Differences in fibroid vascularity after three months of pre-treatment with leuprolide acetate or ulipristal acetate: A pilot study

Application of dezocine patient-controlled epidural analgesia in postoperative analgesia in patients with total myomectomy

BACKGROUND

Uterine fibroids are common benign gynecological conditions. Patients who experience excessive menstruation, anemia, and pressure symptoms should be administered medication, and severe cases require a total hysterectomy. This procedure is invasive and causes severe postoperative pain, which can affect the patient's postoperative sleep quality and, thus, the recovery process.

AIM

To evaluate use of dezocine in patient-controlled epidural analgesia (PCEA) for postoperative pain management in patients undergoing total myomectomy.

METHODS

We selected 100 patients undergoing total abdominal hysterectomy for uterine fibroids and randomized them into two groups: A control group receiving 0.2% ropivacaine plus 0.06 mg/mL of morphine and an observation group receiving 0.2% ropivacaine plus 0.3 mg/mL of diazoxide in their PCEA. Outcomes assessed included pain levels, sedation, recovery indices, PCEA usage, stress factors, and sleep quality.

RESULTS

The observation group showed lower visual analog scale scores, shorter postoperative recovery indices, fewer mean PCEA compressions, lower cortisol and blood glucose levels, and better polysomnographic parameters compared to the control group (P < 0.05). The cumulative incidence of adverse reactions was lower in the observation group than in the control group (P < 0.05).

CONCLUSION

Dezocine PCEA can effectively control the pain associated with total myomectomy, reduce the negative impact of stress factors, and have less impact on patients' sleep, consequently resulting in fewer adverse effects.

Contemporary approaches in the management of uterine leiomyomas

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.

Endometrial Angiogenesis of Abnormal Uterine Bleeding and Infertility in Patients with Uterine Fibroids-A Systematic Review

Uterine fibroids are the most common benign tumors in women, with abnormal uterine bleeding (AUB) as the main reported symptom. Additionally, an association between fibroids and infertility has been established, especially if the fibroid protrudes in the uterine cavity. Hormonal therapy is associated with side-effects and as well as hysterectomy, which is incompatible with a desire to conceive. To improve treatment, it is essential to unravel the etiology of fibroid-related symptoms. We aim to evaluate endometrial angiogenesis in women with fibroids, with and without AUB, and the influence of pharmaceutical therapies in these patients. Furthermore, we explore the possible role of altered angiogenesis in patients with fibroids and infertility. We performed a systematic review according to PRISMA-guidelines (PROSPERO: CRD42020169061), and included 15 eligible studies. Endometrial expression of vascular endothelial growth factor (VEGF) and adrenomedullin was increased in patients with fibroids. This suggests aberrant angiogenesis, potentially involving disturbed vessel maturation, resulting in immature and fragile vessels. Treatment with gonadotropin-releasing hormone agonist, ulipristal acetate, and continuous oral contraception pills reduced several angiogenic parameters, including VEGF. If infertile and fertile patients with fibroids were compared, a significant decreased expression of the bone morphogenetic protein/Smad-protein pathway was found, possibly caused by the increased expression of transforming growth factor-beta. For future therapeutic development, these different angiogenic pathways could be of interest as possible targets to treat fibroid-related symptoms.

MED12 mutations in uterine leiomyomas: prediction of volume reduction by gonadotropin-releasing hormone agonists

BACKGROUND

Gonadotropin-releasing hormone agonists are used to treat premenopausal uterine leiomyomas; however, leiomyoma volume reduction is not always achieved. The reduction rate after this treatment varies for each leiomyoma, even in the same patient. Therefore, an effective method for predicting uterine leiomyoma volume reduction is required to reduce the adverse hypoestrogenic effects and drug-related economic burden related to gonadotropin-releasing hormone agonists.

OBJECTIVE

This study aimed to determine the predictive use of MED12 mutations for evaluating the effect of gonadotropin-releasing hormone agonist treatment concerning reducing uterine leiomyoma volume and to predict the MED12 mutation status based on the findings of magnetic resonance imaging performed before treatment.

STUDY DESIGN

MED12 exon 2 mutation and erythropoietin expression in uterine leiomyomas were evaluated concerning volume reduction, as measured using magnetic resonance imaging. We developed a system for classifying leiomyomas according to T2-weighted magnetic resonance imaging signals to noninvasively predict the presence or absence of MED12 mutations in leiomyomas. Leiomyoma samples (>5 cm) were obtained from 168 patients during surgery (hysterectomy or myomectomy) between 2005 and 2021 at Yokohama City University Hospital. To analyze the rate of leiomyoma volume reduction, 41 patients had been preoperatively administered the gonadotropin-releasing hormone agonist (leuprorelin acetate 3.75 mg, monthly subcutaneous injection) for 3 months; magnetic resonance imaging was performed before and after treatment without contrast material.

