Uterine fibroids: current perspectives

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.

Potential of minimally invasive procedures in the treatment of uterine fibroids: a focus on magnetic resonance-guided focused ultrasound therapy

Minimally invasive treatment options are an important part of the uterine fibroid-treatment arsenal, especially among younger patients and in those who plan future pregnancies. This article provides an overview of the currently available minimally invasive therapy options, with a special emphasis on a completely noninvasive option: magnetic resonance-guided focused ultrasound (MRgFUS). In this review, we describe the background of MRgFUS, the patient-selection criteria for MRgFUS, and how the procedure is performed. We summarize the published clinical trial results, and review the literature on pregnancy post-MRgFUS and on the cost-effectiveness of MRgFUS.

Evaluation of Estrogen, Progesterone, and GCDFP-15 Expression in Uterine Leiomyomas

Approximately, one fourth of women have leiomyomas. Leiomyomas are benign tumors that originated from smooth muscle cells. Estrogen is claimed to relate as a cause but exact mechanism has not fully understood. In this study, 95 leiomyoma cases that have been diagnosed by our department in years between 2010 and 2012 were examined. Age ranges of patients, sizes, locations, and numbers of leiomyomas were identified. Immunohistochemically ER (estrogen), PR (progesterone), and Gross cystic disease fluid protein-15 stains were performed to the paraffin blocks and their percentages of staining were noted. Statistically, submucosal and intramural locations were significantly related to ER and PR (p < 0,001). There were significant relationship between ER and PR in 30-50 years age group (p < 0,001). There were significant relationship between ER, PR and locations (p < 0,001), numbers (p < 0,001), sizes of leiomyomas (below 5 cm; p < 0,001), (between 5 and 10 cm; p = 0,037), larger than 10 cm; p = 0,002). Consequently, relationship between leiomyoma and ER, PR were revealed in this study. Also, relationship between leiomyoma locations and patient ages were identified statistically. There was no immunoreactivity with GCDFP-15 in leiomyomas.

Role of vitamin D in uterine fibroid biology

OBJECTIVE

To provide a detailed summary of current scientific knowledge on uterine fibroids (leiomyomas) in vitro and in in vivo animal models, as well as to postulate the potential role of vitamin D3 as an effective, inexpensive, safe, long-term treatment option for uterine fibroids.

DESIGN

PubMed search articles were used to identify the most relevant studies on uterine fibroids, as well as effects of vitamin D3 on uterine fibroid cells and fibroid tumor growth in in vivo animal models.

SETTING

University research laboratory.

PATIENT(S)

Not applicable.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Not applicable.

RESULT(S)

Despite numerous publications available on uterine fibroids, information about the role that vitamin D3 plays in the regulation of uterine fibroids is limited. Most of the recent vitamin D3-related studies on uterine fibroids were published from our group. Recent studies have demonstrated that vitamin D deficiency plays a significant role in the development of uterine fibroids. Our recent studies have demonstrated that vitamin D3 reduces leiomyoma cell proliferation in vitro and leiomyoma tumor growth in in vivo animal models. These results postulate the potential role of vitamin D3 for an effective, safe, nonsurgical medical treatment option for uterine fibroids.

CONCLUSION(S)

This article reviews human and animal studies and uncovers new possibilities for understanding the vitamin D-based therapeutic option for an effective, safe, long-term treatment of uterine fibroids. On the basis of these results, a clinical trial with vitamin D3 or a hypocalcemic analog, paricalcitol, may be warranted for nonsurgical medical treatment of uterine fibroids.

Benign Metastasizing Leiomyomas to the Lungs: An Institutional Case Series and a Review of the Recent Literature

BACKGROUND

Benign metastasizing leiomyomas (BMLs) represent the extrauterine spread of a benign uterine process. Pulmonary BMLs are the most common example of distant spread of uterine leiomyomas and are usually found incidentally in premenopausal women. The rarity of BMLs accounts for the limited literature that currently exists regarding their underlying pathophysiology, disease course, and management.

