Uterine fibroids: current perspectives

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.

Identification and bioinformatics analysis of overlapping differentially expressed genes in depression, papillary thyroid cancer and uterine fibroids

It is hypothesized that there may be common characteristics between the genetic regulatory networks of different diseases. To identify these potential similarities, analysis of overlapping differentially expressed genes (DEGs) in several diseases, which are believed to be associated in traditional Chinese medicine (TCM) was performed in the present study. The gene expression profiles associated with depression, papillary thyroid carcinoma (PTC) and uterine fibroids (UF) were preliminarily analyzed using Gene Expression Omnibus 2R tools. Gene Ontology enrichment analysis, Kyoto Encyclopedia of Genes and Genomes pathway analysis and protein-protein interaction network analysis of the overlapping DEGs in depression, PTC and UF was performed. The results indicated that multiple genes, including activating transcription factor 3 and WSC domain containing 2 and the phosphoinositide 3 kinase/protein kinase b signaling pathway and its downstream effectors may be common factors associated with depression, PTC and/or UF. The neuroendocrine functions of the hypothalamic-pituitary-ovarian axis and hypothalamic-pituitary-thyroid axis were also identified as being mutually associated with depression, PTC and/or UF. However, due to the limitations of DNA microassays, it is recommended that future studies take epigenetics into consideration. Further transcriptomic, methylomic and metabolomic analyses of depression, PTC and UF are also required to identify and elucidate the key associated biomarkers. In conclusion, the results of the current study shed light on the potential genetic interconnections between depression, PTC and UF, which may be beneficial for understanding their underlying coregulatory mechanisms and contributing to the development of homeotherapy based on bioinformatics prediction.

The Changes of Surgical Treatment for Symptomatic Uterine Myomas in the Past 15 Years

Study Objective:

The aim of this study is to elaborate the changes of the surgical approach of treatment for uterine myomas in Yangpu Hospital in the past 15 years.

Design:

This was retrospective cohort study.

Setting:

Yangpu Hospital, Tongji University School of Medicine, Shanghai, China.

Materials and Methods:

A total of 4113 patients with symptomatic uterine myomas underwent surgical treatments. Interventions: Eight kinds of different surgeries were involved in the study, including abdominal or laparoscopic surgery, hysterectomy, or uterus-sparing myomectomy.

Measurements:

The study collected patients' clinical data and reviewed surgical access and approach, complications, and the results of following up.

Results:

A total of 1559 cases (37.9%) underwent uterus-sparing myomectomy, 3005 cases (73.1%) performed laparoscopic surgeries. The percentage of laparoscopic surgery was significantly higher than homochronous data of laparotomy after 2003 (P < 0.001). The per year total of uterus-reserved surgery was proved to be negatively correlated with patient's age (R² = 0.930; P < 0.001). The rate of myomas recurrence was significantly lower in the combined myomectomy and uterine artery occlusion group (4%, 34/910) than in the single myomectomy group (10.5%, 44/420) (P < 0.001).

Conclusions:

Retaining uterus and minimally invasive surgery were the important trends of surgical treatment for symptomatic uterine myomas. Laparoscopic uterus-sparing myomectomy may be an alternative to hysterectomy to manage to appropriate patients with uterine myomas.

Effects of a microbubble ultrasound contrast agent on high-intensity focused ultrasound for uterine fibroids: a randomised controlled trial

OBJECTIVE

To investigate the effects of a microbubble ultrasound contrast agent on high-intensity focused ultrasound (HIFU) treatment of uterine fibroids.

METHODS

A total of 120 patients with solitary uterine fibroid were randomly assigned into Groups A, B, C and D. Patients in Groups A and B received 1.5 ml of SonoVue, Groups C and D received 1.5 ml of saline before HIFU ablation. HIFU sonication started at 6 min after administration of SonoVue or saline in Groups A and C, whereas it started at 10 min in Groups B and D. On day 1 after HIFU, magnetic resonance imaging was performed. Patients were followed up via phone or clinic visit during the first week after HIFU.

RESULTS

No significant difference was observed in terms of age, fibroid location, diameter of fibroids, signal intensity on T2-weighted imaging, or tumour volume among the four groups (p > 0.05). The use of SonoVue significantly shortened the treatment time and sonication time. The sonication start time of 6 min, relative to 10 min, had significant effects on the treatment time and sonication time. The use of intravenous SonoVue followed by HIFU ablation 6 min later significantly increased the rate of significant grey-scale changes (55.9%) and the non-perfused volume ratio (94.2% ± 10.6%). No significant differences were observed in the incidence of intra-procedure and post-HIFU adverse effects among the four groups (p > 0.05).

CONCLUSIONS

SonoVue could be safely used to enhance the ablation effects of HIFU treatment of uterine fibroids.

Structured vs narrative reporting of pelvic MRI for fibroids: clarity and impact on treatment planning

OBJECTIVES

To evaluate clarity and usefulness of MRI reporting of uterine fibroids using a structured disease-specific template vs. narrative reporting for planning of fibroid treatment by gynaecologists and interventional radiologists.

METHODS

This is a HIPAA-compliant, IRB-approved study with waiver of informed consent. A structured reporting template for fibroid MRIs was developed in collaboration between gynaecologists, interventional and diagnostic radiologists. The study population included 29 consecutive women who underwent myomectomy for fibroids and pelvic MRI prior to implementation of structured reporting, and 42 consecutive women with MRI after implementation of structured reporting. Subjective evaluation (on a scale of 1-10, 0 not helpful; 10 extremely helpful) and objective evaluation for the presence of 19 key features were performed.

