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He Q, Wan S, Jiang M, Li W, Zhang Y, Zhang L, Wu M, Lin J, Zou L, Hu Y. Exploring the therapeutic potential of tonic Chinese herbal medicine for gynecological disorders: An updated review. JOURNAL OF ETHNOPHARMACOLOGY 2024; 329:118144. [PMID: 38583732 DOI: 10.1016/j.jep.2024.118144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 03/19/2024] [Accepted: 04/01/2024] [Indexed: 04/09/2024]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Gynecological disorders have the characteristics of high incidence and recurrence rate, which sorely affects female's health. Since ancient times, traditional Chinese medicine (TCM), especially tonic medicine (TM), has been used to deal with gynecological disorders and has unique advantages in effectiveness and safety. AIM OF THE REVIEW In this article, we aim to summarize the research progress of TMs in-vivo and in-vitro, including their formulas, single herbs, and compounds, for gynecological disorders treatment in recent years, and to offer a reference for further research on the treatment of gynecological disorders and their clinical application in the treatment of TMs. MATERIALS AND METHODS Relevant information on the therapeutic potential of TMs against gynecological disorders was collected from several scientific databases including Web of Science, PubMed, CNKI, Google Scholar and other literature sources. RESULTS So far, there are 46 different formulas, 3 single herbs, and 24 compounds used in the treatment of various gynecological disorders such as premature ovarian failure, endometriosis breast cancer, and so on. Many experimental results have shown that TMs can regulate apoptosis, invasion, migration, oxidative stress, and the immune system. In addition, the effect of TMs in gynecological disorders treatment may be due to the regulation of VEGF, PI3K-AKT, MAPK, NF-κB, and other signaling pathways. Apparently, TMs play an active role in the treatment of gynecological disorders by regulating these signaling pathways. CONCLUSION TMs have a curative effect on the prevention and treatment of gynecological disorders. It could relieve and treat gynecological disorders through a variety of pathways. Therefore, the appropriate TM treatment program makes it more possible to treat gynecological disorders.
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Affiliation(s)
- Qizhi He
- School of Pharmacy, Zunyi Medical University, Guizhou, China; School of Preclinical Medicine, Chengdu University, Chengdu, China
| | - Shun Wan
- Hunan University of Chinese Medicine, Changsha, China
| | - Mingli Jiang
- School of Pharmacy, Zunyi Medical University, Guizhou, China
| | - Wei Li
- School of Preclinical Medicine, Chengdu University, Chengdu, China
| | - Yan Zhang
- School of Preclinical Medicine, Chengdu University, Chengdu, China
| | - Lele Zhang
- School of Preclinical Medicine, Chengdu University, Chengdu, China
| | - Mengyao Wu
- Department of Pharmacology, Zhuzhou Qianjin Pharmaceutical Co., Ltd., Zhuzhou, China
| | - Jie Lin
- Clinical Medical College & Affiliated Hospital of Chengdu University, Chengdu, China
| | - Liang Zou
- School of Pharmacy, Zunyi Medical University, Guizhou, China; Key Laboratory of Coarse Cereal Processing of Ministry of Agriculture and Rural Affairs, Chengdu University, Chengdu, China.
| | - Yingfan Hu
- School of Preclinical Medicine, Chengdu University, Chengdu, China.
