Uterine fibroid management: from the present to the future

Changes in sexuality during ulipristal acetate treatment in women with symptomatic uterine fibroids

OBJECTIVE

To evaluate changes in sexuality in women treated with Ulipristal acetate (UPA) due to symptomatic uterine fibroids.

STUDY DESIGN

A total of 102 women with symptomatic uterine fibroids undergoing conservative therapy with UPA were enrolled in this observational study. Sexuality was evaluated before and after a three month UPA treatment using the Female Sexual Functioning Index (FSFI) as well as the Sexual Activity Questionnaire (SAQ). Before treatment was initiated, participants additionally filled in a standardised questionnaire addressing the expected changes in sexuality due to UPA. Demographic parameters, expectations concerning changes in sexuality, and FSFI- and SAQ-scores were analysed.

RESULTS

The average age of the study collective was 42.3 years. For the majority of the included women (n = 70; 71.4%) sexuality was rated as an important issue and 86 women (87.8%) did not think that UPA would have an impact on the frequency of sexual intercourse, the quality (n = 91; 92.9%) or frequency of orgasms (n = 87; 88.8%) neither sexual receptivity (n = 88; 89.8%). Full data sets were available for 73 patients (71.6%). The FSFI showed significantly higher sub scores regarding desire (3.6 ± 1.2 vs. 3.9 ± 1.2; p = 0.0012) and arousal (4.2 ± 1.7 vs. 4.4 ± 1.9; p = 0.0151) as well as a higher total score (26.6 ± 9.0 vs. 27.4 ± 9.5; p = 0.0008) after UPA treatment. Regarding the SAQ a statistically significant difference regarding the subscore "habit" was found (p < 0.0001) comparing pre with post interventional scores.

CONCLUSION

Sexuality in general seems to be important for women with symptomatic uterine fibroids. As the treatment with UPA appears to improve sexuality, this circumstance can be mentioned in a pre-therapeutic counselling.

The past, present, and future of selective progesterone receptor modulators in the management of uterine fibroids

Uterine fibroids are common in women of reproductive age and can have a significant impact on quality of life and fertility. Although a number of international obstetrics/gynecology societies have issued evidence-based clinical practice guidelines for the management of symptomatic uterine fibroids, many of these guidelines do not yet reflect the most recent clinical evidence and approved indication for one of the key medical management options: the selective progesterone receptor modulator class. This article aims to share the clinical experience gained with selective progesterone receptor modulators in Europe and Canada by reviewing the historical development of selective progesterone receptor modulators, current best practices for selective progesterone receptor modulator use based on available data, and potential future uses for selective progesterone receptor modulators in uterine fibroids and other gynecologic conditions.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Epidemiology of uterine myomas and clinical practice in Spain: An observational study

OBJECTIVE

Characterization of the clinical features of symptomatic uterine myomas in Spanish women visiting the gynaecologist, including impact on quality of life and possible risk factors, description of main therapeutic approaches, and evaluation of symptom and quality of life progression 6 months after inclusion in the study.

STUDY DESIGN

This was an observational, epidemiological, non-interventional, multicentre study performed between June 2015 and March 2016. Data were collected at baseline and follow-up visits 6 months apart from women with a diagnosis of uterine myomas and visiting a participating gynaecologist in outpatient units of private clinics or public hospitals in Spain. Data consisted of a gynaecological clinical inspection, an interview with open questions to the patients, and self-administered generic questionnaires. The main outcome measures were socio-demographic data, clinical history, myoma clinical features, symptomatology, data on surgical choices, patient satisfaction, and risk factors associated to myomas.

RESULTS

Data were collected from 569 patients (1,022 myomas) at 56 hospitals and private gynaecological offices in Spain. Most patients (85%) presented between 1 and 3 myomas, predominantly intramural and subserosal. Most common symptoms reported heavy menstrual bleeding and pelvic pain, and the mean (±SD) symptom severity score in the UFS-QoL questionnaire (range 0-100) was 50.89 ± 20.85. Up to 60.5% of patients had an indication of surgery (55.8% myomectomies, 40.4% hysterectomies) to treat their uterine myomas and 39.5% followed other therapies, mainly pharmacological. After six months of treatment, all patients had experienced significant reduction in symptoms and improvement of quality of life.

CONCLUSIONS

The most frequent symptoms reported by women diagnosed with uterine myomas were heavy menstrual bleeding, pelvic or abdominal pain and dysmenorrhea; QoL was impaired reflecting high symptom distress. We found that surgery was the main therapeutic approach to manage uterine myomas in Spain. Both surgical and non-surgical treatments achieve relevant improvements in symptom severity and quality of life.

Vilaprisan for treating uterine fibroids

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

Matrix Metalloproteinase Activity Correlates With Uterine Myoma Volume Reduction After Ulipristal Acetate Treatment

CONTEXT

Ulipristal acetate (UPA), a selective progesterone receptor modulator, clinically reduces uterine myoma size in 80% of cases. However, the molecular mechanism of action is still poorly understood, as is the reason why 20% of myomas do not respond to treatment.

OBJECTIVE

To elucidate whether matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs) are associated with myoma volume shrinkage after UPA therapy.

DESIGN

Prospective study.

SETTING

Academic research unit of a university hospital.

PATIENTS

Uterine biopsies were obtained from 59 patients with symptomatic myomas undergoing myomectomy, 45 of whom were treated preoperatively with either one or greater than or equal to two, 3-month courses of UPA and 14 not given any hormone therapy to serve as controls. Myoma volume was individually monitored during UPA therapy to determine any substantial clinical response (defined as a reduction in volume of >25%). Three groups were established based on the response to treatment: responsive (R) after one course (n = 12); R after two to four courses (n = 15); and nonresponsive (NR; n = 18).

