Recent Advances in Uterine Fibroid Etiology

Predicting nutrition and environmental factors associated with female reproductive disorders using a knowledge graph and random forests

OBJECTIVE

Female reproductive disorders (FRDs) are common health conditions that may present with significant symptoms. Diet and environment are potential areas for FRD interventions. We utilized a knowledge graph (KG) method to predict factors associated with common FRDs (for example, endometriosis, ovarian cyst, and uterine fibroids).

MATERIALS AND METHODS

We harmonized survey data from the Personalized Environment and Genes Study (PEGS) on internal and external environmental exposures and health conditions with biomedical ontology content. We merged the harmonized data and ontologies with supplemental nutrient and agricultural chemical data to create a KG. We analyzed the KG by embedding edges and applying a random forest for edge prediction to identify variables potentially associated with FRDs. We also conducted logistic regression analysis for comparison.

RESULTS

Across 9765 PEGS respondents, the KG analysis resulted in 8535 significant or suggestive predicted links between FRDs and chemicals, phenotypes, and diseases. Amongst these links, 32 were exact matches when compared with the logistic regression results, including comorbidities, medications, foods, and occupational exposures.

DISCUSSION

Mechanistic underpinnings of predicted links documented in the literature may support some of our findings. Our KG methods are useful for predicting possible associations in large, survey-based datasets with added information on directionality and magnitude of effect from logistic regression. These results should not be construed as causal but can support hypothesis generation.

CONCLUSION

This investigation enabled the generation of hypotheses on a variety of potential links between FRDs and exposures. Future investigations should prospectively evaluate the variables hypothesized to impact FRDs.

Characteristics associated with blood transfusion among women undergoing laparoscopic myomectomy: a National Surgical Quality Improvement Program study

BACKGROUND

Uterine fibroids are the most common benign tumors that affect females. A laparoscopic myomectomy is the standard surgical treatment for most women who wish to retain their uterus. The most common complication of a myomectomy is excessive bleeding. However, risk factors for hemorrhage during a laparoscopic myomectomy are not well studied and no risk stratification tool specific for identifying the need for a blood transfusion during a laparoscopic myomectomy currently exists in the literature.

OBJECTIVE

This study aimed to identify risk factors for intraoperative and postoperative blood transfusion during laparoscopic myomectomies and to develop a risk stratification tool to determine the risk for requiring a blood transfusion.

STUDY DESIGN

This was a retrospective cohort study of the American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2020. Women who underwent a laparoscopic (conventional or robotic) myomectomy were included. Women who received 1 or more blood transfusions within 72 hours after the start time of a laparoscopic myomectomy were compared with those who did not require a blood transfusion. A multivariable analysis was performed to identify risk factors independently associated with the risk for transfusion. Two risk stratification tools to determine the need for a blood transfusion were developed based on the multivariable results, namely (1) based on preoperative factors and (2) based on preoperative and intraoperative factors.

RESULTS

During the study period, 11,498 women underwent a laparoscopic myomectomy. Of these, 331(2.9%) required a transfusion. In a multivariable regression analysis of the preoperative factors, Black or African American and Asian races, Hispanic ethnicity, bleeding disorders, American Society of Anesthesiologists class III or IV classification, and a preoperative hematocrit value ≤35.0% were independently associated with the risk for transfusion. Identified intraoperative factors included specimen weight >250 g or ≥5 intramural myomas and an operation time of ≥197 minutes. A risk stratification tool was developed in which points are assigned based on the identified risk factors. The mean probability of transfusion can be calculated based on the sum of the points.

CONCLUSION

We identified preoperative and intraoperative independent risk factors for a blood transfusion among women who underwent a laparoscopic myomectomy. A risk stratification tool to determine the risk for requiring a blood transfusion was developed based on the identified risk factors. Further studies are needed to validate this tool.

Psychosocial Stress and MicroRNA Expression Profiles in Myometrial Tissue of Women Undergoing Surgical Treatment for Uterine Fibroids

Uterine leiomyomas (fibroids) are the most common non-cancerous tumors affecting women. Psychosocial stress is associated with fibroid risk and severity. The relationship between psychosocial stress and fibroid pathogenesis may involve alterations in microRNAs (miRNAs) although this has yet to be examined. We investigated associations between two psychosocial stress measures, a composite measure of recent stressful life events and perceived social status, with expression levels of 401 miRNAs in myometrium (n = 20) and fibroids (n = 44; 20 with paired fibroid and myometrium samples) among pre-menopausal women who underwent surgery for fibroid treatment. We used linear regressions to identify psychosocial stressors associated with miRNAs, adjusting for covariates (age, body mass index, race/ethnicity, and oral contraceptive use). The association between psychosocial stressors and miRNAs was considered statistically significant at an FDR p < 0.10 and showed a monotonic response (nominal p-trend < 0.05). In the myometrium, 21 miRNAs were significantly associated with a composite measure of recent stressful events, and two miRNAs were associated with perceived social status. No fibroid miRNAs were associated with either stress measure. Pathway analyses revealed miRNA-mRNA targets were significantly enriched (FDR p < 0.05) in pathways relevant to cancer/tumor development. Of the 74 differentially expressed miRNAs between myometrium and fibroids, miR-27a-5p and miR-301b were also associated with stress exposure. Our pilot analysis suggests that psychosocial stress is associated with myometrial miRNA expression and, thus, may have a role in the pathogenesis of fibroids from healthy myometrium.

Safety and efficacy of sirolimus in recurrent intravenous leiomyomatosis, pulmonary benign metastatic leiomyomatosis, and leiomyomatosis peritonealis disseminata: a pilot study

BACKGROUND

Intravenous leiomyomatosis (IVL), pulmonary benign metastatic leiomyomatosis (PBML), and leiomyomatosis peritonealis disseminata (LPD) are leiomyomas with special growth patterns and high postoperative recurrence rates. We report the safety and efficacy of a pilot study of sirolimus in the treatment of recurrent IVL, PBML, and recurrent LPD.

METHODS

This was a pilot study to evaluate the safety and efficacy of sirolimus in the treatment of leiomyomatosis (ClinicalTrials.gov identifier NCT03500367) conducted in China. Patients received oral sirolimus 2 mg once a day for a maximum of 60 months or until disease progression, intolerable toxicity, withdrawal of consent, or investigator decision to stop. The primary end point of this study was the objective response rate. Secondary end points included safety and tolerability, disease control rate, and progression-free survival.

RESULTS

A total of 15 patients with leiomyomatosis were included in the study, including five with recurrent IVL, eight with PBML and two with recurrent LPD. The median follow-up time was 15 months (range 6-54 months), nine patients (60%) had treatment-related adverse events (including all levels), and two patients had treatment-related grade 3 or 4 adverse events. The objective response rate was 20.0% (95% CI, 7.1-45.2%), and the disease control rate was 86.7% (95% CI, 62.1-96.3%). Partial response was achieved in three patients. The median response time in the three partial response patients was 33 months (range 29-36 months), and the sustained remission time of these three patients reached 0, 18, and 25 months, respectively.

CONCLUSIONS

Sirolimus was safe and effective in the treatment of recurrent IVL, PBML, and recurrent LPD.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT03500367. Registered on 18 April 2018.

MiRNAs related in signaling pathways of women's reproductive diseases: an overview

BACKGROUND

One of the main health issues that can affect women's health is reproductive diseases, such as polycystic ovary syndrome (PCOS), endometriosis (EMs), uterine leiomyomas (ULs), and ovarian cancer (OC). Although these diseases are very common, we do not have a complete understanding of their underlying cellular and molecular mechanisms. It is important to mention that the majority of patients are diagnosed with these diseases at later stages because of the absence of early diagnostic techniques and dependable molecular indicators. Hence, it is crucial to discover novel and non-invasive biomarkers that have prognostic, diagnostic and therapeutic capabilities. MiRNAs, also known as microRNAs, are small non-coding RNAs that play a crucial role in regulating gene expression at the post-transcriptional level. They are short in length, typically consisting of around 22 nucleotides, and are highly conserved across species. Numerous studies have shown that miRNAs are expressed differently in various diseases and can act as either oncogenes or tumor suppressors.

METHODS

The author conducted a comprehensive review of all the pertinent papers available in web of science, PubMed, Google Scholar, and Scopus databases.

RESULTS

We achieved three goals: providing readers with better information, enhancing search results, and making peer review easier.

CONCLUSIONS

This review focuses on the investigation of miRNAs and their involvement in various reproductive disorders in women, including their molecular targets. Additionally, it explores the role of miRNAs in the development and progression of these disorders.

Leiomyoma or sarcoma? MRI performance in the differential diagnosis of sonographically suspicious uterine masses

PURPOSE

To assess the diagnostic performance of MRI in distinguishing between leiomyomas and malignant/potentially malignant mesenchymal neoplasms in patients with rapidly enlarging/sonographically suspicious uterine masses.