RESULTS

More key features were absent in the narrative reports 7.3 ± 2.5 (range 3-12) than in structured reports 1.2 ± 1.5 (range 1-7), (p < 0.0001). Compared to narrative reports, gynaecologists and radiologists deemed structured reports both more helpful for surgical planning (p < 0.0001) (gynaecologists: 8.5 ± 1.2 vs. 5.7 ± 2.2; radiologists: 9.6 ± 0.6 vs. 6.0 ± 2.9) and easier to understand (p < 0.0001) (gynaecologists: 8.9 ± 1.1 vs. 5.8 ± 1.9; radiologists: 9.4 ± 1.3 vs. 6.3 ± 1.8).

CONCLUSION

Structured fibroid MRI reports miss fewer key features than narrative reports. Moreover, structured reports were described as more helpful for treatment planning and easier to understand.

KEY POINTS

• Structured reports missed only 1.2 ± 1.5 out of 19 key features, as compared to narrative reports that missed 7.3 ± 2.5 key features for planning of fibroid treatment. • Structured reports were more helpful and easier to understand by clinicians. • Structured template can provide essential information for fibroids treatment planning.

Reducing the spread of occult uterine sarcoma at the time of minimally invasive gynecologic surgery

PURPOSE

This review covers the most recent evidence to discuss the incidence of occult uterine sarcoma, whether morcellation increases tumor dissemination or mortality, and whether there is a difference between different types of morcellation. We will also discuss techniques to reduce the spread of an undiagnosed uterine sarcoma.

METHOD

A comprehensive literature search was made in Pubmed, Medline, the Cochrane Library, and Google Scholar for articles related to the incidence of occult uterine sarcoma after morcellation.

RESULTS

Fibroids are benign uterine tumors and are a common indication for gynecologic surgery. Increasingly, gynecologists are approaching these surgeries with minimally invasive techniques. Uterine sarcomas are rare malignant mesenchymal tumors that are difficult to distinguish preoperatively from uterine fibroids.

CONCLUSION

During a minimally invasive surgery, there is a risk of disseminating an occult sarcoma during tissue extraction. Minimally invasive gynecologists are tasked with balancing taking a minimally invasive approach, which is shown to result in better patient outcomes, with minimizing the risk of spreading an occult sarcoma.

Myomas and Adenomyosis: Impact on Reproductive Outcome

Among uterine structural abnormalities, myomas and adenomyosis represent two distinct, though frequently coexistent entities, with a remarkable prevalence in women of reproductive age. Various mechanisms have been proposed to explain the impact of each of them on reproductive outcome. In respect to myomas, current evidence implies that submucosal ones have an adverse effect on conception and early pregnancy. A similar effect yet is not quite clear and has been suggested for intramural myomas. Still, it seems reasonable that intramural myomas greater than 4 cm in diameter may negatively impair reproductive outcome. On the contrary, subserosal myomas do not seem to have a significant impact, if any, on reproduction. The presence of submucosal and/or large intramural myomas has also been linked to adverse pregnancy outcomes. In particular increased risk for miscarriage, fetal malpresentation, placenta previa, preterm birth, placenta abruption, postpartum hemorrhage, and cesarean section has been reported. With regard to adenomyosis, besides the tentative coexistence of adenomyosis and infertility, to date a causal relationship among these conditions has not been fully confirmed. Preterm birth and preterm premature rupture of membranes, uterine rupture, postpartum hemorrhage due to uterine atony, and ectopic pregnancy have all been reported in association with adenomyosis. Further research on the impact of adenomyosis on reproductive outcome is welcome.

Improved adequacy of endometrial tissue sampled from postmenopausal women using the MyoSure Lite hysteroscopic tissue removal system versus conventional curettage

Objective

To compare the diagnostic suitability of endometrial tissues obtained from postmenopausal women using the MyoSure Lite tissue removal system versus conventional curettage.

Materials and methods

Endometrial tissue was sampled in hysteroscopically normal extirpated uteri from seven postmenopausal women (65.9±6.6 years old) using both hysteroscopicguided morcellation and curettage (two quadrants/uterus with each method). Endometrial sampling was performed immediately after hysterectomy for benign reasons unrelated to uterine pathology. Retrieved endometrial tissue samples were evaluated for volume and diagnostic suitability by a pathologist who was masked to the sampling technique used.

Results

Endometrial tissue sampling times were similar for morcellation (44±23 s) and curettage (47±38 s). Mean tissue volume retrieved with MyoSure (1,411±775 mm³) was significantly greater than with curettage (1±2 mm³; p=0.0004, two-tailed t-test), with larger intact tissue fragments retrieved with morcellation. Both specimen volume and quality obtained by MyoSure Lite were deemed to be significantly better for histologic assessment than the tissues obtained with curettage (p=0.0006 by Fisher's exact test and p=0.0137 by chi-square test, respectively). With dilation and curettage, samples were frequently too scanty for evaluation. Diagnostic concurrence between MyoSure Lite/dilation and curettage samples and histopathology of full-thickness samples taken afterward was also significantly better with MyoSure Lite than with curettage (p=0.0210).

Conclusion

Endometrial tissue sampling using the minimally invasive MyoSure Lite hysteroscopic tissue removal system may provide larger volumes of higher-quality endometrial tissue specimens for pathology assessment compared to specimens obtained using conventional curettage, in postmenopausal women.