RESULTS

Patients with MED12 exon 2 mutations had smaller volume reduction after treatment with the gonadotropin-releasing hormone agonist (P<.001, Mann-Whitney U test) and displayed lower signal intensity on T2-weighted images than those with leiomyomas expressing wild-type MED12 exon 2. The newly proposed magnetic resonance imaging-based classification system showed that MED12 exon 2 mutations were more frequent in the low-signal group than in the high-signal group, with nearly equal proportions of mutated and wild-type MED12 exon 2 leiomyomas noted in the intermediate group. The low-signal group had significantly lower erythropoietin expression levels than the high-signal group (P<.001, Kruskal-Wallis test with the Dunn posthoc analysis).

CONCLUSION

MED12 mutation status can be a candidate marker for predicting the effect of gonadotropin-releasing hormone agonists on uterine leiomyoma reduction. Magnetic resonance imaging findings can be used to determine MED12 mutation status as a noninvasive strategy to select patients who will most likely benefit from gonadotropin-releasing hormone agonist treatment.

Application Effect of Laparoscopic Myomectomy and Comprehensive Rehabilitation Nursing on Patients with Uterine Fibroids

Background. Uterine fibroids are most common in women aged 30-50 and are the most common benign gynecological tumors. Relevant data suggest that about 25% of patients with uterine fibroids are at childbearing age. Uterine fibroids not only cause the discomfort symptoms, and affect the pregnancy, but also have certain malignant transformation risk, thus needed to be treated positively and promptly. Aim. This study is aimed at exploring the effect of laparoscopic myomectomy and comprehensive rehabilitation nursing on patients with uterine fibroids. Methods. The clinical data of 110 cases of uterine fibroids admitted to our hospital from August 2019 to December 2021 were analyzed retrospectively, and they were divided into two groups according to postoperative rehabilitation strategies. Both groups were treated with laparoscopic myomectomy. The A group was treated with routine rehabilitation strategy, while the B group was treated with comprehensive rehabilitation nursing strategy. The differences in operation-related indicators, stress factors, inflammatory factors, nutritional indicators, knowledge mastery, occurrence of adverse symptoms and pain scores, negative emotion scores, nursing satisfaction, and simplified comfort status scale (GCQ) scores between the two groups under nursing strategies were compared. Results. The postoperative exhaust time ( $13.14\pm 2.03$ ) h, bed time ( $9.86\pm 1.94$ ) h, postoperative hospital stay ( $4.37\pm 1.31$ ) d, and total hospital stay ( $6.78\pm 1.69$ ) d in the B group were shorter than those in the A group, and the hospitalization expenses ( $0.74\pm 0.25$ ) million were less than those in the A group ( $P<0.05$ ). Before operation, stress factors, inflammatory factors, and nutritional indexes were compared between the two groups ( $P>0.05$ ). On the 3rd day after operation, tumor necrosis factor-α (TNF-α), cortisol (Cor), norepinephrine (NE), and interleukin-1β (IL-1β) in the two groups showed a significantly upward trend compared with those before operation, and albumin and transferrin were significantly fell compared with those before operation. However, the values of stress factor and inflammatory factor in the B group were significantly lower than those in the A group, and the values after the decrease of nutritional index were significantly higher than those in the A group ( $P<0.05$ ). The pain scores at 24 h, 48 h, and 72 h after operation in the B group were significantly lower than those in the A group ( $P<0.05$ ). Negative emotions, nursing satisfaction, and GCQ scores were compared between the two groups before intervention ( $P>0.05$ ). After the intervention, the scores of Hamilton Depression Scale (HAMD) and Hamilton Anxiety Scale (HAMA) in the two groups were significantly lower than those before the intervention, and the scores of nursing satisfaction and GCQ were higher than those before the intervention. The values of negative emotions in the B group after the decline were significantly lower than those in the A group, while the values of nursing satisfaction and GCQ after the increase were higher than those in the A group ( $P<0.05$ ). The excellent and good rate of knowledge acquisition in the B group was 94.55% (52/55), which was significantly higher than 78.18% (43/55) in the A group ( $P<0.05$ ). The incidence of adverse symptoms in the B group was 9.09% (5/55), which was lower than 21.82% (12/55) in the A group, while the difference was not statistically significant ( $P>0.05$ ). Conclusion. Laparoscopic myomectomy combined with comprehensive rehabilitation nursing can reduce the postoperative stress state of patients with uterine fibroids, improve patient satisfaction, reduce adverse emotions, and promote rehabilitation.