METHODS

IRB-approved retrospective study including 88 patients (51 ± 11 years) who underwent MRI for rapidly enlarging/sonographically suspicious uterine mass at our Institution between January 2016 and December 2021, followed by surgery or >12 months follow-up. Qualitative image analysis was independently performed by 2 radiologists and included lesion's margins (sharp/irregular), architecture (homogeneous/inhomogeneous), presence of endometrial infiltration (yes/no), necrotic areas (yes/no), hemorrhagic areas (yes/no), predominant signal intensity on T1-WI, T2-WI, CE T1-WI, DWI, and ADC map. The same radiologists performed quantitative image analysis in consensus, which included lesion's maximum diameter, lesion/myometrium signal intensity ratio on T2-WI and CE T1-weighted images, lesion/endometrium signal intensity ratio on DWI and ADC map and necrosis percentage. Lesions were classified as benign or malignant. Imaging findings were compared with pathology and/or follow-up.

RESULTS

After surgery (52/88 patients) or follow-up (36/88 patients, 33 ± 20 months), 83/88 (94.3%) lesions were classified as benign and 5/88 (5.7%) as malignant/potentially malignant. Presence of necrotic areas, high necrosis percentage, hyperintensity on DWI and high lesion/endometrium DWI signal intensity ratio were significantly associated with malignant/potentially malignant lesions (p = 0.027, 0.002, 0.008 and 0.015, respectively). The two readers identified malignant/potentially malignant lesions with 95.5% accuracy, 80.0% sensitivity, 96.4% specificity, 57.1 % PPV, 93.3% NPV.

CONCLUSION

MRI has high accuracy in identifying malignant/potentially malignant myometrial masses. In everyday practice, however, MRI positive predictive value is relatively low given the low pre-test malignancy probability.

Should acupuncture become a complementary therapy in the treatment of uterine fibroid: a systematic review and meta-analysis of randomized controlled trials

Background

Uterine fibroids (UFs) are the most common benign tumors in women of reproductive age. The most effective treatment is myomectomy, but there is no long-term or low-invasive treatment option exists. Acupuncture can be used to treat UFs in a variety of ways. However, there is no meta-analytic synthesis including valid data that explored the efficacy of acupuncture for UFs.

Objective

To assess the efficacy and safety of acupuncture for treating UFs.

Methods

The PRISMA 2020 checklist was used. We identified and extracted the trials through may 2023 from six databases. The quality of the trials was assessed using the risk of bias (2.0). Meta-analysis was performed using RevMan 5.4 software, and it was synthesized using the random-effects model if the included studies were in high heterogeneity. Subgroup and sensitivity analysis were used if necessary.

Results

A total of 1,035 trials were identified, of which 11 were included in the review and meta-analysis. In terms of acupuncture scheme design and fibroid-related symptoms, the trials are highly heterogeneous. All 11 trials have reported acupuncture types, with traditional acupuncture and electroacupuncture being the more representative subgroups. A qualitative review of existing evidence shows that acupuncture has no serious adverse reaction on UFs. Meta-analysis shows that acupuncture can effectively reduce the volume of UFs (MD - 3.89, 95% CI - 5.23 to - 2.56, P < 0.00001) or uterine volume (MD - 16.22, 95% CI - 19.89 To - 12.55, p < 0.00001), reduce the score of fibroid symptoms (MD - 3.03, 95% CI - 3.45 to - 2.60, p < 0.00001), improve the treatment efficiency (RR: 0.19, 95% CI: 0.13 to 0.25, p < 0.00001), and likely do not affect the estrogen level.

Invisible Hand behind Female Reproductive Disorders: Bisphenols, Recent Evidence and Future Perspectives

Reproductive disorders are considered a global health problem influenced by physiological, genetic, environmental, and lifestyle factors. The increased exposure to bisphenols, a chemical used in large quantities for the production of polycarbonate plastics, has raised concerns regarding health risks in humans, particularly their endocrine-disrupting effects on female reproductive health. To provide a basis for future research on environmental interference and reproductive health, we reviewed relevant studies on the exposure patterns and levels of bisphenols in environmental matrices and humans (including susceptible populations such as pregnant women and children). In addition, we focused on in vivo, in vitro, and epidemiological studies evaluating the effects of bisphenols on the female reproductive system (the uterus, ovaries, fallopian tubes, and vagina). The results indicate that bisphenols cause structural and functional damage to the female reproductive system by interfering with hormones; activating receptors; inducing oxidative stress, DNA damage, and carcinogenesis; and triggering epigenetic changes, with the damaging effects being intergenerational. Epidemiological studies support the association between bisphenols and diseases such as cancer of the female reproductive system, reproductive dysfunction, and miscarriage, which may negatively affect the establishment and maintenance of pregnancy. Altogether, this review provides a reference for assessing the adverse effects of bisphenols on female reproductive health.

Psychosocial stress and microRNA expression profiles in myometrial tissue of women undergoing surgical treatment for uterine fibroids

Uterine leiomyomas (fibroids) are the most common non-cancerous tumor affecting women. Psychosocial stress is associated with fibroid risk and severity. The relationship between psychosocial stress and fibroid pathogenesis may involve alterations in microRNAs (miRNAs) although this has yet to be examined. We investigated associations between two psychosocial stress measures, a composite measure of recent stressful life events and perceived social status, with expression levels of 401 miRNAs in myometrium (n = 20) and fibroids (n = 44; 20 matched between tissues) from pre-menopausal women who underwent surgery for fibroid treatment. We used linear regressions to identify psychosocial stressors associated with miRNAs, adjusting for covariates (age, body mass index, and race/ethnicity). Psychosocial stressors were modeled as ordinal variables and results were considered statistically significant if the overall variable significant was below false discovery threshold (FDR < 0.10) and showed a monotonic dose-response (nominal p-trend < 0.05). In the myometrium, 16 miRNAs were significantly associated with total stressful events and two miRNAs were associated with perceived social status. No fibroid miRNAs were associated with either stress measure. Pathway analyses revealed miRNA-mRNA targets were significantly enriched (FDR < 0.05) in pathways relevant to cancer/tumor development. Of the 74 differentially expressed miRNAs between myometrium and fibroids (p < 0.05), miR-27a-5p was also associated with stress exposure. Our pilot analysis suggests that psychosocial stress is associated with changes in myometrium miRNAs, and thus, plays a role in the pathogenesis of fibroids from healthy myometrium.

Characterization of m6A modifiers and RNA modifications in uterine fibroids

Uterine leiomyoma or fibroids are the most common prevalent noncancerous tumors of the uterine muscle layer. Common symptoms associated with fibroids include pelvic pain, heavy menstrual bleeding, anemia, and pelvic pressure. These tumors are a leading cause of gynecological care but lack long-term therapy as the origin and development of fibroids are not well understood. Several next-generation sequencing technologies have been performed to identify the underlying genetic and epigenetic basis of fibroids. However, there remains a systemic gap in our understanding of molecular and biological process that define uterine fibroids. Recent epitranscriptomics studies have unraveled RNA modifications that are associated with all forms of RNA and are thought to influence both normal physiological functions and the progression of diseases. We quantified RNA expression profiles by analyzing publicly available RNA-seq data for 15 known epigenetic mediators to identify their expression profile in uterine fibroids compared to myometrium. To validate our findings, we performed RT-qPCR on a separate cohort of uterine fibroids targeting these modifiers confirming our RNA-seq data. We then examined protein profiles of key m6A modifiers in fibroids and their matched myometrium. In concordance with our RNA expression profiles, no significant differences were observed in these proteins in uterine fibroids compared to myometrium. To determine abundance of RNA modifications, mRNA and small RNA from fibroids and matched myometrium were analyzed by UHPLC MS/MS. In addition to the prevalent N6-methyladenosine (m6A), we identified 11 other known modifiers but did not identify any aberrant expression in fibroids. We then mined a previously published dataset and identified differential expression of m6A modifiers that were specific to fibroid genetic sub-type. Our analysis also identified m6A consensus motifs on genes previously identified to be dysregulated in uterine fibroids. Overall, using state-of-the-art mass spectrometry, RNA expression and protein profiles, we characterized and identified differentially expressed m6A modifiers in relation to driver mutations. Despite the use of several different approaches, we identified limited differential expression of RNA modifiers and associated modifications in uterine fibroids. However, considering the highly heterogenous genomic and cellular nature of fibroids, and the possible contribution of single molecule m6A modifications to fibroid pathology, there is a need for greater in-depth characterization of m6A marks and modifiers in a larger and varied patient cohort.

Comparison of efficacy of single-port versus conventional laparoscopic treatment for uterine leiomyoma: a latest meta-analysis

Objective

Single-port laparoscopy has been proposed as an ideal surgical method for the treatment of uterine leiomyoma. It can effectively remove the lesion, reduce the loss of hemoglobin, and has superior cosmetic effects. Therefore, we searched relevant studies and conducted a meta-analysis to evaluate the effect of single-port laparoscopy on myoma resection, hemoglobin loss, and scar beauty compared to conventional laparoscopy.

Methods

We systematically searched PubMed, EMBASE, scope, Cochrane, CNKI, and other databases to find randomized controlled studies on the efficacy of single-port laparoscopy and traditional laparoscopy for meta-analysis. The main outcomes of our study were the duration of surgery, the reduction of hemoglobin, and the cosmetic effect of the postoperative scar. The effect model was selected according to heterogeneity (random effect model or fixed effect model), and the relevant sensitivity analysis and publication bias test were performed.

