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Singh S, Kumar P, Rathore SS, Singh Y, Garg N. Contemporary approaches in the management of uterine leiomyomas. Eur J Obstet Gynecol Reprod Biol 2023; 287:195-210. [PMID: 37385088 DOI: 10.1016/j.ejogrb.2023.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 04/24/2023] [Accepted: 06/20/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND Leiomyomas (fibroids), the most common benign solid tumours in females, originate from the myometrium and are associated with poor quality of life for patients. The current management of uterine leiomyomas mainly includes surgical interventions such as hysterectomy and myomectomy, either by laparoscopy or laparotomy, which have several complications and are not ideal for preserving fertility. Therefore, there is a need to develop or repurpose medical treatments that do not require surgical intervention. OBJECTIVE Many drugs are used to treat the symptoms associated with uterine fibroids. The main objective of this systematic review is to give an up-to-date account of potential pharmacological agents (non-surgical methods) for the management of uterine leiomyomas. SEARCH STRATEGY PubMed was searched for scientific and clinical literature using the keyword 'uterine fibroids' along with the drug names described in each section. For example, 'uterine fibroids' and 'ulipristal acetate' were the keywords used to search for literature on ulipristal acetate (UPA). RESULTS Various preclinical and clinical studies have shown that some drugs and herbal formulations exhibit activity in the management of uterine leiomyomas. Recent studies found that drugs such as UPA, elagolix, EC313, asoprisnol, nutritional supplements and herbal preparations were helpful in treating the symptoms associated with uterine leiomyomas. CONCLUSION Many drugs show efficacy in patients with symptomatic uterine fibroids. UPA is one of the most studied and prescribed medicines for uterine fibroids; however, its usage has been restricted due to a few recent incidences of hepatic toxicity. Herbal drugs and natural supplements have also shown promising effects on uterine fibroids. The synergistic effects of nutritional and herbal supplements have been reported in certain cases, and should be studied in detail. Further research is warranted to identify the mode of action of the drugs, and to determine the precise conditions that would explain the causes of toxicity in some patients.
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Affiliation(s)
- Shikha Singh
- Department of Prasuti Tantra, Faculty of Ayurveda, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Praveen Kumar
- Department of Medicinal Chemistry, Faculty of Ayurveda, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Saurabh Singh Rathore
- Department of Biotechnology, Mahatma Gandhi Central University, Raghunathpur, Motihari, East Champaran, Bihar, India
| | - Yashasvi Singh
- Department of Urology, CSSB, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Neha Garg
- Department of Medicinal Chemistry, Faculty of Ayurveda, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India.
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What happens after randomised controlled trials? Uterine fibroids and ulipristal acetate: systematic review and meta-analysis of "real-world" data. Arch Gynecol Obstet 2021; 303:1121-1130. [PMID: 33389100 DOI: 10.1007/s00404-020-05918-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 11/23/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE "Real-world" data incorporates studies performed outside of controlled environments, allowing for a better understanding of the effects of treatment in routine clinical practice. We, therefore, performed a systematic review to summarise available "real-world studies" reporting on the use of ulipristal acetate (UPA) for management of uterine fibroids. METHODS We designed a prospective protocol according to PRISMA guidelines and registered it with PROSPERO (ID: CRD42019151393). We searched all major databases for relevant citations until 20th September 2019. Our screen included studies for risk of bias using an adapted structured quality assessment tool. Random-effects meta-analysis was used to calculate proportion estimates for each outcome including 95% confidence interval. Reported heterogeneity was assessed using I2. RESULTS Initial search yielded 755 studies and 13 were included in the final synthesis. Administration of UPA resulted in reduction in the size of fibroids in 56.5% of women, improved menorrhagia in 83% of women, improved perception of pain in 80.1% of women and lead to an improvement in global symptom scores in 85.2% of women. Mean reduction in surgical blood loss and surgical time with use of UPA was 59.85 ml and 12.47 min, respectively. Qualitative analysis suggested that there was no difference in overall surgical experience for patients treated with UPA compared to those without pre-treatment. CONCLUSIONS Our findings are consistent with previously reported data that UPA is an acceptable management option for women with fibroids. However, it provides limited benefits when used as a pre-operative adjunct, in terms of blood loss and surgical time.