How to use power Doppler ultrasound in transvaginal assessment of uterine fibroids

Measuring vascularization in uterine fibroids is important for their diagnosis, treatment and prognosis. Vascularization can be measured by power Doppler ultrasound. The power Doppler signal depends on fibroid characteristics and on a variety of ultrasound-machine settings. Literature describing which machine settings influence the power Doppler signal is limited. Each manufacturer names settings and presets at their own discretion, with little information available publicly. Consistency of machine settings is important for correct interpretation of images in daily practice and is essential in yielding reproducible data for research. The aims of this paper, drawing from both a literature search and semistructured interviews with ultrasound-machine engineers and clinical experts in gynecological ultrasound, were: (1) to provide comprehensive background information on ultrasound physics and fibroid characteristics; (2) to present an overview of machine settings relevant to both two- and three-dimensional power Doppler, including power Doppler frequency, pulse repetition frequency, gain, wall-motion filter, acoustic power, persistence and signal rise; and (3) to provide a step-by-step tutorial on the optimal settings for vascular evaluation of uterine fibroids using power Doppler. The step-by-step tutorial comprises six steps to optimize the power Doppler signal, create a preset and acquire a reliable three-dimensional volume. This step-by-step tutorial should help research groups and clinicians to use power Doppler correctly and reproducibly in the evaluation of uterine fibroids. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Comparison of computer simulations and clinical treatment results of magnetic resonance guided focused ultrasound surgery (MRgFUS) of uterine fibroids

Purpose

Magnetic resonance‐guided focused ultrasound surgery (MRgFUS) can be used to noninvasively treat symptomatic uterine fibroids by heating with focused ultrasound sonications while monitoring the temperature with magnetic resonance (MR) thermometry. While prior studies have compared focused ultrasound simulations to clinical results, studies involving uterine fibroids remain scarce. In our study, we perform such a comparison to assess the suitability of simulations for treatment planning.

Methods

Sonications (N = 67) were simulated retrospectively using acoustic and thermal models based on the Rayleigh integral and Pennes bioheat equation followed by MR‐thermometry simulation in seven patients who underwent MRgFUS treatment for uterine fibroids. The spatial accuracy of simulated focus location was assessed by evaluating displacements of the centers of mass of the thermal dose distributions between simulated and treatment MR thermometry slices. Temperature–time curves and sizes of 240 equivalent minutes at 43°C (240EM₄₃) volumes between treatment and simulation were compared.

Results

The simulated focus location showed errors of 2.7 ± 4.1, −0.7 ± 2.0, and 1.3 ± 1.2 mm (mean ± SD) in the anterior–posterior, foot–head, and right–left directions for a fibroid absorption coefficient of 4.9 Np m^–1 MHz^–1 and perfusion parameter of 1.89 kg m^–3 s^–1. Linear regression of 240EM₄₃ volumes of 67 sonications of patient treatments and simulations utilizing these parameters yielded a slope of 1.04 and a correlation coefficient of 0.54. The temperature rise ratio of simulation to treatment near the end of sonication was 0.47 ± 0.22, 1.28 ± 0.60, and 1.49 ± 0.71 for 66 sonications simulated utilizing fibroid absorption coefficient of 1.2, 4.9, and 8.6 Np m^–1 MHz^–1, respectively, and the aforementioned perfusion value. The impact of perfusion on peak temperature rise is minimal between 1.89 and 10 kg m^–3 s^–1, but became more substantial when utilizing a value of 100 kg m^–3 s^–1.

Conclusions

The results of this study suggest that perfusion, while in some cases having a substantial impact on thermal dose volumes, has less impact than ultrasound absorption for predicting peak temperature elevation at least when using perfusion parameter values up to 10 kg m^–3 s^–1 for this particular array geometry, frequencies, and tissue target which is good for clinicians to be aware of. The results suggest that simulations show promise in treatment planning, particularly in terms of spatial accuracy. However, in order to use simulations to predict temperature rise due to a sonication, knowledge of the patient‐specific tissue parameters, in particular the absorption coefficient is important. Currently, spatially varying patient‐specific tissue parameter values are not available during treatment, so simulations can only be used for planning purposes to estimate sonication performance on average.

Uterine fibroid vascularization: from morphological evidence to clinical implications

Uterine fibroids are the most common cause of solid pelvic tumours, occurring in 20-30% of fertile women and presenting clinical complications that seriously affect women's health. They commonly cause severe symptoms, such as heavy, prolonged menstrual bleeding and anaemia. The study of microscopic and macroscopic vascular aspects of uterine fibroids is important for understanding the clinical manifestations of uterine fibroids, for predicting the effectiveness of alternative treatments to surgery, i.e. uterine artery embolization, for improving surgery outcomes and for carrying out a differential diagnosis with other benign conditions, e.g. adenomyosis, or malignancy, e.g. leiomyosarcoma, and to develop new therapeutic approaches. In this review, current knowledge of how the vascular network and angiogenesis are implied in the formation of uterine fibroids and in the pathogenesis of related symptoms is explored, and evidence on the role of ultrasound in evaluating fibroid vascularization is summarized. This review combines anatomical, morphological and biomolecular information related to angiogenic mechanisms with diagnostic and clinical information, highlighting the various interconnections. Uterine and fibroid vascularization need further investigation to gain a deeper understanding of the pathogenetic elements that lead to the formation of uterine fibroids and their clinical manifestations.