The Management of Uterine Leiomyomas

Optimal Dose of Pituitrin in Laparoscopic Uterine Myomectomy: A Double-Blinded, Randomized Controlled Trial

STUDY OBJECTIVE

To determine the optimal effective dose of pituitrin in laparoscopic myomectomy for uterine leiomyoma.

DESIGN

Double-blinded, randomized controlled trial.

SETTING

Tertiary women's hospital in China.

PATIENTS

Total of 118 patients who underwent laparoscopic myomectomy.

INTERVENTIONS

Patients randomly received 0, 2, 4, or 6 units of pituitrin injected into the myometrium surrounding the myoma.

MEASUREMENTS AND MAIN RESULTS

Rate of satisfactory surgical condition, hemodynamic changes, total surgical time, and blood loss were recorded. The rates of satisfactory surgical conditions were 6.7%, 72.4%, 89.7%, and 93.3% in groups 0U, 2U, 4U, and 6U, respectively; they were higher in groups 2U, 4U, and 6U than those in group 0U, but there were no significant differences among the groups 2U, 4U, and 6U. The blood loss was higher in group 0U than that in groups 2U, 4U, and 6U (p < .01). Pituitrin was associated with a transient decrease in blood pressures and an increase in heart rate in a dose-dependent fashion, with more pronounced changes in groups 4U and 6U, and these groups also required a higher amount of vasoactive drug to correct hemodynamic changes (p < .05).

CONCLUSION

Two units of pituitrin could provide a satisfactory surgical field with minimal hemodynamic changes for laparoscopic uterine myomectomy.

Comparison of High-Intensity Focused Ultrasound and Conventional Surgery for Patients with Uterine Myomas: A Systematic Review and Meta-Analysis

OBJECTIVE

Uterine myomas are one of the most common gynecologic tumors in premenopausal women. The conventional surgical treatments are myomectomy and hysterectomy, but high-intensity focused ultrasound (HIFU) is a new noninvasive treatment creating no surgical wound. The aim of this study was to evaluate the effectiveness and safety of HIFU treatment compared with conventional surgery for patients with uterine myomas.

DATA SOURCES

PubMed, Embase, and the Cochrane Library were searched for studies published before January 2021.

METHODS OF STUDY SELECTION

Studies comparing the outcome of HIFU and conventional surgery-myomectomy and hysterectomy-for patients with uterine myomas were included. We conducted meta-analyses by using a random effects model. Uterine myoma symptom score and quality-of-life score were analyzed using the mean difference (MD). The recovery time and frequency of major adverse events were also evaluated.

TABULATION, INTEGRATION, AND RESULTS

Ten studies were included. HIFU relieved uterine myoma symptoms significantly when compared with conventional surgery at 6 (MD -1.61; 95% confidence interval [CI], -2.88 to -0.33) and 12 (MD -2.44; 95% CI, -3.68 to -1.20) months after treatment. Similarly, HIFU group improve the quality-of-life score significantly at 6 (MD 2.14; 95% CI, 0.86-3.42) and 12 (MD 2.34; 95% CI, 0.82-3.86) months after treatment when compared with the surgery group.

CONCLUSION

HIFU could be an effective and safe treatment option for patients with uterine myomas. However, one of its side effects, skin burns, requires further research and discussion. Additional studies involving more randomized controlled trials are warranted.

Alterations in lipid profile upon uterine fibroids and its recurrence

Uterine fibroids (UF) is the most common (about 70% cases) type of gynecological disease, with the recurrence rate varying from 11 to 40%. Because UF has no distinct symptomatology and is often asymptomatic, the specific and sensitive diagnosis of UF as well as the assessment for the probability of UF recurrence pose considerable challenge. The aim of this study was to characterize alterations in the lipid profile of tissues associated with the first-time diagnosed UF and recurrent uterine fibroids (RUF) and to explore the potential of mass spectrometry (MS) lipidomics analysis of blood plasma samples for the sensitive and specific determination of UF and RUF with low invasiveness of analysis. MS analysis of lipid levels in the myometrium tissues, fibroids tissues and blood plasma samples was carried out on 66 patients, including 35 patients with first-time diagnosed UF and 31 patients with RUF. The control group consisted of 15 patients who underwent surgical treatment for the intrauterine septum. Fibroids and myometrium tissue samples were analyzed using direct MS approach. Blood plasma samples were analyzed using high performance liquid chromatography hyphened with mass spectrometry (HPLC/MS). MS data were processed by discriminant analysis with projection into latent structures (OPLS-DA). Significant differences were found between the first-time UF, RUF and control group in the levels of lipids involved in the metabolism of glycerophospholipids, sphingolipids, lipids with an ether bond, triglycerides and fatty acids. Significant differences between the control group and the groups with UF and RUF were found in the blood plasma levels of cholesterol esters, triacylglycerols, (lyso) phosphatidylcholines and sphingomyelins. Significant differences between the UF and RUF groups were found in the blood plasma levels of cholesterol esters, phosphotidylcholines, sphingomyelins and triacylglycerols. Diagnostic models based on the selected differential lipids using logistic regression showed sensitivity and specificity of 88% and 86% for the diagnosis of first-time UF and 95% and 79% for RUF, accordingly. This study confirms the involvement of lipids in the pathogenesis of uterine fibroids. A diagnostically significant panel of differential lipid species has been identified for the diagnosis of UF and RUF by low-invasive blood plasma analysis. The developed diagnostic models demonstrated high potential for clinical use and further research in this direction.

Comparison of Laparoscopic Myomectomy with and without Uterine Artery Occlusion in Treatment of Symptomatic Multiple Myomas

Objective

Uterine artery occlusion (UAO) is a minimally invasive approach often used to treat symptomatic uterine myomas. This study aimed to compare the clinical effects of laparoscopic UAO (LUAO) in combination with laparoscopic myomectomy (LM) with LM alone to treat symptomatic multiple uterine myomas.

Methods

This was a prospective observational study. In total, 122 patients with symptomatic multiple uterine myomas underwent LUAO + LM or LM alone between April 2015 and October 2017. The surgical procedure time, blood loss, highest postoperative temperature, hospital length of stay, number of removed myomas, surgical complications, and recurrence rate of the two groups were compared.

Results

Mean blood loss was significantly lower in the LUAO + LM group compared with the LM group (177.97 ± 104.09 mL vs 258.10 ± 119.55 mL, p < 0.05). No significant difference in surgical procedure time, hospital length of stay, highest postoperative temperature, and surgical complications was found between the LUAO + LM group and LM group. The number of removed myomas was considerably higher in the LUAO + LM group than in the LM group (4[4–7] vs 3[3–5], p < 0.05). The recurrence rate in the LUAO + LM group was considerably lower than that in the LM group (6.2% vs 25.9%).

Conclusion

LUAO in combination with LM was associated with higher surgical quality and lower recurrence of myomas compared with LM alone. LUAO in combination with LM is recommended for women with symptomatic multiple uterine myomas who wish to retain their uteruses.

MRI-based pictorial review of the FIGO classification system for uterine fibroids

Uterine fibroids are the most common gynecologic neoplasm and contribute to significant morbidity, particularly when submucosal in location or large enough to cause bulk symptoms. Correctly classifying fibroids is essential for treatment planning and prevention of complications. Ultrasound is the first-line imaging modality for characterizing uterine fibroids. However, MRI allows for high-resolution, multiplanar visualization of leiomyomata that affords a more accurate assessment than ultrasound, particularly when fibroids are numerous. The FIGO system was developed in order to more uniformly and consistently describe and classify uterine fibroids. In this article, we review the MRI appearance of each of the FIGO classification types, detailing key features to report. Additionally, we present a proposed template for structured reporting of uterine fibroids based on the FIGO classification system.