INTERVENTIONS

UPA treatment given as preoperative management for symptomatic myomas.

MAIN OUTCOME MEASURES

MMP and TIMP expression assessed by zymography and immunohistochemistry.

RESULTS

Compared with controls and NR myomas, responders showed significantly higher expression levels for MMP-1 (P < 0.0001) and MMP-2 (P = 0.009) and significantly lower expression levels for TIMP-1 (P = 0.040).

CONCLUSIONS

The correlation found between MMP expression and volume fold change supports the notion that MMPs play a key role in UPA-induced myoma shrinkage.

The Investigation and Management of Adenomyosis in Women Who Wish to Improve or Preserve Fertility

The management of adenomyosis remains a great challenge to practicing gynaecologists. Until recently, hysterectomy has been the only definitive treatment in women who have completed child bearing. A number of nonsurgical and minimally invasive, fertility-sparing surgical treatment options have recently been developed. This review focuses on three aspects of management, namely, (1) newly introduced nonsurgical treatments; (2) management strategies of reproductive failures associated with adenomyosis; and (3) surgical approaches to the management of cystic adenomyoma.

Ulipristal acetate for uterine fibroids: 2 years of real world experience in a UK hospital

Ulipristal acetate (UPA), is a selective progesterone-receptor modulator, it decreases fibroid size and reduces menstrual bleeding. We reviewed its use at the Heart of England Foundation Trust (HEFT), one of the largest prescribing trusts in the UK. The electronic records of patients treated with UPA from January 2013 to August 2015 were reviewed. One hundred and thirty four patients received UPA, 20 women (15%) received a second course. Eighty percent reported subjective global improvements in symptoms after the first course; 45.5% described amenorrhoea or light bleeding compared to 4.5% prior to treatment. Fewer patients were anaemic (Hb <11 g/dL) following treatment (8.2% versus 33.6%). The majority of fibroids (34%) reduced or remained the same size (25%). Two-thirds of women treated for symptom control avoided surgical intervention. UPA improves symptoms and modifies the use of surgery in treating fibroids. Correcting anaemia prior to major surgery reduces the risk of blood transfusion and optimises a patient's condition as part of an enhanced recovery pathway. Impact Statement What is already known on this subject: In women with heavy menstrual bleeding secondary to fibroids, UPA has been shown to reduce fibroid size and control uterine bleeding, inducing amenorrhoea in the majority. Initially, only licenced for pre-operative use, an expansion of the licence has included on-going intermittent use for symptomatic fibroids. What the results of this study add: Our review is the largest published cohort of women treated with UPA. It demonstrates symptomatic improvements and advantageous modifications in fibroid size in women of all ethnicities and ages. Our inclusion of women with a uterine size greater than 16 weeks and fibroid diameter larger than 10 cm demonstrates the benefits of UPA with increased fibroid dimensions. What the implications are of these findings for clinical practice and/or further research: These findings can allow clinicians to consider alternative surgical interventions or even avoid surgery completely in a proportion of patients with fibroids. Correcting anaemia and optimising a patient's pre-operative condition reduces post-operative complications and ongoing morbidity. However, 25% of fibroids failed to respond to UPA treatment, further research into the characteristics of women and fibroids that show favourable clinical outcomes will allow identification of those women who are likely to benefit from treatment and prevent futile use in others.

Emerging treatment options for uterine fibroids

INTRODUCTION

Uterine fibroids (also known as leiomyomas or myomas) are the most common form of benign uterine tumors. Current management strategies involve mainly surgical interventions, but the choice of treatment is guided by patient age and desire to preserve fertility or avoid 'radical' surgery such as hysterectomy. Areas covered: There is growing evidence of the crucial role of progesterone pathways in the pathophysiology of uterine fibroids, leading to increasing use of selective progesterone receptor modulators (SPRMs) such as ulipristal acetate. We searched all published studies on medical management of fibroids with SPRMs. Expert opinion: The need for alternatives to surgical intervention is very real, especially for women seeking to preserve their fertility. These options now exist, with SPRMs proven to treat fibroid symptoms effectively. Gynecologists now have new tools in their armamentarium, opening up novel strategies for the management of uterine fibroids.

The role of atorvastatin in suppressing tumor growth of uterine fibroids

BACKGROUND

Medical therapeutic options remain quite limited for uterine fibroids treatment. Statins, competitive inhibitors of 3-hydroxy-3-methylglutaryl-coenzyme A reductase, have anti-tumoral effects on multiple cancer types, however, little is known about their effects on uterine fibroids.

METHODS

Initially, we conducted a retrospective study of 120 patients with uterine fibroids and hyperlipidemia from the Second Affiliated Hospital of Wenzhou Medical University. Then, we evaluated the effect of atorvastatin on proliferation and apoptosis both in immortalized uterine fibroids cells and primary uterine fibroids cells. Furthermore, the molecular mechanism by which atorvastatin suppressed uterine fibroids cell growth was explored.

RESULTS

Our results showed that atorvastatin use for 1 or 2 years significantly suppressed growth of uterine fibroids. Atorvastatin inhibited the proliferation of immortalized and primary uterine fibroids cells in a dose and time-dependent manner and stimulated apoptosis of uterine fibroids cells by inducing caspase-3 activation, up-regulating Bim and down-regulating Bcl-2. Additionally, atorvastatin treatment suppressed phosphorylation of ERK1/2 and JNK. Furthermore, GGPP, a downstream lipid isoprenoid intermediate, significantly rescued the effect of atorvastatin.

CONCLUSIONS

These results suggest that atorvastatin exerts anti-tumoral effects on uterine fibroids through inhibition of cell proliferation and induction of apoptosis in HMG-CoA-dependent pathway. Our results provide the first clinical and preclinical data on the use of atorvastatin as a promising nonsurgical treatment option for uterine fibroids.

