The impact of uterine leiomyomas: a national survey of affected women

Black Women's Psychosocial Experiences with Seeking Surgical Treatment for Uterine Fibroids: Implications for Clinical Practice

INTRODUCTION

Black women are more likely to undergo surgery for uterine fibroids compared with non-Black women. However, few studies have characterized the psychosocial experiences of Black women seeking fibroid treatment. We aimed to identify factors that shape Black women's fibroid management decisions; explore how discrimination based on race, class, and gender feature in treatment-seeking experiences, and compare experiences across age and socioeconomic status.

METHODS

We conducted semistructured interviews with 37 Black women undergoing surgery for fibroid management. We used a thematic analysis to code transcripts and identify themes.

RESULTS

Participants were predominately single, college educated, and insured. Respondents reported that patient-doctor interactions, support from social networks, fertility consequences, and fear of fibroid malignancy influenced their fibroid management decisions. Knowledge and perceptions of fibroids were also influenced by community norms and differed by socioeconomic status; women of higher socioeconomic status had greater fibroid awareness than women of lower socioeconomic status. Discrimination was discussed in the context of historical inequity against Black women, with one participant questioning whether Black women were valued less in clinical settings compared with non-Black women. Although several women discussed positive experiences seeking fibroids care, others expressed medical mistrust or said that alternative management options were not offered by clinicians.

CONCLUSIONS

Fibroid management decisions were influenced not only by interactions with clinicians and social networks, and concerns about fertility and fibroid malignancy, but also by broader social and historical conditions. These findings suggest that clinicians should deliver intersectional gynecologic care that centers the voices of Black women seeking fibroid treatment.

Predictors of response for elagolix with add-back therapy in women with heavy menstrual bleeding associated with uterine fibroids

BACKGROUND:

Uterine fibroids are one of the most common neoplasms found among women globally, with a prevalence of approximately 11 million women in the United States alone. The morbidity of this common disease is significant because it is the leading cause of hysterectomy and causes significant functional impairment for women of reproductive age. Factors including age, body mass index, race, ethnicity, menstrual blood loss, fibroid location, and uterine and fibroid volume influence the incidence of fibroids and severity of symptoms. Elagolix is an oral gonadotropin-releasing hormone receptor antagonist that competitively inhibits pituitary gonadotropin-releasing hormone receptor activity and suppresses the release of gonadotropins from the pituitary gland, resulting in dose-dependent suppression of ovarian sex hormones, follicular growth, and ovulation. In Elaris Uterine Fibroids 1 and Uterine Fibroids 2, 2 replicate multicenter, double-blind, randomized, placebo-controlled, phase 3 studies, treatment of premenopausal women with elagolix with hormonal add-back therapy demonstrated reduction in heavy menstrual bleeding associated with uterine fibroids.

OBJECTIVE:

This analysis aimed to evaluate the safety and efficacy of elagolix (300 mg twice a day) with add-back therapy (1 mg estradiol/0.5 mg norethindrone acetate once a day) in reducing heavy menstrual bleeding associated with uterine fibroids in various subgroups of women over 6 months of treatment.

STUDY DESIGN:

Data were pooled from Elaris Uterine Fibroid-1 and Uterine Fibroid-2 studies, which evaluated premenopausal women (18–51 years) with heavy menstrual bleeding (>80 mL menstrual blood loss per cycle, alkaline hematin methodology) and ultrasound-confirmed uterine fibroid diagnosis. Subgroups analyzed included age, body mass index, race, ethnicity, baseline menstrual blood loss, fibroid location, and uterine and primary fibroid volume (largest fibroid identified by ultrasound). The primary endpoint was the proportion of women with <80 mL menstrual blood loss during the final month and ≥50% menstrual blood loss reduction from baseline to final month. Secondary and other efficacy endpoints included mean change in menstrual blood loss from baseline to final month, amenorrhea, symptom severity, and health-related quality of life. Adverse events and other safety endpoints were monitored.

RESULTS:

The overall pooled Elaris Uterine Fibroid-1 and Uterine Fibroid-2 population was typical of women with fibroids, with a mean age of 42.4 (standard deviation, 5.4) years and a mean body mass index of 33.6 (standard deviation, 7.3) kg/m² and 67.6% of participants being black or African American women. A wide range of baseline uterine and fibroid volumes and menstrual blood loss were also represented in the overall pooled study population. In all subgroups, the proportion of responders to the primary endpoint, mean change in menstrual blood loss, amenorrhea, reduction in symptom severity, and improvement in health-related quality of life were clinically meaningfully greater for women who received elagolix with add-back therapy than those who received placebo and consistent with the overall pooled study population for the primary endpoint (72.2% vs 9.3%), mean change in menstrual blood loss (−172.5 mL vs −0.8 mL), amenorrhea (50.4% vs 4.5%), symptom severity (−37.1 vs −9.2), and health-related quality of life score (39.9 vs 8.9). Adverse events by subgroup were consistent with the overall pooled study population.

CONCLUSION:

Elagolix with hormonal add-back therapy was effective in reducing heavy menstrual bleeding associated with uterine fibroids independent of age, body mass index, race, ethnicity, baseline menstrual blood loss, fibroid location, and uterine and primary fibroid volume.

Analysis of magnetic resonance signal intensity changes in the sacrococcygeal region of patients with uterine fibroids treated with high intensity focused ultrasound ablation

Objective: To evaluate the magnetic resonance (MR) signal intensity changes in the sacrococcygeal region of patients with uterine fibroids treated with high intensity focused ultrasound (HIFU).Materials and Methods: Two hundred and sixty-seven patients with uterine fibroids treated with HIFU between January and December 2016 were retrospectively reviewed. All patients underwent enhanced pre- and post-HIFU MRI. Multivariate analysis was used to assess the relationship between the factors and the signal intensity changes in the sacrum and the soft tissue adjacent to the sacrum.Results: Among the 267 patients, 122 (46%) had MR signal intensity changes in the sacrum and/or the soft tissue adjacent to the sacrum after HIFU. Multivariate analysis showed that the position of the uterus, the distance from the dorsal side of the fibroid to the sacrum, and the ablation efficiency were significantly correlated with MR signal intensity changes in the sacrum and the soft tissue adjacent to the sacrum. Further analysis showed a significant relationship between the location of the MR signal intensity changes and uterine size, the enhancement degree of the uterus. Leg pain was only seen in patients with MR signal intensity changes both in the sacrum and the soft tissue adjacent to the sacrum.Conclusions: The location of the uterus, the distance between the dorsal side of the fibroids to the sacrum, and ablation efficiency have a significant relationship with the MR signal intensity changes. The size of the uterus and the degree of enhancement are related to the locations of MR signal changes.

Validation of a menstrual pictogram and a daily bleeding diary for assessment of uterine fibroid treatment efficacy in clinical studies

BACKGROUND

To evaluate the psychometric and measurement properties of two patient-reported outcome instruments, the menstrual pictogram superabsorbent polymer-containing version 3 (MP SAP-c v3) and Uterine Fibroid Daily Bleeding Diary (UF-DBD). Test-retest reliability, criterion, construct validity, responsiveness, missingness and comparability of the MP SAP-c v3 and UF-DBD versus the alkaline hematin (AH) method and a patient global impression of severity (PGI-S) were analyzed in post hoc trial analyses.

RESULTS

Analyses were based on data from up to 756 patients. The full range of MP SAP-c v3 and UF-DBD response options were used, with score distributions reflecting the cyclic character of the disease. Test-retest reliability of MP SAP-c v3 and UF-DBD scores was supported by acceptable intraclass correlation coefficients when stability was defined by the AH method and Patient Global Impression of Severity (PGI-S) scores (0.80-0.96 and 0.42-0.94, respectively). MP SAP-c v3 and UF-DBD scores demonstrated strong and moderate-to-strong correlations with menstrual blood loss assessed by the AH method. Scores increased in monotonic fashion, with greater disease severities, defined by the AH method and PGI-S scores; differences between groups were mostly statistically significant (P < 0.05). MP SAP-c v3 and UF-DBD were sensitive to changes in disease severity, defined by the AH method and PGI-S. MP SAP-c v3 and UF-DBD showed a lower frequency of missing patient data versus the AH method, and good agreement with the AH method.

CONCLUSIONS

This evidence supports the use of the MP SAP-c v3 and UF-DBD to assess clinical efficacy endpoints in UF phase III studies replacing the AH method.

A systematic review of the psychosocial impact of fibroids before and after treatment

OBJECTIVE

Despite the high prevalence of uterine fibroids, the psychosocial impact of fibroids has not been evaluated across different quality of life indicators and compared with other chronic conditions. Here, we rigorously analyzed available evidence pertaining to the psychosocial burden of uterine fibroids in premenopausal women and compared validated quality of life and symptom scores before and after treatment.

