Effect of tibolone on postmenopausal women with myomas

The Impact of Hormonal Replacement Treatment in Postmenopausal Women with Uterine Fibroids: A State-of-the-Art Review of the Literature

Background and Objectives: Hormonal replacement therapy (HRT) is effective in treating many debilitating symptoms of menopause. However, its use in women with uterine fibroids is widely debated, based on the susceptibility of these tumors to sexual steroids. This review aims to ascertain the effects of HRT on leiomyomas development and growth in postmenopausal women. Materials and Methods: Electronic databases (i.e., MEDLINE, Scopus, ClinicalTrials.gov, EMBASE, Sciencedirect, the Cochrane Library at the CENTRAL Register of Controlled Trials, Scielo) were searched from January 1990 until May 2019. All English-written studies evaluating the impact of various HRT regimens on uterine leiomyomas were selected. Results: Seventeen papers, considering a total of 1122 participants, were included. Fifteen of these were prospective trials, of which nine were randomized controlled trials. The remaining two works were a retrospective observational trial and a retrospective case series respectively. Five studies evaluated the effects of tibolone, also comparing it with various estrogen/progestin combinations, while two were about raloxifene. Thirteen studies compared different combinations of estrogens/progestins, the most common being transdermal estrogens (used in nine studies) and medroxyprogesterone acetate at different doses (used in 10 studies). Conclusions: For women with uterine fibroids, the choice of the most appropriate HRT regimen is crucial to avoid leiomyomas growth and the symptoms possibly related to it. Available data are conflicting, but suggest that uterine fibroids might be influenced by HRT, without representing an absolute contraindication to hormonal replacement therapy. Women with uterine fibroids subjected to HRT should be periodically examined and hormonal treatment should be discontinued if leiomyomas appear to increase in size. Moreover, the minimal effective dose of progestin should be employed.

Hormone therapy in menopausal women with fibroids: is it safe?

Menopause is an important transition in the life of women. It has been estimated that by the year 2030, worldwide 1.2 billion women will be menopausal. The most bothersome symptoms of menopause are believed to be due to declines in estrogen levels in postmenopausal women. Thus, hormone therapy is an effective treatment option for menopausal women, although prolonged use of hormone therapy is associated with a slightly increased risk of breast cancer, thromboembolism, and stroke. A literature search for studies evaluating the effects of hormone therapy in menopausal women with asymptomatic fibroids demonstrated variable effects of hormone therapy on the volume and size of the fibroids. Some studies have demonstrated an increase in size of pre-existing asymptomatic fibroids and formation of new fibroids with higher doses of progestogen in combination therapy. The finding of low resistance index in uterine arteries of women with asymptomatic fibroids is associated with an increased risk of fibroid growth, and thus making the measurement of pulsatility index of uterine arteries a possible screening tool before initiating hormone therapy in menopausal women with fibroids. Although the effect of hormone treatment is variable and statistically insignificant in many cases, the newer selective estrogen receptor modulators having tissue-specific estrogen agonistic and antagonistic actions such as raloxifene have a favorable clinical profile and may be better alternatives in women with asymptomatic fibroids.

Medical Therapies for Uterine Fibroids - A Systematic Review and Network Meta-Analysis of Randomised Controlled Trials

Background

Uterine fibroids are common, often symptomatic and a third of women need repeated time off work. Consequently 25% to 50% of women with fibroids receive surgical treatment, namely myomectomy or hysterectomy. Hysterectomy is the definitive treatment as fibroids are hormone dependent and frequently recurrent. Medical treatment aims to control symptoms in order to replace or delay surgery. This may improve the outcome of surgery and prevent recurrence.

Purpose

To determine whether any medical treatment can be recommended in the treatment of women with fibroids about to undergo surgery and in those for whom surgery is not planned based on currently available evidence.

Study Selection

Two authors independently identified randomised controlled trials (RCT) of all pharmacological treatments aimed at the treatment of fibroids from a list of references obtained by formal search of MEDLINE, EMBASE, Cochrane library, Science Citation Index, and ClinicalTrials.gov until December 2013.

Data Extraction

Two authors independently extracted data from identified studies.