Systematic molecular and clinical analysis of uterine leiomyomas from fertile-aged women undergoing myomectomy

STUDY QUESTION

What are the distributions and associated clinical characteristics of mediator complex subunit 12 (MED12), high mobility group AT-hook 2 (HMGA2) and fumarate hydratase (FH) aberrations in uterine leiomyomas from fertile-aged myomectomy patients?

SUMMARY ANSWER

These driver mutations account for the majority (83%) of tumours in fertile-aged patients.

WHAT IS KNOWN ALREADY

Alterations affecting MED12, HMGA2 and FH account for 80-90% of uterine leiomyomas from middle-aged hysterectomy patients, while the molecular background of tumours from young myomectomy patients has not been systematically studied.

STUDY DESIGN, SIZE, DURATION

A retrospective series of 361 archival uterine leiomyoma samples from 234 women aged ≤45 years undergoing myomectomy in 2009-2014 was examined. Associations between the molecular data and detailed clinical information of the patients and tumours were analysed.

PARTICIPANTS/MATERIALS, SETTING, METHODS

DNA was extracted from formalin-fixed paraffin-embedded samples and MED12 exons 1 and 2 were sequenced to identify mutations. Level of HMGA2 expression was evaluated by immunohistochemistry. Biallelic FH inactivation was analysed with 2-succinylcysteine staining, which is an indirect method of assessing FH deficiency. All patients' medical histories were reviewed, and clinical information of patients and tumours was combined with molecular data.

MAIN RESULTS AND THE ROLE OF CHANCE

The median age at operation was 34 years. The majority (58%) of patients were operated on for a single leiomyoma. Known driver mutations were identified in 83% of tumours (71% MED12; 9% HMGA2; 3% FH). In solitary leiomyomas, the MED12 mutation frequency was only 43%, and 29% were wild-type for all driver alterations. MED12 mutations were associated with multiple tumours, smaller tumour size and subserosal location.

LIMITATIONS, REASONS FOR CAUTION

Although comprehensive, the study is retrospective in nature and all samples have been collected for routine diagnostic purposes. The use of paraffin-embedded samples and immunohistochemistry may have led to an underestimation of mutations. Due to the limited sample size and rarity of especially FH-deficient leiomyomas, the data are partly descriptive.

WIDER IMPLICATIONS OF THE FINDINGS

The contribution of driver mutations in leiomyomas from young myomectomy patients is comparable to tumours obtained from hysterectomies of mostly middle-aged women. Our results support the earlier findings that MED12 mutations are associated with multiple tumours, smaller tumour size and subserosal location. The study emphasizes the distinct molecular background of solitary leiomyomas, and more research is needed to clarify the underlying causes of the notable proportion of wild-type leiomyomas.

STUDY FUNDING/COMPETING INTEREST(S)

The study was supported by the Academy of Finland (307773), the Sigrid Jusélius Foundation, the Cancer Foundation Finland and the iCAN Digital Precision Cancer Medicine Flagship. The authors declare no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

Magnetic Resonance-Guided High-Intensity Focused Ultrasound Ablation of Uterine Fibroids-Efficiency Assessment with the Use of Dynamic Contrast-Enhanced Magnetic Resonance Imaging and the Potential Role of the Administration of Uterotonic Drugs

OBJECTIVE

The assessment of the usefulness of dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) when qualifying patients with uterine fibroids (UFs) for magnetic resonance-guided high-intensity ultrasound (MR-HIFU).

MATERIAL AND METHODS

This retrospective, single center study included 283 women who underwent DCE-MRI and were treated with MR-HIFU. The patients were divided according to non-perfused volume (NPV) as well as by the type of curve for patients with a washout curve in the DCE-MRI study and patients without a washout curve. The studied women were assessed in three groups according to the type of uterotonics administered. Group A (57 patients) received one dose of misoprostol/diclofenac transvaginally and group B (71 patients) received oxytocin intravenously prior to the MR-HIFU procedure. The remaining 155 women (group C) were treated with the traditional non-drug enhanced MR-HIFU procedure.

RESULTS

The average NPV value was higher in no washout group, and depended on the uterotonics used.

CONCLUSIONS

We demonstrated a correlation between dynamic contrast enhancement curve types and the therapeutic efficacy of MR-HIFU. Our results suggest that DCE-MRI has the potential to assess treatment outcomes among patients with UFs, and patients with UFs that present with a washout curve may benefit from the use of uterotonic drugs. More studies are required to draw final conclusions.

Thirty years of mirena: A story of innovation and change in women's healthcare

Since its introduction in 1990, the levonorgestrel-releasing intrauterine system (LNG-IUS) has played a key role in shaping the healthcare landscape of women. Here we explore the development of the first LNG-IUS (Mirena®) and the early clinical trials that demonstrated its potential. We highlight the contraceptive and therapeutic benefits of Mirena®, and discuss how clinical practice has been changed since the introduction of LNG-IUS and other long-acting reversible contraceptive methods. The history of Mirena® is rich in innovation and has also paved the way to the development of smaller intrauterine systems with lower hormone doses. Along with Mirena®, these newer LNG-IUS contribute to improving contraceptive choices for women, allowing them to select the option that is right for them and that meets their needs no matter their age, parity or circumstances.

Laparoscopic surgery in a patient with foramen of Winslow hernia due to large uterine fibroids: a case report and literature review

BACKGROUND

Foramen of Winslow hernia (FWH) is a rare but emergent condition caused by an increase in the foramen diameter, visceral mobility, and intra-abdominal pressure. To the best of our knowledge, this is the first study to report a case of FWH secondary to large uterine fibroids that was successfully treated with laparoscopic surgery.

CASE PRESENTATION

A 52-year-old woman with large uterine fibroids was diagnosed with FWH. Because of the absence of signs of bowel ischemia and peritonitis, we performed an elective laparoscopic surgery through a 5-port system after bowel decompression using a long intestinal tube. Although foramen of Winslow closure was not performed, her postoperative course was uneventful.

CONCLUSIONS

Laparoscopic surgery for FWH is considered an extremely effective surgical treatment option because of its safety and efficacy in performing delicate procedures (such as adhesiolysis) with a good magnified field of view.

Comparative Effectiveness and Safety of High-Intensity Focused Ultrasound for Uterine Fibroids: A Systematic Review and Meta-Analysis

Background: Uterine fibroids are common benign tumors among premenopausal women. High- intensity focused ultrasound (HIFU) is an emerging non-invasive intervention which uses the high-intensity ultrasound waves from ultrasound probes to focus on the targeted fibroids. However, the efficacy of HIFU in comparison with that of other common treatment types in clinical procedure remains unclear.

Objective: To investigate the comparative effectiveness and safety of HIFU with other techniques which have been widely used in clinical settings.

Methods: We searched the Cochrane Central Register of Controlled Trials, PubMed, EMBASE, Cumulative Index to Nursing & Allied Health Literature, Web of Science, ProQuest Nursing & Allied Health Database, and three Chinese academic databases, including randomized controlled trials (RCTs), non-RCTs, and cohort studies. The primary outcome was the rate of re-intervention, and the GRADE approach was used to interpret the findings.

Results: About 18 studies met the inclusion criteria. HIFU was associated with an increased risk of re-intervention rate in comparison with myomectomy (MYO) [pooled odds ratio (OR): 4.05, 95% confidence interval (CI): 1.82–8.9]. The results favored HIFU in comparison with hysterectomy (HYS) on the change of follicle-stimulating hormone [pooled mean difference (MD): −7.95, 95% CI: −8.92–6.98), luteinizing hormone (MD: −4.38, 95% CI: −5.17−3.59), and estradiol (pooled MD: 43.82, 95% CI: 36.92–50.72)]. HIFU had a shorter duration of hospital stay in comparison with MYO (pooled MD: −4.70, 95% CI: −7.46−1.94, p < 0.01). It had a lower incidence of fever (pooled OR: 0.15, 95% CI: 0.06–0.39, p < 0.01) and a lower incidence of major adverse events (pooled OR: 0.04, 95% CI: 0.00–0.30, p < 0.01) in comparison with HYS.