Unexpected uterine leiomyosarcoma in a woman with multiple myomas treated with ulipristal acetate: case report and literature review

Ulipristal acetate (UPA) has been recognized as an alternative strategy to surgery in the management of symptomatic women with uterine fibroids. We present a case report on a woman with hereditary fibrinogen deficiency exclusively treated with UPA for myoma-related menorrhagia and abdominal pain, who subsequently underwent a hysterectomy because of clinical worsening. A FIGO IB uterine leiomyosarcoma was found among multiple myomas. A review of the literature found two other cases of uterine leiomyosarcoma in patients treated with UPA: clinical data are reported. The aim of this case report is to increase clinicians' awareness that, although rare, leiomyosarcoma can develop in a uterus with multiple myomas and no reliable diagnostic tools exist yet. Thus, a clinical and instrumental careful reevaluation and patient counseling should be a priority when planning to repeat UPA treatment cycles.

The AKT/BCL-2 Axis Mediates Survival of Uterine Leiomyoma in a Novel 3D Spheroid Model

A deeper understanding of the pathways that drive uterine leiomyoma (ULM) growth and survival requires model systems that more closely mimic the in vivo tumors. This would provide new insights into developing effective therapeutic strategies for these common benign tumors of childbearing-aged women. In this study, we examined the role of BCL-2 in mediating ULM survival in the context of increased protein kinase B (AKT) and oxidative stress using a three-dimensional (3D), spheroid-based model that more closely resembles the native ULM tumor microenvironment. Human primary cells from matched myometrium (MM) and ULM tissues were used to establish spheroid cultures in vitro. Histological and immunohistochemical methods were used to assess the spheroid architecture and characteristics. Viability assays for 3D cultures were used to evaluate their response to BH3 mimetics and the superoxide inducer, paraquat (PQ). Primary MM and ULM cells formed spheroids in culture. Notably, ULM spheroids exhibited low proliferation, increased oxidative stress, and secretion of interstitial collagen. Knockdown studies revealed that AKT sustained BCL-2 expression in ULM. The targeting of BCL-2 with BH3 mimetics effectively reduced viability and induced apoptosis in a subset of ULM spheroids. ULM spheroids that did not respond to BH3 mimetics alone responded to combination treatment with PQ. In conclusion, BCL-2 mediates AKT survival of ULM, providing compelling evidence for further evaluation of BH3 mimetics for ULM treatment. ULM spheroids recapitulated intrinsic features of the native ULM tumor microenvironment and can be used as a model for preclinical testing of potential therapeutic options for ULM.

Abnormal uterine bleeding: managing endometrial dysfunction and leiomyomas

Abnormal uterine bleeding refers to any change in the regularity, frequency, heaviness or length of menstruation. There are several potential causes for bleeding disturbance, the two most common being primary endometrial dysfunction and fibroids. Management of abnormal uterine bleeding involves both medical and surgical options and will largely depend on a patient's fertility plans. The use of levonorgestrel-releasing intrauterine devices for heavy menstrual bleeding is increasing in Australia, and they are considered first-line medical management for women accepting of hormonal therapies. Tranexamic acid, non-steroidal anti-inflammatory drugs, the combined oral contraceptive pill and oral progestins offer alternatives. Hysterectomy offers a definitive surgical approach to abnormal uterine bleeding and is associated with high levels of patient satisfaction. Women wishing to preserve their fertility, or avoid hysterectomy, may be offered myomectomy. Submucosal fibroids should be removed via hysteroscopy in symptomatic or infertile patients. Intramural and subserosal fibroids may be removed via an open or laparoscopic approach. There are several minimally invasive options, including uterine artery embolisation, magnetic resonance-guided focused ultrasound and endometrial ablation, but patients should be aware that there is insufficient evidence to ensure fertility preservation with these procedures and further research is needed. Areas for additional research include cost-effectiveness of treatments and quality of life comparisons between management options using patient reported outcome measures to evaluate patient satisfaction.

A Comprehensive Review of the Pharmacologic Management of Uterine Leiomyoma

Uterine leiomyomata are the most common benign tumors of the gynecologic tract impacting up to 80% of women by 50 years of age. It is well established that these tumors are the leading cause for hysterectomy with an estimated total financial burden greater than $30 billion per year in the United States. However, for the woman who desires future fertility or is a poor surgical candidate, definitive management with hysterectomy is not an optimal management plan. Typical gynecologic symptoms of leiomyoma include infertility, abnormal uterine bleeding (AUB)/heavy menstrual bleeding (HMB) and/or intermenstrual bleeding (IMB) with resulting iron-deficiency anemia, pelvic pressure and pain, urinary incontinence, and dysmenorrhea. The morbidity caused by these tumors is directly attributable to increases in tumor burden. Interestingly, leiomyoma cells within a tumor do not rapidly proliferate, but rather the increase in tumor size is secondary to production of an excessive, stable, and aberrant extracellular matrix (ECM) made of disorganized collagens and proteoglycans. As a result, medical management should induce leiomyoma cells toward dissolution of the extracellular matrix, as well as halting or inhibiting cellular proliferation. Herein, we review the current literature regarding the medical management of uterine leiomyoma.

Current Practices for Treatment of Uterine Fibroids

The treatment of uterine fibroids depends on symptoms of patients, size of the fibroid, desire for future pregnancy, and preference of the treating gynecologist. The present study was undertaken to compare treatment preferences in women desirous and nondesirous of pregnancy by an experienced gynecologist in symptomatic uterine fibroids. Newer medical or minimally invasive treatment modalities are increasingly being used for the treatment of fibroids. However, conventional surgical treatment such as myomectomy and hysterectomy are still preferred by gynecologists.

