Options for Medical Treatment of Myomas

Effect of Vitamin D3 Supplementation on Symptomatic Uterine Leiomyoma in Women with Hypovitaminosis D

Objective

The objective of this study is to evaluate the effect of Vitamin D3 on symptoms, uterine and leiomyoma volume in women with symptomatic leiomyoma and hypovitaminosis D.

Materials and Methods

In this pilot, interventional, prospective study, 30 premenopausal women with uterine leiomyoma and concomitant hypovitaminosis D (<30 ng/ml) received Vitamin D3 in doses of 60,000 IU weekly for 8 weeks followed by 60,000 IU every 2 weeks for another 8 weeks. Change in symptoms, uterine, and leiomyoma volume was evaluated at 8 weeks and 16 weeks. Serum Vitamin D3 levels were repeated at 16 weeks of therapy.

Results

A significant negative correlation was observed between the baseline 25-hydroxy Vitamin D (25(OH) Vitamin D3) and leiomyoma volume (r = -0.434, P < 0.001). There was significant reduction of menstrual blood loss by 29.89% (P = 0.003) and severity of dysmenorrhea, pelvic pain, and backache by 44.12%, 35%, and 50% (P < 0.001, 0.019, and 0.002), respectively, at 16 weeks. At end of therapy, there was 6% reduction in mean uterine volume and 11% in leiomyoma volume which was not significant. Serum 25(OH) Vitamin D₃ was significantly higher than baseline level (17.44 ± 5.82 vs. 39.38 ± 8.22, P < 0.001) at end of therapy.

Conclusion

Vitamin D3 supplementation is effective in reducing leiomyoma-related symptoms and stabilizing uterine and leiomyoma volume.

Scaled Signal Intensity of Uterine Fibroids on T2-Weighted MR Imaging as a Predictor of the Potential Response to Uterine Fibroid Embolization

PURPOSE

To determine feasibility of scaled signal intensity (SSI) of uterine fibroids on T2-weighted magnetic resonance (MR) images to predict volume reduction rate (VRR) after uterine fibroid embolization (UFE).

MATERIALS AND METHODS

In this retrospective study, 66 premenopausal women underwent UFE. Patients underwent follow-up MR imaging 3 months after UFE. SSI of predominant fibroids was measured on T2-weighted MR images obtained before the procedure by standardizing the mean signal intensity to a 0-to-100 scale, with 0 representing rectus abdominis muscle and 100 representing subcutaneous fat (100) for reference values.

RESULTS

VRR of predominant fibroids was 12.3%-99.0% (mean 53.7%). SSI of predominant fibroids was 0.9-73.6 (mean 24.6). SSI was significantly related to VRR of fibroids (P < .01). The optimal SSI cutoff value to predict VRR > 50% was 18.16 with sensitivity of 78.8% and specificity of 66.7%. The optimal SSI cutoff value to predict VRR < 30% was 14.38 with sensitivity of 75% and specificity of 70.7%.

CONCLUSIONS

SSI of fibroids was significantly related to fibroid VRR after UFE. SSI may be useful in the quantified prediction of volume reduction.

Comparison of the inhibitory effect of gonadotropin releasing hormone (GnRH) agonist, selective estrogen receptor modulator (SERM), antiprogesterone on myoma cell proliferation in vitro

Uterine myomas are the most common gynecologic tumor in women of reproductive age. Treatment options of uterine myomas consist of surgical, medical and interventional therapy such as uterine artery embolization or myolysis. Given that it is the most common type of tumor in women of reproductive age, the treatment of uterine myomas must prioritize uterine conservation. There are several drugs for medical treatment of uterine myoma such as gonadotropin releasing hormone (GnRH) agonist, selective estrogen receptor modulator (SERM) and antiprogesterone. The objective of this study was to compare the effect of GnRH agonist, SERM, and antiprogesterone in the treatment of uterine myomas in vitro. The effect of drugs was evaluated through the cell viability assay in cultured leiomyoma cells, western blot analysis of proliferating cell nuclear antigen (PCNA), and BCL-2 protein expression. As a result, mifepristone single-treated group represents the most significant reduction in myoma cell viability and proliferation. When pretreated with leuprolide acetate, raloxifene shows more significant reduction in myoma cell viability and proliferation than mifepristone. This study suggests one of the possible mechanisms how medications act on uterine myoma, especially at the molecular level.

A high concentration of genistein down-regulates activin A, Smad3 and other TGF-β pathway genes in human uterine leiomyoma cells

Previously, we found that high doses of genistein show an inhibitory effect on uterine leiomyoma (UtLM) cell proliferation. In this study, using microarray analysis and Ingenuity Pathways Analysis™, we identified genes (up- or down-regulated, ≥ 1.5 fold, P ≤ 0.001), functions and signaling pathways that were altered following treatment with an inhibitory concentration of genistein (50 µg/ml) in UtLM cells. Downregulation of TGF-β signaling pathway genes, activin A, activin B, Smad3, TGF-β2 and genes related to cell cycle regulation, with the exception of the upregulation of the CDK inhibitor P15, were identified and validated by real-time RT-PCR studies. Western blot analysis further demonstrated decreased protein expression of activin A and Smad3 in genistein-treated UtLM cells. Moreover, we found that activin A stimulated the growth of UtLM cells, and the inhibitory effect of genistein was partially abrogated in the presence of activin A. Overexpression of activin A and Smad3 were found in tissue samples of leiomyoma compared to matched myometrium, supporting the contribution of activin A and Smad3 in promoting the growth of UtLM cells. Taken together, these results suggest that down-regulation of activin A and Smad3, both members of the TGF-β pathway, may offer a mechanistic explanation for the inhibitory effect of a high-dose of genistein on UtLM cells, and might be potential therapeutic targets for treatment of clinical cases of uterine leiomyomas.