METHODS

A retrospective analysis was performed of all BML cases diagnosed and managed at Brigham and Women's Hospital during a 22-year period. The demographic and clinical characteristics of these patients were compared with a PubMed-derived cohort of BML cases reported since 2006.

RESULTS

Benign metastasizing leiomyoma tumors were identified in 10 Brigham and Women's Hospital patients, whereas 57 cases were reported in the literature. The average age at diagnosis was 54.1 and 46.7 years, respectively. Mean interval time from a pertinent gynecologic procedure to BML diagnosis was 23 years at Brigham and Women's Hospital. All patients demonstrated positivity for actin, desmin, and estrogen/progesterone receptors, confirming the diagnosis of uterine leiomyomas. Management primarily consisted of diagnostic resection with subsequent observation with or without hormonal suppression for residual pulmonary nodules. Progression of residual BMLs was noticed in 30% and 8.3% of Brigham and Women's Hospital and literature patients, respectively, when follow-up was reported. One patient in our series required further surgical management.

CONCLUSIONS

Benign metastasizing leiomyomas are a rare cause of pulmonary nodules. They likely represent a clonal spread of uterine leiomyomas to the lungs. Management includes pathologic diagnosis with long-term surveillance with or without hormonal manipulation.

Prescription patterns of Chinese herbal products for patients with uterine fibroid in Taiwan: A nationwide population-based study

ETHNOPHARMACOLOGICAL RELEVANCE

Uterine fibroid (myoma) is one of the most common diseases in women. Although there are several studies on the efficacy of Chinese herbs, there is a lack of large-scale survey on the use of traditional Chinese medicine (TCM) for the treatment of uterine fibroid. This study aimed to investigate the utilization of Chinese herbal products for patients with uterine fibroid, prescribed by licensed TCM doctors in Taiwan.

MATERIALS AND METHODS

A random sample comprised of one million individuals with newly diagnosed uterine fibroid between 2002 and 2010 from the Taiwanese National Health Insurance Research Database was analyzed. Demographic characteristics, TCM usage, the frequency as well as average daily dose of Chinese herbal formulas and the single herbs prescribed for patients with uterine fibroid, were analyzed.

RESULTS

Overall, 35,786 newly diagnosed subjects with uterine fibroid were included. Majority of these patients (87.1%; n=31,161) had visited TCM clinics. Among them, 61.8% of their visits used Chinese herbal remedies. Patients less than 45 years of age tended to use TCM more frequently than elder patients. Gui-Zhi-Fu-Ling-Wan (Cinnamon Twig and Poria Pill) was the most frequently prescribed Chinese herbal formula, while San-Leng (Rhizoma Sparganii) was the most commonly prescribed single herb.

CONCLUSIONS

Our study identified the characteristics and prescription patterns of TCM for patients with uterine fibroid in Taiwan. Further basic mechanistic studies and clinical trials are needed to confirm the therapeutic effects and mechanisms.

Prevalence of noncaesarean uterine surgical scars in a maternity population

The prevalence of noncaesarean section uterine surgical scars in a general obstetric population was 3.0 of 1000 deliveries and among nulliparae 3.4 of 1000 deliveries, calculated from population data of all delivery records in New South Wales from 2005 to 2011. As the population prevalence is low, women with a noncaesarean section uterine surgical scar are unlikely to impact the analyses of factors associated with caesarean section.

Uterine leiomyoma mimicking a gastrointestinal stromal tumor with chronic spontaneous hemorrhage: A case report

Uterine leiomyomas are the most common tumors to affect women. Cases of uterine leiomyoma mimicking a gastrointestinal stromal tumor with chronic spontaneous hemorrhage are extremely rare, and similar cases to that of the present study are yet to be reported. In the current study, a 48-year-old female presented with symptoms of lower abdominal pain after menses that had persisted for 4 months. The patient was initially diagnosed with uterine leiomyoma. However, according to the results of the gross and auxiliary examinations, a diagnosis of a gastrointestinal stromal tumor could not be excluded. Therefore, the patient underwent a rectal sigmoid bowel resection, subtotal hysterectomy and bilateral salpingectomy. Subsequent to surgery, the immunohistochemical examinations confirmed the initial diagnosis of uterine leiomyoma. The surgery had therefore involved an unnecessary organ resection.