Fears and Concerns of Patients with Uterine Fibroids - a Survey of 807 Women

STUDY QUESTIONS

What specific fears and concerns do patients with uterine fibroids have? How are these influenced by sociodemographic factors, duration of condition and level of knowledge among these women?

METHODS

Between January 2016 and January 2017 807 patients were consecutively surveyed at a university hospital speciality fibroid clinic using a two page locally developed and validated questionnaire focusing on fibroid-associated fears and concerns.

RESULTS

The questionnaire was completed by 730 women (90.5%) the majority of whom reported fears/concerns mainly with regards to treatment (need to treat/side-effects/hysterectomy) and the fibroids themselves (increasing size and number). Various parameters influenced the type and severity of fears: Young patients (< 40 years) had concerns particularly with regard to pregnancy/birthing while older patients (> 40 years) were more concerned about general health and significant blood loss. Time interval since diagnosis also affected fears with different concerns between patients with shorter duration of diagnosis (< 12 months) vs. longer duration (> 12 months). Overall only slight differences could be attributed to immigrant background. Higher level of education correlated with less anxiety. Proper information about fibroids relieved fears of malignant change in particular. Doctors and the internet were the most important sources of patient information.

CONCLUSIONS

Due to the benign nature of uterine fibroids and their good treatability, fibroid-associated fears are generally unfounded. Precise knowledge of patient fears and concerns should be integrated into clinical care with targeted psychological support to help patients better understand their condition.

Overhydroxylation of Lysine of Collagen Increases Uterine Fibroids Proliferation: Roles of Lysyl Hydroxylases, Lysyl Oxidases, and Matrix Metalloproteinases

The role of the extracellular matrix (ECM) in uterine fibroids (UF) has recently been appreciated. Overhydroxylation of lysine residues and the subsequent formation of hydroxylysylpyridinoline (HP) and lysylpyridinoline (LP) cross-links underlie the ECM stiffness and profoundly affect tumor progression. The aim of the current study was to investigate the relationship between ECM of UF, collagen and collagen cross-linking enzymes [lysyl hydroxylases (LH) and lysyl oxidases (LOX)], and the development and progression of UF. Our results indicated that hydroxyl lysine (Hyl) and HP cross-links are significantly higher in UF compared to the normal myometrial tissues accompanied by increased expression of LH (LH2b) and LOX. Also, increased resistance to matrix metalloproteinases (MMP) proteolytic degradation activity was observed. Furthermore, the extent of collagen cross-links was positively correlated with the expression of myofibroblast marker (α-SMA), growth-promoting markers (PCNA; pERK1/2; FAK^pY397; Ki-67; and Cyclin D1), and the size of UF. In conclusion, our study defines the role of overhydroxylation of collagen and collagen cross-linking enzymes in modulating UF cell proliferation, differentiation, and resistance to MMP. These effects can establish microenvironment conducive for UF progression and thus represent potential target treatment options of UF.

Economic impact of ulipristal acetate on surgical procedures for uterine fibroids in France

OBJECTIVE

To assess the budget impact of using ulipristal acetate (UPA) 5 mg to treat women with uterine fibroids (UF) causing moderate to severe symptoms.

DESIGN

We modelled trends in the number of surgical procedures for symptomatic UF, with and without the use of UPA for preoperative or intermittent treatment and assessed the budget impact of UPA use from the French national healthcare insurance system perspective.

SETTING

A French national hospital database (PMSI) that records admissions and relative procedures to public and private hospitals.

PARTICIPANTS

Women eligible for surgical procedures for uterine fibroids.

MAIN OUTCOME MEASURES

Economic impact of UPA treatment.

RESULTS

This study based on observational retrospective data shows that the current use of UPA in its preoperative indication was associated with 5645 fewer surgeries from 2013 to 2015. Extrapolation suggests 17 885 fewer surgeries from 2016 to 2019. Overall, preoperative use of UPA results in substantial cost savings for the French national healthcare insurance system, with a cumulated budget impact estimated at €-5 million from 2013 to 2015 and €-13.5 million from 2016 to 2019. In addition, treating women nearing the menopause (≥48 years old) with intermittent treatment from 2017 to 2019 could produce an incremental cost saving of €19 million.

CONCLUSIONS

This study shows that the use of UPA in women eligible for surgical procedures for UF is associated with considerable savings for the French national healthcare insurance system in both preoperative and intermittent indications by decreasing the need to perform surgeries.

Cost and Distribution of Hysterectomy and Uterine Artery Embolization in the United States: Regional/Rural/Urban Disparities