Results

We searched a total of 501 related literature articles and finally included 19 studies involving 21 researchers. Comparison of single-port laparoscopic myomectomy with traditional surgery: Operation time had no significant difference (Standardized Mean Difference [SMD]: 0.13, 95% Confidence interval (CI), -0.04 to 0.30; I²=74%; P = 0.14); The reduction of hemoglobin is lower ([SMD]: -0.04; 95% CI, -0.23 to 0.14; I²=71%; P = 0.65), and the cosmetic effect of postoperative scar is more satisfactory ([SMD]: 0.42, 95% CI: 0.02 to 0.83; I²=72%, P= 0.04). There was no significant difference in conversion rate, postoperative pain, blood loss, postoperative gastrointestinal recovery time, or length of hospital stay.

Conclusion

Compared with traditional laparoscopy, the operation time of the treatment of uterine leiomyoma by single-port laparoscopy is not extended, the reduction of hemoglobin is less, and the cosmetic effect of the scar is better. Therefore, single-port laparoscopy is superior to traditional surgery in the treatment of uterine leiomyoma.

Systematic review registration

https://inplasy.com/inplasy-2023-3-0071/, identifier INPLASY202330071.

Predicting nutrition and environmental factors associated with female reproductive disorders using a knowledge graph and random forests

Objective

Female reproductive disorders (FRDs) are common health conditions that may present with significant symptoms. Diet and environment are potential areas for FRD interventions. We utilized a knowledge graph (KG) method to predict factors associated with common FRDs (e.g., endometriosis, ovarian cyst, and uterine fibroids).

Materials and Methods

We harmonized survey data from the Personalized Environment and Genes Study on internal and external environmental exposures and health conditions with biomedical ontology content. We merged the harmonized data and ontologies with supplemental nutrient and agricultural chemical data to create a KG. We analyzed the KG by embedding edges and applying a random forest for edge prediction to identify variables potentially associated with FRDs. We also conducted logistic regression analysis for comparison.

Results

Across 9765 PEGS respondents, the KG analysis resulted in 8535 significant predicted links between FRDs and chemicals, phenotypes, and diseases. Amongst these links, 32 were exact matches when compared with the logistic regression results, including comorbidities, medications, foods, and occupational exposures.

Discussion

Mechanistic underpinnings of predicted links documented in the literature may support some of our findings. Our KG methods are useful for predicting possible associations in large, survey-based datasets with added information on directionality and magnitude of effect from logistic regression. These results should not be construed as causal, but can support hypothesis generation.

Conclusion

This investigation enabled the generation of hypotheses on a variety of potential links between FRDs and exposures. Future investigations should prospectively evaluate the variables hypothesized to impact FRDs.

Pulmonary benign metastasizing leiomyoma in patients aged 45 years and younger: clinical features and novelty in treatment

BACKGROUND

Pulmonary benign metastasizing leiomyoma (PBML) is the most common extrauterine spread of uterine leiomyoma, and its biological behavior is traditionally thought to be hormone dependent. Studies on older PBML patients have been previously reported, but limited literature has been published regarding the clinical features and treatment of PBML in young women.

METHODS

A total of 65 cases of PBML in women aged 45 years and younger were reviewed, including 56 cases selected from PubMed and 9 cases from our hospital. The clinical characteristics and management of these patients were analyzed.

RESULTS

The median age of all the patients at diagnosis was 39.0 years. PBML most commonly presented as bilateral solid lesions (60.9%), with other rare imaging manifestations. The median interval time from a pertinent gynecologic procedure to diagnosis was 6.0 years. A total of 16.7% of patients received careful observation, and all achieved stable status in a median follow-up time of 18.0 months. A total of 71.4% of patients were administered anti-estrogen therapies, including surgical castration (33.3%), gonadotropin-releasing hormone analog (23.8%) and anti-estrogen drugs (14.3%). Eight of 42 patients underwent surgical resection of metastatic lesions. Patients who underwent curative surgery for the removal of pulmonary lesions combined with adjuvant anti-estrogen therapies had favorable outcomes compared with those who only underwent surgical resection. The disease control rates of surgical castration, gonadotropin-releasing hormone analog, and anti-estrogen drugs were 85.7%, 90.0%, and 50.0%, respectively. For two patients, sirolimus (rapamycin) achieved successful relief of symptoms and control of pulmonary lesions without lowering hormone levels and causing estrogen deficiency symptoms.

CONCLUSIONS

In the absence of standard treatment guidelines for PBML, maintaining a low-estrogen environment using different kinds of antiestrogen therapies has been the mainstream strategy and has satisfying curative effects. A wait-and-see strategy might be an option, but therapeutic approaches must be contemplated when complications or symptoms progress. For PBML in young women, the negative effect on ovarian function of anti-estrogen treatment, especially surgical castration, should be considered. Sirolimus might be a new treatment option for young PBML patients, especially for those who want to preserve ovarian function.

Urinary phytoestrogens and the risk of uterine leiomyomata in US women

BACKGROUND

Uterine leiomyomata (UL) is a common gynecological disease in women. Studied on the relationship between single metabolites of urinary phytoestrogens and UL, especially for the combined effects of mixed metabolites on UL still are insufficient.

METHODS

In this cross-sectional study, we included 1,579 participants from the National Health and Nutrition Examination Survey. Urinary phytoestrogens were assessed by measuring urinary excretion of daidzein, genistein, equol, O-desmethylangolensin, enterodiol and enterolactone. The outcome was defined as UL. Weighted logistic regression was used to analyze the association between single metabolites of urinary phytoestrogens and UL. Notably, we adopted the weighted quantile sum (WQS) regression, Bayesian kernel machine regression (BKMR), and quantile g-computation (qgcomp) models, to investigate the combined effects of six mixed metabolites on UL.

RESULTS

The prevalence of UL was approximately 12.92%. After adjusting age, race/ethnicity, marital status, drinking status, body mass index, waist circumference, menopausal status, ovary removed status, use of female hormones, hormones/hormone modifiers, total energy, daidzein, genistein, O-desmethylangolensin, enterodiol, and enterolactone, the association of equol with UL was significant [Odds ratio (OR) = 1.92, 95% confidence interval (CI): 1.09-3.38]. In the WQS model, mixed metabolites of urinary phytoestrogen had a positive association with UL (OR = 1.68, 95%CI: 1.12-2.51), with the highest weighted chemical of equol. In the gpcomp model, equol had the largest positive weight, followed by genistein and enterodiol. In the BKMR model, equol and enterodiol have positive correlation on UL risk, while enterolactone has negative correlation.

CONCLUSION

Our results implied a positive association between the mixed metabolites of urinary phytoestrogen and UL. This study provides evidence that urinary phytoestrogen-metabolite mixture was closely related to the risk of female UL.

Reproductive and Obstetric Outcomes after UAE, HIFU, and TFA of Uterine Fibroids: Systematic Review and Meta-Analysis

Novel treatment options for uterine fibroids, such as uterine artery embolization (UAE), ultrasound-guided and magnetic resonance-guided high-intensity focused ultrasound (USgHIFU and MRgHIFU), and transcervical radiofrequency ablation (TFA) methods, are widely used in clinical practice. This systematic review and meta-analysis (CRD42022297312) aims to assess and compare reproductive and obstetric outcomes in women who underwent these minimally invasive approaches for uterine fibroids. The search was performed in PubMed, Google Scholar, ScienceDirect, Cochrane Library, Scopus, Web of Science and Embase. Risk of bias was assessed using the Newcastle-Ottawa Scale (NOS) and Cochrane guidelines. The articles were selected to meet the following eligibility criteria: (1) research article, (2) human subject research, and (3) the study of pregnancy outcomes after the treatment of uterine fibroids by either one of three methods-UAE, HIFU, and TFA. The analysis of 25 eligible original articles shows a similar rate of live births for UAE, USgHIFU, MRgHIFU, and TFA (70.8%, 73.5%, 70%, and 75%, respectively). The number of pregnancies varied considerably among these studies, as well as the mean age of pregnant women. However, the results of pregnancy outcomes for TFA are insufficient to draw firm conclusions, since only 24 women became pregnant in these studies, resulting in three live births. The miscarriage rate was highest in the UAE group (19.2%). USgHIFU was associated with a higher rate of placental abnormalities compared to UAE (2.8% vs. 1.6%). The pooled estimate of pregnancies was 17.31% to 44.52% after UAE, 18.69% to 78.53% after HIFU, and 2.09% to 7.63% after TFA. The available evidence confirmed that these minimally invasive uterine-sparing treatment options for uterine fibroids are a good approach for patients wishing to preserve their fertility, with comparable reproductive and obstetric outcomes among the different techniques.