Perfusion volume correlates, percentage of involution, and clinical efficacy at diverse follow-up survey times after MR-guided focused ultrasound surgery in uterine fibroids: first report in a Mexican mestizo population

OBJECTIVES

To evaluate the clinical efficacy of magnetic resonance-guided focused ultrasound surgery in a Mexican mestizo population.

METHODS

This retrospective study included 159 women (mean age 37 ± 6.4 years, range 22-53 years) from 2008 to 2010. Two hundred sixty-eight symptomatic uterine fibroids were treated using MR-guided focused ultrasound surgery. Parameters included initial perfused volume, final perfused volume, non-perfused volume (NPV), and treated volume ratio (TVR). Follow-up up to 15 months assessed treatment efficacy and symptomatic relief. Non-parametric statistics and the Kaplan-Meier method were performed.

RESULTS

T2-weighted hypointense fibroids showed a frequency of 93.6%; isointense and hyperintense fibroids had frequencies of 5.60 and 1.1%. There was a negative correlation between NPV and age (r = -0.083, p = 0.307) and treatment time (r = -0.253, p = 0.001). Median TVR was 96.0% in small fibroids and 76.5% in large fibroids. Involution of 50% and 80% was achieved at months 6-7 and month 11, respectively. Relief of symptoms was significant (p < 0.05).

CONCLUSIONS

Our data show that higher TVR attained immediately post-treatment of MRgFUS favours higher involution percentages at follow-up; however, careful patient selection and use of pretreatment imaging are important components for predicting success using MR-guided focused ultrasound surgery.

KEY POINTS

• Type 1 fibroids were the most common (93.2%). • Age and treated volume were not correlated (r s   = -0.215, p = 0.165). • Small fibroids achieved a higher treated volume than large (96.0% vs. 76.5%). • A 50% involution was achieved at 6-month follow-up for type-1 fibroid. • A decrease of 80% was reached at 11 months for type-1 fibroids.

CYP1A1 genetic polymorphisms and uterine leiomyoma risk: a meta-analysis

BACKGROUND

Some studies assessed the association between CYP1A1 MspI and Ile462Val polymorphisms and uterine leiomyoma (UL) risk. However, the results were controversial. We did this meta-analysis to determine the association between CYP1A1 MspI and Ile462Val polymorphisms and UL risk.

MATERIALS AND METHODS

We searched databases containing PubMed, Springer Link, EMBASE, Chinese National Knowledge Infrastructure (CNKI) up to 11 October 2014. Pooled ORs and 95% CIs were used to assess the strength of the associations.

RESULTS

In total, 9 case-control studies with 2157 UL cases and 2197 healthy controls were included in this meta-analysis. CYP1A1 Ile462Val polymorphism was significantly associated with UL risk (OR = 2.29, 95% CI 1.75-2.99, P < 0.00001). In the subgroup analysis by race, significantly increased risks were found in the Asians (OR = 2.76, 95% CI 1.86-4.09, P < 0.00001) and Caucasians (OR = 1.87, 95% CI 1.30-2.68, P = 0.0007). However, MspI polymorphism was not significantly associated with UL risk (OR = 1.15, 95% CI 0.90-1.47, P = 0.27). In the subgroup analysis by race, no significant association was found in the Asians (OR = 1.15, 95% CI 0.86-1.54, P = 0.35).

CONCLUSION

In summary, the results of the meta-analysis suggested that CYP1A1 Ile462Val polymorphism was significantly associated with UL risk.

An unexpected diagnosis of adenomyosis in the subfertile woman

A 38-year-old nulliparous female presented to an assisted conception clinic with subfertility and a long-standing history of dysmenorrhoea. Transvaginal ultrasound revealed two lesions in the body of the uterus, which were presumed to be fibroids. A decision was made to remove these lesions prior to attempting in vitro fertilisation (IVF). However, on laparotomy, deeply penetrating adenomyosis was discovered, resulting in an unexpected hysterectomy and significant blood loss. Based on our experience, we highlight the importance of suspecting a diagnosis of adenomyosis preoperatively and the methods by which this diagnosis can be made, in order to avoid potential unforeseen outcomes as described in this case. We discuss conservative management options for this condition, particularly in women wishing to preserve fertility.