Hysterectomy, the driving force for symptomatic uterine fibroids since 1895, has decreased over the years, but it is still the number one choice for many women. Since 1995, uterine artery embolization (UAE) has been proven by many researchers to be an effective treatment for uterine fibroids while allowing women to keep their uteri. The preponderance of data collection and research has focused on care quality in terms of efficiency and effectiveness, with little on location and viability related to care utilization, accessibility and physical availability. The purpose of this study was to determine and compare the cost of UAE and classical abdominal hysterectomy with regard to race/ethnicity, region, and location. Data from National Hospital Discharge for 2004 through 2008 were accessed and analyzed for uterine artery embolization and hysterectomy. Frequency analyses were performed to determine distribution of variables by race/ethnicity, location, region, insurance coverage, cost and procedure. Based on frequency distributions of cost and length of stay, outliers were trimmed and categorized. Crosstabs were used to determine cost distributions by region, place/location, procedure, race, and primary payer. For abdominal hysterectomy, 9.8% of the sample were performed in rural locations accross the country. However, for UAE, only seven procedures were performed nationally in the same period. Therefore, all inferential analyses and associations for UAE were assumed for urban locations only. The pattern differed from region to region, regarding the volume of care (numbers of cases by location) and care cost. Comparing hysterectomy and UAE, the patterns indicate generally higher costs for UAE with a mean cost difference of $4223.52. Of the hysterectomies performed for fibroids on Black women in the rural setting, 92.08% were in the south. Overall, data analyzed in this examination indicated a significant disparity between rural and urban residence in both data collection and number of procedures conducted. Further research should determine the background to cost and care location differentials between races and between rural and urban settings. Further, factors driving racial differences in the proportions of hysterectomies in the rural south should be identified to eliminate disparities. Data are needed on the prevalence of uterine fibroids in rural settings.

Subtotal hysterectomy by natural orifice transluminal endoscopic surgery

Study objective:

To introduce the innovative surgical procedure of treating benign uterine pathology with subtotal hysterectomy by natural orifice transluminal endoscopic surgery (NOTES).

Design:

Prospective observational study.

Setting:

Tertiary referral medical center.

Methods:

From June 2014 to May 2016, three patients with benign uterine diseases who were eligible for laparoscopic subtotal hysterectomy were recruited to undergo transvaginal NOTES at a tertiary referral medical center. Intraoperative and postoperative surgical outcomes were measured.

Results:

Subtotal hysterectomy by transvaginal NOTES was successfully completed in all patients without any conversion to conventional laparoscopy. The operative time was 144 ± 4.5 (138–149) minutes with an average estimated blood loss of 133 ± 62 (50–200) mL. None of the patients required an intraoperative blood transfusion. The mean specimen weight was 140 ± 59 (56–188) g. The final histology reports were uterine leiomyoma and adenomyosis in these three cases. There were no intraoperative or postoperative complications. No case required intraoperative or postoperative blood transfusion. No cases were converted to traditional laparoscopy or laparotomy.

Conclusion:

Our preliminary results showed the safety and feasibility of subtotal hysterectomy by transvaginal NOTES in selected patients. It is one of the most minimally invasive surgeries and results in invisible scars.

A randomized control trial to assess efficacy of Mifepristone in medical management of uterine fibroid

BACKGROUND

Fibroids are the most common benign tumours of uterus. Heavy menstrual bleeding is the commonest concern for which medical attention is sought. Hysterectomies for leiomyoma constitute a third of all hysterectomies. Thus, healthcare cost to society due to uterine leiomyomas is of considerable importance.

METHODS

A prospective study was conducted at tertiary care hospital of armed forces. 120 women in pre-menopausal age group with complaints of menorrhagia, Pictorial Bleeding Assessment Chart (PBAC) scoring ≥100 and at least one fibroid ≥2.5 cm in size were recruited in the study. Patients in Group 1 were given Tab Tranexemic acid (500 mg) and Tab Mefenemic acid (500 mg) three times a day during menstrual bleeding for a period of 6 months. Patients in Group 2 were given Tab Mifepristone 50 mg twice a week. They were followed up at 1, 3 and 6 months of starting the medicine. Results were statistically analysed using Microsoft Excel sheet and paired t-test.

RESULTS

The average age was 40 years in the Group 2 and 45 years in Group 1. A size reduction of 36.99% in intramural and 39.39% in submucosal fibroids after six months of treatment with Mifepristone resulted in marked clinical improvement. 10% patients had side effects. In 30% of patients symptoms reappeared during the follow up period.

CONCLUSION

Mifepristone when given in bi-weekly doses was found to be safe, efficacious, and cost effective as compared to treatment with tranexemic acid and mefenemic acid for management of fibroid uterus.

Uterine fibroid therapy using interventional radiology mini-invasive treatments: current perspective

Uterine fibroids are common benign tumors of unclear etiopathology that affect the female reproductive tract. They are responsible for considerable morbidity and deterioration of life quality, and may have a negative impact on the reproductive system as well. Besides surgery aided by uterus-saving techniques, several minimally invasive procedures are now available within the field of interventional radiology that represent a valid solution for women who desire pregnancy and relief from disease-specific symptomatology. The main advantages offered by these techniques are low grade of invasiveness and short times of hospitalization. The most diffuse techniques are uterine artery embolization (UAE) and magnetic resonance-guided high-intensity focused ultrasound (MRgFUS). UAE is an endovascular procedure whose goal is obtained by provoking ischemia of the uterine vessels. MRgFUS is a thermoablation procedure that selectively ablates the symptomatic fibroids. In this review study, both procedures will be described, including a description of technical details, indications, contraindications, complications, and outcomes.

Preoperative evaluation in women with uterine leiomyosarcoma. A nationwide cohort study

INTRODUCTION

The goal of this study was to assess the sensitivity of different preoperative diagnostic tools used in women with uterine leiomyosarcomas.

MATERIAL AND METHODS

Retrospective cohort study of all women with verified uterine leiomyosarcoma in Norway in the period 2000 to 2012. Data were collected from the Cancer Registry of Norway and medical records.