Conclusions: High-intensity focused ultrasound may help maintain feminity and shorten the duration of hospital stay. High-quality clinical studies with a large sample size, a long-term follow-up, and the newest HIFU treatment protocol for evaluating the re-intervention rate are suggested to be carried out. Clinical decision should be based on the specific situation of the patients and individual values.

The associations between serum vitamin D, calcium and uterine fibroids in Chinese women: a case-controlled study

Objective

To investigate the associations between serum vitamin D, calcium and uterine fibroids in a Chinese female population.

Methods

In this case-control study, adult female patients with fibroids (cases) were compared with females without fibroids (controls) in terms of serum 25-hydroxyvitamin D (25OHD) and calcium levels.

Results

Out of 546 total participants (mean age, 41.68 ± 5.99 years; 279 with fibroids and 267 without fibroids), only 232 had serum 25OHD levels above the sufficient threshold (>20 ng/ml). In addition, females with fibroids had lower serum 25OHD levels versus those without fibroids. The prevalence of fibroids in females with deficient (<12 ng/ml) and insufficient (12–20 ng/ml) 25OHD levels were significantly higher than in females with sufficient (>20 ng/ml) 25OHD levels. Serum calcium levels were within normal range in both groups.

Conclusion

Hypovitaminosis D was highly prevalent among a population of Chinese females of reproductive-age, and serum 25OHD levels were lower in female patients with fibroids.

Relationship between thyroid disorders and uterine fibroids among reproductive-age women

Uterine fibroids and thyroid nodules, both of which are crucially affected by estrogen, are common diseases among reproductive-age women. However, little attention has been paid to the association between the two diseases. This retrospective case-control study aimed to assess the relationships among thyroid nodules, thyroid function and uterine fibroids in China. We reviewed the electronic records of 853 reproductive-age women who attended health check-ups at the Second Affiliated Hospital of Wenzhou Medical University from July 1st, 2017, to June 30th, 2018. All subjects received transvaginal pelvic ultrasound, thyroid ultrasound, thyroid function, and other laboratory tests. We found that the prevalence of thyroid nodules in subjects with uterine fibroids was remarkably higher than that in subjects without fibroids. The proportion of thyroid nodules ≥1 cm in subjects with uterine fibroids was significantly higher than that in subjects without fibroids. Women with thyroid nodules had a higher proportion of multiple uterine fibroids than women without thyroid nodules. Among the parameters of thyroid function, the only statistically significant parameter was total triiodothyronine, i.e., women with uterine fibroids had lower total triiodothyronine levels than unaffected controls; however, the total triiodothyronine levels were within the normal ranges. Moreover, no significant difference was noted in thyroid hormone status between subjects with and without uterine fibroids. Our findings suggest that thyroid nodules are positively correlated with uterine fibroids among reproductive-age women in China. Further studies are needed to confirm this association and fully understand the common pathogenetic mechanism underlying the association between uterine fibroids and thyroid nodules.

Vitamin D: Mechanism of Action and Biological Effects in Uterine Fibroids

Uterine fibroids (UFs) are the most common benign gynecological tumors. It was estimated that fifty percent of women presenting with UFs has symptomatology that negatively influences their quality of life. Pharmacological and/or surgical treatments are frequently required, depending on the woman's desire to preserve fertility, with a high impact on healthcare costs. Generally, the use of currently available pharmacological treatments may lead to side effects. Therefore, there is a growing interest in a natural and safe approach for UFs. In recent years, epidemiological studies reported a vitamin D deficiency in patients with UFs raised interest in the potential biological effects of vitamin D supplementation. In vitro studies proved vitamin D efficacy in inhibiting UFs growth by targeting pathways involved in the regulation of various biological processes, including proliferation, extracellular matrix (ECM) remodeling, DNA repair, signaling and apoptosis. However, clinical studies supported only in part the beneficial effects of vitamin D supplementation in reducing UFs growth and tumor volume. Randomized controlled trials and large population studies are mandatory as the potential clinical benefits are likely to be substantial.

Uterine Myomas: Endovascular Treatment

Uterine fibroids embolization is a safe and effective organ sparing treatment for fibroid-related symptoms based on a broad range of published evidence including randomized-controlled trials. Indication to treatment is usually the presence of symptomatic uterine fibroids. In this review, a systematic search of journal articles relevant to the treatment of symptomatic uterine fibroids was conducted, with a special focus on the indication to treatment, technique, procedural outcomes and pain control. All clinical trials published in English language, representing original research, and reporting clinical outcomes associated with interventions for the management of symptomatic uterine fibroids were considered.

Technicity in Canada: A Nationwide Whole-Population Analysis of Temporal Trends and Variation in Minimally Invasive Hysterectomies

STUDY OBJECTIVE

The objective of our study was to provide a contemporary description of hysterectomy practice and temporal trends in Canada.

DESIGN

A national whole-population retrospective analysis of data from the Canadian Institute for Health Information.

SETTING

Canada.

PATIENTS

All women who underwent hysterectomy for benign indication from April 1, 2007, to March 31, 2017, in Canada.

INTERVENTIONS

Hysterectomy.

MEASUREMENTS AND MAIN RESULTS

A total of 369 520 hysterectomies were performed in Canada during the 10-year period, during which the hysterectomy rate decreased from 313 to 243 per 100 000 women. The proportion of abdominal hysterectomies decreased (59.5% to 36.9%), laparoscopic hysterectomies increased (10.8% to 38.6%), and vaginal hysterectomies decreased (29.7% to 24.5%), whereas the national technicity index increased from 40.5% to 63.1% (p <.001, all trends). The median length of stay decreased from 3 (interquartile range 2-4) days to 2 (interquartile range 1-3), and the proportion of patients discharged within 24 hours increased from 2.1% to 7.2%. In year 2016-17, women aged 40 to 49 years had significantly increased risk of abdominal hysterectomy compared with women undergoing hysterectomy in other age categories (p <.001). Comparing women with menstrual bleeding disorders, women undergoing hysterectomy for endometriosis (adjusted relative risk [aRR] 1.36; 95% confidence interval [CI], 1.28-1.44) and myomas (aRR 2.01; 95% CI, 1.94-2.08) were at increased risk of abdominal hysterectomy, whereas women undergoing hysterectomy for pelvic organ prolapse and pelvic pain (aRR 1.47; 95% CI, 1.41-1.53) were at decreased risk. Using Ontario as the comparator, Nova Scotia (aRR 1.35; 95% CI, 1.27-1.43), New Brunswick (aRR 1.25; 95% CI, 1.18-1.32]), Manitoba (aRR 1.35; 95% CI, 1.28-1.43), and Newfoundland and Labrador (aRR 1.18; 95% CI, 1.10-1.27) had significantly higher risks of abdominal hysterectomy. In contrast, Saskatchewan (aRR 0.75; 95% CI, 0.74-0.77) and British Columbia (aRR 0.86; 95% CI, 0.85-0.88) had significantly lower risks, whereas Prince Edward Island, Quebec, and Alberta were not significantly different.

CONCLUSION

The proportion of minimally invasive hysterectomies for benign indication has increased significantly in Canada. The declining use of vaginal approaches and the variation among provinces are of concern and necessitate further study.

