Urological complications of uterine leiomyoma: a review of literature

Associations of per- and polyfluoroalkyl substances with uterine leiomyomata incidence and growth: a prospective ultrasound study

BACKGROUND

Per- and polyfluoroalkyl substances (PFAS) are endocrine-disrupting chemicals used in commercial and consumer products.

OBJECTIVE

We evaluated PFAS exposure in relation to incidence and growth of uterine leiomyomata (UL), hormone-dependent neoplasms that are associated with severe gynecologic morbidity.

METHODS

We studied 1158 participants in the Study of Environment, Lifestyle, and Fibroids, a Detroit-based prospective cohort study of Black females aged 23-35 years at enrollment (2010-2012). At enrollment and four subsequent visits during 10 years of follow-up, participants attended in-person clinic visits, completed questionnaires, provided non-fasting blood samples, and underwent ultrasound for UL detection. We quantified 7 PFAS in baseline plasma samples using mass spectrometry. We used Cox regression and probit Bayesian kernel machine regression to estimate individual and joint effects of PFAS on UL incidence. We fit linear mixed models to estimate effects of individual PFAS on UL growth. We stratified by parity, an important route of PFAS elimination and determinant of UL.

RESULTS

In individual PFAS analyses, we observed inverse associations for perfluorodecanoate (PFDA; ≥0.3 vs. <0.2 ng/ml: hazard ratio [HR] = 0.74; 95% confidence interval [CI]: 0.54-1.00) and perfluoroundecanoate (detected vs. non-detected: HR = 0.78; 95% CI: 0.61-1.01) and a weak positive association for perfluorohexane sulfonate (≥1 vs. <0.6 ng/ml: HR = 1.17; 95% CI: 0.85-1.61), while perfluorooctane sulfonate, perfluorooctanoate, perfluorononanoate (PFNA), and 2-N-methyl-perfluorooctane sulfonamido acetate (MeFOSAA) showed little association with UL incidence. The PFAS mixture was inversely associated with UL incidence, a finding driven by MeFOSAA and PFDA; however, PFNA was positively associated with UL incidence. The inverse association for PFDA and positive association for PFNA were stronger among nulliparous participants. Most PFAS showed slight inverse associations with UL growth.

IMPACT STATEMENT

In this prospective ultrasound study of 1158 Black females aged 23-35 years at enrollment, we conducted a mixtures analysis to account for co-pollutant confounding and interaction. MeFOSAA and PFDA concentrations were inversely associated with UL incidence, while PFNA concentrations were positively associated with UL incidence. Concentrations of most PFAS were associated with decreased UL growth. This study contributes data to the sparse literature on PFAS exposure and UL development.

Prolapse of a Large Degenerating Uterine Leiomyoma: A Case Report

Uterine leiomyomas (ULs) are common benign tumors seen in a large percent of women that can be classified based on their location within the uterus. They can cause a number of pelvic complications and can be managed medically, but more often surgically. Uterine pyomyomas often occur postpartum, possibly from infarction, and can lead to degeneration and sepsis. Our patient presents with a two-month development of a potential pyomyoma, found initially on computed tomography (CT). Office exam reveals a protruding mass from the cervical os, and removal was attempted but ultimately postponed for general anesthesia exam due to pain. The leiomyoma was removed and shown to be necrosing. Pyomyomas are often insidious and can often mimic other concerning pathologies. Modern imaging can show lesions within the pelvis but struggle to determine between fluid collection and possible infarcted masses. The importance of quality care measures in cases like this deserve to be emphasized to prevent serious complications.

Long-term evaluation of uterine fibroid embolisation using MRI perfusion parameters and patient questionnaires: preliminary results

BACKGROUND

Uterine fibroid embolisation (UFE) is an established treatment method for symptomatic uterine myomas. This study evaluates the efficacy of UFE using objective magnetic resonance imaging (MRI) data for size and perfusion analysis as well as patient questionnaires assessing fibroid-related symptoms.

METHOD

Patients underwent MR-Angiography before UFE and 4 days, 6 and 12 months after the procedure. The images were evaluated using dedicated software. Patient questionnaires were completed before UFE and at 12 months follow-up, focussing on the embolization procedure and symptoms associated with uterine fibroids. Statistical analysis of the questionnaires was performed using paired sample t-test and Wilcoxon signed rank test, while Kruskal-Wallis test and Friedman test were applied for MRI-analysis.

RESULTS

Eleven women were included. There was a significant reduction in fibroid-related symptoms. The volume reduction after 12 months was significant in both, uterus and myomas, after an initial increase in uterine volume at the first post-interventional MRI. The perfusion analysis showed that blood flow to the fibroids could be significantly reduced up to 12 months after UFE while uterine tissue was not affected.