Data Synthesis

A Bayesian network meta-analysis was performed following the National Institute for Health and Care Excellence—Decision Support Unit guidelines. Odds ratios, rate ratios, or mean differences with 95% credible intervals (CrI) were calculated.

Results and Limitations

A total of 75 RCT met the inclusion criteria, 47 of which were included in the network meta-analysis. The overall quality of evidence was very low. The network meta-analysis showed differing results for different outcomes.

Conclusions

There is currently insufficient evidence to recommend any medical treatment in the management of fibroids. Certain treatments have future promise however further, well designed RCTs are needed.

Effect of Isopropanolic Cimicifuga racemosa Extract on Uterine Fibroids in Comparison with Tibolone among Patients of a Recent Randomized, Double Blind, Parallel-Controlled Study in Chinese Women with Menopausal Symptoms

Objective. Effect of isopropanolic Cimicifuga racemosa extract (iCR) on uterine fibroid size compared with tibolone. Method. The randomized, double-blind, controlled study in China enrolled 244 patients aged 40-60 years with menopausal symptoms (Kupperman Menopause Index ≥ 15). The participants were treated with either iCR of 40 mg crude drug/day (N = 122) or tibolone 2.5 mg/day (N = 122) orally for 3 months in 2004. Now, we investigated the subset of all women (N = 62) with at least one uterine fibroid at onset of treatment for the effect of iCR (N = 34) on fibroid size compared with tibolone (N = 28) by transvaginal ultrasonography. Results. The median myoma volume decreased upon iCR by as much as -30% (P = 0.016) but increased upon tibolone by +4.7%. The percentage of volume change, mean diameter change and geometric mean diameter change of the iCR group compared to tibolone were statistically significant (P = 0.016, 0.021, 0.016 respectively). Conclusion. Our results suggest that iCR (Remifemin) is a valid herbal medicinal product in patients with uterine myomas as it provides adequate relief from menopausal symptoms and inhibits growth of the myomas in contrast to tibolone.

Can myomectomy be suggested for perimenopausal women before administering hormone replacement therapy?

OBJECTIVES

The aim of this study was to evaluate whether abdominal myomectomy could be a choice for patients with symptomatic fibroids above the age of 48 years, who wish to get hormonal replacement therapy and desire to retain their uterus.

METHODS

We performed 504 abdominal myomectomies between 1990 and 2004. The mean age was 33+/-4.09 years, 9 (1.8%; 9/504) patients were above 48 years and 6 (1.19%; 6/504) of them requested hormonal replacement therapy (HRT) after the enucleation of fibroids. Data of these nine cases were compared to a matched control group of patients who had hysterectomy in the same year in 3 months to those who underwent abdominal myomectomy with same indications for surgery, same location, size and number of fibroids. The main aim of our study was to compare perioperative morbidity, duration of hospital stay between myomectomy and hysterectomy groups and determine the recurrence of fibroids and/or symptoms in 1 year with HRT in the myomectomy group.

RESULTS

The perioperative morbidity did not differ between the compared groups. In the myomectomy group with 1-year HRT we did not observe the recurrence of fibroids and symptoms.

CONCLUSION

Our data suggest that abdominal myomectomy may be a satisfactory option for perimenopausal women with symptomatic fibroids who wish to retain their uterus and get HRT.

Effect of hormone replacement therapy on uterine fibroids in postmenopausal women—a 3-year study

OBJECTIVE

The aim of this prospective 3-year clinical study was to examine the effect of hormone replacement therapy (HRT) on uterine fibroid growth among postmenopausal women.

METHODS

Thirty-seven postmenopausal women with uterine solitary fibroids were recruited randomly for HRT in a 3-year program. All participants received 0.625 mg conjugated equine estrogen (CEE) and 5 mg medroxyprogesterone (MPA) daily. Fibroid volume was measured by transvaginal ultrasonography at baseline and then at 12-month intervals for 3 times. Clinically, significant fibroid growth was defined as an increase in volume of more than 25% compared with baseline. Also, 35 postmenopausal women with uterine fibroid were studied as control who did not receive HRT during the study period.