A Review of Clinical Guidelines on the Management of Iron Deficiency and Iron-Deficiency Anemia in Women with Heavy Menstrual Bleeding

Introduction

Up to one-third of women of reproductive age experience heavy menstrual bleeding (HMB). HMB can give rise to iron deficiency (ID) and, in severe cases, iron-deficiency anemia (IDA).

Aim

To review current guidelines for the management of HMB, with regards to screening for anemia, measuring iron levels, and treating ID/IDA with iron replacement therapy and non-iron-based treatments.

Methods

The literature was searched for English-language guidelines relating to HMB published between 2010 and 2020, using the PubMed database, web searching, and retrieval of clinical guidelines from professional societies.

Results

Overall, 55 guidelines mostly originating from North America and Europe were identified and screened. Twenty-two were included in this review, with the majority (16/22) focusing on guidance to screen women with HMB for anemia. The guidance varied with respect to identifying symptoms, the criteria for testing, and diagnostic hemoglobin levels for ID/IDA. There was inconsistency concerning screening for ID, with 11/22 guidelines providing no recommendations for measurement of iron levels and four contrasting guidelines explicitly advising against initial assessment of iron levels. In terms of treatment, 8/22 guidelines provided guidance on iron therapy, with oral iron administration generally recommended as first-line treatment for ID and/or IDA. Four guidelines recommended intravenous iron administration for severe anemia, in non-responders, or before surgery. Three guidelines provided hemoglobin thresholds for choosing between oral or intravenous iron treatment. Four guidelines discussed the use of transfusion for severe IDA.

Conclusion

Many of the guidelines for managing HMB recognize the importance of treating anemia, but there is a lack of consensus in relation to screening for ID and use of iron therapy. Consequently, ID/IDA associated with HMB is likely to be underdiagnosed and undertreated. A consensus guidance, covering all aspects of screening and management of ID/IDA in women with HMB, is needed to optimize health outcomes in these patients.

Women who bleed heavily during menstruation are at risk of iron deficiency and anemia. This can have a negative effect on the well-being of women and can cause serious complications after surgery. Iron is an important part of the hemoglobin in red blood cells that carries oxygen around the body. Bleeding causes iron to be lost from the body. If there is heavy blood loss, iron stores in the body can become low, leading to iron deficiency. If the iron deficiency is severe enough to impair red blood cell production, iron-deficiency anemia can develop. We reviewed the current guidelines for the care of women with heavy menstrual bleeding, focusing on the detection and treatment of iron deficiency and anemia. Most guidelines include routine testing for anemia. Fewer guidelines consider measuring iron levels. Not all the guidelines include advice on the best way to treat iron deficiency and anemia. For those that do, the recommendations vary and sometimes offer conflicting advice. There is little agreement on when to give iron therapy, and whether this should be given by mouth or by infusion. A lack of clear guidance on detecting and treating iron deficiency and anemia caused by heavy menstrual bleeding puts women at risk of being undiagnosed and untreated. To address these concerns, the authors recommend the development of consensus guidelines. These should contain comprehensive recommendations on all aspects of the diagnosis and management of iron deficiency and anemia in women with heavy menstrual bleeding.

Uterine Fibroids and Progestogen Treatment: Lack of Evidence of Its Efficacy: A Review

BACKGROUND

The objective of this review is to determine the evidence or, conversely, the absence of evidence regarding the effectiveness of progestogens in treating premenopausal women with uterine fibroids. In particular, the goal is to address recurring questions as to whether they are effective or not for managing symptoms commonly attributed to fibroids.

METHODS

A review of the most relevant papers (n = 63) on the efficacy of progesterone and progestogens as medical therapy for uterine fibroids.

RESULTS

Having reviewed the most significant papers on the relationship between uterine fibroids and progesterone/progestogens, it is clear that there is biochemical, histological and clinical evidence that progesterone and progestogens play a critical role in the pathogenesis of myomas.

CONCLUSION

Since progesterone is already implicated in the pathogenesis of this entity, using progestogens to manage fibroids is like constantly adding fuel to the fire, rendering this treatment ineffective.

Large Uterine Fibroids in Pregnancy with Successful Caesarean Myomectomy

Uterine fibroid is the commonest benign tumour of the female reproductive tract. It occurs in 20–40% of women, whereas the estimated incidence in pregnancy is 0.1–3.9%. Uterine fibroid in pregnancy is usually asymptomatic with complications occurring in 10–30% of cases. The first line of management is conservative with counselling for myomectomy after delivery. However, in the presence of intractable symptoms, both antepartum myomectomy and caesarean myomectomy have been reported to be successfully performed in carefully selected cases. We report a case of large subserous uterine fibroid in pregnancy that was referred to our centre at 14 weeks of gestation. She developed generalized body weakness, backache, and breathlessness at 27 weeks gestation. Thus, she was admitted and managed conservatively for eight weeks with significant relief of symptoms. She eventually had a caesarean myomectomy at 35 weeks of gestation; the outcome was a live female baby with a birth weight of 2.3 kg and a large subserous fibroid weighing 9.5 kg. We can therefore say that caesarean myomectomy can be safely performed in carefully selected cases.

National trends and determinants of hospitalization for uterine leiomyomas - Portuguese public database analysis from 2000 to 2015

OBJECTIVE

To determine the trends of hospitalization (inpatients and outpatients) for uterine leiomyomas in Portugal, over a period of fifteen years.

STUDY DESIGN

We perform a population- and register-based retrospective study of women who were hospitalized with a primary diagnosis of uterine fibroid in public hospitals in continental Portugal, in the period between January 1, 2000 and December 31, 2015. Patient data regarding hospital codes, admission and discharge dates, patient age, diagnosis, procedures and complications were extracted from the national database of Administração Central do Sistema de Saúde (ACSS). All calculations were performed with the STATA software, version 13.1. Categorical data were analysed by the χ2 test and the means of continuous variables were analysed with Student's t-test. Statistical significance was set at p < 0.05.

RESULTS

Between 2000 and 2015, 102 476 patients were admitted to public hospitals in Portugal due to uterine leiomyomas. The majority were admitted to hospital for surgery: 73.6 % for hysterectomy and 13.0 % for myomectomy. During this period, the definitive treatment (hysterectomy) decreased from 83.2% to 63.0% (p < 0.001), with a change towards more conservative treatments such as myomectomies (6.4% to 22.6%, p < 0.001). Additionally, in women submitted to hysterectomy, laparoscopic and vaginal routes increased (1.1%-11.5%, p < 0.001 and 2.1%-4.0%, p < 0.001; respectively). Globally, there was a 14.3 % reduction in hospitalizations due to uterine fibroids and an increase in the outpatient rate (from 3.1% to 22.1%). The mean number of hospitalization days for inpatients also decreased (from 6.3 ± 4.1-4.0 ± 3.0, p < 0.001). Regarding urgently hospitalized women, 11.8 % required a blood transfusion. In women submitted to surgical procedures, 0.5 % had an intraoperative complication and 2.3 % a post-operative complication, directly related to the surgical procedure.

CONCLUSION

There was a reduction in hospitalizations due to uterine fibroids and a change towards more conservative treatments.

Association between vitamin D and uterine fibroids: a study protocol of an open-label, randomised controlled trial

INTRODUCTION

Uterine fibroids are the most common pelvic benign tumour with no satisfactory long-term medical treatment. Recent studies have demonstrated that vitamin D significantly inhibited the growth of fibroids in vitro, vivo and a small-sample clinical trial. Therefore, the aim of this randomised clinical trial (RCT) is to evaluate whether supplementation with vitamin D could reduce the risk and inhibit the growth of uterine fibroids in reproductive stage women.