CONCLUSION

This study shows that uterine fibroid embolisation induces a significant long-term decrease in myoma size and perfusion while healthy uterine tissue remains unaffected. Fibroid-related symptoms are reduced for the sake of improved quality of life.

Epigenomic and enhancer dysregulation in uterine leiomyomas

BACKGROUND

Uterine leiomyomas, also known as uterine fibroids or myomas, are the most common benign gynecological tumors and are found in women of reproductive and postmenopausal age. There is an exceptionally high prevalence of this tumor in women by the age of 50 years. Black women are particularly affected, with an increased incidence, earlier age of onset, larger and faster growing fibroids and greater severity of symptoms as compared to White women. Although advances in identifying genetic and environmental factors to delineate these fibroids have already been made, only recently has the role of epigenomics in the pathogenesis of this disease been considered.

OBJECTIVE AND RATIONALE

Over recent years, studies have identified multiple epigenomic aberrations that may contribute to leiomyoma development and growth. This review will focus on the most recent discoveries in three categories of epigenomic changes found in uterine fibroids, namely aberrant DNA methylation, histone tail modifications and histone variant exchange, and their translation into altered target gene architecture and transcriptional outcome. The findings demonstrating how the altered 3D shape of the enhancer can regulate gene expression from millions of base pairs away will be discussed. Additionally, translational implications of these discoveries and potential roadblocks in leiomyoma treatment will be addressed.

SEARCH METHODS

A comprehensive PubMed search was performed to identify published articles containing keywords relevant to the focus of the review, such as: uterine leiomyoma, uterine fibroids, epigenetic alterations, epigenomics, stem cells, chromatin modifications, extracellular matrix [ECM] organization, DNA methylation, enhancer, histone post-translational modifications and dysregulated gene expression. Articles until September 2021 were explored and evaluated to identify relevant updates in the field. Most of the articles focused on in the discussion were published between 2015 and 2021, although some key discoveries made before 2015 were included for background information and foundational purposes. We apologize to the authors whose work was not included because of space restrictions or inadvertent omission.

OUTCOMES

Chemical alterations to the DNA structure and of nucleosomal histones, without changing the underlying DNA sequence, have now been implicated in the phenotypic manifestation of uterine leiomyomas. Genome-wide DNA methylation analysis has revealed subsets of either suppressed or overexpressed genes accompanied by aberrant promoter methylation. Furthermore, differential promoter access resulting from altered 3D chromatin structure and histone modifications plays a role in regulating transcription of key genes thought to be involved in leiomyoma etiology. The dysregulated genes function in tumor suppression, apoptosis, angiogenesis, ECM formation, a variety of cancer-related signaling pathways and stem cell differentiation. Aberrant DNA methylation or histone modification is also observed in altering enhancer architecture, which leads to changes in enhancer-promoter contact strength, producing novel explanations for the overexpression of high mobility group AT-hook 2 and gene dysregulation found in mediator complex subunit 12 mutant fibroids. While many molecular mechanisms and epigenomic features have been investigated, the basis for the racial disparity observed among those in the Black population remains unclear.

WIDER IMPLICATIONS

A comprehensive understanding of the exact pathogenesis of uterine leiomyoma is lacking and requires attention as it can provide clues for prevention and viable non-surgical treatment. These findings will widen our knowledge of the role epigenomics plays in the mechanisms related to uterine leiomyoma development and highlight novel approaches for the prevention and identification of epigenome targets for long-term non-invasive treatment options of this significantly common disease.

Intelligent Noise Reduction Algorithm to Evaluate the Correlation between Human Fat Deposits and Uterine Fibroids under Ultrasound Imaging

This study aimed to realize the automatic diagnosis of fatty degeneration of uterine fibroids. In this study, the traditional nonlocal means (NLM) algorithm was improved by changing the Euclidean distance and introducing a cosine function and applied to the ultrasonic imaging intelligent diagnosis of patients with fatty degeneration of uterine fibroids. Then, the noise reduction effect of the improved NLM algorithm was evaluated based on several indicators, such as peak signal-to-noise ratio (PSNR), mean square error (MSE), contrast-to-noise ratio (CNR), figure of merit (FOM), and structural similarity (SSIM). The accuracy, sensitivity, specificity, and F1 score were adopted to evaluate the improved NLM algorithm for diagnosing fatty degeneration of uterine fibroids, and the Perona-Malik (PM) algorithm and NLM algorithm were used for comparative analysis. The results showed that after the ultrasound images of patients with uterine fibroids were denoised using the improved NLM algorithm, the PSNR, MSE, CNR, FOM, and SSIM were obviously better than the same indicators of the image processed with the PM algorithm and the NLM algorithm, and the differences were statistically significant (P < 0.05). The diagnosis results of patients with fatty degeneration of uterine fibroids found that there was only one patient with missed diagnosis after the ultrasound image was processed with NLM algorithm, and there was no statistical difference between the improved NLM algorithm and the assisted diagnosis accuracy of the pathological examination results (P > 0.05). The average noise reduction time of the PM algorithm, NLM algorithm, and the improved NLM algorithm was 16.38 ± 4.33 s, 18.01 ± 5.14 s, and 23.81 ± 4.62 s, respectively. The diagnosis rate before improvement was 75.0%, the diagnosis accuracy rate for PM was 79.69%, and that after improvement was 85.94%. In summary, the improved NLM algorithm showed a good noise reduction effect on ultrasound images of patients with uterine fibroids, could improve the diagnosis accuracy of fatty degeneration of uterine fibroids, and could assist clinicians in the ultrasound imaging diagnosis of patients with uterine fibroids.