Large Cervical Leiomyoma of the Uterus: A Rare Cause of Chronic Pelvic Pain Associated With Obstructive Uropathy and Renal Dysfunction: A Case Report

Large cervical leiomyomas (≥10cm) are extremely rare. Our case report concerns the surgical treatment of a patient with a large cervical leiomyoma associated with chronic pelvic pain, bilateral hydroureteronephrosis and significant impairment of renal function. A 47-year-old patient of reproductive age with a normal menstrual cycle and a medical history of chronic pelvic pain presented to the gynecology clinic for examination. Clinically, the presence of a large pelvic mass was found, the upper margins of which were palpable at the level of the umbilicus. A preoperative assessment revealed bilateral hydroureteronephrosis due to obstructive uropathy and renal dysfunction. Hydroureteronephrosis, as a consequence of the large pelvic mass, probably originating from the cervix of the uterus, was evaluated as the main cause of renal dysfunction. Tumor markers were negative. The imaging studies confirmed the clinical diagnosis of uterine leiomyoma, and the surgical treatment of the patient with laparotomy was decided. Intraoperatively, the presence of a large uterine cervical fibroid was detected, and a total abdominal hysterectomy and bilateral adnexectomy were performed. Operating was difficult, with significant surgical difficulties. The postoperative course was uneventful, without immediate complications. The patient's symptom relief began gradually, immediately after surgery. Three months after surgery, the patient reported complete relief of her pelvic pain. A re-examination of the urinary tract revealed complete recovery of renal morphology and function. In the paper, after the presentation of the case, a brief review of cervical leiomyomas is attempted based on the literature, mainly regarding the diagnostic and therapeutic approach.

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.

Life Quality in Premenopausal Women after Embolization of Uterine Myomas

Objectives: Fibroids cause significant morbidity and are the most common indication for hysterectomies worldwide, delimiting a major public health problem. Uterine artery embolization (UAE) is an alternative therapy to surgical treatment of symptomatic fibroids; it has satisfactory long-time results and is no longer considered investigational for the treatment of symptomatic fibroids. This study was undertaken to evaluate changes in fibroid specific symptom severity and health-related quality of life (HRQOL) after UAE and to optimize the assessment of safety and outcomes measures for participants who receive UAE to objective compare UAE and surgical alternatives for therapy of symptomatic fibroids. Study design: The analysis was based on questionnaires completed by 270 pre-menopausal females with a mean age of 42 years (range, 38-50 years) who underwent UAE for uterine leiomyomas and/or adenomyosis from November 2013 through December 2019. Only symptomatic women were selected whose symptoms were not improving with medication and who did not wish to have children. The primary outcome measure was a change in fibroid symptoms and HRQOL (health related quality of life) after UAE. Secondary outcomes included the decrease in uterine volume after UAE. Results: Questionnaires were completed by 270 women (100%) at a mean of 12.1 months from UAE. The median follow-up period was two years. Uterine fibroid embolization led to a shrinkage at three months for the 90% of the participants. A reduction of bleeding symptoms, pain and bulk-related symptoms was observed in 89.7%, 88.9%, and 89.5% of the patients, respectively. In the long term, there was no significant difference in parameters assessed compared with the midterm follow-up findings. A total of 6 patients (2.3%) underwent fractional curettage an average of 32.1 months after intervention due to necrotic changes in submucosal fibroids. All participants continued to be satisfied with the intervention, and 240 patients (88.9%) answered that they would recommend uterine fibroid embolization to other patients. Conclusions: Women who undergo UAE have a significant decrease in symptom severity and increase in HRQOL which is associated with high levels of satisfaction with the procedure (even when subsequent therapies are pursued).

Comparison of Multi- and Single-Site Robotic Myomectomy Using the Da Vinci® SP Surgical System: A Propensity Score Matching Analysis

Objective: This study aimed to compare the surgical outcomes between robotic multi-site myomectomy (RMSM) and robotic single-site myomectomy (RSSM), using the da Vinci® SP surgical system and perform propensity score matching analysis to ensure inter-group comparability. Methods: This retrospective study included 105 patients who underwent either three-incision RMSM or RSSM using the da Vinci® SP surgical system. We retrospectively reviewed and compared surgical outcomes using 1:1 propensity score matching. Results: After 1:1 propensity score matching, there were no differences in the total operation time and estimated blood loss between the groups. The docking time (p < 0.0001) and duration of hospital stay (p = 0.0001) were significantly shorter in the RSSM group than in the RMSM group. Conclusions: The surgical outcomes of RSSM were comparable to those of RMSM. Moreover, compared to RMSM, RSSM using the da Vinci® SP surgical system has shorter docking and morcellation times, and duration of hospital stay.

Serum sestrin 2 levels in patients with uterine leiomyomas

Our aim was to evaluate SESN2 levels in patients with uterine leiomyomas by comparing serum SESN2 levels in myoma patients with the levels in healthy women to deepen our understanding of the pathophysiology of uterine leiomyomas. Patients 18-50 years of age who applied to the University of Health Sciences Turkey, Istanbul Kanuni Sultan Suleyman Training and Research Hospital between January and March 2021 and who were diagnosed with uterine leiomyoma were defined as the 'myoma group'. The control group included patients without any sign of leiomyomas in routine ultrasonography. The patients' demographic features, gynecological symptoms, myoma volume and classification were recorded. Serum SESN2 concentrations in venous blood samples were measured using a sandwich enzyme-linked immunosorbent assay (ELISA) kit.The study included 31 patients in the myoma group and 30 in the control group. The mean age/gravid/parity or BMI values did not differ significantly between the groups. The only gynecological symptom that showed a significant difference was menorrhagia. Serum SESN2 levels were significantly higher in the myoma group then the control groups (11.7 ± 2.5) (p < 0.001). In conclusion, although uterine leiomyoma is the most common benign tumour in women of reproductive age, there are no known markers for predicting the development of leiomyomas. Based on the results of the current study, SESN2 could be such a marker.IMPACT STATEMENTWhat is already known on this subject? Uterine leiomyoma is the most common type of benign tumour in women of reproductive age as well as the most common indication for a hysterectomy. Symptoms associated with uterine leiomyoma include abnormal bleeding, chronic pelvic pain, menorrhagia, dysmenorrhoea, dyspareunia and anaemia, which adversely affect the patient's quality of life. Sestrins are a family of metabolic regulator proteins that play a potential role in carcinogenesis.What the results of this study add? This is the first study evaluating the role of sestrin in the development of uterine leiomyomas. Significantly higher levels of sestrin 2 (SESN2) were detected in patients with leiomyomas.What are the implications of these findings for clinical practice and/or further research? Although uterine leiomyoma is the most common type of benign tumour in women of reproductive age, there are still many unknowns regarding its pathophysiology. Further, there are still no known markers for predicting the development of leiomyomas. Hence, primary prevention is not possible. Based on the results of the current study SESN2, could be such a marker. Further studies are needed to confirm the results of this study.

A transcriptome-wide association study of uterine fibroids to identify potential genetic markers and toxic chemicals

Uterine fibroid is one of the most prevalent benign tumors in women, with high socioeconomic costs. Although genome-wide association studies (GWAS) have identified several loci associated with uterine fibroid risks, they could not successfully interpret the biological effects of genomic variants at the gene expression levels. To prioritize uterine fibroid susceptibility genes that are biologically interpretable, we conducted a transcriptome-wide association study (TWAS) by integrating GWAS data of uterine fibroid and expression quantitative loci data. We identified nine significant TWAS genes including two novel genes, RP11-282O18.3 and KBTBD7, which may be causal genes for uterine fibroid. We conducted functional enrichment network analyses using the TWAS results to investigate the biological pathways in which the overall TWAS genes were involved. The results demonstrated the immune system process to be a key pathway in uterine fibroid pathogenesis. Finally, we carried out chemical–gene interaction analyses using the TWAS results and the comparative toxicogenomics database to determine the potential risk chemicals for uterine fibroid. We identified five toxic chemicals that were significantly associated with uterine fibroid TWAS genes, suggesting that they may be implicated in the pathogenesis of uterine fibroid. In this study, we performed an integrative analysis covering the broad application of bioinformatics approaches. Our study may provide a deeper understanding of uterine fibroid etiologies and informative notifications about potential risk chemicals for uterine fibroid.

Highly Cellular Leiomyoma Mixed With a Focus of Adenomyosis

The purpose of this case presentation was to highlight the importance of an adequate evaluation of images when suspicious of atypical leiomyoma and the importance of performing an extemporaneous biopsy during surgery to ensure the lesion is a benign muscular cell tumor.

Here, we present a case of a 34-year-old nulliparous woman who presented with a history of infertility and irregular menstrual cycles. A highly vascularized pelvic mass was visualized by Doppler ultrasound and a contrast MRI suggestive of uterine fibroid. Intraoperatively, the lesion was found adjacent to the uterus, with a second lesion deeper into the myometrium. The pathology reported a highly cellular leiomyoma with a focus of adenomyosis. Both lesions were extirpated without complications. The patient recuperated favorably within three months of follow-up. This case shows an example of a variety of the typical histology that can be found in uterine fibroids. Although the management of atypical leiomyomas could vary in different scenarios, conservative treatment is recommended if fertility wishes are present. In all cases, it is mandatory to exclude any possibilities of malignancy, like sarcoma, which would completely change the intraoperative management.

