patients with uterine sarcomas over a time period of 13 years (2002-2015). Data was extracted from the medical files and survival information was collected by contacting the patient’s general practitioners if last follow-up-status was older than 6 months. For the analysis, patients were split into two groups with either intrasurgical morcellation (M+) or no morcellation (M-) regarding information provided by the surgical report.

Results:

Data on 57 patients with uterine sarcoma were available for further analysis. The median age and body mass index of the patients was 63 years and 27 kg/m², respectively. The sarcoma subtypes were 25 leiomyosarcoma, 19 carcinosarcoma, 9 endometrioid stroma sarcoma, 3 adenosarcoma, and one case without further differentiation. In the majority, no morcellation was performed (M- group, n=44) and 51 patients received open surgery (3 laparoscopic, 1 vaginal, and 2 incomplete surgeries). The median time of follow-up was 31 months. The disease-free survival was 50.5 months and the Cox regression analysis showed a hazard ratio of 3.06 [no significant difference between the two subgroups (p=0.079; 95% confidence interval (CI): 0.9-10.6)]. The overall survival was found as 62.2 months and the Cox regression analysis showed a hazard ratio of 3.216 with a statistically significant difference between the two subgroups (p=0.013; 95% CI: 1.3-8.1).

Conclusion:

Despite the efforts to find a pre-surgical diagnostic tool, the clinical situation remains unsatisfactory. Overall sarcoma prevalence is low during the last 13 years at our university center, but morcellation occurred in a relevant portion of patients (13 of 57). If sarcoma is suspected or diagnosed then en-bloc resection of the uterus can prolong survival. Thus, morcellation of the uterus and not the surgical technique (en-bloc resection) is the prognostic factor and should be avoided in any suspicious case.

Influence of Ulipristal Acetate Therapy on Uterine Fibroid-Related Symptoms and on Uterine and Fibroid Volumes and Vascularity Indices Assessed by Ultrasound

OBJECTIVES

To investigate the modifications of uterine and fibroid volume, to study Doppler changes in uterine arteries and fibroid-supplying vessels, and to assess possible symptomatic relief after 3 months of treatment with ulipristal acetate.

METHODS

Forty-two premenopausal women with symptomatic fibroids were included in the study. They were evaluated clinically for the symptoms reported and underwent ultrasound examinations before starting treatment and after 3 months of therapy with ulipristal acetate. Transvaginal scanning was performed by the same sonographer, who measured the uterine volume and uterine artery pulsatility index and resistive index. Considering that some patients had more than 1 fibroid, the vascularization (supplying vessel pulsatility and resistive indices), locations, and sizes of a total of 73 fibroids were also recorded.

RESULTS

After 3 months of ulipristal acetate, patients had a significant improvement of all symptoms (P < .05). The percentage of uterine volume reduction was 14% (P = .03), with fibroid volume reduction of 32.8% (P = .01). Uterine artery vascular indices decreased after treatment, but their reduction did not reach significant results, whereas all fibroid vascular indices decreased significantly after 3 months of ulipristal acetate (P < .05). When the fibroids were divided according to their localization, all had significant volume reduction after therapy, but type 5 had the highest decrease (42%) compared to other fibroid types (P = .03).

CONCLUSIONS

Fibroid treatment with ulipristal acetate resulted in a significant improvement of fibroid-related symptoms; moreover, it proved to be effective in decreasing both uterine and fibroid volumes and fibroid vascularization. Type 5 fibroids seem to have the most major response to treatment.

Cellular kinetics of MED12-mutant uterine leiomyoma growth and regression in vivo

Cellular mechanisms of uterine leiomyoma (LM) formation have been studied primarily utilizing in vitro models. However, recent studies established that the cells growing in the primary cultures of MED12-mutant LM (MED12-LM) do not carry causal mutations. To improve the accuracy of LM research, we addressed the cellular mechanisms of LM growth and regression utilizing a patient-derived xenograft (PDX) model, which faithfully replicates the patient tumors in situ The growth and maintenance of MED12-LMs depend on 17β-estradiol (E2) and progesterone (P4). We determined E2 and P4-activated MAPK and PI3K pathways in PDXs with upregulation of IGF1 and IGF2, suggesting that the hormone actions on MED12-LM are mediated by the IGF pathway. When hormones were removed, MED12-LM PDXs lost approximately 60% of volume within 3 days through reduction in cell size. However, in contrast to general belief, the survival of LM cells was independent of E2 and/or P4, and apoptosis was not involved in the tumor regression. Furthermore, it was postulated that abnormal collagen fibers promote the growth of LMs. However, collagen fibers of actively growing PDXs were well aligned. The disruption of collagen fibers, as found in human LM specimens, occurred only when the volume of PDXs had grown to over 20 times the volume of unstimulated PDXs, indicating disruption is the result of growth not the cause. Hence, this study revises generally accepted theories on the growth and regression of LMs.