DATA SOURCES

We searched PubMed, PsycINFO, ClinicalTrials.gov, Embase, and Cochrane Library for publications from January 1990 to January 2020.

STUDY ELIGIBILITY CRITERIA

We considered English-language publications that evaluated the association between uterine fibroids diagnosed by imaging studies in premenopausal women and quality of life by standardized and validated questionnaires at baseline and after treatment. We used a detailed list of terms related to quality of life, questionnaires, and uterine fibroids to conduct the search.

METHODS

Three reviewers screened titles and abstracts and then obtained full-text articles for further analysis. The reviewers assessed risk of bias using established Cochrane and Newcastle-Ottawa Scale guidelines. The quality of life scores of premenopausal women with fibroids were reviewed at baseline and compared with those of published quality of life scores in other disease populations in addition to after fibroid treatment.

RESULTS

A total of 57 studies were included in the review: 18 randomized controlled trials and 39 observational studies. Of note, the 36-Item Short Form Survey and European Quality of Life Five-Dimension Scale questionnaires both indicated a diagnosis of uterine fibroids to have a disability score that was similar to or exceeded (was a greater psychosocial stressor) a diagnosis of heart disease, diabetes mellitus, or breast cancer. Quality of life scores were lower at baseline than after treatment in all instruments measuring these variables in women with uterine fibroids, indicating significantly impaired psychosocial functioning. Uterine fibroids were associated with significant patient-reported health disabilities related to bodily pain, mental health, social functioning, and satisfaction with sex life.

CONCLUSION

A diagnosis of uterine fibroids was a significant psychosocial stressor among women at baseline and relative to other diseases. Validated quality of life instruments indicated therapeutic success and the improvement of both physical and emotional symptoms after treatment.

Three-Year Results of the SONATA Pivotal Trial of Transcervical Fibroid Ablation for Symptomatic Uterine Myomata

Objective: This article reports on 3-year clinical outcomes of the Sonography Guided Transcervical Ablation of Uterine Fibroids (SONATA) pivotal trial of transcervical fibroid ablation (TFA) in women with symptomatic uterine myomata.

Materials and Methods: The SONATA, prospective, controlled, multicenter interventional trial enrolled 147 premenopausal women with symptomatic uterine fibroids who underwent uterus-preserving, sonography-guided TFA with the Sonata^® System (Gynesonics, Inc., Redwood City, CA, USA). Clinical outcomes were assessed over 3 years and included surgical reinterventions, Symptom Severity Score (SSS), and Health-Related Quality of Life (HRQoL) subscales of the Uterine Fibroid Symptom and Quality-of-Life Questionnaire, EuroQol 5-Dimension (EQ-5D) questionnaire, Overall Treatment Effect, treatment satisfaction, physical activity, work impairment, pregnancy outcomes, and adverse events.

Results: The 3-year rates of surgical reintervention for heavy menstrual bleeding calculated by the binomial and Kaplan–Meier methods were 9.2% and 8.2%, respectively. Compared to baseline, mean SSS decreased from 55 ± 19 to 22 ± 21, HRQoL increased from 40 ± 21 to 83 ± 23, and EQ-5D increased from 0.72 ± 0.21 to 0.88 ± 0.16 (all p < 0.001). Treatment benefit on the SSS, HRQoL, and EQ-5Q exceeded the minimal clinically important difference at every follow-up visit over 3 years. At 3 years, 94% of the subjects reported treatment satisfaction, 88% reported reduced fibroid symptoms, work absenteeism due to fibroid symptoms decreased from 2.9% to 1.4%, and impairment due to fibroids decreased from 51% to 12% for work, and 58% to 14% for physical activity (all p < 0.001). No late complications occurred.

Conclusions: Women treated with sonography-guided TFA in the SONATA pivotal trial experienced significant and durable reduction of fibroid-related symptoms, with low surgical reintervention rates over 3 years of follow-up.

Utilization of Endovascular and Surgical Treatments for Symptomatic Uterine Leiomyomas: A Population Health Perspective

PURPOSE

To conduct a population-level analysis of surgical and endovascular interventions for symptomatic uterine leiomyomata by using administrative data from outpatient medical encounters.

MATERIALS AND METHODS

By using administrative data from all outpatient hospital encounters in California (2005-2011) and Florida (2005-2014), all patients in the outpatient setting with symptomatic uterine leiomyomata were identified. Patients were categorized as undergoing hysterectomy, myomectomy, uterine artery embolization (UAE), or no intervention. Hospital stay durations and costs were recorded for each encounter.

RESULTS

A total of 227,489 patients with uterine leiomyomata were included, among whom 39.9% (n = 90,800) underwent an intervention, including hysterectomy (73%), myomectomy (19%), or UAE (8%). The proportion of patients undergoing hysterectomy increased over time (2005, hysterectomy, 53.2%; myomectomy, 26.9%; UAE, 18.0%; vs 2013, hysterectomy, 80.1%; myomectomy, 14.4%; UAE, 4.0%). Hysterectomy was eventually performed in 3.5% of patients who underwent UAE and 4.1% who underwent myomectomy. Mean length of stay following hysterectomy was significantly longer (0.5 d) vs myomectomy (0.2 d) and UAE (0.3 d; P < .001 for both). The mean encounter cost for UAE ($3,772) was significantly less than those for hysterectomy ($5,409; P < .001) and myomectomy ($6,318; P < .001). Of the 7,189 patients who underwent UAE during the study period, 3.5% underwent subsequent hysterectomy.

CONCLUSIONS

The proportion of women treated with hysterectomy in the outpatient setting has increased since 2005. As a lower-cost alternative with a low rate of conversion to hysterectomy, UAE may be an underutilized treatment option for patients with uterine leiomyomata.

Contemporary treatment utilization among women diagnosed with symptomatic uterine fibroids in the United States

BACKGROUND

This study evaluated treatment patterns among women diagnosed with symptomatic uterine fibroids (UF) in the United States. Data were retrospectively extracted from the IBM Watson Health MarketScan® Commercial Claims and Encounters and Medicaid Multi-State databases.

METHODS

Women aged 18-64 years with ≥1 medical claim with a UF diagnosis (primary position, or secondary position plus ≥1 associated symptom) from January 2010 to June 2015 (Commercial) and January 2009 to December 2014 (Medicaid) were eligible; the first UF claim during these time periods was designated the index date. Data collected 12 months pre- and 12 and 60 months post-diagnosis included clinical/demographic characteristics, pharmacologic/surgical treatments, and surgical complications. Prevalence (2015) and cumulative incidence (Commercial, 2010-2015; Medicaid, 2009-2015) of symptomatic UF were estimated.

RESULTS

225,737 (Commercial) and 19,062 (Medicaid) women had a minimum of 12 months post-index continuous enrollment and were eligible for study. Symptomatic UF prevalence and cumulative incidence were: 0.57, 1.23% (Commercial) and 0.46, 0.64% (Medicaid). Initial treatments within 12 months post-diagnosis were surgical (Commercial, 36.7%; Medicaid, 28.7%), pharmacologic (31.7%; 53.0%), or none (31.6%; 18.3%). Pharmacologic treatments were most commonly non-steroidal anti-inflammatory drugs and oral contraceptives; hysterectomy was the most common surgical treatment. Of procedures of abdominal hysterectomy, abdominal myomectomy, uterine artery embolization, and ablation in the first 12 months post-index, 14.9% (Commercial) and 24.9% (Medicaid) resulted in a treatment-associated complication. Abdominal hysterectomy had the highest complication rates (Commercial, 18.5%; Medicaid, 31.0%).

CONCLUSIONS

Off-label use of pharmacologic therapies and hysterectomy for treatment of symptomatic UF suggests a need for indicated non-invasive treatments for symptomatic UF.

Uterine-Artery Embolization or Myomectomy for Uterine Fibroids

BACKGROUND

Uterine fibroids, the most common type of tumor among women of reproductive age, are associated with heavy menstrual bleeding, abdominal discomfort, subfertility, and a reduced quality of life. For women who wish to preserve their uterus and who have not had a response to medical treatment, myomectomy and uterine-artery embolization are therapeutic options.

METHODS

We conducted a multicenter, randomized, open-label trial to evaluate myomectomy, as compared with uterine-artery embolization, in women who had symptomatic uterine fibroids and did not want to undergo hysterectomy. Procedural options included open abdominal, laparoscopic, or hysteroscopic myomectomy. The primary outcome was fibroid-related quality of life, as assessed by the score on the health-related quality-of-life domain of the Uterine Fibroid Symptom and Quality of Life (UFS-QOL) questionnaire (scores range from 0 to 100, with higher scores indicating a better quality of life) at 2 years; adjustment was made for the baseline score.