METHODS AND ANALYSIS

The open-label, RCT comprises two parts, including parts I and II. In part I, 2230 vitamin D deficiency or vitamin D insufficiency patients without uterine fibroids will be randomly assigned to two groups: intervention group (according to the level of serum 25-hydroxyvitamin D3, receive 1600 or 800 IU/day of vitamin D3 for 2 years) and control group (followed up at the same time points). By using gynaecological ultrasound examinations, the incidence of uterine fibroids will be employed to measure the outcome in different groups. In part II, 360 uterine fibroids patients with vitamin D deficiency or vitamin D insufficiency will be randomly assigned to intervention group or control group. According to the level of serum 25-hydroxyvitamin D3, 180 patients will receive 1600 or 800 IU/day of vitamin D3 for 2 years. Control group will receive regular follow-up. The outcome measure will be conducted using gynaecological ultrasound examinations to detect the growth of uterine fibroids in each group.

ETHICS AND DISSEMINATION

This study has been approved by the institutional review board of the Second Affiliated Hospital of Wenzhou Medical University (No. LCKY2018-35).

TRIAL REGISTRATION NUMBERS

NCT03586947 and NCT03584529.

A Case Series of Patients with Large Uterine Fibroids and Venous Thromboembolisms

OBJECTIVE

The purpose of this case series is to identify the clinical characteristics of women with uterine fibroids who developed venous thromboembolisms (VTE) and possible risk factors for the development of VTE in this group.

DATA SOURCES

We conducted a systematic search of the Medline, Embase, Cochrane and Scopus databases to retrieve case reports and case series that describe women with an enlarged uterus and VTE. The databases were searched up to August 2019.

STUDY SELECTION

A total of 1485 articles were identified by a librarian. All case series and case reports that reported uterine weight and size of the fibroids were included.

DATA EXTRACTION AND SYNTHESIS

A total of 27 articles were included, describing 35 patients who developed VTE in the presence of uterine fibroids. On average, the uterus measured 22.9 ± 5.0 weeks gestational age and occupied a volume of 2715 cm³ (interquartile range 1296.3-3878.8) on imaging. Two-thirds (60%) of VTEs occurred on the left side, and 87% showed signs of venous compression on imaging. Most patients (89%) required surgical management to relieve the compression caused by the enlarged uterus.

CONCLUSION

VTE in cases of large uterine leiomyomas can be associated with mechanical compression, which requires surgical management to relieve compression. There is an obvious increased risk of VTE in patients with venous stasis secondary to uterine compression; however, there is no current evidence evaluating the use of anticoagulation in such patients. Further research is required to determine the role of prophylactic anticoagulation in reducing the risk of VTE in high-risk patients with large uterine fibroids.

The Medical Device Applied to Uterine Fibroids Morcellation: Analysis of Critical Biological Issues and Drawbacks from A Medical-Legal Prospective

Following the FDA safety communication of 2014 increasing attention has been to the treatment of uterine fibroids, due to the suspicion of a potential leiomyosarcoma (ULM). FDA banned the use of power morcellation in the US, since this technique is likely to spread malignant cells from an unsuspected ULM. We criticized the medical legal consequences of this banning among gynecologists and patients, focusing on the drawbacks of biology and surgery. The authors analyzed literature data on one side, on the incidence, diagnosis and treatment of leiomyoma and ULM, and the other side, on the power morcellations and related critical issues, trying to highlight their main controversial aspects and to outline the possible impact on patients and on medical responsibility. The alternative methods to power morcellation are more invasive surgical solutions (as mini laparotomy or culdotomy), which inevitably involve associated risks with the surgical procedure as such and always request the containing bags. Although the in-bag morcellation is a promising technique, currently the used devices are largely off-label. This highlights the surgical risk, in case of complications, of suffering for malpractice claims both for not having used a containment system, favoring the spread of the neoplasm, and for its off-label use. Since the diagnosis of ULM is by histology after surgery, the fear of legal consequences or medical malpractice for unknown ULM power morcellation, should be targeted to analyze, in terms of cost/benefit ratio, the surgical priority. It should focus on the prevention of the risk of having a rare and statistically limited ULM or on the surgical-related complications, often linked to a slowdown minimally invasive surgery, or on the use of the authorized in-bag morcellations.

Cross-talk between Janus kinase-signal transducer and activator of transcription pathway and transforming growth factor beta pathways and increased collagen1A1 production in uterine leiomyoma cells

OBJECTIVE

To characterize the potential interaction between interleukin-6 (IL6), Janus kinase (JAK)-signal transducer and activator of transcription (STAT)-3 (JAK/STAT3) pathway, and Transforming growth factor beta (TGFβ)-3 , and to determine whether such cross-talk was a contributing factor in the dysregulation of type I collagen production in leiomyomas.

DESIGN

Laboratory study.

SETTING

University research laboratory.

PATIENTS

None.

INTERVENTIONS

Exposure of leiomyoma and myometrial cell lines to IL6 and STAT3 activators/inhibitors. Western immunoblot analysis and immunohistochemistry.

MAIN OUTCOME MEASURES

Expression of STAT3, pSTAT3, SOCS3, COL1A1, and TGFb3.

RESULTS

We observed that IL6 increased pSTAT3 as well as collagen1A1 in uterine leiomyoma cells. Direct activation of the JAK/STAT3 pathway increased collagen1A1 production in leiomyoma cells, whereas inhibition of the pathway significantly decreased collagen1A1 production. We further observed that modulation of the JAK/STAT3 pathway also increased the expression of TGFβ3 protein. Leiomyoma cells exposed to TGFβ3 demonstrated a significant decrease in pSTAT3 protein. Myometrial cells demonstrated a less sensitive response to STAT3 modulation and collagen production.

CONCLUSION

Cross-talk between the TGFβ pathway and JAK/STAT3 pathway contributes to the fibrotic nature of uterine leiomyomas.

Estimated Prevalence and Incidence of Uterine Leiomyoma, and Its Treatment Trend in South Korean Women for 12 years: A National Population-Based Study

Background: Although uterine leiomyoma causes many problems, including infertility, there are few studies that have investigated the epidemiologic characteristics of uterine leiomyoma in South Korea. The aim of this study is to estimate the prevalence and incidence of uterine leiomyoma in South Korea and analyze the treatment trends. Materials and Methods: Women of reproductive age (15-54 years) were selected from the Korean National Health Insurance Service (NHIS) sample cohort dataset, which was collected from 2002 to 2013. Patients with uterine leiomyoma were identified by ICD-10 (International Codes of Disease, 10th Edition) and intervention codes. Prevalence and incidence were calculated from the NHIS cohort dataset and the treatment trends were analyzed for diagnosed patients. Results: The prevalence in overall age groups increased from 0.96% in 2002 to 2.43% in 2013, and the 1-year incidences of all age groups increased. The 26-30 age group showed the highest rate of 1-year incidence increase (2.14-folds, 0.33% in 2003 to 0.70% in 2013). The proportion of myomectomy increased from 22% in 2002 to 49% in 2013, whereas the proportion of hysterectomy decreased from 78% to 45%. Conclusions: The prevalence and incidence of uterine leiomyoma are increasing in South Korea as time progresses, and the rate of incidence increase is higher in younger reproductive women. Overall trends in uterine leiomyoma treatment are shifting to the methods of the saving uterus.

Uterine Isthmus Tourniquet during Abdominal Myomectomy: Support or Hazard? A Randomized Double-Blind Trial

BACKGROUND AND OBJECTIVES

A tourniquet has been suggested as a useful means of reducing massive hemorrhage during myomectomy. However, it is not clear whether the restricted perfusion affects the ovaries. In the present study, we examined the effect of a tourniquet on ovarian reserve and blood loss during myomectomy.