Ethanolic Extracts of Adlay Testa and Hull and Their Active Biomolecules Exert Relaxing Effect on Uterine Muscle Contraction through Blocking Extracellular Calcium Influx in Ex Vivo and In Vivo Studies

Dysmenorrhea is one of the most prevalent disorders in gynecology. Historically, adlay (Coix lachryma-jobi L. var. Ma-yuen Stapf.) has been explored for its anti-tumor, pain relief, anti-inflammatory, and analgesic effects. The aim of this study was to evaluate the effects of adlay seeds on the inhibition of uterine contraction and thus dysmenorrhea relief, in vitro and in vivo. HPLC-MS and GC were used to elucidate the ethyl acetate fraction of adlay testa ethanolic extract (ATE-EA) and ethyl acetate fraction of adlay hull ethanolic extract (AHE-EA). Elucidation yielded flavonoids, phytosterols, and fatty acids. Uterine leiomyomas and normal adjacent myometrial tissue were evaluated by oxytocin- and PG-induced uterine contractility. ATE-EA and AHE-EA suppressed uterine contraction induced by prostaglandin F2 alpha (PGF_2α), oxytocin, carbachol, and high-KCl solution ex vivo. In addition, the external calcium (Ca²⁺) influx induced contraction, and increased Ca²⁺ concentration was inhibited by ATE-EA and AHE-EA on the uterine smooth muscle of rats. Furthermore, ATE-EA and AHE-EA effectively attenuated the contraction of normal human myometrium tissues more than adjacent uterine leiomyoma in response to PGF_2α. 3,5,6,7,8,3′,4′-Heptamethoxyflavone and chrysoeriol produced a remarkable inhibition with values of IC₅₀ = 24.91 and 25.59 µM, respectively. The experimental results showed that treatment with ATE-EA at 30 mg/day effectively decreased the writhing frequency both on the oxytocin-induced writhing test and acetic acid writhing test of the ICR mouse.

Fibroids and Urinary Symptoms Study (FUSS)

OBJECTIVE

The aims of the study were to characterize pelvic floor and urinary symptoms in women seeking treatment for uterine fibroids and to explore the association between uterine/fibroid size and pelvic floor symptoms.

METHODS

Women seeking treatment for uterine fibroids at a single academic center were enrolled in this cross-sectional study. All participants underwent pelvic imaging and completed the Symptom Severity Subscale of the Uterine Fibroid Symptom and Health-Related Quality of Life Questionnaire (UFS-QOL) and the Pelvic Floor Distress Inventory (PFDI-20).

RESULTS

One hundred ninety-five women with a mean age of 41 ± 6 years and body mass index of 29 ± 7 kg/m2 were included. In this cohort, 58% identified as Black and 38% had at least 1 vaginal delivery. Women attributed pelvic pain (68%), dyspareunia (37%), and urinary incontinence (31%) to their fibroids. The mean ± SD UFS-QOL score was 48.7 ± 25.4, and 63% of participants reported being at least "somewhat bothered" by tightness/pressure in pelvic area, 60% by frequent daytime urination, and 47% by nocturia. The mean PFDI-20 score was 45.5 ± 31.9. Women reported being at least "somewhat bothered" by heaviness/dullness in the pelvis (60%), frequent urination (56%), pelvic pain or discomfort (48%), and sensation of incomplete bladder emptying (43%). The PFDI-20 and UFS-QOL scores were not correlated with uterine volume (r = 0.12, P = 0.12, and r = 0.06, P = 0.44) or fibroid size (r = 0.09, P = 0.26, and r = 0.01, P = 0.92).

CONCLUSIONS

Women presenting for evaluation and treatment of fibroids report high rates of pelvic floor symptoms, particularly urinary frequency and pelvic pressure. However, uterine size and fibroid size are not associated with pelvic floor symptom bother.

Female detrusor underactivity: Two uterine leiomyoma cases

INTRODUCTION

Female urinary retention is rare.