RESULTS

A total of 254 women, recruited at 29 hospitals in the United Kingdom, were randomly assigned: 127 to the myomectomy group (of whom 105 underwent myomectomy) and 127 to the uterine-artery embolization group (of whom 98 underwent embolization). Data on the primary outcome were available for 206 women (81%). In the intention-to-treat analysis, the mean (±SD) score on the health-related quality-of-life domain of the UFS-QOL questionnaire at 2 years was 84.6±21.5 in the myomectomy group and 80.0±22.0 in the uterine-artery embolization group (mean adjusted difference with complete case analysis, 8.0 points; 95% confidence interval [CI], 1.8 to 14.1; P = 0.01; mean adjusted difference with missing responses imputed, 6.5 points; 95% CI, 1.1 to 11.9). Perioperative and postoperative complications from all initial procedures, irrespective of adherence to the assigned procedure, occurred in 29% of the women in the myomectomy group and in 24% of the women in the uterine-artery embolization group.

CONCLUSIONS

Among women with symptomatic uterine fibroids, those who underwent myomectomy had a better fibroid-related quality of life at 2 years than those who underwent uterine-artery embolization. (Funded by the National Institute for Health Research Health Technology Assessment program; FEMME Current Controlled Trials number, ISRCTN70772394.).

Quality of Life after Laparoscopic and Open Abdominal Myomectomy

STUDY OBJECTIVE

To evaluate the baseline and postoperative changes in quality of life and symptom-severity scores in women undergoing laparoscopic or open abdominal myomectomy for symptomatic myomas.

DESIGN

Prospective cohort study of patients choosing myomectomy for symptomatic uterine myomas.

SETTING

Academic medical center.

PATIENTS

A total of 143 women enrolled in the study. Of these, 80 women completed both a preoperative questionnaire and at least 1 postoperative questionnaire between 6 and 27 months after surgery.

INTERVENTIONS

A total of 52 women had open abdominal myomectomy, and 28 had laparoscopic myomectomy between October 2014 and September 2017.

MEASUREMENTS AND MAIN RESULTS

The results of the Uterine Fibroid Symptom and Health-Related Quality-of-Life Questionnaire were compared before and after laparoscopic or open myomectomy. Women undergoing open abdominal myomectomy had larger and more numerous myomas than women undergoing laparoscopic myomectomy. Baseline quality-of-life scores were less adversely affected for women having laparoscopic myomectomy (mean [standard deviation], 57 [24] laparoscopic vs 43 [19] open abdominal, p = .01). However, baseline symptom-severity scores were statistically similar (49 [22] for laparoscopic and 57 [20] for open abdominal, p = .08) approaches. Six to 12 months after surgery, both open abdominal and laparoscopic surgeries provided excellent and similar improvements in symptom-severity and quality of life (postoperative symptoms severity scores, mean [standard deviation], 20 [14] laparoscopic vs 13 [11] open abdominal, p = .24 and quality-of-life scores, mean [standard deviation], 91 [16] laparoscopic vs 88 [17] open abdominal, p = .49). These improvements were sustained for women who returned questionnaires up to 27 months of follow-up.

CONCLUSION

Women with symptomatic myomas have a compromised quality of life, and they experience a similarly dramatic improvement in quality of life and decrease in symptom-severity after both laparoscopic and open abdominal myomectomies.

Activin A induces tumorigenesis of leiomyoma via regulation of p38β MAPK-mediated signal cascade

OBJECTIVE

The objective of this study was to investigate the role of p38-C/EBPβ signaling in leiomyoma cells and myometrial cells challenged with Activin A, and to identify specifically the isoform of p38 MAPK that mediates the effects of Activin A.

METHODS

The immortalization human leiomyoma cells (HuLM) and human myometrial cells (HM), and mouse myometrial tissues were treated with Activin A (4 nM) in response to p38α/β inhibition (10 μM SB202190) or depletion (p38 α/β-targeting siRNA or p38β muscle specific-knock out mice). p38 MAPK signaling molecules (p-p38 and p-C/EBPβ) and ECM components (COL1A1 and/or FN) were analyzed by Western blotting.

RESULTS

Activin A induced ECM accumulation in leiomyoma cells and myofibroblastic transformation in myometrical cells specifically by p38β MAPK.

CONCLUSION

This study is the first to demonstrate that activation of C/EBPβ by p38β MAPK may contribute to tumorigenesis and progression of Activin A-induced leiomyoma. Specific p38β inhibition may represent a novel and promising intervention for leiomyoma.

Myomectomy associated blood transfusion risk and morbidity after surgery

OBJECTIVE

To evaluate blood transfusion risks and the associated 30-day postoperative morbidity after myomectomy.

DESIGN

Retrospective cohort study.

SETTING

Not applicable.

PATIENT(S)

Women who underwent myomectomies for symptomatic uterine fibroids (N = 3,407).

INTERVENTION(S)

Blood transfusion during or within 72 hours after myomectomy.

MAIN OUTCOME MEASURE(S)

The primary outcomes were rate of blood transfusion with myomectomy and risk factors associated with receiving a transfusion. The secondary outcome was 30-day morbidity after myomectomy.

RESULT(S)

The overall rate of blood transfusion was 10% (hysteroscopy, 6.7%; laparoscopy, 2.7%; open/abdominal procedures, 16.4%). Independent risk factors for transfusion included as follows: black race (adjusted odds ratio [aOR] 2.27, 95% confidence interval [CI] 1.62-3.17) and other race (aOR 1.77, 95% CI 1.20-2.63) compared with white race; preoperative hematocrit <30% compared to ≥30% (aOR 6.41, 95% CI 4.45-9.23); preoperative blood transfusion (aOR 2.81, 95% CI 1.46-5.40); high fibroid burden (aOR 1.91, 95% CI 1.45-2.51); prolonged surgical time (fourth quartile vs. first quartile aOR 11.55, 95% CI 7.05-18.93); and open/abdominal approach (open/abdominal vs. laparoscopic aOR 9.06, 95% CI 6.10-13.47). Even after adjusting for confounders, women who required blood transfusions had an approximately threefold increased risk for experiencing a major postoperative complication (aOR 2.69, 95% CI 1.58-4.57).

CONCLUSION(S)

Analysis of a large multicenter database suggests that the overall risk of blood transfusion with myomectomy is 10% and is associated with an increased 30-day postoperative morbidity. Preoperative screening of women at high risk for transfusion is prudent as perioperative transfusion itself leads to increased major postoperative complications.

Anxiety of myoma patients: results of standardized interviews with the State Trait Anxiety Inventory and the Kessler 10 questionnaire

Introduction: The aim of this study was to explore a possible relation between myoma-related anxieties and general state or trait anxiety or psychological distress, to get a better understanding of the impact of anxiety on the patients.Methods: This prospective study was conducted at the myoma clinic of a large university hospital in a major European city from November 2016 to February 2017. Patients completed standardized questionnaires on myoma-related fears, the State Trait Anxiety Inventory (STAI), and the Kessler 10.Results: Eighty-five out of 88 women agreed to participate. State-anxiety on the STAI had a mean of 49.4 (11 points above the norm (p < .001)), and trait-anxiety had a mean of 42.0 (5 points above the norm (p = .001)). Thirty-seven percent of the patients had distress values on the K10 above the norm (defined as <20). More myoma-related fears correlated with higher scores on the Kessler and STAI. The scores were not related to the level of information about myomas or duration of illness.Conclusions: Myoma-related fears correlated with higher mental distress and elevated state and trait anxiety levels. Thus, physicians can contribute to the overall well-being of patients when they relieve them of the myoma-related anxiety. Further research is needed to determine whether treatment has any impact on anxiety or mental distress.

Hemoperitoneum due to bleeding from a vein overlying a subserous uterine myoma: a case report

Background

Fibroids are the most common pelvic tumors in women; serious complications are rare but can be life-threatening.

Case presentation

We present a case report of a 38-year-old Persian woman with acute abdominal pain and a history of uterine fibroids. The patient refused to undergo a laparoscopic myomectomy. Her ultrasound examination revealed free fluid in the abdominal cavity, and her vital signs were indicative of vasogenic shock. A diagnostic laparoscopy was performed to identify and control the source of bleeding: 400 ml of blood and blood clots were removed. Active bleeding was seen from a vein overlying a subserosal myoma. A laparotomic myomectomy was performed, and the patient was discharged 3 days after surgery with no complications.