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Ciebiera M, Jakiel G, Nowicka G, Laganà AS, Ghezzi F, Łoziński T, Wojtyła C, Włodarczyk M. The effect of ulipristal acetate on tumor necrosis factor α, insulin-like growth factor 1, and plasminogen activator inhibitor-1 serum levels in patients with symptomatic uterine fibroids. Arch Med Sci 2020; 20:751-761. [PMID: 39050181 PMCID: PMC11264157 DOI: 10.5114/aoms.2020.94296] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Accepted: 01/02/2020] [Indexed: 07/27/2024] Open
Abstract
Introduction Uterine fibroids (UFs) are benign tumors of the female reproductive system originating from the smooth muscle of the uterus. Currently, progesterone is known to play a key role in the differentiation of the myometrial tissue to form UFs and their abnormal growth. The mechanism of action of progesterone in UF tumorigenesis involves its effect on increasing the concentrations and dysregulation of selected growth factors. Material and methods A retrospective cohort study was performed to evaluate and compare tumor necrosis factor α (TNF-α), insulin-like growth factor 1 (IGF-1), plasminogen activator inhibitor-1 (PAI-1) serum concentrations in patients with UFs without prior hormonal treatment, patients with UFs treated with a 3-month standard ulipristal acetate (UPA - a type of selective progesterone receptor modulator) scheme (5 mg/day) and in control patients without UFs. A total of 120 patients were divided into 3 groups (controls, UFs with UPA treatment, UFs without UPA treatment). Results There were no significant differences in TNF-α serum concentrations between patients with UFs who underwent UPA treatment and patients who did not. Serum concentrations of IGF-1 and PAI-1 did not show significant intergroup differences. Conclusions No significant differences were found between TNF-α concentrations in the serum of patients with UFs treated with UPA, and patients without UPA treatment. In addition, our data analysis did not show significant differences in the concentrations of IGF-1 and PAI-1 between patients with UFs and the control group. Further studies on the dependence of specific symptoms on selected growth factors are mandatory.
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Affiliation(s)
- Michał Ciebiera
- II Department of Obstetrics and Gynecology, The Center of Postgraduate Medical Education, Warsaw, Poland
| | - Grzegorz Jakiel
- I Department of Obstetrics and Gynecology, The Center of Postgraduate Medical Education, Warsaw, Poland
| | - Grażyna Nowicka
- Department of Biochemistry and Pharmacogenomics, Faculty of Pharmacy, Medical University of Warsaw, Poland
| | - Antonio Simone Laganà
- Department of Obstetrics and Gynecology, “Filippo Del Ponte” Hospital, University of Insubria, Varese, Italy
| | - Fabio Ghezzi
- Department of Obstetrics and Gynecology, “Filippo Del Ponte” Hospital, University of Insubria, Varese, Italy
| | | | - Cezary Wojtyła
- European Observatory of Health Inequalities, State University of Applied Sciences, Kalisz, Poland
- Department of Gynecologic Oncology and Obstetrics, The Center of Postgraduate Medical Education, Warsaw, Poland
| | - Marta Włodarczyk
- Department of Biochemistry and Pharmacogenomics, Faculty of Pharmacy, Medical University of Warsaw, Poland
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Differences in fibroid vascularity after three months of pre-treatment with leuprolide acetate or ulipristal acetate: A pilot study. Eur J Obstet Gynecol Reprod Biol 2019; 245:186-192. [PMID: 31679806 DOI: 10.1016/j.ejogrb.2019.08.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 08/02/2019] [Accepted: 08/09/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVES To investigate differences in volume and fibroid vascularity expressed in vascular index after three months of (pre-)treatment with leuprolide acetate (LPA) or ulipristal acetate (UPA). STUDY DESIGN Prospective pilot study of 23 premenopausal women with uterine fibroids. Patients who started with LPA or UPA and had at least one fibroid with a size between 3 and 12 cm, were included consecutively. Per patient one fibroid was evaluated. The ultrasound was performed at baseline and after three months using LPA or UPA using a standardized protocol. 