MATERIALS AND METHODS

In a randomized double-blind clinical trial, fertile nonobese patients scheduled for abdominal myomectomy at Rasool-e-Akram Hospital from February 2018 to June 2019 were randomized to a tourniquet (n = 46) or a non-tourniquet group (n = 35). Serum levels of anti-Müllerian hormone (AMH) and follicle-stimulating hormone (FSH) were measured before and 3 months after surgery, blood loss was recorded during surgery, and serum levels of hemoglobin (Hb) were recorded before surgery, 6 h and 3 days after surgery. SPSS version 21 was used for statistical analysis.

RESULTS

Demographic, obstetric, and myoma characteristics were similar in the 2 groups (p > 0.05). The mean baseline values of AMH and FSH did not differ between groups (p > 0.05). After surgery, only FSH was higher in the control group (p = 0.043). Despite the time taken to fasten and open the tourniquet, the mean operating time was shorter in the tourniquet group (p < 0.001). Blood loss was higher in the control group (p = 0.005). The drop in Hb levels at 6 h after surgery was higher in the non-tourniquet group (p = 0.002). Blood loss was significantly associated with the duration of surgery (r = 0.523, p < 0.001).

CONCLUSION

The use of a tourniquet during abdominal myomectomy significantly reduced the mean volume of blood loss compared to the non-tourniquet group, while it did not prolong the duration of surgery, nor reduced the ovarian reserve. A tourniquet is a safe and efficient measure during abdominal myomectomy.

Vitamins and Uterine Fibroids: Current Data on Pathophysiology and Possible Clinical Relevance

Uterine fibroid (UF) is the most common benign tumor pathology of the female reproductive organs. UFs constitute the main reason for a hysterectomy and hospitalization due to gynecological conditions. UFs consist of uterine smooth muscle immersed in a large amount of extracellular matrix (ECM). Genetic studies have demonstrated that UFs are monoclonal tumors originating from the myometrial stem cells that have underwent specific molecular changes to tumor initiating stem cells which proliferate and differentiate later under the influence of steroid hormones. There is growing interest in the role of micronutrients, for example, vitamins, in UFs. This article is a comprehensive review of publications regarding the available data concerning the role of vitamins in the biology and management of UFs. In summary, the results showed that some vitamins are important in the biology and pathophysiology of UFs. For example, vitamins A and D deserve particular attention following studies of their influence on the treatment of UF tumors. Vitamins B3, C, and E have not been as widely studied as the abovementioned vitamins. However, more research could reveal their potential role in UF biology.

No 371 - Le morcellement durant la chirurgie gynécologique: Son utilisation, ses complications et les risques liés à la présence de tumeurs malignes insoupçonnées

OBJECTIF

La présente directive clinique conseille les gynécologues quant au recours au morcellement tissulaire pendant une chirurgie gynécologique. RéSULTATS: Le morcellement effectué au cours d'une chirurgie gynécologique peut permettre l'ablation de masses utérines volumineuses, offrant ainsi aux femmes une solution chirurgicale à effraction minimale. Les conséquences oncologiques indésirables du morcellement tissulaire devraient être atténuées par l'amélioration de la sélection des patientes, la tenue d'examens préopératoires et l'adoption de techniques novatrices réduisant au minimum la dispersion tissulaire. ÉVIDENCE: La littérature publiée a été récupérée au moyen de recherches menées dans PubMed et Medline au printemps 2014 à l'aide d'une terminologie contrôlée (« leiomyosarcoma », « uterine neoplasm », « uterine myomectomy », « hysterectomy ») et de mots-clés (« leiomyoma », « endometrial cancer », « uterine sarcoma », « leiomyosarcoma », « morcellation »). Les résultats retenus provenaient de revues systématiques, d'essais cliniques randomisés, d'essais cliniques contrôlés et d'études observationnelles de langue anglaise ou française. Aucune restriction de date n'a été imposée. Les recherches ont été refaites régulièrement, et les résultats ont été incorporés à la directive clinique jusqu'en juillet 2017. Nous avons également tenu compte de la littérature grise (non publiée) trouvée sur les sites Web d'organismes d'évaluation des technologies de la santé et d'autres organismes liés aux technologies de la santé, dans des collections de directives cliniques et dans des registres d'essais cliniques, et obtenue auprès d'associations nationales et internationales de médecins spécialistes.

VALEURS

La qualité des données probantes a été évaluée en fonction des critères décrits dans le rapport du Groupe d'étude canadien sur les soins de santé préventifs. AVANTAGES, INCONVéNIENTS ET COûTS: Les gynécologues offrent aux femmes une chirurgie à effraction minimale pouvant comprendre le recours à un morcellateur électromécanique pour faciliter le retrait des tissus. Les femmes devraient être informées que l'utilisation d'un morcellateur en présence de tumeurs utérines (sarcomes, tumeurs endométriales), cervicales ou tubo-ovariennes jusque-là insoupçonnées est associée à un risque accru de dissémination. Le morcellement tissulaire devrait être précédé d'une évaluation complète, d'une sélection appropriée des patientes et de l'obtention du consentement éclairé de ces dernières, et devrait être effectué par des chirurgiens ayant une formation adéquate en matière de pratiques de morcellement tissulaire sûres. DéCLARATIONS SOMMAIRES: RECOMMANDATIONS.

No. 371-Morcellation During Gynaecologic Surgery: Its Uses, Complications, and Risks of Unsuspected Malignancy

OBJECTIVE

This guideline provides guidance to gynaecologists regarding the use of tissue morcellation in gynaecologic surgery.

OUTCOMES

Morcellation may be used in gynaecologic surgery to allow removal of large uterine specimens, thus providing women with a minimally invasive surgical option. Adverse oncologic outcomes of tissue morcellation should be mitigated through improved patient selection, preoperative investigations, and novel techniques that minimize tissue dispersion.

EVIDENCE

Published literature was retrieved through searches of PubMed and Medline in the spring of 2014 using appropriate controlled vocabulary (leiomyosarcoma, uterine neoplasm, uterine myomectomy, hysterectomy) and key words (leiomyoma, endometrial cancer, uterine sarcoma, leiomyosarcoma, and morcellation). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date limits, but results were limited to English or French language materials. Searches were updated on a regular basis and incorporated in the guideline to July 2017. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The quality of evidence in this document was rated using the criteria described in the report of the Canadian Task Force on Preventive Health Care.

BENEFITS, HARMS, AND COSTS

Gynaecologists offer women minimally invasive surgery, and this may involve tissue morcellation and the use of a power morcellator for specimen retrieval. Women should be counselled that in the case of unexpected uterine (sarcoma, endometrial), cervical, and/or tubo-ovarian cancer, the use of a morcellator is associated with increased risk of tumour dissemination. Tissue morcellation should be performed only after complete investigation, appropriate patient selection, and informed consent and by surgeons with appropriate training in the safe practices of tissue morcellation.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Treatment Choices in a National Cohort of Canadian Women With Symptomatic Uterine Fibroids

OBJECTIVES

To describe treatment choices made at the time of enrollment in CAPTURE, a Canadian patient registry for women with symptomatic uterine fibroids (UFs), and to define demographic and clinical characteristics that independently predict these choices.

METHODS

Women arranging appointments for UF care were eligible to enrol. At the time of the enrollment visit, women's self-reported treatment histories were noted, along with their clinical characteristics. Tretment options were discussed and chosen during that visit. Patients could choose medical and/or surgical treatment, or they could opt for no active treatment (i.e., "watchful waiting"); treatment decisions were not binding.