Conclusion

Surgeons should consider the possibility of this complication in women with acute abdominal pain and a history of uterine leiomyoma.

The impact of ultrasound-guided high-intensity focused ultrasound for uterine fibroids on ovarian reserve

Objective: To evaluate the impact of ultrasound-guided high-intensity focused ultrasound (USgHIFU) for uterine fibroids on ovarian reserve in women of reproductive age.Materials and methods: From September 2015 to September 2017, 84 patients with uterine fibroids in reproductive age were enrolled from Chongqing Haifu Hospital, Three Gorges Central Hospital of Chongqing and Aegisroen obstetric gynecology Clinic of Seoul, Korea. Blood was collected before HIFU treatment and 6 months after USgHIFU treatment. The enzyme-linked immune analysis was used for assay of circulating anti-Mullerian hormone (AMH).Results: All the 84 patients were successfully treated with USgHIFU and 67 patients completed the follow-up. The median age of the 67 patients was 38 years at the time of treatment. The median AMH value before and 6 months after treatment was 1.26 ng/mL and 1.27 ng/mL, respectively. Patients who completed AMH measurements 6 months after treatment were further classified into three groups based on age, including younger than 35 years, 36 to 40 years, and older than 40 years. The median AMH values before treatment were 3.04 ng/mL, 1.73 ng/mL and 0.87 ng/mL, and the corresponding values 6 months after treatment were 3.24, 1.44 and 0.75, respectively. A significant difference in AMH level was observed in the group of patients at the age between 36 and 40 years (p < 0.05), but no significant difference in AMH levels was observed in the other two groups (p > 0.05).Conclusion: Based on our results, we conclude that USgHIFU has no influence on ovarian reserve.

Use of multiparametric MRI to characterize uterine fibroid tissue types

BACKGROUND

Although the biological characteristics of uterine fibroids (UF) have implications for therapy choice and effectiveness, there is limited MRI data about these characteristics. Currently, the Funaki classification and Scaled Signal Intensity (SSI) are used to predict treatment outcome but both screening-tools appear to be suboptimal. Therefore, multiparametric and quantitative MRI was studied to evaluate various biological characteristics of UF.

METHODS

87 patients with UF underwent an MRI-examination. Differences between UF tissues and myometrium were investigated using T2-mapping, Apparent Diffusion Coefficient (ADC) maps with different b-value combinations, contrast-enhanced T1-weighted and T2-weighted imaging. Additionally, the Funaki classification and SSI were calculated.

RESULTS

Significant differences between myometrium and UF tissue in T2-mapping (p = 0.001), long-TE ADC low b-values (p = 0.002), ADC all b-values (p < 0.001) and high b-values (p < 0.001) were found. Significant differences between Funaki type 3 versus type 1 and 2 were observed in SSI (p < 0.001) and T2-values (p < 0.001). Significant correlations were found between SSI and T2-mapping (p < 0.001; ρ_s = 0.82), ADC all b-values (p = 0.004; ρ_s = 0.31), ADC high b-values (p < 0.001; ρ_s = 0.44) and long-TE ADC low b-values (p = 0.004; ρ_s = 0.31).

CONCLUSIONS

Quantitative MR-data allowed us to distinguish UF tissue from myometrium and to discriminate different UF tissue types and may, therefore, be a useful tool to predict treatment outcome/determine optimal treatment modality.

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 study's 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.

Effects of combined GnRH receptor antagonist linzagolix and hormonal add-back therapy on vaginal bleeding-delayed add-back onset does not improve bleeding pattern

Linzagolix is a novel, oral GnRH receptor antagonist developed for the treatment of endometriosis and uterine fibroids. We assessed high-dose linzagolix safety and bleeding pattern effects in healthy women using combined versus delayed hormonal add-back therapy (ABT). This was a single-center, open-label, parallel-group study in 32 premenopausal women, who were randomized to daily linzagolix (200 mg)/ABT for 10 weeks ("Combined-ABT") or linzagolix (200 mg) for 4 weeks followed by linzagolix (200 mg)/ABT for 6 weeks ("Delayed-ABT"). Main outcome measures included bleeding records, trough estradiol (E2) concentrations and adverse events. Linzagolix alone promptly reduced bleeding, leading to amenorrhea in all women by week 5. When combined ABT was started (week 5), spotting (≤ 0.80 days/week/subject) and bleeding (≤ 0.53 days/week/subject) occurred; bleeding was markedly more frequent than after ABT start in the "Combined-ABT" group. In the "Combined-ABT" group, spotting (≤ 0.69 days/week/subject) and occasional bleeding (≤ 0.25 days/week/subject) occurred during the first half of treatment with a tendency to further decrease during the second half. Linzagolix alone rapidly reduced E2 reaching median week 4 levels of 4.1 pg/mL. Median E2 after combined linzagolix/ABT ranged between 35 and 42 pg/mL for the "Delayed-ABT" group (weeks 5-10) and between 24 and 32 pg/mL for the "Combined-ABT" group (weeks 1-10). Linzagolix was well tolerated. Most frequently reported adverse events were headache (32/156) and hot flushes (19/156). Hot flushes exclusively occurred in the "Delayed-ABT" group. In this study, treatment start with a combined linzagolix/ABT regimen resulted in better bleeding control, no hot flushes, and lower median E2 levels than a "Delayed-ABT" regimen. These results may help defining the linzagolix/ABT regimen to be adopted when treating sex-hormone-dependent diseases. Clinical Trial Registration Number-EudraCT Number: 2017-003822-34.

Health-Related Quality of Life With Ulipristal Acetate for Treatment of Uterine Leiomyomas: A Randomized Controlled Trial

Ulipristal acetate is associated with significant improvements in health-related quality of life and symptom severity compared with placebo in women with symptomatic uterine leiomyomas.

OBJECTIVE:

To investigate effects of ulipristal acetate on health-related quality of life (QOL) and symptom severity in women with symptomatic uterine leiomyomas and abnormal uterine bleeding.

METHODS:

Women were randomized to ulipristal (5 mg, 10 mg) or placebo in two phase 3, multicenter, double-blind, placebo-controlled trials (VENUS I and II). Health-related QOL and symptom severity were assessed at baseline, and over one (VENUS I and II) and two (VENUS II) 12-week treatment courses using the Uterine Fibroid Symptom Health-Related Quality of Life questionnaire. In pooled VENUS I and II data, change from baseline to the end of the first course for each Uterine Fibroid Symptom Health-Related Quality of Life scale was analyzed, including a Revised Activities subscale that measured physical and social activities. The proportion of women achieving meaningful change in the Symptom Severity (20 or more points), Health-Related QOL Total (20 or more points), and Revised Activities (30 or more points) scales was calculated. In VENUS II data, change from baseline to the end of each course in each scale was analyzed for each treatment arm.

RESULTS:

In pooled analyses, the intent-to-treat population included 589 patients (placebo, n=169; ulipristal 5 mg, n=215; ulipristal 10 mg, n=205). Significantly greater improvements from baseline in all Uterine Fibroid Symptom Health-Related Quality of Life scales were observed with both ulipristal doses compared with placebo (P<.001). A meaningful change in Revised Activities was achieved by 51 patients receiving placebo (34.9%), compared with 144 (73.5%; OR 5.0 [97.5% CI 2.9–8.6]) and 141 (80.6%; OR 7.9 [97.5% CI 4.3–14.6]) patients receiving ulipristal 5 mg, and 10 mg, respectively. In VENUS II, at end of courses 1 and 2, both ulipristal doses demonstrated significant improvements from baseline compared with placebo for all Uterine Fibroid Symptom Health-Related Quality of Life scales (P<.01). Mean Revised Activities scores showed that beneficial ulipristal effects were maintained in course 2, and improvements occurred on switching to ulipristal; results for other scales were similar.

CONCLUSION:

Ulipristal was associated with significant improvements in health-related QOL and symptom severity compared with placebo for women with symptomatic uterine leiomyomas.

CLINICAL TRIAL REGISTRATION:

ClinicalTrials.gov, NCT02147197 and NCT02147158.

FUNDING SOURCE:

Allergan plc, Dublin, Ireland.