RESULTS

There were 212 women diagnosed with uterine leiomyosarcoma in the 13-year period. Histopathological examinations by fractional curettage or endometrial biopsies verified malignancy in 55/142 (38.7%). MRI suggested malignancy in 45/55 (81%) of the examinations. CT evaluations indicated suspected malignancy in 64/107 women (59.8%). Biomarkers had low sensitivity for leiomyosarcoma, but suggested more advanced stage disease when high values were detected. Stage IV disease was present in 53.1% versus 25.5% (p = 0.01) of women with CA 125 values above 35 kU/L, compared with women with normal CA 125 values. In 115/212 (54.2%), leiomyosarcoma was only diagnosed postoperatively by histopathological examination of the removed specimen.

CONCLUSIONS

Preoperative diagnostic modalities appear to have low sensitivity for differentiating leiomyosarcoma from fibroids. In Norway, approximately 54% of uterine leiomyosarcoma are unidentified before surgery. MRI evaluation was the imaging modality with the greatest sensitivity in identifying leiomyosarcoma preoperatively.

Comparing the effect of aromatase inhibitor (letrozole) + cabergoline (Dostinex) and letrozole alone on uterine myoma regression,a randomized clinical trial

OBJECTIVE

To evaluate the effect of letrozole in combination with cabergoline and letrozole alone on regression of symptomatic uterine myomas in women of reproductive age.

DESIGN

Randomized controlled clinical trial.

SETTING

University hospital.

PATIENTS

Ninety-one women of reproductive age were enrolled in the study and 88 women were eligible. Eight participants were excluded from the study.

INTERVENTIONS

Eighty women of reproductive age with symptomatic myomas >4cm were evaluated in two groups. Participants in Group 1 received 2.5mg letrozole once daily and cabergoline 0.5mg/week from the first day of the menstrual cycle for 12 weeks, and participants in Group 2 received letrozole alone.

MAIN OUTCOME MEASURES

Changes in uterine size and volume; myoma size, volume and number; and side effects of treatment.

RESULTS

Overall, 76 patients completed the study. Compared with baseline values, mean uterine volume was reduced significantly in both groups (p=0.01), and there was no significant difference between groups (p=0.99). The mean number of dominant myomas was reduced significantly in both groups (p=0.03), with no significant difference between groups (p=0.6). The mean volume of myomas was reduced significantly in both groups (p=0.01), with no significant difference between groups (p=0.45). Although a significant decrease in number and volume of myomas was documented in each group (p<0.05), the intergroup analyses did not reveal significant differences between the two groups in terms of the change in number (p=0.28) and volume (p=0.96) of myomas. Headache was significantly more common in the letrozole+cabergoline group (nine vs two cases, p=0.02), but the two groups were comparable for the remaining minor side effects.

CONCLUSION

This study showed that 12 weeks of treatment with letrozole with and without cabergoline improved the size and volume of the uterus and myomas, led to symptom improvement, and could be used for short-term treatment prior to surgery or fertility programmes.

CONDENSATION

Condensation letrozole in combination with cabergoline in the management of uterine fibroids.

Pierre J, Gala R. Recurrent Pneumothoraces in a Patient With Pulmonary Benign Metastasizing Leiomyoma

BACKGROUND

Pulmonary benign metastasizing leiomyoma (BML) is a rare disease with a malignant characteristic of spread from the uterus. Most cases are asymptomatic, and only 1% are associated with pneumothorax.

CASE REPORT

We present the case of a 42-year-old female with recurrent pneumothoraces leading to an incidental finding of diffuse bilateral pulmonary nodules. The diagnosis of BML was based on the patient's history of uterine leiomyomata and confirmed by a biopsy showing benign smooth muscle staining for desmin and vimentin.

CONCLUSION

BML should be considered in women with a history of leiomyomata who develop pneumothoraces resulting from peripheral pulmonary nodules. A standardized treatment regimen has yet to be established, and therapy plans require a multidisciplinary approach, involving gynecology, cardiothoracic surgery, and pulmonology.

Effectiveness of ultrasound-guided percutaneous microwave ablation for symptomatic uterine fibroids: a multicentre study in China

PURPOSE

To evaluate the clinical efficacy of ultrasound-guided percutaneous microwave ablation (PMWA) therapy for symptomatic uterine fibroids in a multicentre study.

MATERIALS AND METHODS

Patients with symptomatic uterine fibroids who underwent PMWA at multiple treatment centres in China between January 2013 and August 2015 were prospectively studied to compare the reduction rate of uterine fibroids, haemoglobin level and uterine fibroid symptom and health-related quality of life questionnaire (UFS-QOL) scores before and at 3, 6 and 12 months after ablation.

RESULTS

A total of 311 patients (405 leiomyomas) from eight treatment centres underwent the treatment (age, 29-55 years; mean ± SD, 41 ± 5.11 years). The mean diameter of the myomas ranged from 2.03 to 12.50 cm (mean, 5.10 ± 1.28 cm) and the volume ranged from 4.40 to 1022.14 cm³ (mean, 95.01 ± 70.29 cm³). Forty-eight myomas were identified as FIGO type 1/2 fibroids, 256 as type 3/4 fibroids and 101 as type 5/6 fibroids. The mean ablation rate was 86.6% (54.0-100%). The mean reduction rate was 63.5%, 78.5% and 86.7% at 3, 6 and 12 months posttreatment, respectively. The haemoglobin level increased significantly from 88.84 ± 9.31 g/L before treatment to 107.14 ± 13.32, 116.05 ± 7.66 and 117.79 ± 6.51 g/L at 3, 6 and 12 months posttreatment, respectively (p = .000). The symptom severity score (SSS) and health-related quality of life (HRQL) scores were also significantly improved posttreatment compared with before treatment (p = .000).