Discussing sarcoma risks during informed consent for nonhysterectomy management of fibroids: an unmet need

There is no reliable way to distinguish symptomatic uterine fibroids from sarcoma without a surgical specimen. Many women with a uterine sarcoma are initially managed without hysterectomy under a presumed fibroid diagnosis, without understanding sarcoma risks. Currently many alternatives to hysterectomy, including medical and procedural interventions, for treatment of fibroids are promoted. The sarcoma incidence among women with presumed fibroids is 0.29% (1/340) to 0.05% (1/2000). Nonmetastatic leiomyosarcoma has a 63% 5-year survival rate whereas metastatic leiomyosarcoma has a 14% 5-year survival rate. In uterine sarcoma, we often cannot identify who has sarcoma before making a potentially cure-denying decision by delaying surgery. Therefore, women electing an alternative to hysterectomy for fibroids should undergo an informed consent process that specifically includes discussion of uterine sarcoma incidence and mortality. Alternatives to hysterectomy for presumed fibroids remain preferable treatment options for many women with symptomatic fibroids, so long as underlying sarcoma risks are adequately discussed. The challenge for obstetrician- gynecologists then is how to provide better informed consent and maintain the primacy of patient autonomy over our concern to "First, do no harm." Major threats to patient's autonomy are faced in the sarcoma risk discussion. How we should present sarcoma risk information to avoid being dismissive of sarcoma or frightening women toward hysterectomy is unstudied. Research is needed to determine how to provide sarcoma risk information with less bias during informed consent.

Fertility impairment associated with uterine fibroids - a review of literature

Uterine fibroids (also known as leiomyomas or myomas) are the most common benign tumors affecting reproductive organs in women. They are monoclonal tumors of the uterine smooth muscle, which spring from myometrium. It is estimated that they occur in 50-60% of the female population and rise to 70% by the age of 50. While mostly asymptomatic, myomas can be connected with several conditions, including abnormal bleeding with subsequent anemia, pelvic masses, pelvic pain, bulk symptoms, unfavorable impact on fertility and obstetric complications. Factors, which predispose the emergence of fibroids are: hormones, Afro-American ethnicity, age, obesity, adverse pregnancy outcome history, early menarche, genetic factors, alcohol, caffeine or eating too much red meat. On the other hand, there are factors, which can decrease this risk: pregnancy, early menopause and tobacco smoking. There are several mechanisms of fertility impairment in females with fibroids: alternations in uterus function (flawed blood supply, increased contractility), changes in the normal uterus anatomy, local hormonal changes induced by fibroids. In this review the connection between fibroids and infertility is analyzed.

Ulipristal acetate as a treatment option for uterine fibroids

Uterine fibroids are the most common benign uterine tumours. Clinical symptoms include abnormal bleeding, pelvic pressure, pelvic pain, infertility and obstetric complications. Approximately one third of women with fibroids will require treatment. The management also depends on the number, size, and location of the fibroids. There are surgical and non-surgical treatment options. The choice of therapy depends on different factors, such as the severity of symptoms, tumour characteristics, age, and wish to preserve the uterus and fertility. There is growing evidence of the main role of progesterone pathways in the pathophysiology of uterine fibroids due to the use of selective progesterone receptor modulators such as ulipristal acetate. The efficacy of long-term intermittent use of UPA was recently demonstrated by randomised controlled studies. There is great demand for alternatives to surgical intervention, especially in women seeking to preserve their fertility. One of these alternatives is ulipristal acetate, which is proven to treat fibroid symptoms effectively.

Progesterone Receptor Isoforms, Nuclear Corepressor-1 and Steroid Receptor Coactivator-1 and B-Cell Lymphoma 2 and Akt and Akt Phosphorylation Status in Uterine Myomas after Ulipristal Acetate Treatment: A Systematic Immunohistochemical Evaluation

OBJECTIVE

To investigate whether ulipristal acetate (UPA) treatment modifies the expression of progesterone receptor (PR), its nuclear cofactors steroid receptor coactivator-1 (SRC1) and nuclear corepressor-1 (NCoR1), prosurvival factor B-cell lymphoma 2 (Bcl-2), and Akt in uterine myomas.

PATIENTS

Prospective study of 59 women with symptomatic myomas undergoing myomectomy. Forty-two patients were treated preoperatively with UPA; the remaining 17 were not and they served as controls.

METHOD

Tissue microarrays were obtained from surgical specimens and immunohistochemistry was performed. Blinded quantification of expression of PR (PR-A vs. PR-B), coactivator SRC1 and corepressor NCoR1, and prosurvival factor Bcl-2, and Akt and evaluation of Akt phosphorylation levels.

RESULTS

Compared with the control group, UPA does not alter PR protein levels or expression patterns in myomas, and the PR-A/PR-B ratio was similar, as well as cytoplasmic or nuclear expression of cofactors SRC1 and NCoR1. Bcl-2 was heterogeneously expressed throughout the samples and no significant modification in expression was evidenced. No significant difference was found in Akt expression and phosphorylation between treated and untreated myomas.

CONCLUSION

This study did not find any significant change in the expression of the studied factors in myomas after UPA exposure. In conclusion, various theories on myomas cells proposed on the basis of in vitro studies are not supported in vivo.

Uterine fibroids - what's new?

Uterine fibroids are the commonest benign tumours of women and affect all races with a cumulative lifetime risk of around 70%. Despite their high prevalence and the heavy economic burden of treatment, fibroids have received remarkably little attention compared to common female malignant tumours. This article reviews recent progress in understanding the biological nature of fibroids, their life cycle and their molecular genetic origins. Recent progress in surgical and interventional management is briefly reviewed, and medical management options, including treatment with selective progesterone receptor modulators, are also discussed.