RESULTS

Fibroid volume had increased significantly after 1 year both in HRT users and non-users. These increases continued to the second year significantly in HRT users but not in non-users. However, the volumes declined significantly at the third year to similar levels as those measured at baseline in control. In HRT users, fibroid volume though significantly increased at the third year (vs. baseline) but declined insignificantly in comparison with the second year. Clinically, at end of the third year study, one of 34 and three of 34 women increased fibroid volume over 25% compared with baseline in HRT non-users and users, respectively.

CONCLUSIONS

HRT does increase uterine fibroid volume statistically. However, its effect appears in the first 2 years of use. The increased fibroid volume begins to decline at the third year both in HRT users and non-users. Clinically, the increased effect of HRT on uterine fibroid of postmenopausal women should be not over-emphasized at least for 3 years of usage.

Short-term administration of tibolone plus GnRH analog before laparoscopic myomectomy

STUDY OBJECTIVE

To evaluate whether tibolone modifies the effectiveness of gonadotropin-releasing hormone (GnRH) analog administered before laparoscopic myomectomy.

DESIGN

Prospective, randomized, open, placebo-controlled clinical trial (Canadian Task Force classification I).

SETTING

University-affiliated hospital.

PATIENTS

Sixty-six women with symptomatic leiomyomas.

INTERVENTIONS

Patients received 2 months of treatment with GnRH analog and iron plus tibolone (group A) or placebo (group B); group C received only iron. Laparoscopic myomectomy was performed after medical treatment.

MEASUREMENTS AND MAIN RESULTS

Uterine volume, number and volume of leiomyomas, echogenicity and volume of the largest leiomyomas, hematologic values, and myoma-related symptoms were evaluated at baseline, 1 week before, and 1 week after surgery. We observed significant (p <0.05) reductions in uterine and leiomyomata volume, myoma-related symptoms, and improvement in hematologic values before surgery in groups A and B, without significant difference between groups compared with baseline values and group C. Operating time and blood loss were significantly (p <0.05) lower in groups A and B, without significant difference compared with group C. After surgery, significant numbers of women in group C had worsening of hematologic values (p <0.05).

CONCLUSION

Adding tibolone to the GnRH analog regimen before laparoscopic myomectomy does not modify the effectiveness of GnRH analog administered alone.

Long term effects of Tibolone on postmenopausal women with uterine myomas

OBJECTIVES

The aim of the present study is to evaluate the long term effects of Tibolone (Livial) on uterine myomas volume as well as on uterine arteries pulsatility index (PI) in postmenopausal women.

METHODS

This study included 66 naturally menopausal women. Twenty of them (group A) had no uterine myomas; 23 of them (group B) had a single, asymptomatic, intramural or subserous myoma of a maximum diameter less or equal than 2 cm; 23 of them (group C) had a single, asymptomatic, intramural or subserous myoma of a maximum diameter between 2 and 5 cm. The volume of the myomas as well as the pulsatility index of the uterine arteries was assessed by transvaginal ultrasonography every 6 months after administration of Tibolone (2.5 mg daily).

RESULTS

No statistically significant difference on myomas volume was found after a 3-year period of Tibolone administration. The uterine artery basal PI was significantly higher in group A compared to that of groups B and C. After 6 months of Tibolone administration the PI in group A was significantly lower compared to the basal one whereas in groups B and C was significantly higher compared to the basal value.

CONCLUSIONS

Our results suggest that treating postmenopausal woman with Tibolone on a long-term basis: (a) does not increase the volume of uterine myomas and (b) has an early effect on uterine haemodynamics (decrease of PI in women without myomas and increase of PI in women with myomas).

Effects of raloxifene treatment on uterine leiomyomas in postmenopausal women

OBJECTIVE

To evaluate the effects of raloxifene administration on uterine and uterine leiomyoma sizes in postmenopausal women.

DESIGN

Prospective randomized, double-blind, placebo-controlled clinical trial.

SETTING

Department of Gynecology, Obstetrics, and Pathophysiology of Human Reproduction, University of Naples "Federico II", Italy.

PATIENT(S)

Seventy spontaneous postmenopausal women affected by uterine leiomyomas.

INTERVENTION(S)

Twelve cycles (of 28 days each) of treatment with raloxifene (60 mg daily per os) or placebo.