Importance of Fibrosis in the Pathogenesis of Uterine Leiomyoma and the Promising Anti-fibrotic Effects of Dipeptidyl Peptidase-4 and Fibroblast Activation Protein Inhibitors in the Treatment of Uterine Leiomyoma

Uterine fibroid or leiomyoma is the most common benign uterus tumor. The tumor is primarily composed of smooth muscle (fibroid) cells, myofibroblast, and a significant amount of extracellular matrix components. It mainly affects women of reproductive age. They are uncommon before menarche and usually disappear after menopause. The fibroids have excessive extracellular matrix components secreted by activated fibroblast cells (myofibroblast). Myofibroblast has the characteristics of fibroblast and smooth muscle cells. These cells possess contractile capability due to the expression of contractile proteins which are normally found only in muscle tissues. The rigid nature of the tumor is responsible for many side effects associated with uterine fibroids. The current drug treatment strategies are primarily hormone-driven and not anti-fibrotic. This paper emphasizes the fibrotic background of uterine fibroids and the mechanisms behind the deposition of excessive extracellular matrix components. The transforming growth factor-β, hippo, and focal adhesion kinase-mediated signaling pathways activate the fibroblast cells and deposit excessive extracellular matrix materials. We also exemplify how dipeptidyl peptidase-4 and fibroblast activation protein inhibitors could be beneficial in reducing the fibrotic process in leiomyoma. Dipeptidyl peptidase-4 and fibroblast activation protein inhibitors prevent the fibrotic process in organs such as the kidneys, lungs, liver, and heart. These inhibitors are proven to inhibit the signaling pathways mentioned above at various stages of their activation. Based on literature evidence, we constructed a narrative review on the mechanisms that support the beneficial effects of dipeptidyl peptidase-4 and fibroblast activation protein inhibitors for treating uterine fibroids.

Of Elephants and Other Mammals: A Comparative Review of Reproductive Tumors and Potential Impact on Conservation

Reproductive tumors can impact conception, pregnancy, and birth in mammals. These impacts are well documented in humans, while data in other mammals are limited. An urgent need exists to understand the reproductive impact of these lesions in endangered species, because some endangered species have a documented high prevalence of reproductive tumors. This article documents that the prevalence of both benign and malignant neoplasia differs between African and Asian elephants, with Asian elephants more frequently diagnosed and negatively affected by both. The prevalence of these tumors across mammalian species is compared, and impact plus treatment options in human medicine are reviewed to inform decision making in elephants. Evidence suggests that reproductive tumors can negatively impact elephant conservation. Future studies that document reproductive outcomes, including the success of various treatment approaches in elephants with tumors will benefit conservation efforts.

Uterine leiomyoma as useful model to unveil morphometric and macromolecular collagen state and impairment in fibrotic diseases: An ex-vivo human study

Collagen is one of the main components of the extracellular matrix (ECM), involved, among all, in the maintenance of the structural support of tissues. In fibrotic diseases, collagen is overexpressed, and its production determines the formation of a significantly stiffer ECM. The cross-linking of high-resolution analytical tools, able to investigate both the tridimensional organization and the secondary structure of collagen in fibrotic diseases, could be useful to identify defined markers correlating the status of this protein with specific pathological conditions. To this purpose, an innovative multidisciplinary approach based on Phase-Contrast MicroComputed Tomography, Transmission Electron Microscopy, and Fourier Transform Infrared Imaging Spectroscopy was exploited on leiomyoma samples and adjacent myometrium to characterize microstructural collagen features. Uterine leiomyoma is a common gynecological disorder affecting women in fertile age. It is characterized by a massive collagen production due to the repairing processes occurring at myometrium level, and, hence, it represents a valuable model to investigate collagen self-organization in a pathological condition. Moreover, to evaluate the sensitivity of this multidisciplinary approach, the effects of eicosapentaenoic (EPA) and docosahexaenoic (DHA) omega-3 fatty acids in collagen reduction were also investigated.

Efficacy and Satisfaction Evaluation of Rapid Rehabilitation Nursing Intervention in Patients with Laparoscopic Myomectomy

Objective. To evaluate the efficacy and satisfaction of rapid rehabilitation nursing in patients with laparoscopic myomectomy. Methods. In this retrospective study, a total of 60 patients scheduled for a laparoscopic myomectomy in our hospital from January 2019 to February 2022 were enrolled and assigned at a ratio of 1 : 1 to receive either routine nursing (routine group) or rapid rehabilitation nursing (study group) according to different nursing methods. Outcome measures included nursing efficiency and nursing satisfaction. Results. Rapid rehabilitation nursing resulted in less intraoperative blood loss, shorter postoperative exhaust time and hospital stay, and a lower incidence of bladder irritation ( $123.56\pm 30.68$ , $22.54\pm 5.07$ , $5.70\pm 1.06$ , and 4.55%) versus the routine nursing ( $185.78\pm 32.78$ , $31.02\pm 5.28$ , $7.57\pm 2.19$ , 18.18%) ( $P<0.05$ ). Rapid rehabilitation nursing was associated with a lower incidence of complications (3.33%) versus routine nursing (20.00%) ( $P<0.05$ ). The eligible patients receiving rapid rehabilitation nursing showed a significantly higher satisfaction (96.67%) versus routine nursing (80.00%) ( $P<0.05$ ). Conclusion. Rapid rehabilitation nursing is effective in the nursing of patients after laparoscopic myomectomy by minimizing the physical and mental stress of patients, shortening the length of hospital stay, reducing the occurrence of related complications, and boosting the quality of life of patients, so it is worthy of clinical application.

Association of Vitamin D Anabolism-Related Gene Polymorphisms and Susceptibility to Uterine Leiomyomas

Background: Uterine leiomyomas (ULs) is the most common gynecological benign tumor in women. Our previous study showed that the phenomenon of vitamin D deficiency existed in patients with ULs. However, the association of vitamin D anabolism-related gene polymorphisms and susceptibility to ULs was unclear.

Methods: Vitamin D anabolism-related gene polymorphisms in 110 patients with ULs and 110 healthy controls were detected by sequencing and the differences of the 92 SNPs were analyzed in the two groups via chi-square test. To verify the association between the significantly different SNPs and the risk of ULs, the SNPs were genotyped in another 340 patients and 340 healthy controls. Additionally, an unconditional logistic regression model was conducted to calculate the odds ratio (OR) of ULs occurrence and the 95% confidence interval (CI), adjusting for age and BMI.

Findings: In sequencing samples, there were differences in DHCR7 rs1044482 C > T (p = 0.008) and NADSYN1 rs2276360 G > C (p = 0.025) between patients with ULs and healthy controls. DHCR7 rs1044482 was related to the susceptibility to ULs in validation samples (heterogeneous: adjusted OR = 1.967, p = 0.002; homogenous: adjusted OR = 2.494, p = 0.002; additive: adjusted OR = 1.485, p < 0.041; and dominant: adjusted OR = 2.084, p < 0.001). Stratified analysis further showed that the DHCR7 rs1044482 polymorphisms were associated with ULs risks in women over 40 and with 18.5–25.0 BMI. In contrast to the wild-type CG haplotype vectors, individuals with TC haplotypes had a higher risk of developing ULs.

Interpretation: The vitamin D anabolism-related gene DHCR7 rs1044482 C > T polymorphism was a risk factor of ULs, especially in patients over 40 with 18.5–25.0 BMI, while the relationship between NADSYN1 rs2276360 and ULs risk was not clear.

Inhibiting effect of miR-29 on proliferation and migration of uterine leiomyoma via the STAT3 signaling pathway

Aim: Uterine leiomyoma is the most common benign tumor of female genitalia, and the incidence is rising gradually. This study explores the mechanism of miR-29 and STAT3 signaling pathways on uterine leiomyoma.

Methods: GSE64763 and GSE5244 datasets were downloaded. Enrichment analyses were performed in GSE64763. PPI network was constructed, and the significant module was identified. Uterine leiomyoma cell lines were divided into NC, miR-29 mimic, anti-NC, and miR-29 inhibitor groups. Plate clone formation and Transwell assays detected the proliferation, invasion, and migration of cells. The expression levels of STAT3, proliferation, EMT, invasion-associated proteins were determined by Western blotting.

Results: Differently expressed genes were mainly enriched in positive regulation of cell migration and gene expression, cell proliferation. Through GSEA, JAK-STAT is a significantly correlated enrichment pathway. A Venn diagram was drawn to identify the common miRNA (miR-29-3p). miR-29 inhibitors promoted protein expression of STAT-3, Cyclin D1, and c-Myc compared with the anti-NC control (P < 0.01), and miR-29 inhibitors promoted cell proliferation in uterine leiomyoma cells (P < 0.05). Furthermore, miR-29 inhibitors promoted the protein expression of MMP-2 and MMP-9 (P < 0.01), and EMT promoting proteins N-cadherin, snail, vimentin, and Transwell assay showed that miR-29 inhibitors promoted cell migration in uterine leiomyoma (P < 0.01).

Conclusions: High expression of miR-29 could inhibit cell proliferation, invasion, and metastasis in uterine leiomyoma, which might be related to the inhibition of the STAT3 signaling pathway, and could provide a novel target for the treatment of uterine leiomyoma.

Identification of PDGFRα+ cells in uterine fibroids - link between angiogenesis and uterine telocytes

INTRODUCTION

Telocytes (TCs), also called interstitial Cajal-like cells (ICLC), CD34+ cells or PDGFRα+ cells (platelet-derived growth factor receptor α positive cells), a new type of cell of mesenchymal origin, were described over one decade ago. The unique nature of these cells still deserves attention from the scientific community. Telocytes make homo- and heterocellular contact with myocytes, immunocytes and nerves, have their own immunohistochemical and secretome profiles and thus might regulate local regenerative processes including angiogenesis and fibrosis. The aim of our study was to observe the missing link between angiogenesis and telocytes in leiomyoma, the most common benign tumors affecting women of reproductive age.