Alternative Oral Agents in Prophylaxis and Therapy of Uterine Fibroids-An Up-to-Date Review

Uterine fibroids (UFs) are the most common tumors of the female genital tract. The effect of UFs on the quality of life and the overall cost of treatment are significant issues worldwide. Tumor size and location are the two specific factors which influence the occurrence of symptoms, the need for, and method of, treatment (some tumors require surgery while some can be treated with selected drugs). Primary prevention and treatment of early UF disease are worthy goals that might have a great impact on health care systems. Several treatments and prophylactic methods can be used in this endeavor. This publication presents current data about lesser-known substances which may have a beneficial effect on the treatment or prophylaxis of UFs and can be administered orally, serving as an alternative to (or complement of) surgery or selective progesterone receptor modulators (SPRMs). Early prevention and treatment of UFs in women from high-risk groups should be our priority. Innovative forms of UF management are under intensive investigation and may be promising options in the near future. Many of them evaluated vitamin D, paricalcitol, epigallocatechin gallate (EGCG), elagolix, aromatase inhibitors (AIs), and cabergoline and deemed them to be safe and effective. The next step in such projects should be properly constructed randomized control trials (RCTs), carried out by successive phases.

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.

Uterine Fibroids: Burden and Unmet Medical Need

Uterine fibroids affect a wide cross-section of the population, with prevalence, symptom severity, and overall disease burden generally higher among black women, likely due to both genetic and environmental factors. Potential symptoms of uterine fibroids include painful and excessive uterine bleeding, interference with everyday life and self-image, and impaired fertility. Because of the high estimated prevalence and costs associated with treatments, the direct and indirect costs of uterine fibroids are substantial for both the health care system and the individual patient. Special patient populations—such as black women, women seeking to retain fertility, and women with asymptomatic fibroids—have particular treatment needs that require a variety of diagnostic methods and treatment options. Despite the widespread occurrence of uterine fibroids and newer treatment options, little high-quality data are available to formulate evidence-based guidelines that address these unmet patient needs. Specific areas in need of attention include improving diagnostic techniques, increasing patient access to early treatment, and identifying best practices for this diverse patient population.

Impact of uterine fibroid symptoms on health-related quality of life of US women: evidence from a cross-sectional survey

BACKGROUND

Uterine fibroids (UF) are associated with significant health-related quality of life (HRQL) impact. This study examined the impact of UF symptoms on HRQL.

METHODS

An online cross-sectional survey of 18 to 49 year old US women was conducted and collected demographics, UF prevalence, symptoms, and HRQL using the UFS-QOL. Descriptive statistics were used to examine the impact of symptom presence, severity, bothersomeness, and number of UF symptoms on HRQL. Analyses were weighted to match the US female population distribution. Multivariate regressions were performed with each subscale as a dependent variable to examine the impact of individual UF symptoms on HRQL.

RESULTS

A total of 59,411 (15.5%) panel members completed the prevalence screener; 4848 met inclusion criteria; 955 had UF and no hysterectomy. Mean age was 40.3; 58% were white; 63% were married/civil union. Common UF symptoms were: lower back pain (65%), fatigue/weariness (63%), bloating (61%), pelvic pain/cramping during menses (63%), and heavy bleeding during menses (54%). Mean UFS-QoL subscale scores were significantly (p < .05) worse among women with a UF symptom versus women without the symptom. Women who rated their UF symptoms as severe had significantly (p < .001) worse UFS-QoL scores than women with mild or moderate symptoms. UFS-QoL subscale scores worsened as the number of symptoms increased. In the regressions, the presence of bleeding and non-bleeding symptoms were related to worse UFS-QoL subscale scores.

CONCLUSION

HRQL among women with UF was significantly impacted by UF-related symptoms. Greater impact was observed as the number and severity of symptoms increased.

Laparoscopic uterine artery bipolar coagulation plus myomectomy vs traditional laparoscopic myomectomy for "large" uterine fibroids: comparison of clinical efficacy

PURPOSE

Laparoscopic myomectomy is the uterus-preserving surgical approach of choice in case of symptomatic fibroids. However, it can be a difficult procedure even for an experienced surgeon and can result in excessive blood loss, prolonged operating time and postoperative complications. A combined approach with laparoscopic uterine artery occlusion and simultaneous myomectomy was proposed to reduce these complications. The aim of this study was to evaluate the safety and efficacy of the combined laparoscopic approach in women with symptomatic "large" intramural uterine fibroids, compared to the traditional laparoscopic myomectomy alone.

METHODS

Prospective nonrandomized case-controlled study of women who underwent a conservative surgery for symptomatic "large" (≥ 5 cm in the largest diameter) intramural uterine fibroids. The "study group" consisted of women who underwent the combined approach (laparoscopic uterine artery bipolar coagulation and simultaneous myomectomy), while women who underwent the traditional laparoscopic myomectomy constituted the "control group". A comparison between the two groups was performed, and several intraoperative and postoperative outcomes were evaluated.

RESULTS

No significant difference in the overall duration of surgery between women of the "study group" and "control group" emerged; however, a significantly shorter surgical time for myomectomy was observed in the "study group". The intraoperative blood loss and the postoperative haemoglobin drop were significantly lower in the "study group". No difference in the postoperative pain between groups emerged, and the postoperative hospital stay was similar in the two groups.

CONCLUSIONS

The laparoscopic uterine artery bipolar coagulation and simultaneous myomectomy is a safe and effective procedure, even in women with symptomatic "large" intramural uterine fibroids, with the benefit of a significant reduction in the intraoperative blood loss when compared to the traditional laparoscopic myomectomy.