MRI predictors of clinical success in MR-guided focused ultrasound (MRgFUS) treatments of uterine fibroids: results from a single centre

OBJECTIVES

To assess the technical and clinical results of MRgFUS treatment and factors affecting clinical treatment success.

MATERIALS AND METHODS

A total of 252 women (mean age, 42.1 ± 6.9 years) with uterine fibroids underwent MRgFUS. All patients underwent MRI before treatment. Results were evaluated with respect to post-treatment nonperfused volume (NPV), symptom severity score (SSS), reintervention rate, pregnancy and safety data.

RESULTS

NPV ratio was significantly higher in fibroids characterized by low signal intensity in contrast-enhanced T1-weighted fat saturated MR images and in fibroids distant from the spine (>3 cm). NPV ratio was lower in fibroids with septations, with subserosal component and in skin-distant fibroids (p < 0.001). NPV ratio was highly correlated with clinical success: NPV of more than 80 % resulted in clinical success in more than 80 % of patients. Reintervention rate was 12.7 % (mean follow-up time, 19.4 ± 8 months; range, 3-38). Expulsion of fibroids (21 %) was significantly correlated with a high clinical success rate. No severe adverse events were reported.

CONCLUSIONS

Adequate patient selection and correct treatment techniques, based on the learning curve of this technology, combined with technical advances of the system, lead to higher clinical success rates with low complications rate, comparable to other uterine-sparing treatment options.

KEY POINTS

• MRgFUS appears to be a valid alternative to other uterus-preserving therapies • Patient selection is a significant factor in achieving high NPV ratios • MRI screening parameters correlate with the amount of fibroid ablation in MRgFUS • NPV results of more than 80 % correlate with higher clinical success rates.

Venous thromboembolism secondary to uterine fibroids: a case of phlegmasia cerulea dolens and review of the literature

Uterine fibroids are usually benign soft tissue tumors, however, when they become large, they can cause external venous compression. We present a case of a 45-year-old woman who presented with phlegmasia cerulea dolens from a large uterine fibroid. She was successfully treated with hysterectomy, venous thrombectomy, and fasciotomy. We review the literature for previous reports of venous thromboembolism resulting from uterine fibroids. The patient characteristics, thrombotic complications, and treatment modalities are reviewed.

Matrix production and remodeling as therapeutic targets for uterine leiomyoma

Uterine leiomyoma, commonly known as fibroids, is a benign neoplasm of smooth muscle in women. The incidence of clinically symptomatic fibroids in reproductive-age women is approximately 20 %, with nearly 80 % of black women suffering from this condition. Symptoms include severe pain and hemorrhage; fibroids are also a major cause of infertility or sub-fertility in women. Uterine leiomyoma consist of hyperplastic smooth muscle cells and an excess deposition of extracellular matrix, specifically collagen, fibronectin, and sulfated proteoglycans. Extracellular matrix components interact and signal through integrin-β1 on the surface of uterine leiomyoma smooth muscle cells, provide growth factor storage, and act as co-receptors for growth factor-receptor binding. ECM and growth factor signaling through integrin-β1 and growth factor receptors significantly increases cell proliferation and ECM deposition in uterine leiomyoma. Growth factors TGF-β, IGF, PDGF, FGF and EGF are all shown to promote uterine leiomyoma progression and signal through multiple pathways to increase the expression of genes encoding matrix or matrix-modifying proteins. Decreasing integrin expression, reducing growth factor action and inhibiting ECM action on uterine leiomyoma smooth muscle cells are important opportunities to treat uterine leiomyoma without use of the current surgical procedures. Both natural compounds and chemicals are shown to decrease fibrosis and uterine leiomyoma progression, but further analysis is needed to make inroads in treating this common women's health issue.