CONCLUSION

PMWA is an effective, minimally invasive treatment for symptomatic leiomyomas that can significantly improve the quality of life of patients.

A rare case with synchronous gastric gastrointestinal stromal tumor, pancreatic neuroendocrine tumor, and uterine leiomyoma

Background

Although gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract, they comprise less than 1% of all gastrointestinal tumors. Neuroendocrine tumors (NET) of the gastro-enteropancreatic system are also rare, representing about 2% of all gastrointestinal neoplasms. Pancreatic localization of NET is extremely uncommon—these tumors are only 1–5% of all pancreatic cancers.

Case presentation

We describe an unusual case with triple tumor localization—a gastric tumor, a formation in the pancreas, which involves the retroperitoneal space, and a uterine leiomyoma. The exact diagnosis was confirmed with immunohistochemical study after surgical treatment of the patient. Distal pancreatic resection, splenectomy, partial gastrectomy, omentectomy, and hysterectomy were performed. The histological examination proved an epithelioid type of gastric GIST. Immunostaining showed focal positive expression of c-kit and no mitotic figures per 50 HPF. Histology of the pancreatic and retroperitoneal formation proved a well-differentiated NET with origin from the islets of Langerhans. The immunohistochemical study demonstrated co-expression of chromogranin A and synaptophysin.

Conclusions

This is the fourth case published so far of a patient with synchronous pancreatic NET and gastric GIST. The main objective of the study is to present a unique case because we have not found any reports for coexistence of the described three types of neoplasm, as in our patient, and we hope that it will be valuable in the future investigations about the genesis, diagnosis, and treatment of these types of tumors.

Uterine fibroid management: from the present to the future

Uterine fibroids (also known as leiomyomas or myomas) are the most common form of benign uterine tumors. Clinical presentations include abnormal bleeding, pelvic masses, pelvic pain, infertility, bulk symptoms and obstetric complications.Almost a third of women with leiomyomas will request treatment due to symptoms. Current management strategies mainly involve surgical interventions, but the choice of treatment is guided by patient's age and desire to preserve fertility or avoid 'radical' surgery such as hysterectomy. The management of uterine fibroids also depends on the number, size and location of the fibroids. Other surgical and non-surgical approaches include myomectomy by hysteroscopy, myomectomy by laparotomy or laparoscopy, uterine artery embolization and interventions performed under radiologic or ultrasound guidance to induce thermal ablation of the uterine fibroids.There are only a few randomized trials comparing various therapies for fibroids. Further investigations are required as there is a lack of concrete evidence of effectiveness and areas of uncertainty surrounding correct management according to symptoms. The economic impact of uterine fibroid management is significant and it is imperative that new treatments be developed to provide alternatives to surgical intervention.There is growing evidence of the crucial role of progesterone pathways in the pathophysiology of uterine fibroids due to the use of selective progesterone receptor modulators (SPRMs) such as ulipristal acetate (UPA). The efficacy of long-term intermittent use of UPA was recently demonstrated by randomized controlled studies.The need for alternatives to surgical intervention is very real, especially for women seeking to preserve their fertility. These options now exist, with SPRMs which are proven to treat fibroid symptoms effectively. Gynecologists now have new tools in their armamentarium, opening up novel strategies for the management of uterine fibroids.

Polymeric materials for embolic and chemoembolic applications

Percutaneous transcatheter embolization procedures involve the selective occlusion of blood vessels. Occlusive agents, referred to as embolics, vary in material characteristics including chemical composition, mechanical properties, and the ability to concurrently deliver drugs. Commercially available polymeric embolics range from gelatin foam to synthetic polymers such as poly(vinyl alcohol). Current systems under investigation include tunable, bioresorbable microspheres composed of chitosan or poly(ethylene glycol) derivatives, in situ gelling liquid embolics with improved safety profiles, and radiopaque embolics that are trackable in vivo. This article reviews commercially available materials used for embolization as well as polymeric materials that are under investigation.

Effects of herbal medicine on human uterine tumor-bearing nude mice

Aim:

Uterine leiomyomas are the most common benign uterine neoplasms associated with significant morbidity. Herbal formulas capable of restoring yin-yang balance by dispersing blood stasis may be useful for managing fibroid symptoms.

Materials and Methods:

In this study, the antitumor properties of three herbs viz., Trogopterus xanthipes Milen-Edwards, Paeonia lactiflora Pallas, and Ulmus davidiana Planch were evaluated in nude mice injected intravenously with human malignant myomas. Tumor fragments were xenografted subcutaneously through a flank incision in female mice. The mice entered the study for 8 weeks when their tumors reached the threshold volume (260 mm³). The mice were randomly allocated to receive subcutaneous injections of normal saline (Group 1; negative control), P. lactiflora Pallas (Group 2), U. davidiana Planch (Group 3), T. xanthipes Milen-Edwards (Group 4), and intravenous injections of paclitaxel (Group 5; positive control). The weight and tumor volume were measured, followed by histopathology.

Results:

A few cases of abdominal distention and death were observed in the negative control group. Furthermore, a considerable enlargement of the liver and spleen was observed in the negative control group at autopsy with a gradual increase in body weight during the experiment. The mean tumor volume which increased in negative control mice reduced in mice treated with herbal remedies or paclitaxel from day 14 onwards (P < 0.05). The degree of necrosis and apoptosis induction from herbal treatments was similar to that of paclitaxel.