The Rising Phoenix-Progesterone as the Main Target of the Medical Therapy for Leiomyoma

Leiomyomas, also known as uterine fibroids, are a common benign tumor in women of reproductive age. These lesions disrupt the function of the uterus causing menorrhagia and pelvic pressure as well as reproductive disorders. These women pose a true challenge for clinicians in the attempt of choosing the suitable treatment for each patient. Patient's age, interest in fertility preservation, and leiomyoma location and size are all factors to be taken into account when deciding upon the preferable therapeutic option. For the past few decades, surgical treatment was the only reliable long-term treatment available. A variety of surgical approaches have been developed over the years but these developments have come at the expense of other treatment options. The classical medical treatment includes gonadotropin-releasing hormone (GnRH) agonists and antagonists. These agents are well known for their limited clinical effect as well as their broad spectrum of side effects, inspiring a need for new pharmacological treatments. In recent years, promising results have been reported with the use of selective progesterone receptor modulators (SPRM). Long-term clinical trials have shown a reduction in bleeding and shrinkage of leiomyoma mass. These results instill hope for women suffering from symptomatic leiomyomas seeking an effective, long-term medical option for their condition.

Updated approaches for management of uterine fibroids

Uterine anatomy and uterine fibroids (UFs) characteristics have been classically considered as almost a unique issue in gynecology and reproductive medicine. Nowadays, the management of UF pathology is undergoing an important evolution, with the patient's quality of life being the most important aspect to consider. Accordingly, surgical techniques and aggressive treatments are reserved for only those cases with heavy symptomatology, while the clinical diagnostic based on size and number of UFs remains in a second plane in these situations. Moreover, the development of several noninvasive surgical techniques, especially the appearance of ulipristal acetate as a medical etiological treatment, has substantially changed the clinical indications. As a consequence, after almost 2 decades without relevant updates, it has been necessary to update the protocols for the management of UFs in the Spanish Society of Gynecology and Obstetrics twice. Accordingly, we believe that it is necessary to translate our experience to protocolize the medical care for patients with UFs, incorporating these new therapeutic options, and selecting the best treatment for them. We highlight the importance of achieving the patient's goals and decisions by improving the clinical diagnosis for these type of pathologies, allowing enhanced personalized treatments, as well as the reduction of potential risks and unnecessary surgeries.

Laparoscopy or laparotomy as the way of entrance in myoma enucleation

PURPOSE

Uterine myomas are the main cause of benign uterine diseases in premenopausal women. Objective of the present paper is to investigate the current best treatment modalities of myomas, depending on age of the patient and her desire to preserve fertility, as well as on clinical presentation of this pathology, such as size, number, and location of fibroids and, furthermore, on surgical experience of the gynecologist.

METHODS

The design of our work is a systematic literature review of existing studies, reviews, and meta-analysis conducted in PubMed and Cochrane Library to identify relevant literature. Commonly, the myomectomy is to be recommended in women desiring to preserve fertility when myomas are associated with symptoms such as excessive bleeding, pelvic discomfort, or palpable abdominally fibroids. The decision of surgical approach for myomectomy should be individualized, depending on size and location, as well as on surgeon's experience. The different modalities of myomectomy, laparoscopic, hysteroscopic, robotic-assisted, or laparotomic are in detail presented in the paper, according to Society of Obstetricians and Gynecologists of Canada (SOGC) clinical practice guidelines and taking into consideration possible concerns of myomectomy such as uterine rupture, development of adhesions, and myomas' recurrence.

Laparoscopic Versus Open Hysterectomy for Benign Disease in Uteri Weighing >1 kg: A Retrospective Analysis on 258 Patients

STUDY OBJECTIVE

To present a large single-center series of hysterectomies for uteri ≥1 kg and to compare the laparoscopic and open abdominal approach in terms of perioperative outcomes and complications.

DESIGN

A retrospective analysis of prospectively collected data (Canadian Task Force classification II-2).

SETTING

An academic research center.

PATIENTS

Consecutive women who underwent hysterectomy for uteri ≥1 kg between January 2000 and December 2016. Patients with a preoperative diagnosis of uterine malignancy or suspected uterine malignancy were excluded. The subjects were divided according to the intended initial surgical approach (i.e., open or laparoscopic). The 2 groups were compared in terms of intraoperative data and postoperative outcomes. Multivariable analysis was performed to identify possible independent predictors of overall complications. A subanalysis including only obese women was accomplished.

INTERVENTIONS

Total laparoscopic versus abdominal hysterectomy (±bilateral adnexectomy).

MEASUREMENTS AND MAIN RESULTS

Intra- and postoperative surgical outcomes. A total of 258 patients were included; 55 (21.3%) women were initially approached by open surgery and 203 (78.7%) by laparoscopy. Nine (4.4%) conversions from laparoscopic to open surgery were registered. The median operative time was longer in the laparoscopic group (120 [range, 50-360] vs 85 [range, 35-240] minutes, p = .014). The estimated blood loss (150 [range, 0-1700] vs 200 [50-3000] mL, p = .04), postoperative hemoglobin drop, and hospital stay (1 [range, 1-8] vs 3 [range, 1-8] days, p < .001) were lower among patients operated by laparoscopy. No difference was found between groups in terms of intra- and postoperative complications. However, the overall rate of complications (10.8% vs. 27.2%, p = .015) and the incidence of significant complications (defined as intraoperative adverse events or postoperative Clavien-Dindo ≥2 events, 4.4% vs 10.9%, p = .04) were significantly higher among patients who initially received open surgery. The laparoscopic approach was found to be the only independent predictor of a lower incidence of overall complications (odds ratio = 0.42; 95% confidence interval, 0.19-0.9). The overall morbidity of minimally invasive hysterectomy was lower also in the subanalysis concerning only obese patients.

CONCLUSION

In experienced hands and in dedicated centers, laparoscopic hysterectomy for uteri weighing ≥1 kg is feasible and safe. Minimally invasive surgery retains its well-known advantages over open surgery even in patients with extremely enlarged uteri.