MAIN OUTCOME MEASURE(S)

At entry and at every 3 cycles, uterine and uterine leiomyoma dimensions were measured by means of transvaginal ultrasound. The difference between uterine and leiomyoma volumes (Delta size) was calculated in all subjects. The characteristics of uterine bleeding and the side effects of the treatments were assessed using a daily diary.

RESULT(S)

After 6, 9, and 12 cycles of therapy, in subjects treated with raloxifene, the mean uterine and uterine leiomyoma size were significantly decreased, and the mean Delta size significantly increased in comparison with basal values and the placebo group. No significant differences in uterine bleeding were detected between the two groups.

CONCLUSION(S)

In postmenopausal women raloxifene appears to act selectively on uterine leiomyomas, reducing their size.

Effectiveness of short-term administration of tibolone plus gonadotropin-releasing hormone analogue on the surgical outcome of laparoscopic myomectomy

OBJECTIVE

To evaluate whether administration of tibolone changes the effectiveness of GnRH analogue administered before laparoscopic myomectomy.

DESIGN

Prospective, randomized, open, placebo-controlled clinical trial.

SETTING

Department of Gynecology and Obstetrics, University of Naples Federico II, Naples, Italy.

PATIENT(S)

66 women with symptomatic uterine leiomyomas.

INTERVENTION(S)

Treatment for 2 months with leuprolide acetate and iron tablets, plus tibolone (group A) or placebo tablets (group B); or with leuprolide acetate and iron tablets (group C).

MAIN OUTCOME MEASURE(S)

Laparoscopic myomectomy at the end of treatment. Operative time and blood loss during surgery were recorded. Uterine volume, volume and number of uterine leiomyomas, volume and echogenicity of the largest uterine leiomyomas, hematologic data, and myoma-related symptoms were evaluated at baseline and 1 week before and after surgery.

RESULT(S)

Uterine and leiomyomata volume and myoma-related symptoms were significantly reduced and hematologic variables improved significantly in groups A and B, compared with baseline values and with group C. Operative time and blood loss were significantly less in groups A and B than in group C. After surgery, hematologic variables were significantly worse in group C compared with groups A and B. During the study no significant difference was detected between groups A and B.

CONCLUSIONS

Administration of tibolone administration in patients treated with GnRH analogue before laparoscopic myomectomy does not change the effectiveness of the analogue administered alone.

Uterine myoma in postmenopause: a comparison between two therapeutic schedules of HRT

OBJECTIVES

It is still controversial whether hormone replacement therapy (HRT) can affect the onset of uterine myomas or their growth in postmenopause. It is likely that some therapeutic schedules can influence the myometrial growth differently, due to a more potent stimulation of the uterine receptors. The aim of the present study is to evaluate the effects of two different hormonal treatment schedules on the risk of uterine myoma onset or progression.

METHODS

In a 2 year prospective randomised study we compared an oral cyclic association of oestradiol valerate and cyproterone acetate versus a sequential combination of transdermal E(2) and per oral medrossiprogesterone acetate on 240 postmenopausal women with and without uterine myomas.

RESULTS

Among the patients without uterine myomas treated with the transdermal-oral combination we noted the onset of myomas in 5% of cases after 24 months of treatment, while no new uterine formation was observed for the orally treated women (P<0.01). Among the patients with uterine myomas at the beginning of the study, in the group transdermally treated we found a mean increase in myoma volumes of 25.3% in the following 24 months, which was significantly different compared with the initial volume of myomas. On the other hand, women treated with the oral combination showed no significant modification of myoma volumes at the end of the study.

CONCLUSIONS

Percutaneous-oral schedule of HRT seems to affect the growth of uterine myomas more than a single oral combination of oestradiol valerate and cyproterone acetate.

Effects of hormone replacement therapy on postmenopausal uterine myoma

OBJECTIVES

To evaluate the effects of sequential continuous hormone replacement therapy (HRT) on myoma size and on pulsatility index (PI) of uterine arteries and to verify the correlation between uterine artery flow impedance and the growth rate of myoma in women receiving HRT.