WITHDRAWN: Uterine myomas: Clinical impact and pathophysiological bases

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Ulipristal acetate on quality of life and sexual function of women with uterine fibromatosis

To evaluate quality of life and sexual function of childbearing-age women, affected by uterine fibromatosis undergoing medical treatment with ulipristal acetate. The data obtained by filling the questionnaires European Quality of Life Five-Dimension Scale and modified Female Sexual Function Index, were analyzed to assess UPA usefulness in improving QoL and sexual activity. A total of 139 patients affected by uterine fibromatosis undergoing conservative ulipristal acetate treatment were enrolled in this prospective observational cohort study. Seventy-one women (average age 46.5 years) answered the questionnaires: QoL and sexuality were evaluated before and after ulipristal acetate treatment. 59 patients (83.1%) had an improvement of QoL and general health state, with a reduction of VAS score after ulipristal acetate treatment. EQ-5D-5L showed a statistically significant improvement of usual act impairment, mobility, discomfort, anxiety/depression (p < .0005). There was no difference in personal care management after therapy. Modified FSFI showed a statistically significant improvement (p < .0001) of sexual satisfaction and sexual life. A not statistically significant improvement in dyspareunia was also highlighted. This study provides a clear picture about QoL impact on women and confirms the effectiveness of the ulipristal acetate in improving different aspects of daily and sexual life of patients undergoing medical treatment.

Two-port myomectomy using bag-contained manual morcellation: A comparison with three-port myomectomy using power morcellation

OBJECTIVES

To evaluate the feasibility and safety of two-port myomectomy using bag-contained manual morcellation compared to three-port myomectomy using power morcellation.

MATERIAL AND METHODS

A retrospective chart review was conducted for 428 cases of either two-port or three-port laparoscopic myomectomy performed by single operator in the university hospital between January 2011 and December 2016.

RESULTS

The cohorts of three-port myomectomy with power morcellation was consisted of two hundred and forty-eight patients. One hundred and eighty patients underwent two-port myomectomy with manual morcellation in contained bag. Two-port group showed shorter hospital stay (5.16 ± 1.39 d vs. 4.83 ± 1.19 d, p = 0.001), less estimated blood loss (61.8 ± 58.2 mL vs. 50.2 ± 52.4 mL, p = 0.001), and higher hemoglobin level at postoperative day 1 (10.7 ± 1.17 g/dL vs. 11.0 ± 1.14 g/dL, p = 0.028) with statistical significance. Morcellation time (25.8 ± 9.30 min vs. 18.9 ± 10.11 min, p = 0.001) and total operative time (82.4 ± 30.19 min vs. 76.4 ± 25.47 min, p = 0.047) were also significantly shorter in two-port group. There were no identified spillages of fibroids, ruptures of specimen bag during manual morcellation in two-port myomectomy. In both groups, there were no cases of leiomyosarcoma diagnosed postoperatively.

CONCLUSION

Two-port laparoscopic myomectomy with bag-contained manual morcellation is a feasible and safe alternative for three-port with power morcellation. Its surgical outcomes were shown to be superior to conventional laparoscopic myomectomy according to our study but further evaluation in near future is needed.

Transcervical Radiofrequency Ablation of Symptomatic Uterine Fibroids: 2-Year Results of the SONATA Pivotal Trial

Objective: To report 2-year results of sonography-guided transcervical fibroid ablation (TFA) using the Sonata^® system in women with symptomatic uterine fibroids. Design: This is a prospective multicenter single-arm interventional trial. Methods: Premenopausal women with up to 10 clinically relevant uterine fibroids, each ranging from 1 to 5 cm in diameter, were treated with sonography-guided TFA on an outpatient basis and returned for regular follow-up visits for 2 years. Assessed outcomes included changes in symptom severity, heath-related quality of life, general health status, work and activity limitations, treatment satisfaction, adverse events, surgical reintervention, and occurrence of pregnancy and associated outcomes. Results: Among 147 enrolled women, 125 (85%) returned for follow-up at 2 years. Compared with baseline, symptom severity decreased from 55 ± 19 to 24 ± 18 (p < 0.001), health-related quality of life increased from 40 ± 21 to 83 ± 19 (p < 0.001), and EuroQol 5-Dimension scores increased from 0.72 ± 0.21 to 0.89 ± 0.14 (p < 0.001). Overall treatment satisfaction at 2 years was 94%. The mean percentage of missed work time, overall work impairment, and activity impairment significantly decreased at follow-up. Through 2 years, surgical reintervention for heavy menstrual bleeding was performed in 5.5% of patients. One singleton pregnancy occurred with a normal peripartum outcome. Conclusions: TFA treatment with the Sonata system provides significant clinical improvement through 2 years postablation, with a low incidence of surgical reintervention. Other favorable outcomes included a rapid return to work and substantial improvements in quality of life, symptom severity, work productivity, and activity levels.

Clinical Performance of Radiofrequency Ablation for Treatment of Uterine Fibroids: Systematic Review and Meta-Analysis of Prospective Studies

Background: Radiofrequency ablation (RFA) has emerged as a safe and effective treatment option for women with symptomatic uterine fibroids and can be delivered by laparoscopic, transvaginal, or transcervical approaches. The evidence regarding typical patient outcomes with RFA has not previously been examined in a comprehensive fashion. Materials and Methods: We performed a systematic review of prospective studies for treatment of uterine fibroids with RFA. Main outcomes were procedure time, patient recovery metrics, change in fibroid volume, symptom severity score (SSS), health-related quality of life (HRQL), and reinterventions. Data were analyzed with random effects meta-analysis and metaregression. Results: We identified 32 articles of 1283 unique patients (median age: 42 years) treated with laparoscopic RFA (19 articles), transvaginal RFA (8 articles), or transcervical fibroid ablation (5 articles). Mean procedure time was 49 minutes, time to discharge was 8.2 hours, time to normal activities was 5.2 days, and time to return to work was 5.1 days. At 12 months follow-up, fibroid volume decreased by 66%, HRQL increased by 39 points, and SSS decreased by 42 points (all P < .001 versus baseline). The annual cumulative rate of reinterventions due to fibroid-related symptoms was 4.2%, 8.2%, and 11.5% through 3 years. Conclusions: RFA of uterine fibroids significantly reduces fibroid volume, provides significant durable improvements in fibroid-related quality of life, and is associated with favorable reintervention rates.

The Significant Risk Factors of Intra-Operative Hemorrhage during Laparoscopic Myomectomy: A Systematic Review

Laparoscopic myomectomy (LM) is becoming increasingly common in the management of uterine myomas and is usually offered regardless of the number, location, and size of the myomas. It has a generally low rate of periprocedural complications and is preferred to laparotomy for several reasons that are not limited to decreased length of hospital stay, number of sutures, smaller incisions, and decreased pain. However, blood loss during LM remains a challenge. To be able to stratify patients and provide better management after LM, it is crucial to identify these predictors of blood loss. Therefore, the aim of this review was to identify the risk factors for periprocedural blood loss after laparoscopic uterine myomectomy. According to our data synthesis, age, body mass index, and phase of the menstrual cycle do not seem to affect the blood loss during LM. Conversely, size and number of myomas, as well as operative time, was directly related to the increase of blood loss.

Clinical Utility Of Elagolix As An Oral Treatment For Women With Uterine Fibroids: A Short Report On The Emerging Efficacy Data

Uterine fibroids (UFs) are the most common gynaecological benign disease. Even though often asymptomatic, UFs can worsen women's health and their quality of life, causing heavy bleeding and anaemia, pelvic discomfort and reduced fertility. Surgical treatment of UFs could be limited by its invasiveness and the desire to preserve fertility. Thus, effective medical therapies for the management of this condition are needed. Common drugs used to control bleeding, such us hormonal contraceptive or levonorgestrel-releasing intrauterine system, have no effect on fibroids volume. Among other more efficient treatments, the gonadotropin-releasing hormone (GnRH) agonist or the selective progesterone-receptor modulators have a non-neutral safety profile; thus, they are used for limited periods or for cyclic treatments. Elagolix is a potent, orally bioavailable, non-peptide GnRH antagonist that acts by a competitive block of the GnRH receptor. The biological effect is a dose-dependent inhibition of gonadal axis, without a total suppression of estradiol concentrations. For this reason, even though comparative studies between elagolix and GnRH agonists have not been performed, elagolix has been associated with a better profile of adverse events. Recently, elagolix received US FDA approval for the treatment of moderate to severe pain caused by endometriosis. Several clinical trials assessed the efficacy of elagolix for the treatment of heavy bleeding caused by UFs and the definitive results of Phase III studies are expected. Available data on elagolix and UFs showed that the drug, with or without low-dose hormone add-back therapy, is able to significantly reduce menstrual blood loss, lead to amenorrhea and improve haemoglobin concentrations in the majority of participants in comparison with placebo. The safety and tolerability profile appeared generally acceptable. The concomitant use of add-back therapy can prevent bone loss due to the hypoestrogenic effect and can improve safety during elagolix treatment.