No. 109-Hysterectomy

OBJECTIVE

To identify the indications for hysterectomy, preoperative assessment, and available alternatives required prior to hysterectomy. Patient self-reported outcomes of hysterectomy have revealed high levels of patient satisfaction. These may be maximized by careful preoperative assessment and discussion of other treatment choices. In most cases hysterectomy is performed to relieve symptoms and improve quality of life. The patient's preference regarding treatment alternatives must be considered carefully.

OPTIONS

The areas of clinical practice considered in formulating this guideline are preoperative assessment including alternative treatments, choice of method for hysterectomy, and evaluation of risks and benefits. The risk-to-benefit ratio must be examined individually by the woman and her health practitioners.

OUTCOMES

Optimizing the decision-making process of women and their caregivers in proceeding with a hysterectomy having considered the disease process, and available alternative treatments and options, and having reviewed the risks and anticipated benefits.

EVIDENCE

Using Medline, PubMed, and the Cochrane Database, English language articles were reviewed from 1996 to 2001 as well as the review published in the 1996 SOGC guidelines. The level of evidence has been determined using the criteria described by the Canadian Task Force on the Periodic Health Examination.

BENEFITS, HARMS, AND COSTS

Hysterectomy is the treatment of choice for certain gynaecologic conditions. The predicted advantages must be carefully weighed against the possible risks of the surgery and other treatment alternatives. In the properly selected patient, the result from the surgery should be an improvement in the quality of life. The cost of the surgery to the health care system and to the patient must be interpreted in the context of the cost of untreated conditions. The approach selected for the hysterectomy will impact on the cost of the surgery.

RECOMMENDATIONS

Benign Disease Preinvasive Disease Invasive Disease Acute Conditions Other Indications Surgical Approach VALIDATION: Medline searches were performed in preparing this guideline with input from experts in their field across Canada. The guideline was reviewed and accepted by SOGC Council and Executive.

SPONSOR

The Society of Obstetricians and Gynaecologists of Canada.

Proteomic Analysis Identifies Tenascin-C Expression Is Upregulated in Uterine Fibroids

Uterine leiomyomas (fibroids) are the most common gynecological tumors, which are enriched in the extracellular matrix (ECM). Fibroids are leading cause of abnormal uterine bleeding and hysterectomy. One of the major questions yet to be answered is the overproduction of specific ECM components in human uterine fibroids, particularly in relation to mutations in the driver gene mediator complex subunit 12 ( MED12). Surgical specimens from 14 patients with uterine leiomyoma having fibroids and corresponding adjacent normal myometrium (ANM) were utilized to analyze genetic and proteomic expression patterns in the tissue samples. MED12 mutations in the fibroids were screened by Sanger sequencing. iTRAQ was used to label the peptides in small-, medium-, and large-sized fibroid samples of annotated MED12 mutation from the same patient. The mixtures of the peptides were fractionated by hydrophilic interaction liquid chromatography (HILIC) and analyzed by liquid chromatography-tandem mass spectrometry (LC-MS/MS) to identify the differential expression proteins. Using isobaric tagged-based quantitative mass spectrometry on 3 selected patients, ECM-related protein tenascin-C (TNC) was observed significantly upregulated (>1.5-fold) with a confidence corresponding to false discovery rate (FDR) <1% in small-, medium-, and large-sized fibroid samples regardless of MED12 mutation status. The TNC was validated on additional patient samples using Western blotting (WB) and immunohistochemistry (IHC) and confirmed significant overexpression of this protein in fibroids compared to matched ANM. Proteomic analyses have identified the increased ECM protein expression, TNC, as a hallmark of uterine fibroids regardless of MED12 mutations. Further functional studies focusing on the upregulated ECM proteins in leiomyogenesis will lead to the identification of novel ECM drug targets for fibroid treatment.