METHODS

In a prospective 1-year study 60 postmenopausal women were enrolled into three study-groups to receive continuous transdermal 17beta-oestradiol 0.05 mg/day plus nomegestrolo acetate 5 mg/day sequentially added: 20 patients (group A) unaffected by uterine myomas, 20 patients (group B) with single asymptomatic myoma <3 cm/14 cm3, 20 patients (group C) with single asymptomatic myoma >3 cm/14 cm3. The changes in myoma volume and in PI were assessed by means of transvaginal ultrasonographic scan every 3 months. The patients with myoma were divided into two subgroups: quiescent myoma (B1, C1) and growing myoma (B2, C2).

RESULTS

No significant increase of uterine fibroids volume was found after 1-year HRT (24.14+/-20.02-->28.81+/-30.02 cm3). Six out of eight myomas growing during HRT belonged to group C. The uterine artery basal PI value of group A was significantly higher (P<0.01) than the corresponding PI in group B and C. At 3 months follow-up, uterine artery PI was significantly higher (P<0.01) than the basal value in both group B (1.70+/-0.22-->1.88+/-0.16) and C (1.59+/-0.28-->1.92+/-0.21). The baseline PI values in group B1 and C1 were significantly higher than the baseline values observed in group B2 and C2 (1.76+/-0.17 vs. 1.32+/-0.02, 1.76+/-0.16 vs. 1.24+/-0.08) and significantly lower than those observed in group A (2.39+/-0.47). After 3 months of HRT, the PI values were not significantly higher than the baseline values in groups B1 and C2 (1.76+/-0.17-->1.90+/-0.17; 1.24+/-0.08-->1.74+/-0.16), while they were significantly higher in group C1 (1.76+/-0.16-->2.01+/-0.17).

CONCLUSIONS

Sequential continuous HRT does not increase the volume of the uterine myoma. The findings of very low resistance index in the uterine arteries of women with growing myoma may indicate the risk of growth of the neoplasia during HRT. The assessment of PI in the uterine arteries could be helpful in predicting the growth rate of the myomas before starting HRT.

A randomized study of the effects of tibolone and transdermal estrogen replacement therapy in postmenopausal women with uterine myomas

OBJECTIVE

To evaluate the effects of two types of hormone replacement therapy, an estrogen-progestin combination and tibolone, on uterine myomas in menopausal women.

STUDY DESIGN

Thirty-eight menopausal women with one or more uterine myomas were randomized to treatment with a transdermal system continuously releasing estradiol 50 microg/day combined with oral medroxyprogesterone acetate (MPA) 10 mg/day for 12 days/month or tibolone tablets 2.5 mg/day. The scheduled duration of both treatments was 12 months. Physical examination and abdominal/transvaginal ultrasonography were performed before entering the study and at 3, 6 and 12 months of treatment. At each ultrasonography the overall uterine volume was determined as well as the size of each myoma and the endometrial thickness and characteristics.

RESULTS

No statistically significant difference was detected between the two groups at any time during treatment. However, within-group analysis showed a significant increase of uterine volume and of myoma number and size in the estrogen-progestin group, whereas no such increase occurred in the patients treated with tibolone. Also, the mean endometrium width increased significantly from baseline to the end of treatment in the estrogen-progestin group, but not in the tibolone group.

CONCLUSIONS

Tibolone seems a valid alternative in menopausal patients with uterine myomas as it provides adequate relief from menopausal symptoms and avoids volume increase of the uterus and myomas.

Impact on uterine bleeding and endometrial thickness: tibolone compared with continuous combined estradiol and norethisterone acetate replacement therapy

OBJECTIVE

To evaluate endometrial thickness and the incidence of uterine bleeding in postmenopausal women using either tibolone 2.5 mg or continuous combined 2 mg estradiol and 1 mg norethisterone acetate (E+NETA) daily as hormone replacement therapy.

DESIGN

We compared diary records of self-reported uterine bleeding and measurements of endometrial thickness, area, and volume by transvaginal sonography at baseline and after 1, 3, 6, and 12 months in a 1-year, prospective, randomized, double-blind, single-center trial of 100 postmenopausal women aged 46-69 years. Bleeding frequencies and endometrial thickness were assessed by Chi-square tests and analysis of covariance, respectively.