MATERIAL AND METHODS

We observed uterine tissue samples from leiomyoma, adjacent myometrium and unchanged tissue from patients with leiomyoma and control subjects using routine histology, histochemistry, immunofluorescence (CD117, CD31, CD34, PDGFRα, tryptase, sFlt-1) and image analysis methods.

RESULTS

The decline of the telocyte density in the foci of fibroids correlated with poor vascularization inside the leiomyoma. Moreover, the expression of sFlt-1 (anti-angiogenic-related factor) significantly increased inside a fibroid. In leiomyoma the decrease of telocyte and blood micro-vessel density was accompanied by prevalence of collagen deposits, unlike the unchanged myometrium.

CONCLUSIONS

Our results demonstrate TCs in human uterine fibroids and highlight their possible involvement in the pathogenesis of myometrial pathology in the context of angiogenesis.

Pregnancy outcomes after ultrasound-guided high-intensity focused ultrasound (USgHIFU) for conservative treatment of uterine fibroids: experience of a single institution

OBJECTIVE

To assess the impact of ultrasound-guided high-intensity focused ultrasound (USgHIFU) ablation for uterine fibroids on fertility.

MATERIAL AND METHODS

A retrospective observational study was conducted of 560 reproductive-age women with symptomatic uterine fibroids who underwent USgHIFU therapy at Mútua Terrassa University Hospital, Spain, between February 2008 and February 2018. We analyzed pregnancy outcomes including time to conception, pregnancy approach, gestational age, delivery mode, neonatal outcomes and complications during pregnancy and delivery.

RESULTS

After USgHIFU treatment, 71 pregnancies were obtained in 55 patients. Of these, 58 (82%) cases were natural pregnancies and 13 (18%) were in vitro fertilization (IVF) pregnancies. The median time to conception was 12 (range 1-72) months. There were 43 (61%) successful deliveries, including a twin gestation, 22 (31%) spontaneous abortions and 6 (8%) therapeutic abortions. The rate of full-term deliveries was 91% (39/43) and the remaining 9% (4/43) were preterm deliveries. Of the 44 live births, 25 (57%) were born vaginally and 19 (43%) by cesarean section. The complications reported included 3 women with retained placenta (7%), 2 with placenta previa (5%) and 1 with severe preeclampsia (2%). The mean birth weight was 3.1 (range: 1.4-4.3) kg, and except for a baby born with a tetralogy of Fallot, all newborns developed well without complications during postpartum and breastfeeding.

CONCLUSION

Patients undergoing USgHIFU treatment of uterine fibroids can achieve full-term pregnancies with few intrapartum or postpartum complications. More studies are required to compare fertility and perinatal outcomes between patients who underwent or not USgHIFU.

Clinical Value of Body Mass Index and Waist-Hip Ratio in Clinicopathological Characteristics and Prognosis of Uterine Leiomyomata

Objective

To explore the relationship between body mass index (BMI) and waist-to-hip ratio (WHR) and clinicopathological characteristics and prognosis of uterine leiomyomata (UL).

Methods

A retrospective analysis of the clinical data of 133 patients with UL admitted to our hospital from September 2018 to August 2019. According to the BMI standard, the patients were divided into the normal group (n = 32), the super-recombination group (n = 45), and the obesity group (n = 56). According to WHR, the patients were divided into the normal body group (n = 32) and the obesity body group (n = 101). The prognosis of all patients with UL at 3 months postoperatively was evaluated. The relationship between BMI patients and clinical characteristics in different groups was compared, and univariate analysis and multivariate logistic regression model were used to analyze the factors affecting the prognosis of UL patients.

Results

The proportion of UL patients in the overweight/obese group was higher than that of the normal group, the proportion of the obese body group was higher than that of the normal body group, and the proportion of the good prognosis group was higher than that of the poor prognosis group (P < 0.05). The difference between the overweight/obese group and the normal group and the obese body group and the normal body group was irregular vaginal bleeding, the number of tumors, and the diameter of the lesion (P < 0.05), and the differences between the degenerations in the obese body group and the normal body group were statistically significant (P < 0.05). Multivariate analysis showed that BMI, WHR, surgical method, and tumor location were all independent risk factors that affected the prognosis of the surgery (P < 0.05).

Conclusion

Elevated BMI and WHR can be accompanied by an increased risk of UL. Obesity is a risk factor for UL. Overweight/obese women are more clinically pathological than normal patients, and overweight/obese patients have worse surgical prognosis than normal patients. In order to reduce the prevalence of UL and improve the clinicopathological characteristics and prognosis of patients, clinically obese women should be instructed to use reasonable diet and exercise to control weight.

A-kinase anchoring protein 13 interacts with the vitamin D receptor to alter vitamin D-dependent gene activation in uterine leiomyoma cells

OBJECTIVE

To determine if A-kinase anchoring protein 13 (AKAP13) interacts with the vitamin D receptor (VDR) to alter vitamin D-dependent signaling in fibroid cells. Uterine leiomyomas (fibroids) are characterized by a fibrotic extracellular matrix and are associated with vitamin D deficiency. Treatment with vitamin D (1,25-dihydroxyvitamin D₃) reduces fibroid growth and extracellular matrix gene expression. A-kinase anchoring protein 13 is overexpressed in fibroids and interacts with nuclear hormone receptors, but it is not known whether AKAP13 may interact with the VDR to affect vitamin D signaling in fibroids.

DESIGN

Laboratory studies.

SETTING

Translational science laboratory.

INTERVENTION(S)

Human immortalized fibroid or myometrial cells were treated with 1,25-hydroxyvitamin D₃ (1,25(OH)₂D₃) and transfected using expression constructs for AKAP13 or AKAP13 mutants, RhoQL, C3 transferase, or small interfering ribonucleic acids (RNAs).

MAIN OUTCOME MEASURE(S)

Messenger ribonucleic acid (mRNA) levels of AKAP13, fibromodulin, and versican as measured by quantitative real-time polymerase chain reaction. Glutathione S-transferase-binding assays. Vitamin D-dependent gene activation as measured by luciferase assays.

RESULT(S)

1,25(OH)₂D₃ resulted in a significant reduction in mRNA levels encoding AKAP13, versican, and fibromodulin. Small interfering RNA silencing of AKAP13 decreased both fibromodulin and versican mRNA levels. Glutathione S-transferase-binding assays revealed that AKAP13 bound to the VDR through its nuclear receptor interacting region. Cotransfection of AKAP13 and VDR significantly reduced vitamin D-dependent gene activation. RhoA pathway inhibition partially relieved repression of vitamin D-dependent gene activation by AKAP13.

CONCLUSION(S)

These data suggest that AKAP13 inhibited the vitamin D receptor activation by a mechanism that required, at least in part, RhoA activation.

Single Incision Laparoscopic Surgery for Leiomyoma in the Adolescent Patient: A Case Report

BACKGROUND

Single-incision laparoscopic surgery (SILS) is an exciting new modality in the field of minimal access surgery. This case illustrates the feasibility of single-incision laparoscopic surgery for uterine pathology in the pediatric and adolescent population.

CASE

A 19-year-old girl presented with pelvic pain. Transabdominal pelvic ultrasound and magnetic resonance imaging revealed multiple fibroids with rapid enlargement over a year. In collaboration with the Minimally Invasive Gynecologic Surgery team, single incision laparoscopic myomectomy was performed with satisfactory results.

SUMMARY AND CONCLUSION

Complex uterine pathology can be managed with minimally invasive surgery with excellent clinical outcomes. SILS is a rapidly developing field that may represent the future of laparoscopic surgery and can be used to treat reproductive pathology in the pediatric and adolescent population.

MicroRNA-139-5p Regulates Fibrotic Potentials via Modulation of Collagen Type 1 and Phosphorylated p38 MAPK in Uterine Leiomyoma

PURPOSE

This study aimed to elucidate whether microRNA-139-5p is involved in the pathogenesis of uterine leiomyoma.

MATERIALS AND METHODS

Human leiomyoma and matched human smooth muscle samples were obtained from 10 women who underwent hysterectomy for uterine leiomyoma. MicroRNA (miRNA) expression was analyzed by quantitative real-time polymerase chain reaction. To assess the effects of miR-139-5p on cultured leiomyoma cells, cell migration, collagen gel contraction, wound healing, and the expression levels of hallmark proteins were evaluated in cells transfected with a miR-139-5p mimic.

RESULTS

The expression of miR-139-5p was significantly lower in leiomyoma tissues than in matched smooth muscle tissues. Restored miR-139-5p expression in miR-139-5p mimic-transfected human leiomyoma cells resulted in decreased contractility of the ECM and cell migration. In addition, upregulation of miR-139-5p decreased the protein expression of collagen type 1 and phosphorylated p38 MAPK.

CONCLUSION

Expression of miR-139-5p is downregulated in leiomyoma cells and modulation of miR-139-5p may be involved inthe pathogenesis of leiomyomas through the regulation of collagen type 1 and phosphorylated p38 MAPK. Therefore, miR-139-5p is a potential therapeutic target for leiomyoma.