Elagolix Alone or With Add-Back Therapy in Women With Heavy Menstrual Bleeding and Uterine Leiomyomas: A Randomized Controlled Trial

OBJECTIVE

To evaluate elagolix, an oral gonadotropin-releasing hormone receptor antagonist, alone or with add-back therapy, in premenopausal women with heavy menstrual bleeding (greater than 80 mL per month) associated with uterine leiomyomas.

METHODS

This double-blind, randomized, placebo-controlled, parallel-group study evaluated efficacy and safety of elagolix in cohorts 1 (300 mg twice daily) and 2 (600 mg daily) with four arms per cohort: placebo, elagolix alone, elagolix with 0.5 mg estradiol/0.1 norethindrone acetate, and elagolix with 1.0 mg estradiol/0.5 mg norethindrone acetate. A sample size of 65 per group was planned to compare elagolix with add-back to placebo on the primary end point: the percentage of women who had less than 80 mL menstrual blood loss and 50% or greater reduction in menstrual blood loss from baseline to the last 28 days of treatment. Safety assessments included changes in bone mineral density.

RESULTS

From April 8, 2013, to December 8, 2015, 571 women were enrolled, 567 were randomized and treated (cohort 1=259; cohort 2=308), and 80% and 75% completed treatment, respectively. Participants had a mean±SD age of 43±5 years (cohort 2, 42±5 years), and 70% were black (cohort 2, 74%). Primary end point responder rates in cohort 1 (cohort 2) were 92% (90%) for elagolix alone, 85% (73%) for elagolix with 0.5 mg estradiol/0.1 mg norethindrone acetate, 79% (82%) for elagolix with 1.0 mg estradiol/0.5 mg norethindrone acetate, and 27% (32%) for placebo (all P<.001 vs placebo). Elagolix groups had significant decreases compared with placebo in lumbar spine bone mineral density, which was attenuated by adding 1.0 mg estradiol/0.5 mg norethindrone acetate.

CONCLUSION

Elagolix with and without add-back significantly reduced menstrual blood loss in women with uterine leiomyomas. Add-back therapy reduced hypoestrogenic effects on bone mineral density.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT01817530; EU Clinical Trial Register, 2013-000082-37.

Psychometric validation of the 1-month recall Uterine Fibroid Symptom and Health-Related Quality of Life questionnaire (UFS-QOL)

Background

To evaluate the psychometric characteristics of the 1-month recall Uterine Fibroid Symptom and Health-Related Quality of Life questionnaire (UFS-QOL), including the Revised Activities subscale.

Methods

VENUS I and II were phase III, randomized, double-blind, placebo-controlled trials of ulipristal acetate in women with uterine fibroids (UF) and abnormal uterine bleeding. Women completed the 1-month recall UFS-QOL at baseline and after 12 weeks’ treatment. Uterine bleeding was assessed via a daily diary (both studies); the Patient Global Impression of Improvement scale (PGI-I) was completed in VENUS II. Psychometric analyses examined internal consistency reliability and construct validity of the UFS-QOL; confirmatory factor analysis (CFA) compared model fit of the original and Revised Activities subscales. Analyses were conducted separately for VENUS I and II.

Results

One hundred and fifty-seven patients in VENUS I and 429 in VENUS II were included. Changes in mean Symptom Severity and health-related quality of life (HRQoL) scale scores indicated symptom burden reductions and HRQoL improvements. Cronbach’s alpha coefficients were high at baseline and after 12 weeks’ treatment (all ≥0.76, meeting the >0.70 threshold), demonstrating strong internal consistency reliability. Correlations between UFS-QOL scores and bleeding diary responses (range: −0.35 to −0.63), and UFS-QOL scores and PGI-I responses (range: −0.48 to −0.70), ranged from moderate to strong after 12 weeks’ treatment (all p < 0.0001). Patients with absence of bleeding or controlled bleeding after 12 weeks’ treatment scored significantly better (p < 0.001) on each UFS-QOL scale than patients not achieving those end points, supporting construct validity. CFA confirmed model fit for the Revised Activities subscale.

Conclusions

The 1-month recall UFS-QOL, including the Revised Activities subscale, is a valid, reliable measure to assess UF symptoms and their impact on HRQoL.

Trial registration

ClinicalTrials.gov, NCT02147197. Registered May 26, 2014; retrospectively registered. ClinicalTrials.gov, NCT02147158. Registered May 26, 2014; retrospectively registered.

Electronic supplementary material

The online version of this article (10.1186/s41687-019-0146-x) contains supplementary material, which is available to authorized users.

Liquid Biopsy as a Tool for Differentiation of Leiomyomas and Sarcomas of Corpus Uteri

Utilization of liquid biopsy in the management of cancerous diseases is becoming more attractive. This method can overcome typical limitations of tissue biopsies, especially invasiveness, no repeatability, and the inability to monitor responses to medication during treatment as well as condition during follow-up. Liquid biopsy also provides greater possibility of early prediction of cancer presence. Corpus uteri mesenchymal tumors are comprised of benign variants, which are mostly leiomyomas, but also a heterogenous group of malignant sarcomas. Pre-surgical differentiation between these tumors is very difficult and the final description of tumor characteristics usually requires excision and histological examination. The leiomyomas and malignant leiomyosarcomas are especially difficult to distinguish and can, therefore, be easily misdiagnosed. Because of the very aggressive character of sarcomas, liquid biopsy based on early diagnosis and differentiation of these tumors would be extremely helpful. Moreover, after excision of the tumor, liquid biopsy can contribute to an increased knowledge of sarcoma behavior at the molecular level, especially on the formation of metastases which is still not well understood. In this review, we summarize the most important knowledge of mesenchymal uterine tumors, the possibilities and benefits of liquid biopsy utilization, the types of molecules and cells that can be analyzed with this approach, and the possibility of their isolation and capture. Finally, we review the typical abnormalities of leiomyomas and sarcomas that can be searched and analyzed in liquid biopsy samples with the final aim to pre-surgically differentiate between benign and malignant mesenchymal tumors.

Different methylation levels in the KLF4, ATF3 and DLEC1 genes in the myometrium and in corpus uteri mesenchymal tumours as assessed by MS-HRM

Mesenchymal tumours of the corpus uteri comprise common benign lesions - leiomyomas and very rare malignant variants - sarcomas. It can be difficult to distinguish between the particular types of mesenchymal tumours pre-surgically. Primarily, leiomyomas and the very aggressive leiomyosarcomas can be easily misdiagnosed when using only imaging devices. Therefore, a reliable non-invasive marker for these tumour types would provide greater certitude for patients that the lesion remains benign. Our collection comprises 76 native leiomyomas, an equal number of healthy myometrium samples and 49 FFPE samples of various types of sarcomas. The methylation level was assessed by MS-HRM method and we observed differences in the methylation level between healthy, benign and (semi)malignant tissues in the KLF4 and DLEC1 genes. The mean methylation levels of leiomyomas compared to myometrium and leiomyosarcomas were 70.7% vs. 6.5% vs. 39.6 % (KLF4) and 66.1% vs. 14.08% vs. 37.5% (DLEC1). The ATF3 gene was differentially methylated in leiomyomatous and myometrial tissues with 98.1% compared to 76.6%. The AUC values of the predictive logistic regression model for discrimination between leiomyomas and leiomyosarcomas based on methylation levels were 0.7829 (KLF4) and 0.7719 (DLEC1). Finally, our results suggest that there should be distinct models for the methylation events in benign leiomyomas and sarcomas, and that the KLF4 and DLEC1 genes can be considered potential methylation biomarkers for uterine leiomyomas.

Ulipristal Acetate for Treatment of Symptomatic Uterine Leiomyomas: A Randomized Controlled Trial

OBJECTIVE

To assess efficacy and tolerability of ulipristal acetate, a selective progesterone receptor modulator, for treatment of symptomatic uterine leiomyomas.

METHODS

This phase 3, double-blind, placebo-controlled study enrolled premenopausal women (aged 18-50 years) with abnormal uterine bleeding, one or more discrete leiomyomas, and uterine size 20 weeks of gestation or less. Patients were randomized 1:1:1 to 5 mg ulipristal, 10 mg ulipristal, or placebo once daily for 12 weeks followed by 12-week drug-free follow-up. Coprimary endpoints were rate of and time to amenorrhea, defined as no bleeding for the last 35 consecutive days of treatment. Secondary endpoints included rates of amenorrhea from day 11 and change from baseline to endpoint in the Revised Activities subscale of the Uterine Fibroid Symptom and Quality of Life questionnaire, which includes questions pertaining to physical and social activities. Safety assessments included adverse event monitoring and endometrial biopsies. A sample size of 150 was planned to compare separately each dose of ulipristal with placebo.