Conclusion:

Collectively, three herbs viz., T. xanthipes Milen-Edwards, P. lactiflora Pallas, and U. davidiana Planch were able to induce necrosis and apoptosis of uterine leiomyoma cells, proving antitumor properties against uterine fibroids.

Effect of Non-Cavity Distorting Intramural Fibroids on Assisted Reproduction Outcomes: A Cohort Study

Introduction

The impact of uterine fibroids on fertility and the beneficial role of surgery is controversial. Current data suggest that submucosal and intramural fibroids that distort the endometrial cavity decrease pregnancy and implantation rates. However, the impact of intramural fibroids without intracavitary component is unclear. The aim of this study is to clarify the impact of the uterine myomas and myomectomy in patients undergoing assisted reproductive techniques (ART).

Methods

Retrospective cohort study performed in Instituto Universitario Dexeus including 1072 cycles of IVF performed in infertile patients: 473 in patients with uterine myomas not treated before ART, 79 in patients undergoing ART after myomectomy and 520 in patients included as a control group.

Results

Our results show that there is a significant 64% reduction in the clinical pregnancy rate in women with cavity-distorting intramural fibroids, a 51% significant reduction in the clinical pregnancy rate and a 53% significant reduction in the delivery rate in patients with non-distorting intramural fibroids.

Conclusions

Our study supports the opinion that non-cavity distorting intramural fibroids have a detrimental effect on live births, clinical pregnancy, implantation and delivery rates in patients undergoing ART.

Perineal leiomyoma in a postmenopausal woman: A case report

Leiomyomas in the female reproductive system are commonly located in the uterus and typically regress following the menopause. Vulval leiomyomas are rare, and to the best of our knowledge, perineal leiomyomas in postmenopausal women have not been previously reported in the literature. The present case describes a 60-year-old Chinese woman who experienced perineal tenderness and lumbosacral radiating pain. The patient, who went through the menopause 12 years previously, had presented with a painful perineal mass for 1 year, which was subsequently diagnosed as a postmenopausal perineal leiomyoma. The mass was locally resected, and histopathological examination of the lesion resulted in a diagnosis of benign epithelioid leiomyoma. Immunohistochemical staining identified that the leiomyoma was positive for estrogen receptor and negative for progesterone receptor expression. The patient was followed up for 1 year and did not experience any pain or recurrence. The symptoms of local and lumbosacral radiating pain are extremely rare and may be induced by peripheral nerve stimulation. The etiology of postmenopausal perineal leiomyoma may be associated with infection, dietary, stress and environmental factors, and the role of estrogen cannot be overemphasized in cases of postmenopausal leiomyoma.

Benign Metastasizing Leiomyoma

Benign metastasizing leiomyoma (BML) is a rare and poorly characterized disease affecting primarily premenopausal women. Asymptomatic patients are often diagnosed incidentally by radiographs or other lung-imaging procedures performed for other indications, and the diagnosis is eventually confirmed by biopsy. Patients with BML are usually treated pharmacologically with antiestrogen therapies or surgically with oophorectomy or hysterectomy. Antiestrogen therapy is typically efficacious and, in general, most patients have a favorable prognosis. Asymptomatic patients with a confirmed diagnosis of BML, may be followed conservatively without treatment.

Female Reproductive Disorders, Diseases, and Costs of Exposure to Endocrine Disrupting Chemicals in the European Union

CONTEXT

A growing body of evidence suggests that endocrine-disrupting chemicals (EDCs) contribute to female reproductive disorders.

OBJECTIVE

To calculate the associated combined health care and economic costs attributable to specific EDC exposures within the European Union (EU).

DESIGN

An expert panel evaluated evidence for probability of causation using the Intergovernmental Panel on Climate Change weight-of-evidence characterization. Exposure-response relationships and reference levels were evaluated, and biomarker data were organized from carefully identified studies from the peer-reviewed literature to represent European exposure and approximate burden of disease as it occurred in 2010. Cost-of-illness estimation used multiple peer-reviewed sources.

SETTING, PATIENTS AND PARTICIPANTS AND INTERVENTION

Cost estimation was carried out from a societal perspective, ie, including direct costs (eg, treatment costs) and indirect costs such as productivity loss.

RESULTS

The most robust EDC-related data for female reproductive disorders exist for 1) diphenyldichloroethene-attributable fibroids and 2) phthalate-attributable endometriosis in Europe. In both cases, the strength of epidemiological evidence was rated as low and the toxicological evidence as moderate, with an assigned probability of causation of 20%–39%. Across the EU, attributable cases were estimated to be 56 700 and 145 000 women, respectively, with total combined economic and health care costs potentially reaching €163 million and €1.25 billion.

CONCLUSIONS

EDCs (diphenyldichloroethene and phthalates) may contribute substantially to the most common reproductive disorders in women, endometriosis and fibroids, costing nearly €1.5 billion annually. These estimates represent only EDCs for which there were sufficient epidemiologic studies and those with the highest probability of causation. These public health costs should be considered as the EU contemplates regulatory action on EDCs.