3D scans were evaluated using VOCAL software to calculate outcomes of volume, vascular index (VI) without shell ("shell off") and of the inner shell. RESULTS Four patients in the LPA group were additionally excluded from analyses due to insufficient quality of 3D scans. In the ten remaining patients (pre-)treated with LPA both volume and vascular indices of the fibroid reduced significantly after three months from a median of 224.3 cm3 (IQR 338.0) to 124.8 cm3 (IQR 186.1) (p = 0,05); median VI fibroid (shell off) reduced from 4.30 (IQR 4.72) to 0.93 (IQR 1.54) (p = 0,05); and VI inner capsule from 6.34 (IQR 7.51) to 1.28 (IQR 2.13) (p = 0,05). After UPA (n = 9) changes in fibroid volume and vascular indices did not reach statistical significance. Volume reduced from 248.5 cm3 (IQR 271.9) to 140.7 cm3 (IQR 209.4) (p > 0,05); median VI fibroid (shell off) from 2.97 (IQR 3.81) to 2.90 (IQR 4.82) (p > 0,05); and VI inner capsule from 2.56 (IQR 7.48) to 2.89 (IQR 4.83) (p > 0,05). A strong positive correlation was found between the VI of the fibroid (shell off) at baseline with the volume change after three months of LPA use (LPA r = 0.636, p = 0.048, 95% CI = -0.03 - 1.00). CONCLUSION In this pilot study we observed a consistent and statistically significant decrease in VI and fibroid volume after three months of LPA treatment in patients with uterine fibroids. The decrease in fibroid volume and VI was less consistent after UPA use. The strong correlation between the VI at baseline and volume reduction, may in theory be used to predict the volume reduction after LPA.
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Ciebiera M, Męczekalski B, Łukaszuk K, Jakiel G. Potential synergism between ulipristal acetate and vitamin D3 in uterine fibroid pharmacotherapy - 2 case studies. Gynecol Endocrinol 2019; 35:473-477. [PMID: 30632825 DOI: 10.1080/09513590.2018.1550062] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
This is a preliminary report of the first cases of successful simultaneous use of ulipristal acetate (UPA) and vitamin D3 in uterine fibroid (UF) oral treatment in humans. We present two cases of 37- and 49-year-old females with clinically symptomatic UFs and vitamin D deficiency. Both patients were treated with a standard 3 months of UPA scheme (5 mg daily) with the additional use of vitamin D3 (7000 IU daily orally). In the 37-year-old female all the symptoms (pain, pressure, frequent urination) decreased, total tumor volume after the treatment changed by 47.8%. In the 49-year-old female most symptoms perished, total tumor volume was reduced by 63.3%. UPA and vitamin D share synergistic anti-fibroid properties. Further studies are necessary to show the exact effect of UPA and vitamin D as co-drugs.
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Affiliation(s)
- Michał Ciebiera
- a Second Department of Obstetrics and Gynecology , The Center of Postgraduate Medical Education , Warsaw , Poland
| | - Błażej Męczekalski
- b Department of Gynecological Endocrinology , Poznan University of Medical Sciences , Poznań , Poland
| | - Krzysztof Łukaszuk
- c Department of Obstetrics and Gynecological Nursing, Faculty of Health Sciences , Medical University of Gdańsk , Gdańsk , Poland
- d INVICTA Fertility and Reproductive Center , Gdańsk , Poland
| | - Grzegorz Jakiel
- e First Department of Obstetrics and Gynecology , The Center of Postgraduate Medical Education , Warsaw , Poland
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Mallick R, Oxley S, Odejinmi F. The Use of Ulipristal Acetate (Esmya) Prior to Laparoscopic Myomectomy: Help or Hindrance? Gynecol Minim Invasive Ther 2019; 8:62-66. [PMID: 31143625 PMCID: PMC6515756 DOI: 10.4103/gmit.gmit_79_18] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 12/13/2018] [Accepted: 12/24/2018] [Indexed: 12/12/2022] Open
Abstract
Introduction: The aim of this study was to assess the operative effects, both positive and negative, of pretreatment with ulipristal acetate (UPA) on laparoscopic myomectomy. Materials and Methods: We conducted a retrospective analysis of prospectively collected data from patients who underwent a laparoscopic myomectomy over a 2-year period. Results: A total of 62 patients were included, of which 10 received a 3-month preoperative course of UPA, and 52 patients received no pretreatment. There was no statistically significant difference between the two groups (no pretreatment vs. UPA pretreatment) with regard to blood loss (214.4 [±214.96] vs. 160 [±51.64], P = 0.432), operating time (111.64 [±41.8] vs. 117.5 [±50.4], P = 0.694), and duration of inpatient stay (1.27 [±0.56] vs. 1.11 [±0.33], P = 0.419). There were no complications in either group. In 100% of cases with UPA pretreatment, a distortion of the fibroid capsule with a more technically challenging dissection was noted, compared to 0% in the no pretreatment group. This anatomical distortion may result in more cases of incomplete resection and a potentially higher risk of recurrence. Conclusion: We conclude that UPA confers no operative benefits and should be used with caution in the presurgical treatment of fibroids. The use of UPA may indeed result in a more technically difficult myomectomy with distorted cleavage planes and carry a potential risk of incomplete resection.