Abnormal Uterine Bleeding

Abnormal uterine bleeding is a frequent condition in Gynecology. It may impact physical, emotional sexual and professional aspects of the lives of women, impairing their quality of life. In cases of acute and severe bleeding, women may need urgent treatment with volumetric replacement and prescription of hemostatic substances. In some specific cases with more intense and prolonged bleeding, surgical treatment may be necessary. The objective of this chapter is to describe the main evidence on the treatment of women with abnormal uterine bleeding, both acute and chronic. Didactically, the treatment options were based on the current International Federation of Gynecology and Obstetrics (FIGO) classification system (PALM-COEIN). The etiologies of PALM-COEIN are: uterine Polyp (P), Adenomyosis (A), Leiomyoma (L), precursor and Malignant lesions of the uterine body (M), Coagulopathies (C), Ovulatory dysfunction (O), Endometrial dysfunction (E), Iatrogenic (I), and Not yet classified (N). The articles were selected according to the recommendation grades of the PubMed, Cochrane and Embase databases, and those in which the main objective was the reduction of uterine menstrual bleeding were included. Only studies written in English were included. All editorial or complete papers that were not consistent with abnormal uterine bleeding, or studies in animal models, were excluded. The main objective of the treatment is the reduction of menstrual flow and morbidity and the improvement of quality of life. It is important to emphasize that the treatment in the acute phase aims to hemodynamically stabilize the patient and stop excessive bleeding, while the treatment in the chronic phase is based on correcting menstrual dysfunction according to its etiology and clinical manifestations. The treatment may be surgical or pharmacological, and the latter is based mainly on hormonal therapy, anti-inflammatory drugs and antifibrinolytics.

Prospective, randomized comparison of the use of FloShield Air System® versus the reference technique (water + povidone-iodine solution) during gynecologic endoscopic surgery to evaluate the operative lens vision quality

BACKGROUND

The FloShield Air System^® is a new device for laparoscopic surgery that utilizes a continuous dry CO₂ gas flow over the scope to defog the lens and protect it from condensation, debris and smoke. We set out to compare the performance and efficiency of the device in terms of operative lens vision quality (OLVQ) with the reference technique (water + povidone-iodine (PVI) solution) during gynecologic laparoscopic surgery.

MATERIALS AND METHODS

We conducted a single-center randomized prospective study between March and June 2016 (Trials Database Registration NCT02702531) including 53 patients undergoing gynecologic laparoscopic surgery with water + PVI solution and 51 patients who underwent surgical procedures with the FloShield Air System. The primary outcome measure was the number of laparoscope removals during surgery. Secondary outcome measures were the time to clean, assessment of the quality of vision, the correlation between the laparoscopic surgical complexity and outcomes, and cost effectiveness.

RESULTS

Overall, the mean patient age was 43.2 years (range 22-86) and body mass index 24.8 (range 16.8-42.7). The mean number of endoscope removals during surgery was 7.0 (range 0-37) in the water + PVI solution arm and 2.8 (range 0-12) in the FloShield Air System^® arm. The number of removals was significantly lower in the FloShield arm (p < 0.001). No difference in time to clean, quality of vision, level of laparoscopic procedure complexity, or cost was observed between the groups.

CONSLUSIONS

The FloShield Air System^® resulted in fewer laparoscopic lens removals than the water + PVI solution solution, but that there was no difference in quality of vision, cleaning time or cost, especially for the more complex surgery.

The use of selective progestin receptor modulators (SPRMs) and more specifically ulipristal acetate in the practice of gynaecology

This review discusses the development of selective progestin receptor modulators (SPRMs) for use in women's health and specifically the use of ulipristal acetate (UPA) as emergency contraception (EC) and as a treatment for symptomatic fibroids in women who want to preserve their fertility or avoid a hysterectomy. As an EC, UPA 30 mg should be recommended for women, within 102 h of unprotected intercourse. As a treatment of fibroids, UPA (5 mg daily dose) should be administered for periods of three months as a pre-surgical strategy, reducing bleeding and fibroid size and facilitating surgery. A proportion of these patients may even avoid surgery. Future developments will demonstrate whether UPA can be used for other indications such as endometriosis and breast cancer prevention or treatment.

Very small embryonic-like stem cells (VSELs) in adult mouse uterine perimetrium and myometrium

We have earlier reported the presence of very small embryonic-like stem cells (VSELs) in adult mouse uterus along with slightly bigger progenitors termed endometrial stem cells (EnSCs) and their regulation by ovarian hormones thus demonstrating a crucial role played by them during proliferation, differentiation and remodeling of the endometrium. Present study is a brief communication wherein we have examined the effect of higher dose of estrogen (E, 2 μg/day), progesterone (P, 1 mg/day) and follicle stimulating hormone (FSH, 5 IU/day for 5 days) specifically on the myometrium and perimetrium surrounding the endometrium in bilaterally ovariectomized mice. Similar treatment with E & P was recently used in a study published in the journal Nature to study the effect of steroid hormones on hematopoietic stem cells and this treatment regimen helps achieve hormone levels observed during pregnancy. Quiescent spherical stem cells (lacking PCNA expression) with high nucleo-cytoplasmic ratio and nuclear OCT-4A were detected in the perimetrium of atrophied (bilaterally ovariectomized) uterus. PCNA expression was observed after treatment and cells with cytoplasmic OCT-4B were invariably observed in the myometrium. VSELs were clearly visualized after treatment and the effect of P and FSH was more prominent compared to E on the development of myometrium. It is speculated that stem cells with nuclear OCT-4A located in the perimetrium differentiate to give rise to endothelial and myometrial cells with cytoplasmic OCT-4B. Based on the results of present study and published reports showing the presence of pluripotent markers (OCT-4, NANOG and SOX2) in human myometrial side population and expression of particularly OCT-4A in human leiomyomas, we speculate that these nuclear OCT-4 positive stem cells located in the perimetrium are the possible tumor initiating cells leading to the development of leiomyomas rather than the mesenchymal cells which express cytoplasmic OCT-4B.