RESULTS

The most common medication proposed and chosen was ulipristal acetate (UPA), and the most common procedure was myomectomy. These treatments were also the most commonly identified in patients' histories. Medication alone and medication in combination with surgery were the most common treatment approaches chosen (46% and 26%, respectively). Surgery alone and watchful waiting were chosen by 14% and 13% of patients, respectively. Significant predictors of active treatment included patient pregnancy plans, overall symptom severity, and prior treatment history (medical and surgical). Other parameters, including patient age and history of specific UF symptoms, appear to influence the choice of medical therapies (UPA, gonadotropin-releasing hormone agonists, or other options) and procedures (myomectomy or hysterectomy).

CONCLUSIONS

This real-world study documents the patient factors associated with the treatment decisions of women seeking care for symptomatic UFs in contemporary Canadian gynaecology practice. Subsequent analyses will follow the outcomes of these treatments over two years in this population.

Quality of ultrasonography reporting and factors associated with selection of imaging modality for uterine fibroids in Canada: results from a prospective cohort registry

BACKGROUND

Uterine fibroids are common in women and their management is heavily influenced by information gathered through imaging. We aimed to evaluate the type and quality of imaging performed for assessment of uterine fibroids in Canada.

METHODS

Starting in July 2015, premenopausal women with symptomatic fibroids were enrolled in a prospective, noninterventional, observational registry (Canadian Women With Uterine Fibroids Registry [CAPTURE]) that included 19 Canadian sites. Clinical characteristics were extracted from the baseline visit. We evaluated the association between demographic and clinical variables of interest with regard to imaging type using unadjusted and adjusted logistic regression models.

RESULTS

Of 1493 women, 1148 had ultrasonography, 135 had magnetic resonance imaging (MRI), 80 had other types of imaging and 130 did not have imaging reported within 12 months of the baseline visit. After adjusting for demographic and clinical characteristics, patients who underwent MRI had larger fibroids (odds ratio [OR] per 1-cm increase 1.11, 95% confidence interval [CI] 1.05-1.17) and more numerous fibroids (1 v. > 1; OR 1.74, 95% CI 1.14-2.64) compared with those who underwent ultrasonography only. For ultrasonography reporting, quality criteria were met for 268 of 1148 patients (23.3%). There was a difference in the quality of reporting among the 19 sites (p < 0.001). Logistic regression model accounting for within-site variability showed that reporting results from ultrasonography in the province of Quebec were less likely to meet all quality criteria (OR 0.20, 95% CI 0.06-0.66) and those from sites in more populated cities (≥ 400 000 inhabitants) were more likely to do so (OR 6.15, 95% CI 2.20-17.18).

INTERPRETATION

We determined that imaging modality for fibroids is associated with patient characteristics. The quality of reporting results for ultrasonography of fibroids in Canada falls short of internationally endorsed guidelines and needs improvement.

STUDY REGISTRATION

ClinicalTrials.gov, no. NCT02580578.

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.

Comparison of Focused Ultrasound Surgery and Hysteroscopic Resection for Treatment of Submucosal Uterine Fibroids (FIGO Type 2)

The aim of the study described here was to compare the effectiveness of focused ultrasound surgery (FUS), which uses high-intensity focused ultrasound to perform tissue ablation, with that of hysteroscopic transcervical resection of myoma (TCRM) for the treatment of type 2 submucosal fibroids. A prospective cohort study was performed in patients who underwent FUS or TCRM from January 2012 to December 2014. Uterine Fibroid Symptom (UFS) and Quality of Life (QoL) questionnaires were used to measure fibroid-related symptoms and quality of life before and at 3, 6 and 12 mo after treatment. Technical results, adverse events and post-operative recovery times of both groups were also compared. A total of 81 patients with at least one type 2 submucosal fibroid were enrolled. The mean diameter of type 2 submucosal fibroids was 3.8 ± 0.9 cm (range: 2.0-5.0 cm) for 39 patients in the FUS group and 3.5 ± 0.8 cm (range: 2.0-4.8 cm) for the 42 patients enrolled in the TCRM group. No major complication occurred in any patients for either treatment. In both groups, the UFS score decreased significantly and the QoL score increased significantly from baseline successively at 3, 6 and 12 mo post-treatment (p < 0.05). Time spent in hospital post-treatment was significantly shorter (2.56 ± 0.98 d) for the FUS group compared with the TCRM group (3.31 ± 0.60 d) (p < 0.05). Time to return to work after treatment was also significantly shorter for the FUS group (3.14 ± 0.83 d) than for the TCRM group (6.09 ± 0.9 d) (p < 0.05). FUS and TCRM are both tolerable and effective treatments with significant improvement of symptom and quality of life for patients with type 2 submucosal fibroids ≤5 cm in diameter.

Impact of intramural non-cavity-distorting leiomyoma on placental histopathology and perinatal outcome in singleton live births resulting from in vitro fertilization treatment

PURPOSE

To evaluate the effect of non-cavity-distorting intramural leiomyomas on the placental histopathology pattern and perinatal outcome in singleton live births resulting from in vitro fertilization treatment.

METHODS

The study population included all singleton live births following in vitro fertilization treatment with autologous oocytes during the period from 2009 to 2017. Primary outcomes included anatomical, inflammation, vascular malperfusion, and villous maturation placental features. Secondary outcomes included fetal, maternal, delivery, and perinatal complications.

RESULTS

A total of 1119 live births were included in the final analysis and were allocated to the group of pregnancies with non-cavity-distorting intramural myomas (n = 101) and without myomas (n = 1018). After the adjustment for confounding factors, the non-cavity-distorting intramural myomas were found to be significantly associated with assisted placental delivery (OR 2.4; 95% CI 1.5-3.9), furcate cord insertion (OR 3.6; 95% CI 1.4-9.3), circumvallate membranes insertion (OR 5.2; 95% CI 1.4-19.3), chronic deciduitis (OR 8.2; 95% CI 1.6-42.2), focal intramural fibrin deposition (OR 25.1; 95% CI 2.1-306.2), subchorionic thrombi (OR 3.6; 95% CI 1.7-7.6), maternal vasculopathy (OR 2.5; 95% CI 1.2-5.5), and chorangioma (OR 5.9; 95% CI 1.4-25.2) as well as with the failure of labor progress (OR 2.4; 95% CI 1.3-4.4) and induction (OR 3.2; 95% CI 1.2-9.0).

CONCLUSION

Intramural non-cavity-distorting myomas have a significant impact on the placental histopathology with a higher incidence of dysfunctional labor.

The Evolving Role of Natural Compounds in the Medical Treatment of Uterine Fibroids

Uterine fibroids (UFs) remain a significant health issue for many women, with a disproportionate impact on women of color, likely due to both genetic and environmental factors. The prevalence of UFs is estimated to be approximately 70% depending on population. UF-derived clinical symptoms include pelvic pain, excessive uterine bleeding, gastrointestinal and voiding problems, as well as impaired fertility. Nowadays numerous methods of UF treatment are available-from conservative treatment to invasive surgeries. Selecting an appropriate treatment option should be individualized and adjusted to the patient's expectations as much as possible. So far, the mainstay of treatment is surgery, but their negative impact of future fertility is clear. On the other hand, emerging new pharmaceutical options have significant adverse effects like liver function impairment, hot flashes, bone density loss, endometrial changes, and inability to attempt conception during treatment. Several natural compounds are found to help treat UFs and relieve their symptoms. In this review we summarize all the current available data about natural compounds that may be beneficial for patients with UFs, especially those who want to preserve their future fertility or have treatment while actively pursuing conception. Vitamin D, epigallocatechin gallate, berberine, curcumin, and others are being used as alternative UF treatments. Moreover, we propose the concept of using combined therapies of natural compounds on their own or combined with hormonal agents to manage UFs. There is a strong need for more human clinical trials involving these compounds before promoting widespread usage.