Impact of Contraception on Uterine Fibroids

Background and Objectives: Uterine fibroids develop in 25–40% of women of childbearing age; however, there are discrepancies resulting from population and socioeconomic differences. The pathogenesis of fibroids is not clear. The aim of the study was to assess the potential connection between the use of oral contraceptives and the occurrence of uterine fibroids in women of childbearing age. Materials and Methods: In this prospective, survey, case–control study, data were collected from Caucasian female patients (mean age = 30) using a questionnaire concerning the onset, duration and form of hormonal contraception, and medical and obstetrical history. The questionnaires were handed personally to hospitalized patients as well as distributed through Google forms on social media. Results: In a study group (n = 140) of patients using hormonal contraception, 37.8% of them were diagnosed with uterine fibroids, whereas among the patients not using hormonal contraception (n = 206), uterine fibroids were diagnosed in 59.6% of the patients. The most common hormonal contraception was two-component hormonal tablets used by 93.3% of the patients. Taking contraceptives was a uterine fibroids protective factor (OR = 0.4, p = 0.007). In the study group, 5.5% of the patients were pregnant and 60.42% were diagnosed with uterine fibroids (OR = 4.4, p < 0.000001). Conclusion: Contraception was found to be a protective factor for uterine fibroids among the women surveyed. The presented data confirm the theory about the hormonal dependence of uterine fibroids.

Vascular biology of uterine fibroids: connecting fibroids and vascular disorders

Fibroids are benign tumors caused by the proliferation of myometrial smooth muscle cells in the uterus that can lead to symptoms such as abdominal pain, constipation, urinary retention, and infertility. While traditionally thought of as a disease process intrinsic to the uterus, accumulating evidence suggests that fibroid growth may be linked with the systemic vasculature system, although cell-intrinsic factors are certainly of principal importance in their inception. Fibroids are associated with essential hypertension and preeclampsia, as well as atherosclerosis, for reasons that are becoming increasingly elucidated. Factors such as the renin-angiotensin-aldosterone system, estrogen, and endothelial dysfunction all likely play a role in fibroid pathogenesis. In this review, we lay out a framework for reconceptualizing fibroids as a systemic vascular disorder, and discuss how pharmaceutical agents and other interventions targeting the vasculature may aid in the novel treatment of fibroids.

Several Fusion Genes Identified in a Spermatic Cord Leiomyoma With Rearrangements of Chromosome Arms 3p and 21q

BACKGROUND/AIM

Benign smooth-muscle tumors, leiomyomas, occur in nearly every organ but are most common in the uterus. Whereas much is known about the genetics of uterine leiomyomas, little genetic information exists about leiomyomas of other organs. Here, we report and discuss the genetic findings in a para-testicular leiomyoma.

MATERIALS AND METHODS

Cytogenetic, array comparative genomic hybridization (aCGH) RNA sequencing, reverse-transcription polymerase chain reaction (RT- PCR), and Sanger sequencing analyses were performed on a leiomyoma of the spermatic cord removed from a 61-year-old man.

RESULTS

The karyotype was 48~50,XY,add(3) (p21),+4,+7,+8,+9,add(21)(q22)[cp9]/46,XY[2]. aCGH confirmed the trisomies and also detected multiple gains and losses from 3p and 21q. RNA sequencing detected the chimeras ARHGEF3-CACNA2D2, TRAK1-TIMP4, ITPR1- DT-NR2C2, CLASP2-IL17RD, ZNF621-LARS2, CNTN4- RHOA, and NR2C2-CFAP410. All chimeras were confirmed by RT-PCR and Sanger sequencing.

CONCLUSION

Our data, together with those previously published, indicate that a group of leiomyomas may be cytogenetically characterized by aberrations of 3p and the formation of fusion genes.

A comparison of the pregnancy outcomes between ultrasound-guided high-intensity focused ultrasound ablation and laparoscopic myomectomy for uterine fibroids: a comparative study

Objective: To compare the pregnancy outcomes between ultrasound-guided high-intensity focused ultrasound (USgHIFU) ablation and laparoscopic myomectomy (LM).Materials and methods: This study included 676 women with symptomatic uterine fibroids who wished to become pregnant underwent USgHIFU or LM at three hospitals in China from 1 May 2009 to 31 May 2018. The related information of pregnancy and delivery were followed up and analyzed using the chi-square test and two-sided Student t-test.Results: The median follow-up duration was 5 (1-8) years; 20 patients (2.9%) were lost to follow-up. 320 patients were treated with UsgHIFU, and 336 were treated with LM. Two hundred nineteen (68.4%) women became pregnant after USgHIFU ablation, and 224 (66.7%) became pregnant after LM. Four hundred forty-three patients had 501 pregnancies (natural pregnancies, 405; in vitro fertilisation-embryo transfer pregnancies, 38). Average times to pregnancy were 13.6 ± 9.5 months after USgHIFU and 18.9 ± 7.3 months after LM (p < 0.05). The rate of cesarean delivery was lower in the USgHIFU group (41.6%) than in the LM group (54.9%) (p < 0.05). Incidences of placenta increta, placenta previa, and postpartum hemorrhage were low after USgHIFU compared with after LM. Incidences of preterm birth, fetal distress, fetal growth restriction, and puerperal infection were higher after USgHIFU than after LM. There was a risk of uterine rupture after both procedures.Conclusions: Compared with LM, USgHIFU ablation can significantly shorten the time to pregnancy, although pregnancy rates of the two procedures are similar. Some risks in pregnancy and delivery after HIFU should be evaluated and monitored.

Genomic alterations in gynecological malignancies: histotype-associated driver mutations, molecular subtyping schemes, and tumorigenic mechanisms

There are numerous histological subtypes (histotypes) of gynecological malignancies, with each histotype considered to largely reflect a feature of the "cell of origin," and to be tightly linked with the clinical behavior and biological phenotype of the tumor. The recent advances in massive parallel sequencing technologies have provided a more complete picture of the range of the genomic alterations that can persist within individual tumors, and have highlighted the types and frequencies of driver-gene mutations and molecular subtypes often associated with these histotypes. Several large-scale genomic cohorts, including the Cancer Genome Atlas (TCGA), have been used to characterize the genomic features of a range of gynecological malignancies, including high-grade serous ovarian carcinoma, uterine corpus endometrial carcinoma, uterine cervical carcinoma, and uterine carcinosarcoma. These datasets have also been pivotal in identifying clinically relevant molecular targets and biomarkers, and in the construction of molecular subtyping schemes. In addition, the recent widespread use of clinical sequencing for the more ubiquitous types of gynecological cancer has manifested in a series of large genomic datasets that have allowed the characterization of the genomes, driver mutations, and histotypes of even rare cancer types, with sufficient statistical power. Here, we review the field of gynecological cancer, and seek to describe the genomic features by histotype. We also will demonstrate how these are linked with clinicopathological attributes and highlight the potential tumorigenic mechanisms.

Robotic single-site versus multi-port myomectomy: a case-control study

Background

This study aimed to evaluate the compatibility of robotic single-site (RSS) myomectomy in comparison with the conventional robotic multi-port (RMP) myomectomy to achieve successful surgical outcomes with reliability and reproducibility.

Methods

This retrospective case–control study was performed on 236 robotic myomectomies at a university medical center. After 1:1 propensity score matching for the total myoma number, total myoma diameter, and patient age, 90 patients in each group (RSS: n = 90; RMP: n = 90) were evaluated. Patient demographics, preoperative parameters, intraoperative characteristics, and postoperative outcome measures were analyzed.

Results

The body mass index, parity, preoperative hemoglobin levels, mean maximal myoma diameter, and anatomical type of myoma showed no mean differences between RSS and RMP myomectomies. The RSS group was younger, had lesser number of myomas removed, and had a smaller sum of the maximal diameter of total myomas removed than the RMP group. After propensity score matching, the total operative time (RSS: 150.9 ± 57.1 min vs. RMP: 170 ± 74.5 min, p = 0.0296) was significantly shorter in the RSS group. The RSS group tended to have a longer docking time (RSS: 9.8 ± 6.5 min vs. RMP: 8 ± 6.2 min, p = 0.0527), shorter console time (RSS: 111.1 ± 52.3 min vs. RMP: 125.8 ± 65.1 min, p = 0.0665), and shorter time required for in-bag morcellation (RSS: 30.1 ± 17.2 min vs. RMP: 36.2 ± 25.7 min, p = 0.0684). The visual analog scale pain score 1 day postoperatively was significantly lower in the RSS group (RSS: 2.4 ± 0.8 days vs. RMP: 2.7 ± 0.8 days, p = 0.0149), with similar consumption of analgesic drugs. The rate of transfusion, estimated blood loss during the operation, and length of hospital stay were not different between the two modalities. No other noticeable complications were observed in either group.

Conclusions

Da Vinci RSS myomectomy is a compatible option with regard to reproducibility and safety, without significantly compromising the number and sum of the maximal diameter of myomas removed. The advantage of shorter total operative time and less pain with the same amount of analgesic drugs in RSS myomectomy will contribute to improving patient satisfaction.

Uterine myoma is associated with an increased risk of lung cancer: A nationwide population-based cohort study

OBJECTIVE

The rate of lung cancer in female patients is increasing, with different features from male patients being displayed. Hormonal factors could play a role. The association between the development of uterine myoma (UM) and female hormones has also been reported. The relationship between female lung cancer and UM may be due to the effect of female hormones.