RESULTS

Self-reported bleeding was significantly less in the tibolone group. Bleeding episodes were reported by 27.7% of women in the tibolone group and by 59.2% in the E+NETA group. The mean number of days with bleeding was 5.8 +/- 27.0 in the tibolone group and 35.6 +/- 58.6 in the E+NETA group. Six women in the tibolone group and seven in the E+NETA group discontinued the study; three in the E+NETA group because of bleeding. The mean endometrial thickness at baseline was 2.56 +/- 0.81 mm in the tibolone group and 2.58 +/- 1.04 mm in the E+NETA group. After 1 year, the corresponding figures were 3.32 +/- 1.58 mm and 3.07 +/- 1.68 mm. Thus, 86% of women in the tibolone group and 93% in the E+NETA group had an endometrial thickness of less than 5 mm.

CONCLUSIONS

Use of tibolone 2.5 mg daily for 1 year was associated with significantly less bleeding and spotting compared with daily continuous combined 2 mg estradiol and 1 mg norethisterone acetate in postmenopausal women in the presence of both minimal and nonprogressive increase of endometrial thickness associated with the two regimens.

Leiomyoma of the round ligament in a postmenopausal woman

OBJECTIVE

Leiomyoma of the round ligament of the uterus is a rare condition. We present the first case of a postmenopausal, previously hysterectomised, woman who received combined hormonal replacement therapy and developed a leiomyoma of the right round ligament.

METHOD

In sections of the tumor, immunohistochemical reaction with monoclonal antibodies against smooth muscle actin, desmin, vimentin, estrogen receptor and progesterone receptor was performed.

RESULTS

The leiomyoma showed bizarre histologic appearance in absence of mitotic figures and degenerative changes. Leiomyocytes presented a positive immunohistochemical reaction with monoclonal antibodies against smooth muscle actin, desmin vimentin and progesterone receptor in absence of estrogen receptor.

CONCLUSION

Progestin as part of a combined hormonal replacement therapy may play an important role in promoting the development of leiomyoma in hormonal responsive tissue of the round ligament in postmenopausal women.

Tibolone: a review

Tibolone appears to be at least as efficacious as other forms of hormonal replacement therapy (HRT) on climacteric symptoms. It does not cause withdrawal bleeding when used in women with at least 1 year of amenorrhea. It is, therefore, not indicated in perimenopause because it may cause irregular bleeding. The androgenic action of tibolone may have a two-fold benefit: on the one hand, it may help depression and libido more than other forms of HRT, while, on the other hand, it may improve some lipid parameters such as Lp(a), and triglycerides. However, this androgenic action, may also be responsible for the reduction of HDL cholesterol, that may thus reduce the beneficial effect of tibolone on lipids. It is estimated that only 30% of cardiovascular risk protection of HRT is due to improvement of classical lipids parameters while a great role is played by the direct effect of estrogen on vessels. Tibolone, as well as estrogen, has been shown to induce peripheral vasodilatation and also has a direct effect on vascular reactivity thus increasing peripheral blood flow with no changes in blood pressure or cardiac output. Tibolone seems to exert a similar effect as other forms of HRT on markers of bone metabolism and bone mass, but no data is yet available on fracture prevention.

Clinical presentation of uterine fibroids

It is often accepted that fibroids cause a variety of female reproductive problems, such as menorrhagia, pain, infertility, pregnancy loss and pregnancy complications. Understandably, therefore, many 'successful' medical or surgical interventions have been proposed. However, while fibroids are certainly commonly associated with these conditions, it remains unclear whether this is coincidental, because of the high prevalence of fibroids, or causal. In particular, this chapter explores the roles of fibroids in menorrhagia, discussing possible pathophysiological mechanisms and the utility of medical and surgical management. Similarly, the relationship between fibroids and infertility is examined, concluding that fibroids are not causative in the vast majority of cases and thereby questioning the effectiveness of myomectomy as a treatment for infertility. The use of hormone replacement therapy in post-menopausal women with existing fibroids is also discussed, concluding that this is generally safe and appropriate. In pregnancy, it is a commonly held tenet that uterine fibroids enlarge and that they are associated with various adverse outcomes such as miscarriage, placental abruption, fetal growth retardation and Caesarean section. This chapter evaluates the available evidence for this and concludes that, as with infertility, the role of fibroids has been exaggerated. Nonetheless, pregnancy management options are discussed.