The role of magnetic resonance-guided focused ultrasound in fertility-sparing treatment of uterine fibroids-current perspectives

Uterine fibroids (UFs) are the most common benign tumours of the female reproductive system and the most frequent reason for hysterectomy worldwide. UFs are reported in 20%–70% of women of reproductive age depending on a study group. Although most women with UFs are asymptomatic, over 30% of them will present with different symptoms. Abnormal uterine bleeding, pain, pressure and infertility are the most common. Lesions that cause these kinds of symptoms may require medical intervention.

Trends in UF treatment change along with patient awareness and the introduction of new methods and techniques. Selecting an appropriate treatment option should be individualised and adjusted to the patient’s expectations as much as possible. This choice will mostly depend on the patient’s age, UF location, the size and number of lesions, severity of symptoms and, most importantly, the patient’s expectations concerning the preservation of fertility. Observations made for the past few years showed an increasing number of pre- and perimenopausal women who wish to preserve their uterus or decline surgery. In line with current trends and demands in medicine, great importance is attached to the development and upgrade of new minimally invasive or noninvasive procedures in UF therapy.

Magnetic resonance-guided high-intensity focused ultrasound (MR-HIFU) is not associated with severe destruction of the uterine cavity and walls. For this reason, this method may be considered as a kind of hope in fertility-sparing UF therapy and the data about its use in this indication raises future hope. In this review, we summarise the available data on the use of MR-HIFU as a fertility-sparing method in the treatment of UFs. We also indicate how it could evolve in the future.

According to the available data, MR-HIFU is a relatively safe noninvasive method which seems not to deteriorate fertility compared to the pre-treatment status. MR-HIFU may constitute an alternative solution and be chosen in patients who meet the qualification criteria and deny other methods, which also facilitates the use of other treatment options in case the procedure is ineffective. Further randomised studies are necessary to confirm the above information.

Significance of changes in inflammatory parameters following uterine artery embolization in pre-menopausal females

The purpose of the present study was to describe the course of changes in laboratory inflammatory markers following bilateral uterine artery embolization (UAE) as a treatment for leiomyomas and adenomyosis. The body temperature was measured and blood samples were collected to determine white blood cell (WBC) count and C-reactive protein (CRP) levels in 270 patients on the day prior to UAE and for up to 4 days post-embolization. Aside from a single case with a non-inflammatory complication, none of the other cases had any complications. Post-UAE leukocytosis with a mean maximum value of 10.8±3.5x10⁹/l (range, 5.9-18.6x10⁹/l) was observed one-year post-intervention. The mean leukocyte numbers were indicated to be higher on day 3 post-UAE. The CRP level was also increased post-UAE, with a mean maximum value of 7.75±3.5 mg/dl. Maximum levels were reached in 8 patients on the 2nd and in 11 patients on the 3rd post-operative day. The maximum pain score was ~5.5 and reached its lowest level at the end of the 12th week post-intervention. The present study did not consider an association between the embolic material used or uterus size with the level of treatment success. No complications were observed post-UAE; however, a significant increase in the WBC count was observed within the first 3 days, indicating mild leukocytosis.

The effects and costs of laparoscopic versus abdominal myomectomy in patients with uterine fibroids: a systematic review and meta-analysis

BACKGROUND

Abdominal myomectomy (AM) and laparoscopic myomectomy (LM) are commonly see surgery for the uterine fibroids, several randomized controlled trials (RCTs) have compared the role of AM and LM, the results remained inconsistent. Therefore, we attempted this meta-analysis to analyze the role of LM versus AM in patients with uterine fibroids.

METHODS

We searched PubMed et al. databases from inception date to July 31, 2019 for RCTs that compared LM versus AM in patients with uterine fibroids. Two authors independently screened the studies and extracted data from the published articles. Summary odd ratios(OR) or mean differences(MD) with 95% confidence intervals(CI) were calculated for each outcome by means of fixed- or random-effects model.

RESULTS

Twelve RCTs with a total of 1783 patients were identified, with 887 patients for and 897 patients for AM. Compared with AM, LM could significantly decrease the blood loss (OR = - 29.78, 95% CI -57.62- - 0.95), shorten the duration of postoperative ileus (OR = - 10.91, 95% CI -18.72- - 3.11), reduce the length of hospital stay (OR = - 1.57, 95% CI -2.05- - 1.08), but LM was associated with longer duration of operation (OR = 16.10, 95% CI 6.52-25.67) and higher medical cost (OR = 17.61, 95% CI 7.34-27.88).

CONCLUSIONS

LM seems to be a better choice for patients with uterine fibroids, more related studies are needed to identify the role of LM and AM for the treatment of uterine fibroids.

Effects of uterine artery occlusion during myomectomy on ovarian reserve: Serial follow-up of sex hormone levels, ultrasound parameters and Doppler characteristics

AIM

To evaluate the influence of uterine artery occlusion at myomectomy (UAO + M) on ovarian reserve based on serum sex hormone levels, ultrasound and color Doppler examinations.

METHODS

In this cohort study, nine women with symptomatic uterine myomas underwent UAO + M were recruited. Each woman was assessed preoperatively and 3, 6 months postoperatively, through a serial of hormonal, ultrasound parameters and Doppler examination for ovarian stromal blood flow. The data were analyzed using generalized estimating equations.

RESULTS

There was no significant difference in serum anti-Müllerian hormone (AMH) or follicle-stimulating hormone (FSH) levels before and 3, 6 months after UAO + M. The ovarian volume, antral follicle count (AFC) and ovarian stromal blood flow had significant changes in the right ovary. Ovarian volume and AFC significantly reduced at 3 months and recovered at 6 months postoperatively (P = 0.046, P = 0.019, respectively). Peak systolic velocity and end diastolic velocity significantly decreased at 3 months and leveled off at 6 months (P < 0.001, P = 0.001, respectively). Resistance index significantly increased at 3 months and decreased at 6 months (P = 0.037). A similar trend in ultrasound and Doppler findings was observed in the left ovary, but no statistical significance was found.

CONCLUSION

UAO + M had no detrimental effect on ovarian reserve 6 months postoperatively based on AMH and FSH levels. AFC, ovarian volume and stromal blood flow were transiently decreased in 3 months and recovered in 6 months.

Comparison of Reduced-Port Robotic Surgery (RPRS) with conventional 2 port laparoscopy for myomectomy

OBJECTIVE

To compare the surgical outcomes between Reduced-Port Robotic Surgery (RPRS) using the Octo-Port system and conventional 2 port laparoscopy for myomectomy.

STUDY DESIGN

This is a prospective, non-randomized study, which compared and analyzed data from 41 patients who underwent RPRS myomectomy and 22 patients who underwent conventional 2 port laparoscopic myomectomy from April 2016 through July 2019. We compared the myoma enucleation time, suture time, myoma type, and the location of the largest myoma between the two groups.

RESULTS

The patients were not different between the two groups. The myoma enucleation time (26.7 ± 20.9 vs. 22.0 ± 13.7, p = 0.380), hemoglobin drop (2.38 ± 0.9 vs 2.1 ± 0.8, p = 0.280), weight of the myomas (205.3 ± 161.5 vs. 163.4 ± 89.1, p = 0.261), and estimated blood loss (181.1 ± 163.4 vs. 187.3 ± 77.5, p = 0.840) were not significantly different between the two groups. Notably, only the suture time (15.5 (10-21.5) vs. 20 (18-27), p = 0.005) was lesser in women who underwent RPRS myomectomy than in those who underwent conventional 2 port myomectomy.

CONCLUSION

Our data suggest that RPRS myomectomy is comparable to conventional 2 port laparoscopic myomectomy in terms of safety and feasibility and may be more advantageous for suturing after myoma enucleation.

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.