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Affiliation(s)
- Rebecca Mallick
- Department of Obstetrics and Gynaecology, Brighton and Sussex University Hospitals NHS Trust, Princess Royal Hospital, Haywards Heath, England, UK
| | - Sam Oxley
- Department of Obstetrics and Gynaecology, Barts Health NHS Trust, Whipps Cross Hospital, London, UK
| | - Funlayo Odejinmi
- Department of Obstetrics and Gynaecology, Barts Health NHS Trust, Whipps Cross Hospital, London, UK
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Santoro A, Angelico G, Arciuolo D, Inzani F, Fanfani F, Romualdi D, Scambia G, Zannoni GF. Failure of ulipristal acetate treatment as an indication for uterine malignancy: Two case reports. Medicine (Baltimore) 2018; 97:e11532. [PMID: 30075519 PMCID: PMC6081078 DOI: 10.1097/md.0000000000011532] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION To study the clinical, pathological and therapeutic implications of ulipristal acetate (UPA) treatment failure in patients affected by uterine smooth muscle tumors. CASE PRESENTATION Two patients affected by uterine leiomyosarcoma were preoperatively diagnosed as uterine leiomyomas and, thus, treated conservatively with UPA and morcellation. Both patients experienced a worsening of symptoms (persistent bleeding) after 3 month of treatment with UPA. Therefore a myomectomy with morcellation of tumor specimens was performed. Pathological examination of morcellated specimens revealed the unsuspected diagnosis of leiomyosarcoma based on the presence of severe nuclear atypia, tumor necrosis and increased mitotic activity. Unfortunately after 6 month of follow-up, 1 patient died for multiple peritoneal recurrences and lung metastases. The other patient is still alive after 3 month of follow-up and shows no local recurrences or metastases. CONCLUSION Our reported cases emphasize that the poor or absent response to UPA treatment in addition to the instrumental evidence of a single mass may be indicative of the presence of an unsuspected leiomyosarcoma clinically and radiologically misdiagnosed as leiomyoma. The awareness of this possibility would avoid a delay in the diagnosis as well as unuseful and potentially dangerous treatments such as morcellation.
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Affiliation(s)
- Angela Santoro
- Department of Woman and Child Health, Woman Health Area, Catholic University of the Sacred Heart, Rome
| | - Giuseppe Angelico
- Department of Woman and Child Health, Woman Health Area, Catholic University of the Sacred Heart, Rome
| | - Damiano Arciuolo
- Department of Woman and Child Health, Woman Health Area, Catholic University of the Sacred Heart, Rome
| | - Frediano Inzani
- Department of Woman and Child Health, Woman Health Area, Catholic University of the Sacred Heart, Rome
| | - Francesco Fanfani
- Department of Medicine and Aging Sciences, University “G.D’ Annunzio,” Chieti-Pescara, Italy
| | - Daniela Romualdi
- Department of Woman and Child Health, Woman Health Area, Catholic University of the Sacred Heart, Rome
| | - Giovanni Scambia
- Department of Woman and Child Health, Woman Health Area, Catholic University of the Sacred Heart, Rome
| | - Gian Franco Zannoni
- Department of Woman and Child Health, Woman Health Area, Catholic University of the Sacred Heart, Rome
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