CASE PRESENTATION

Case 1, a 35-year-old nulliparous woman, and case 2, a 47-year-old nulliparous woman, had transient urinary retention. A urodynamics revealed increased bladder sensation in case 1 and detrusor underactivity with a large post-void residual in cases 1 and 2. Both women had a uterine leiomyoma of >10 cm in diameter. Soon after extraction of the tumor, retention episodes disappeared completely in case 1.

CONCLUSION

Although rare, uterine leiomyoma should be listed as a cause of female detrusor underactivity.

Oral and uterine leiomyomas exhibit high immunoexpression of Cripto-1 compared to normal myometrium

Leiomyomas are the most common benign tumors in women. Many of them are associated with significant morbidity. The present study aimed to analyze histomorphological and histochemical characteristics and immunoexpression of Cripto-1 in oral leiomyomas (OL), uterine leiomyomas (UL), and normal myometrium (NM). Sample was composed of ten OL, 11 UL and 11 NM. Histomorphological characteristics were analyzed at 100 and 400x magnifications with HE staining. The immunoexpression of Cripto-1 was analyzed in five high-power fields. Statistical analysis considered a significant difference when p<0.05. Six OL disclosed moderate/intense inflammatory infiltrate, while ten UL exhibited mild infiltrate (p=0.024). When analyzing all leiomyomas together, 20 exhibited hyalinization, whereas no NM exhibited this alteration (p<0.001). There was no statistical difference in the distribution of mast cells among the lesions. The median Cripto-1 was higher in UL (9.0), followed by OL and NM (4.0). Associations of the Cripto-1 expression between leiomyomas (separately and together) and NM were statistically significant (p<0.001). These results indicate that OL and UL exhibit similar histomorphological and histochemical characteristics, as well as differences to NM. The higher immunoexpression of Cripto-1 in leiomyomas compared to NM suggests that this protein may influence cell proliferation and tissue architecture of oral and uterine leiomyomas.

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

INTRODUCTION

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

METHODS AND ANALYSIS

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

ETHICS AND DISSEMINATION

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

TRIAL REGISTRATION NUMBERS

NCT03586947 and NCT03584529.

Uterine myomas and lower urinary tract dysfunctions: A literature review

Different types of urinary symptoms associated with myomas are reported, including urinary incontinence or dysuria. They are rarely investigated in patients and their prevalence is not well known. While myomas are the first reason to perform hysterectomy in France, few studies have evaluated the impact of surgical treatment in women with urinary symptoms. Our objective was to conduct a review of the literature regarding urinary symptoms associated with myomas and the impact of their treatment on these symptoms. We reviewed articles indexed in MEDLINE dealing with urinary symptoms and myomas, and published until September 2018. The prevalence of urinary symptoms in women with uterine myomas is highly variable depending on whether the authors are interested in symptoms or urodynamic results. The most frequently reported urinary symptoms are urgency (31-59%), dysuria (4-36%) and stress urinary incontinence (SUI, 20 80%). While some studies have found the anterior location of myomas and the size superior to 5 cm as a risk factor for UI, other studies have not found a correlation between myomas topography and symptom scores. The treatments of uterine myomas seem to have an impact on women's urinary symptoms. Although hysterectomy is considered as a risk factor for pelvic floor disorders, the removal of the uterus may sometimes improve or cure urinary symptoms. Most authors also found a significant improvement in urinary symptom scores after myomectomy and myomas embolization. More studies are needed to clarify the impact of myomas treatment on urinary symptoms.

Frequent milk and soybean consumption are high risks for uterine leiomyoma: A prospective cohort study

This study aims to retrospectively analyze the potential risk factors for uterine leiomyoma and prospectively examine whether these risk factors can increase the incidence of uterine leiomyoma.Women who attended our outpatient department from January 1, 2010 to December 31, 2010 were enrolled. General demographical characteristics, personal information, and living habits were collected. Univariate and multivariate logistic regression analyses were used to identify the potential risk factors. Follow-up was regularly conducted to complete the prospective analysis.A total of 1273 women were enrolled including 213 uterine leiomyomas (case group) and 1060 nonuterine leiomyoma women (control group). No statistical differences were found on the age, marital status, number and complication of pregnancy, frequent physical exercise, frequent alcohol consumption, and family history of uterine diseases between two groups (all P > .05). Mean body mass index (P = .043), high school education (P = .041), frequent smoking (P = .030), frequent caffeine consumption (P = .019), frequent milk or soybean consumption (P = .025), and frequent oral contraceptive use (P = .034) were statistically correlated with the onset of uterine leiomyoma. Multivariate analysis verified that frequent milk or soybean consumption (7.349 [5.081-9.454]; P = .039] and frequent oral contraceptive use (8.103 [4.486-12.583]; P = .018] were the independent risk factors for uterine leiomyoma.Frequent milk or soybean consumption and frequent oral contraceptive use are associated with a high risk of uterine leiomyoma, and proper education on the prevention of uterine leiomyoma is highly recommended in clinical practice.