Vaginal Myomectomy Using the Dührssen (Longitudinal Median Cervical) Incision: A Case Series of 19 Patients

STUDY OBJECTIVE

To examine demographics and outcome measures of women having undergone vaginal excision of myomas through the Dührssen (longitudinal median cervical) incision.

DESIGN

Prospective case series (Canadian Task Force classification II-3).

SETTING

A London teaching hospital.

PATIENTS

Nineteen patients with either a submucous myoma (type 1) located near the cervix or a pedunculated intracavity myoma (type 0), excised via the Dührssen incision.

INTERVENTIONS

Dührssen (median longitudinal) incision on the anterior or posterior cervical lip.

MEASUREMENTS AND MAIN RESULTS

Duration of procedures, intraoperative complications, estimated blood loss, length of stay, percent of patients discharged in 24 hours, and readmission rates were studied. Between 2009 and 2016, 19 women had their myomas (submucous type 1, n = 17; pedunculated intracavity type 0, n = 2) removed vaginally with the Dührssen incision. The median age at time of procedure was 46 years (range, 43-55), and the most common indication was menorrhagia, which occurred in 90% of cases. The median myoma size was 7 cm (range, 6-9), whereas the median duration of surgery was 60 minutes (range, 40-120). Anterior cervical incisions were performed in 60% of cases, and 20% of the patients received gonadotropins for medical debulking of the myomas before surgery. One patient sustained a bladder injury that occurred when making the anterior cervical incision. The median length of stay was 8 hours (range, 6-36) and the median estimated blood loss was 90 mL (range, 50-150). The median duration of follow-up was 4 years (range, .5-6), and no patients had symptoms that were attributable to the procedure.

CONCLUSION

This is a useful technique that complements a minimally invasive surgeon's repertoire and is a viable alternative when hysteroscopic myomectomy is deemed unsuitable because of location and size of the myomas.

Advanced Hysteroscopic Surgery: Quality Assurance in Teaching Hospitals

Advanced hysteroscopic surgery (AHS) is a vitally important technique in the armamentarium for the management of many day-to-day clinical problems, such as menorrhagia, surgical excision of uterine myomata and septa in the management of female infertility, hysteroscopic excision of chronically retained products of conception (placenta accreta), and surgical removal of intramural ectopic pregnancy. In today's climate of accountability, it is necessary that gynecologists take a more active role in assuring the quality of their work. In this article, we discuss the quality assurance system from the point of view of the surgical audit meetings in some of the major teaching hospitals affiliated with the University of Queensland (Brisbane, Queensland, Australia).

Ulipristal acetate before high complexity endoscopic (hysteroscopic, laparoscopic) myomectomy - a mini-review

Uterine myomas (fibromas, leiomyomas) are the most common tumours in women, and their clinical signs and symptoms are presented by 25-40% of patients with these benign tumours.

According to current guidelines, the armamentarium for myoma management consists of: medical therapy (GnRH, SPRMs), non-surgical alternatives including uterine artery embolisation (UAE), vaginal temporary occlusion of uterine arteries using clamp-like device or MRgFUS technique, and surgical treatment (including minimally invasive techniques). In cases of submucous myomas STEPW classification correlates very well with the risk of incomplete hysteroscopic myomectomies. According to limited literature data, ulipristal acetate as a pre-treatment seems to be very prudent in high complexity hysteroscopic myomectomy (STEPW II, score 5-6). In patients with large uterine myomas (FIGO type 3, 4, 5) undergoing laparoscopic myomectomy, three-month pre-treatment with ulipristal acetate before laparoscopy is feasible and can be recommended because of shorter time of surgery, lower intraoperative blood loss, lower haemoglobin drop, and low postoperative blood transfusion rate.

Ulipristal acetate for pre-operative treatment of moderate-to-severe uterine fibroids in women of reproductive age in The Netherlands: cost minimization analysis and budget impact analysis

OBJECTIVE

Ulipristal acetate has been found to be non-inferior to other pre-operative treatments of uterine fibroids, particularly leuprolide. The objective of this study was to assess the pharmacoeconomic profile of ulipristal acetate compared to leuprolide for the pre-operative treatment of moderate-to-severe uterine fibroids in women of reproductive age in The Netherlands. The analysis was performed and applied within the framework of the ulipristal acetate submission for reimbursement in 2012.

METHODS

A decision model was developed to compare the total costs of ulipristal acetate compared to leuprolide, the standard care in The Netherlands. The target population of this study corresponded to the type of patients included in the PEARL II clinical trial; i.e. women of reproductive age requiring pre-operative treatment for uterine fibroids. Sensitivity analysis was implemented to assess uncertainties. Data regarding costs, effects, and other input parameters were obtained from relevant published literatures, the Dutch Healthcare Insurance Board, and expert opinion obtained by means of a panel of experts from several medical centers in The Netherlands.

RESULTS

In The Netherlands, the total costs of ulipristal acetate and leuprolide were estimated at €4,216,027 and €4,218,095, respectively. The annual savings of ulipristal acetate were, therefore, estimated at €2,068. The major driver of this cost difference was the cost of administration for leuprolide. Sensitivity analyses showed that ulipristal acetate mostly remained cost-saving over a range of assumptions. The budget impact analysis indicated that the introduction of ulipristal acetate was estimated to result in cost savings in the first 3 years following the introduction. The results of this study were used in the decision on reimbursement of ulipristal acetate according to the Dutch Reference Pricing system in 2012.

CONCLUSION

Ulipristal acetate was cost saving compared to leuprolide and has the potential to provide substantial savings on the healthcare budget in The Netherlands.