METHODS

Data from 50 711 Taiwanese women with UM were retrieved from the National Health Insurance Research Database between 2000 and 2012. They were propensity-score matched with 50 711 women without UM (control group). A multivariate Cox proportional hazard regression model was used to compare the incidence of lung cancer between groups and to determine the hazard ratio of lung cancer in the UM group.

RESULTS

The risk of lung cancer was significantly higher in women with myoma (adjusted hazard ratio: 1.62, 95% confidence ratio = 1.24-2.12). Stratified analyses demonstrated that the significantly increased risk of lung cancer was more likely to be found in certain groups, such as women who (a) are of younger age, (b) have a mid-level income, (c) have the highest urbanisation level, (d) are office workers and (e) with a longer follow-up period of myoma. Furthermore, myomectomy did not affect the risk pattern.

CONCLUSION

The results from this nationwide population-based cohort study suggested that UM is associated with a higher risk of developing lung cancer. However, the exact underlying mechanism accounted for this remains unclear, and our findings still need to be verified by further comprehensive studies elsewhere.

Macrophages and Immune Responses in Uterine Fibroids

Uterine fibroids represent the most common benign tumors of the uterus. They are considered a typical fibrotic disorder. In fact, the extracellular matrix (ECM) proteins—above all, collagen 1A1, fibronectin and versican—are upregulated in this pathology. The uterine fibroids etiology has not yet been clarified, and this represents an important matter about their resolution. A model has been proposed according to which the formation of an altered ECM could be the result of an excessive wound healing, in turn driven by a dysregulated inflammation process. A lot of molecules act in the complex inflammatory response. Macrophages have a great flexibility since they can assume different phenotypes leading to the tissue repair process. The dysregulation of macrophage proliferation, accumulation and infiltration could lead to an uncontrolled tissue repair and to the consequent pathological fibrosis. In addition, molecules such as monocyte chemoattractant protein-1 (MCP-1), granulocyte macrophage-colony-stimulating factor (GM-CSF), transforming growth factor-beta (TGF-β), activin A and tumor necrosis factor-alfa (TNF-α) were demonstrated to play an important role in the macrophage action within the uncontrolled tissue repair that contributes to the pathological fibrosis that represents a typical feature of the uterine fibroids.

Nutraceuticals in fibroid management after ulipristal acetate administration: An observational study on patients' compliance

OBJECTIVE

On May 13, 2020, the Italian government Pharmaceutical Agency (AIFA) stopped ulipristal acetate (UPA) treatments for uterine fibroids (UFs), so patients shifted to other natural treatments. The authors tested the patients' compliance with UF natural treatments.

METHODS

Thirty patients of reproductive age (30-45 years) affected by UFs stopped UPA intake and started epigallocatechin gallate (EGCG) plus vitamin D3 treatment. Patients were asked to complete the Uterine Fibroid symptoms and Quality of Life (UFS-QOL) questionnaire, divided into symptoms severity (SS) and health-related quality of life (HRQL), after UPA suspension and to repeat it after 3 months of natural treatment. Collected data were analyzed using paired Student's t test, considering a P value less than 0.05 to be significant.

RESULTS

The SS score was significantly lower (-12.19%) for natural treatment when compared with UPA administration. The HRQL score significantly improved (+11.79%) after shifting treatment from UPA to natural therapy. All the investigated parameters appeared improved by 10% after the natural treatment. No adverse effects were reported following the natural treatment.

CONCLUSION

Natural treatments showed positive compliance in patients with UFs, based on HRQL score, representing an alternative therapeutic opportunity for patients forced to stop UPA therapy.

Transcriptome Analyses of Myometrium from Fibroid Patients Reveals Phenotypic Differences Compared to Non-Diseased Myometrium

Uterine fibroid tissues are often compared to their matched myometrium in an effort to understand their pathophysiology, but it is not clear whether the myometria of uterine fibroid patients represent truly non-disease control tissues. We analyzed the transcriptomes of myometrial samples from non-fibroid patients (M) and compared them with fibroid (F) and matched myometrial (MF) samples to determine whether there is a phenotypic difference between fibroid and non-fibroid myometria. Multidimensional scaling plots revealed that M samples clustered separately from both MF and F samples. A total of 1169 differentially expressed genes (DEGs) (false discovery rate < 0.05) were observed in the MF comparison with M. Overrepresented Gene Ontology terms showed a high concordance of upregulated gene sets in MF compared to M, particularly extracellular matrix and structure organization. Gene set enrichment analyses showed that the leading-edge genes from the TGFβ signaling and inflammatory response gene sets were significantly enriched in MF. Overall comparison of the three tissues by three-dimensional principal component analyses showed that M, MF, and F samples clustered separately from each other and that a total of 732 DEGs from F vs. M were not found in the F vs. MF, which are likely understudied in the pathogenesis of uterine fibroids and could be key genes for future investigation. These results suggest that the transcriptome of fibroid-associated myometrium is different from that of non-diseased myometrium and that fibroid studies should consider using both matched myometrium and non-diseased myometrium as controls.

Epigenomic tensor predicts disease subtypes and reveals constrained tumor evolution

Understanding the epigenomic evolution and specificity of disease subtypes from complex patient data remains a major biomedical problem. We here present DeCET (decomposition and classification of epigenomic tensors), an integrative computational approach for simultaneously analyzing hierarchical heterogeneous data, to identify robust epigenomic differences among tissue types, differentiation states, and disease subtypes. Applying DeCET to our own data from 21 uterine benign tumor (leiomyoma) patients identifies distinct epigenomic features discriminating normal myometrium and leiomyoma subtypes. Leiomyomas possess preponderant alterations in distal enhancers and long-range histone modifications confined to chromatin contact domains that constrain the evolution of pathological epigenomes. Moreover, we demonstrate the power and advantage of DeCET on multiple publicly available epigenomic datasets representing different cancers and cellular states. Epigenomic features extracted by DeCET can thus help improve our understanding of disease states, cellular development, and differentiation, thereby facilitating future therapeutic, diagnostic, and prognostic strategies.

Leistico et al. apply tensor decomposition and classification methods to integrate information from hierarchical heterogenous epigenomic datasets and identify histone modification patterns that discriminate disease conditions, tissue types, and differentiation states. Leiomyomas are shown to possess alterations in distal enhancers and large-scale regions confined to chromatin contact domains.

Effects of Phthalate Esters on Human Myometrial and Fibroid Cells: Cell Culture and NOD-SCID Mouse Data

Evidence is growing that phthalate esters play an important role in the pathogenesis of estrogen-dependent gynecologic diseases, especially uterine fibroids. We aimed to investigate whether in vitro treatment with di-(2-ethylhexyl)-phthalate (DEHP) affects angiogenesis, proliferation, and apoptosis in uterine fibroids. To ascertain this, we evaluated vascular endothelial growth factor (VEGF) expression and AKT/ERT phosphorylation and compared the fibroid volume between nonobese diabetic/severe combined immunodeficiency (NOD/SCID) mice fed with and without DEHP. VEGF expression was measured using enzyme-linked immunosorbent assay, and AKT/ERK phosphorylation was analyzed by western blot analysis in human myometrial and fibroid cells. The volume of the fibroid tissues implanted to NOD/SCID mice was measured, and the expression of collagen type I protein, Ki-67, proliferating cell nuclear antigen, and B cell lymphoma 2 were analyzed using immunohistochemistry. We could see significant increases in VEGF expression and AKT phosphorylation in human myometrial and fibroid cells treated with DEHP. The volume of the fibroid tissues was significantly increased in NOD/SCID mice fed with DEHP, which was accompanied by increased expression of collagen type I and AKT phosphorylation. Taken together, these results suggest that exposure to phthalate esters may influence uterine fibroid pathogenesis by increasing VEGF and collagen expression and upregulating AKT phosphorylation.

Candidate Genes for Age at Menarche Are Associated With Uterine Leiomyoma

Age at menarche (AAM) is an important marker of the pubertal development and function of the hypothalamic-pituitary-ovarian system. It was reported as a possible factor for a risk of uterine leiomyoma (UL). However, while more than 350 loci for AAM have been determined by genome-wide association studies (GWASs) to date, no studies of these loci for their association with UL have been conducted so far. In this study, we analyzed 52 candidate loci for AAM for possible association with UL in a sample of 569 patients and 981 controls. The results of the study suggested that 23 out of the 52 studied polymorphisms had association with UL. Locus rs7759938 LIN28B was individually associated with the disease according to the dominant model. Twenty loci were associated with UL within 11 most significant models of intergenic interactions. Nine loci involved in 16 most significant models of interactions between single-nucleotide polymorphism (SNP), induced abortions, and chronic endometritis were associated with UL. Among the 23 loci associated with UL, 16 manifested association also with either AAM (7 SNPs) or height and/or body mass index (BMI) (13 SNPs). The above 23 SNPs and 514 SNPs linked to them have non-synonymous, regulatory, and expression quantitative trait locus (eQTL) significance for 35 genes, which play roles in the pathways related to development of the female reproductive organs and hormone-mediated signaling [false discovery rate (FDR) ≤ 0.05]. This is the first study reporting associations of candidate genes for AAM with UL.