RESULTS

From March 2014 to March 2016, 157 patients were randomized. Demographics were similar across treatment groups. Amenorrhea was achieved by 25 of 53 (47.2% [97.5% CI 31.6-63.2]) and 28 of 48 (58.3% [97.5% CI 41.2-74.1]) patients treated with 5 mg and 10 mg ulipristal, respectively, compared with 1 of 56 (1.8% [97.5% CI 0.0-10.9]) placebo-treated patients (both P<.001). Time to amenorrhea was shorter for both ulipristal doses compared with placebo (P<.001), and both doses of ulipristal resulted in improved quality of life compared with placebo (P<.001). Common adverse events (5% or greater in either ulipristal group during treatment) were hypertension, elevated blood creatinine phosphokinase, and hot flushes. Serious adverse events occurred in four patients, but none was considered related to treatment. Endometrial biopsies were benign.

CONCLUSION

Ulipristal at 5 mg and 10 mg were well tolerated and superior to placebo in rate of and time to amenorrhea in women with symptomatic uterine leiomyomas.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov number, NCT02147197.

Unexpected coexistent endometriosis in women with symptomatic uterine leiomyomas is independently associated with infertility, nulliparity and minor myoma size

PURPOSE

To determine risk factors for unexpected coexistent endometriosis in laparoscopic myomectomy for symptomatic uterine leiomyomas.

METHODS

This was a single-centre, retrospective cohort study conducted at a University Women's Hospital with a certified endometriosis centre. Data were collected from patients with symptomatic uterine leiomyomas who underwent laparoscopic myomectomy. The main outcome measured in the study was the presence of histologically confirmed endometriosis. Binary regression analysis was used to investigate risk factors for the coexistence of endometriosis. Postoperative complications were classified according to the Clavien-Dindo classification.

RESULTS

From 2014 to 2018, 223 patients underwent laparoscopic myomectomy for symptomatic leiomyomas, and 57 (25.6%) had unexpected endometriosis. Women with endometriosis significantly more frequently were nulliparous (66.7% vs. 51.2%; p = 0.04), had reported infertility (31.6% vs. 15.7%; p = 0.01) and smaller leiomyomas (mean diameter 4.92 cm) than women without endometriosis (mean diameter 6.02 cm; p = 0.006). Coexistent endometriosis significantly increased mean operative time (168.4 vs. 142.8 min; p = 0.05) while intra- and postoperative complications showed a similar distribution (p = 0.87) and length of hospital stay (p = 0.26). Binary regression analysis identified 2.3- and 2.2-fold increases in the risk of endometriosis for infertility (p = 0.042) and nulliparity (p = 0.041), respectively. Myoma size influenced the risk of endometriosis by a factor of 0.8 per cm (p = 0.037).

CONCLUSIONS

Coexistent endometriosis should be expected in leiomyoma patients particularly with nulliparity, infertility or minor myoma size as independent risk factors. Preoperative counselling should incorporate surgical therapy of coexisting endometriosis.

Long-Term Clinical Outcomes of Transcervical Radiofrequency Ablation of Uterine Fibroids: The VITALITY Study

Objective: The aim of this research was to learn the long-term (> 5 years) clinical outcomes of transcervical radiofrequency ablation of uterine fibroids.

Materials and Methods: For this retrospective, single-arm, long-term data-collection study, 23 women with heavy menstrual bleeding secondary to fibroids were treated with transcervical radiofrequency ablation guided by integrated intrauterine sonography (using the Sonata^® System, Gynesonics, Redwood City, CA). This study was within the 12-month Fibroid Ablation Study-EU clinical trial in Mexico. Symptoms were assessed using the Uterine Fibroid Symptom and Quality-of-Life's Symptom Severity Score (SSS) and Health-Related Quality of Life (HRQoL) subscales. Patients were queried regarding pregnancy and surgical reinterventions.

Results: Seventeen women (73.9%) provided long-term follow-up information, with a mean of 64.4 months ±4.5 months (range: 57–73 months). From baseline, mean SSS decreased significantly from 64.9 ± 16.9 to 27.6 ± 36.1, and mean HRQoL improved significantly from 27.2 ± 22.4 to 76.0 ± 32.6 (p = 0.002, and p = 0.0001, respectively). There were no surgical reinterventions through the first 3.5 years post-treatment. There was an 11.8% incidence of surgical reinterventions over 5.4 years of average follow-up, with 2 hysterectomies occurring after 3.5 and 4 years postablation, respectively (event rate: 2.2% per year; 95% confidence interval; 0.3%, 7.9%). Freedom from surgical reintervention at 1, 2, and 3 years was 100%, and, at 4 and 5 years, was 88.2% ± 7.8%. There was a single pregnancy occurring within the first year of treatment leading to a normal-term delivery by elective repeat cesarean section.

Conclusions: Transcervical radiofrequency ablation with the Sonata System produced substantial durable clinical benefits beyond 5 years with a low reintervention rate.

Symptoms and Health Quality After Laparoscopic and Robotic Myomectomy

Background and Objectives:

To compare the symptom severity and health quality outcomes of women who underwent laparoscopic and robotic myomectomy.

Methods:

This was a prospective nonrandomized cohort study. The Uterine Fibroid Symptom and Health Related Quality of Life Questionnaire was administered to 33 laparoscopic myomectomy and 31 robotic myomectomy patients before and year after surgery. Symptom severity and health quality scores were compared between the preoperative and postoperative periods for laparoscopic and robotic myomectomy procedures.

Results:

The mean age, operation time, estimated blood loss, body mass index, largest fibroid diameter, length of hospital stay, and number of fibroids removed were comparable for both groups (P > .05). Symptom severity scores decreased significantly for both laparoscopic and robotic myomectomy patients at year after surgery (P < .05), and health-related quality of life scores increased significantly in both groups at 1 year after surgery (P < .05). Improvement in symptom severity and health quality was higher in the laparoscopy group; however, this was not statistically different from the robotic myomectomy group (P > .05).

Conclusion:

Laparoscopic and robotic myomectomy provide significant reductions in fibroid-associated symptom severity and significant improvement in quality of life at 1 year after surgery. The rate of improvement was comparable for both procedures.

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.

Burden, Prevalence, and Treatment of Uterine Fibroids: A Survey of U.S. Women

BACKGROUND

Most women will experience uterine fibroids by the age of 50, yet few data exist describing the overall patient experience with fibroids. The objective of this population-based survey was to characterize symptom burden, patient awareness, and treatment decision-making for fibroids, including a comparison among women of varying backgrounds.

MATERIALS AND METHODS

Women (≥18 years) were recruited via email from GfK KnowledgePanel^®, a representative panel of US households, or identified with opt-in consumer panels. The Uterine Fibroid Symptom and Health-Related Quality of Life (UFS-QOL) questionnaire and Aberdeen Menorrhagia Severity Scale (AMSS) were included.

RESULTS

Eligible women were grouped into three cohorts: "at-risk" (symptoms suggestive of fibroids without clinical diagnosis, n = 300), "diagnosed" (n = 871), and fibroid-related "hysterectomy" (n = 272). Cohort and intracohort race/ethnicity and income analyses revealed differences in symptom burden, awareness/perception, and treatment history. Based on UFS-QOL scores, at-risk women reported significantly greater symptom severity and decreased health-related QOL versus diagnosed women; Hispanic women reported greater symptom severity versus white and black women. At-risk women also reported heavy menstrual bleeding and significant impact on work productivity. Among diagnosed women, 71% used pharmacologic therapy for symptom relief, and 30% underwent surgical or procedural treatment. Initial discussions with healthcare providers significantly impacted treatment outcomes; the hysterectomy cohort was most likely to first discuss hysterectomy.

CONCLUSIONS

Women with fibroids or symptoms suggestive of fibroids experience significant distress that reduces QOL, particularly racial minorities and women in lower income brackets. Survey results suggest that many women are likely undiagnosed, underscoring the need for improved awareness and education.

Optimizing research in symptomatic uterine fibroids with development of a computable phenotype for use with electronic health records

BACKGROUND

Women with symptomatic uterine fibroids can report a myriad of symptoms, including pain, bleeding, infertility, and psychosocial sequelae. Optimizing fibroid research requires the ability to enroll populations of women with image-confirmed symptomatic uterine fibroids.