Predominant suppression of follicle-stimulating hormone β-immunoreactivity after long-term treatment of intact and castrate adult male rats with the gonadotrophin-releasing hormone agonist deslorelin

Gonadotrophin-releasing hormone (GnRH) agonists are used to treat gonadal steroid-dependent disorders in humans and to contracept animals. These agonists are considered to work by desensitising gonadotrophs to GnRH, thereby suppressing follicle-stimulating hormone (FSH) and luteinising hormone (LH) secretion. It is not known whether changes occur in the cellular composition of the pituitary gland after chronic GnRH agonist exposure. Adult male Sprague-Dawley rats were treated with a sham, deslorelin, or deslorelin plus testosterone implant for 41.0 ± 0.6 days. In a second experiment, rats were castrated and treated with deslorelin and/or testosterone. Pituitary sections were labelled immunocytochemically for FSHβ and LHβ, or gonadotrophin α subunit (αGSU). Deslorelin suppressed testis weight by two-thirds and reduced plasma FSH and LH in intact rats. Deslorelin decreased the percentage of gonadotrophs, although the effect was specific to the FSHβ-immunoreactive (-ir) cells. Testosterone did not reverse the deslorelin-induced reduction in the overall gonadotroph population. However, in the presence of testosterone, the proportion of gonadotrophs that was FSHβ-ir increased in the remaining gonadotrophs. There was no effect of treatment on the total LHβ-ir cell population, although the loss of FSHβ in bi-hormonal cells increased the proportion of mono-hormonal LHβ-ir gonadotrophs. The castration-induced plasma LH and FSH increases were suppressed by deslorelin, testosterone or both. Castration increased both LH-ir and FSH-ir without increasing the overall gonadotroph population, thus increasing the proportion of bi-hormonal cells. Deslorelin suppressed these increases. Testosterone increased FSH-ir in deslorelin-treated castrate rats. Deslorelin did not affect αGSU immunoreactivity, suggesting that the gonadotroph population per se is not eliminated by deslorelin, although the ability of gonadotrophs to synthesise FSHβ is compromised. We hypothesise that the FSH dominant suppression may be central to the long-term contraceptive efficacy of deslorelin in the male.

Effect of a selective progesterone receptor modulator on induction of apoptosis in uterine fibroids in vivo

Aim. To determine if hormonal treatment induces apoptosis in uterine fibroids. Methods. Immunohistochemical examination of fibroid tissue, using avidin-biotin complex and cleaved caspase-3 antibody for detecting apoptosis, was performed in premenopausal women who underwent 12-week treatment with oral SPRM (6 patients with 5 mg and 5 patients with 10 mg of ulipristal acetate per day) or gonadoliberin agonist (GnRHa, 17 patients) and subsequent myomectomy or hysterectomy for symptomatic uterine fibroids. Ten patients with no presurgical hormonal treatment were used as controls. Results. Apoptosis was present in a significantly higher proportion of patients treated with ulipristal acetate compared to GnRHa (P = 0.01) and to patients with no hormonal treatment (P = 0.01). In contrast to an AI of 158.9 in SPRM patients, the mean AI was 27.5 and 2.0 in GnRHa and control groups, respectively. No statistical difference in the AI was observed between the two groups of patients treated with ulipristal acetate (5 mg or 10 mg). Conclusion. Treatment with ulipristal acetate induces apoptosis in uterine fibroid cells. This effect of SPRM may contribute to their positive clinical effect on uterine fibroids.

The Effect of Anastrazole on Symptomatic Uterine Leiomyomata

OBJECTIVE

To evaluate the effect of anastrazole on symptomatic uterine leiomyomata.

METHODS

This was a prospective intervention study carried out in a university department of obstetrics and gynecology. Forty-one premenopausal women eligible for hysterectomy with 45 uterine leiomyomata were enrolled and treated with anastrazole 1 mg daily for three cycles of 28 days each. The effect of treatment was evaluated on leiomyoma and uterine volumes, endometrial thickness, gonadotrophins, estradiol and hematocrit levels, menstrual pattern, severity of leiomyoma-related symptoms, and adverse effects. The effects of leiomyoma location, size, and age of participants on tumor volume changes were evaluated.

RESULTS

Thirty-five women with 39 leiomyomata finished the study. Anastrazole resulted in a mean 55.7% reduction of leiomyoma volumes (163 mL to 72 mL, P<.001), a 29.9% reduction in total uterine volumes (278 mL to 195 mL, P<.001), and an 11.3% increase of the hematocrit levels (33.4% to 37.2%, P<.001) at the end of the treatment. Leiomyoma location had no significant effect on volume decrease. Leiomyoma volume decreased in women aged older than 40 years (P=.002), whereas no difference was found in women younger than 40. The size of large (greater than 50 mm) leiomyomata decreased significantly (P=.004). Less difference was observed in small (50 mm or less) leiomyomata (P=.031). No differences were detected in hormonal status. Anastrazole improved leiomyoma-related symptomatology and caused no serious adverse effects.

CONCLUSION

In premenopausal women, anastrazole reduces the size of uterine leiomyomata, improves symptomatology, and is generally well tolerated.

LEVEL OF EVIDENCE

III.