Long-term intermittent pharmacological therapy of uterine fibroids - a possibility to avoid hysterectomy and its negative consequences

Uterine fibroids are found in almost 20-40% of women of reproductive age. For each woman an individualised treatment method should be applied because the hysterectomy procedure is not a good option in every case. The uterus is an organ necessary not only in reproduction. Its removal may result in: pelvic floor dysfunction and stress urinary incontinence, negative impair on life quality, depressive disorders, increased risk of cardiovascular and neurodegenerative diseases, and higher incidence of neoplastic disease. According to the last scientific reports, selective progesterone receptor modulators are the effective therapeutic option in uterine fibroids in women of reproductive age because progesterone is an important factor in their pathogenesis. Ulipristal acetate (UPA) is a progesterone receptor antagonist. It inhibits cell proliferation and angiogenesis in uterine fibroids and also reduces collagen deposits in extracellular matrix. Significant data concerning ulipristal acetate efficacy have been provided by scientific research, especially from the consecutive PEARL studies. Oral ulipristal acetate effectively and safely controls bleeding and pain in patients with symptomatic fibroids. It reduces fibroid volume and restores quality of life. The results of UPA long-term intermittent treatment are largely maintained during the off-treatment periods.

Myoma-associated pain frequency and intensity: a retrospective evaluation of 1548 myoma patients

OBJECTIVE

To analyze the possible relation between symptoms (especially pain) reported by myoma patients and objective features of their myomas as determined by ultrasound. Specifically: (1) What is the frequency and intensity of myoma-related pain? (2) Does the pain intensity depend on the number, size, or location of the myomas? (3) Is there any correlation between premenstrual pain, menstrual pain, and pain during sexual intercourse?

STUDY DESIGN

A retrospective analysis of data from a patient questionnaire and ultrasound exams, collected from February 2009 until January 2013 at the myoma clinic of a university hospital in a large European city. The study analyzed data from 1548 myoma patients. Patients completed a 0-10 Likert scale questionnaire about their symptoms. The number, size, and location of myomas were determined from ultrasound exams.

RESULTS

The three most frequent symptoms reported were hypermenorrhea, dysmenorrhea, and premenstrual pain. There was no statistically significant relationship between premenstrual pain or pain during sexual intercourse on the one hand and the number, size, or location of myomas on the other hand. For women with severe dysmenorrhea (Likert-scale scores of 8-10), submucosal myomas were significantly more frequent than all other myoma locations (p=0.01). Severe dysmenorrhea (Likert-scale scores of 8-10) was reported by a significantly (p<0.001) greater portion of the women whose largest myoma had a largest diameter of <5cm than by the women whose largest myoma had a diameter ≥5cm. The number of myomas did not have a significant influence on the dysmenorrhea intensity. The three types of pain (premenstrual, menstrual, and/or during sexual intercourse) had moderate pairwise correlations (ρ values from 0.304 to 0.542) that were all statistically highly significant (p<0.001).

CONCLUSION

Myoma-associated pain is, alongside hypermenorrhea, the most frequent problem reported by the affected patients. Unlike premenstrual pain and pain during sexual intercourse, the intensity of menstrual pain is clearly dependent on the location and size of the largest myoma. Further research is needed to better understand the degree to which the pain reported by the patients is due to features of the myomas versus other possible factors.

Association of estrogen and progesterone receptor gene polymorphisms and their respective hormones in uterine leiomyomas

The steroid hormones estradiol and progesterone play an important role in the pathophysiology of fibroids that occurs in 20-25 % of women in the reproductive age. Our study examines the risk imposed by estrogen and progesterone plasma levels in correlation with the ERβ (-13950T/C) and PGR (+331G/A) receptor gene polymorphisms. The study population included 296 individuals (146 UL cases and 150 female controls). Hormonal levels were estimated by ELISA and genotyping was carried out by PCR-RFLP analysis, and the obtained results were statistically analyzed. Estrogen levels were found to be high in cases with the "TC" genotype of ERβ receptor polymorphism compared to controls, whereas individuals with "GA" and "AA" genotype of PGR receptor polymorphism showed high progesterone levels for cases when compared to controls. The TC genotype of the ERβ receptor polymorphism and the GA and AA genotypes of the PGR receptor polymorphism and their respective hormonal levels can be developed as markers in the prediction of uterine fibroids.

Therapeutic options for management of endometrial hyperplasia

Endometrial hyperplasia (EH) comprises a spectrum of changes in the endometrium ranging from a slightly disordered pattern that exaggerates the alterations seen in the late proliferative phase of the menstrual cycle to irregular, hyperchromatic lesions that are similar to endometrioid adenocarcinoma. Generally, EH is caused by continuous exposure of estrogen unopposed by progesterone, polycystic ovary syndrome, tamoxifen, or hormone replacement therapy. Since it can progress, or often occur coincidentally with endometrial carcinoma, EH is of clinical importance, and the reversion of hyperplasia to normal endometrium represents the key conservative treatment for prevention of the development of adenocarcinoma. Presently, cyclic progestin or hysterectomy constitutes the major treatment option for EH without or with atypia, respectively. However, clinical trials of hormonal therapies and definitive standard treatments remain to be established for the management of EH. Moreover, therapeutic options for EH patients who wish to preserve fertility are challenging and require nonsurgical management. Therefore, future studies should focus on evaluation of new treatment strategies and novel compounds that could simultaneously target pathways involved in the pathogenesis of estradiol-induced EH. Novel therapeutic agents precisely targeting the inhibition of estrogen receptor, growth factor receptors, and signal transduction pathways are likely to constitute an optimal approach for treatment of EH.