OBJECTIVE

Our objective was to develop an electronic health record-based algorithm to identify women with symptomatic uterine fibroids for a comparative effectiveness study of medical or surgical treatments on quality-of-life measures. Using an iterative process and text-mining techniques, an effective computable phenotype algorithm, composed of demographics, and clinical and laboratory characteristics, was developed with reasonable performance. Such algorithms provide a feasible, efficient way to identify populations of women with symptomatic uterine fibroids for the conduct of large traditional or pragmatic trials and observational comparative effectiveness studies. Symptomatic uterine fibroids, due to menorrhagia, pelvic pain, bulk symptoms, or infertility, are a source of substantial morbidity for reproductive-age women. Comparing Treatment Options for Uterine Fibroids is a multisite registry study to compare the effectiveness of hormonal or surgical fibroid treatments on women's perceptions of their quality of life. Electronic health record-based algorithms are able to identify large numbers of women with fibroids, but additional work is needed to develop electronic health record algorithms that can identify women with symptomatic fibroids to optimize fibroid research. We sought to develop an efficient electronic health record-based algorithm that can identify women with symptomatic uterine fibroids in a large health care system for recruitment into large-scale observational and interventional research in fibroid management.

STUDY DESIGN

We developed and assessed the accuracy of 3 algorithms to identify patients with symptomatic fibroids using an iterative approach. The data source was the Carolina Data Warehouse for Health, a repository for the health system's electronic health record data. In addition to International Classification of Diseases, Ninth Revision diagnosis and procedure codes and clinical characteristics, text data-mining software was used to derive information from imaging reports to confirm the presence of uterine fibroids. Results of each algorithm were compared with expert manual review to calculate the positive predictive values for each algorithm.

RESULTS

Algorithm 1 was composed of the following criteria: (1) age 18-54 years; (2) either ≥1 International Classification of Diseases, Ninth Revision diagnosis codes for uterine fibroids or mention of fibroids using text-mined key words in imaging records or documents; and (3) no International Classification of Diseases, Ninth Revision or Current Procedural Terminology codes for hysterectomy and no reported history of hysterectomy. The positive predictive value was 47% (95% confidence interval 39-56%). Algorithm 2 required ≥2 International Classification of Diseases, Ninth Revision diagnosis codes for fibroids and positive text-mined key words and had a positive predictive value of 65% (95% confidence interval 50-79%). In algorithm 3, further refinements included ≥2 International Classification of Diseases, Ninth Revision diagnosis codes for fibroids on separate outpatient visit dates, the exclusion of women who had a positive pregnancy test within 3 months of their fibroid-related visit, and exclusion of incidentally detected fibroids during prenatal or emergency department visits. Algorithm 3 achieved a positive predictive value of 76% (95% confidence interval 71-81%).

CONCLUSION

An electronic health record-based algorithm is capable of identifying cases of symptomatic uterine fibroids with moderate positive predictive value and may be an efficient approach for large-scale study recruitment.

Comparison of the influence of three fibroid treatment options: supracervical hysterectomy, ulipristal acetate and uterine artery embolization on ovarian reserve - an observational study

BACKGROUND

To assess and compare the influence of three fibroid treatment options: supracervical hysterectomy, ulipristal acetate and uterine artery embolization on ovarian reserve.

METHODS

Prospective, observational, open-label study performed at the 3rd Chair and Department of Gynecology of the Medical University of Lublin, Poland. Premenopausal Caucasian women with symptomatic uterine fibroids were recruited into 3 groupspatients qualified for supracervical hysterectomies; patients qualified for preoperative ulipristal acetate (UPA) treatment scheduled for supracervical hysterectomies or myomectomies; patients qualified for uterine artery embolization (UAE). The following markers of ovarian reserve were investigated: antral follicle count (AFC), anti-Mullerian hormone (AMH), inhibin B (INHB), follicle stimulating hormone (FSH) and estradiol (E2). These markers were assessed before and 3 months after supracervical hysterectomies, before and 3 months after UAEs, and before and after 3 months of UPA treatment, before the scheduled surgeries. Baseline characteristics (age, parity, dominant fibroid volume, hemoglobin level, BMI, as well as AFC, AMH, INHB, FSH and E2) were compared between the study groups by Kruskall-Wallis ANOVA. Pre- and post-interventional values of AFC, AMH, INHB, FSH and E2 in the studied groups were compared with the Wilcoxon matched pairs test.

RESULTS

Twenty-six, 27 and 30 patients were included in the final analysis in the supracervical hysterectomy, UPA and UAE groups, respectively. Three months after supracervical hysterectomy INHB and E2 significantly decreased, while AFC, AMH and FSH remained unchanged. After 3 months of UPA treatment the values of all the assessed markers of ovarian reserve were not significantly different in comparison to baseline. Conversely, three months after UAE the values of AFC, AMH, INHB, and E2 were significantly decreased, while FSH was significantly increased.

CONCLUSIONS

Of the compared fibroid treatment methods UAE seems to have the greatest impact on ovarian function and should not be offered to patients concerned about their ovarian function. Supracervical hysterectomy did not affect the most accurate markers of ovarian reserve, and therefore appears to be safe in terms of ovarian function. UPA did not change any of the studied markers of ovarian reserve and seems a reasonable option when ovarian function is concerned.

Vilaprisan for treating uterine fibroids

The medical strategy to antagonize myoma size and related-symptoms is to reduce estrogen and progesterone activity on myomas. This can be obtained with the GnRH agonist (GnRHa) or with compounds that antagonize progesterone stimulatory activity on myomas. Selective progesterone receptor modulators (SPRMs) bind progesterone receptor (PR), leading to both agonist and antagonist effects. The result of SPRMs's action is tissue-specific and it depends on the particular affinity and strength of each SPRM. Area covered: Ulipristal acetate (UPA) is the first SPRM registered for myoma treatment. UPA reduces heavy uterine bleeding within 7 days from the onset of treatment, whereas a longer time is required with GnRHa treatment. Vilaprisan is a novel powerful SPRM. Phase I and II studies give encouraging results on the efficacy of vilaprisan at different doses. Like other SPRMs, vilaprisan induces benign changes of endometrium (PR modulator-associated endometrial changes, PAECs). These disappear as treatment is discontinued. Unlike GnRHa treatment, neither UPA nor vilaprisan induce hypoestrogenism and associated symptoms. Phase III studies are ongoing to confirm efficacy and safety of vilaprisan in long-term treatment of symptomatic fibroids. Expert opinion: It is fundamental to underline the rapidity of action (only 3 days) in the control of myoma-related bleeding.

Symptomatic Fibroid Management: Systematic Review of the Literature

Background and Objectives:

Symptomatic uterine fibroids are a societal and healthcare burden with no clear consensus among medical professionals as to which procedural treatment is most appropriate for each symptomatic patient. Our purpose was to determine whether recommendations can be made regarding best practice based on review and analysis of the literature since 2006.

Database:

A systematic search of journal articles relevant to the treatment of symptomatic uterine fibroids was performed within PubMed, clinical society websites, and medical device manufacturers' websites. All clinical trials published in English, representing original research, and reporting clinical outcomes associated with interventions for the management of symptomatic uterine fibroids were considered. Each article was screened and selected based on study type, content, relevance, American College of Obstetricians and Gynecologists score, and internal/external validity. Outcomes of interest were patient baseline characteristics, fibroid characteristics, procedural details, complications, and long-term follow-up. Random-effects meta-analyses were used to test the quantitative data. Assessment of 143 full-length articles through January 2016 produced 45 articles for the quantitative analysis. The weighted combined results from hysterectomy trials were compared with those from uterine-preserving fibroid studies (myomectomy, uterine artery embolization, laparoscopic radiofrequency ablation, and magnetic resonance-guided focused ultrasound).

Conclusion:

We explored trends that might guide clinicians when counseling patients who need treatment of symptomatic fibroids. We found that fibroid therapy is trending toward uterine-conserving treatments and outcomes are comparable across those treatments. Since minimally invasive options are increasing, it is important for the clinician to provide the patient with evidence-based therapeutic strategies.

Focused ultrasound: tumour ablation and its potential to enhance immunological therapy to cancer

Various kinds of image-guided techniques have been successfully applied in the last years for the treatment of tumours, as alternative to surgical resection. High intensity focused ultrasound (HIFU) is a novel, totally non-invasive, image-guided technique that allows for achieving tissue destruction with the application of focused ultrasound at high intensity. This technique has been successfully applied for the treatment of a large variety of diseases, including oncological and non-oncological diseases. One of the most fascinating aspects of image-guided ablations, and particularly of HIFU, is the reported possibility of determining a sort of stimulation of the immune system, with an unexpected "systemic" response to treatments designed to be "local". In the present article the mechanisms of action of HIFU are described, and the main clinical applications of this technique are reported, with a particular focus on the immune-stimulation process that might originate from tumour ablations.