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Vannuccini S, Petraglia F, Carmona F, Calaf J, Chapron C. The modern management of uterine fibroids-related abnormal uterine bleeding. Fertil Steril 2024; 122:20-30. [PMID: 38723935 DOI: 10.1016/j.fertnstert.2024.04.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 04/29/2024] [Accepted: 04/29/2024] [Indexed: 06/21/2024]
Abstract
Uterine fibroids (UFs) are the most common female benign pelvic tumors, affecting >60% of patients aged 30-44 years. Uterine fibroids are asymptomatic in a large percentage of cases and may be identified incidentally using a transvaginal ultrasound or a magnetic resonance imaging scan. However, in approximately 30% of cases, UFs affect the quality of life and women's health, with abnormal uterine bleeding and heavy menstrual bleeding being the most common complaints, along with iron deficiency (ID) and ID anemia. Medical treatments used for UFs-related abnormal uterine bleeding include symptomatic agents, such as nonsteroidal antiinflammatory drugs and tranexamic acid, and hormonal therapies, including combined oral contraceptives, gonadotropin-releasing hormone agonists or antagonists, levonorgestrel intrauterine systems, selective progesterone receptor modulators, and aromatase inhibitors. Nevertheless, few drugs are approved specifically for UF treatment, and most of them manage the symptoms. Surgical options include fertility-sparing treatments, such as myomectomy, or nonconservative options, such as hysterectomy, especially in perimenopausal women who are not responding to any treatment. Radiologic interventions are also available: uterine artery embolization, high-intensity focused ultrasound or magnetic resonance-guided focused ultrasound, and radiofrequency ablation. Furthermore, the management of ID and ID anemia, as a consequence of acute and chronic bleeding, should be taken into account with the use of iron replacement therapy both during medical treatment and before and after a surgical procedure. In the case of symptomatic UFs, the location, size, multiple UFs, or coexistent adenomyosis should guide the choice with a shared decision-making process, considering long- and short-term treatment goals expected by the patient, including pregnancy desire or wish to preserve the uterus independently of reproductive goals.
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Affiliation(s)
- Silvia Vannuccini
- Division of Obstetrics and Gynecology, Department of Experimental, Clinical, and Biomedical Sciences, University of Florence, Careggi University Hospital, Florence, Italy.
| | - Felice Petraglia
- Division of Obstetrics and Gynecology, Department of Experimental, Clinical, and Biomedical Sciences, University of Florence, Careggi University Hospital, Florence, Italy
| | - Francisco Carmona
- Department of Obstetrics and Gynecology, Hospital Clínic of Barcelona, Barcelona, Spain
| | - Joaquim Calaf
- Hospital Sant Pau, Autonomous University of Barcelona, Barcelona, Spain
| | - Charles Chapron
- Département de Gynécologie, Obstétrique et Médecine de la Reproduction, Faculté de Santé, Faculté de Médicine Paris Centre, Centre Hospitalier Universitaire (CHU), Université Paris-Cité, Paris, France
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Donnez J, Taylor HS, Marcellin L, Dolmans MM. Uterine fibroid-related infertility: mechanisms and management. Fertil Steril 2024; 122:31-39. [PMID: 38453041 DOI: 10.1016/j.fertnstert.2024.02.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 02/29/2024] [Indexed: 03/09/2024]
Abstract
Fibroids are a common pathology and increasingly observed in women seeking medical treatment for infertility. The longer reproductive horizon because of improvements in medical care and current trend for women to postpone childbearing are making fibroid-related infertility increasingly common. This review aimed to critically analyze the association between uterine fibroids and infertility, mechanisms by which uterine fibroids may impair fertility, and management of myoma-related infertility. The association of fibroids with infertility is a source of controversy. As the focus of this review is infertility, it is crucial to analyze the mechanisms by which fertility may be impaired by the presence of fibroids. Current management strategies involve mainly surgical interventions, including myomectomy by hysteroscopy, laparotomy, or laparoscopy, and nonsurgical approaches, such as uterine artery embolization and focused ultrasound performed under radiologic or echographic guidance. The risks and benefits of each option should be discussed with patients, and several factors need to be considered, including the skills of surgeons and availability of different resources in various centers. Concerning the efficacy of oral gonadotropin-releasing hormone antagonists (i.e., elagolix, relugolix, and linzagolix), they were shown to have a rapid impact on heavy menstrual bleeding (HMB) in >70% of women. When used without add-back therapy, these drugs cause a significant reduction in fibroid volume, namely, approximately 50% from baseline to week 24. Further studies are required to determine the best protocol and optimal dosage if a reduction in myoma volume is the main goal, as in case of myoma-related infertility.
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Affiliation(s)
- Jacques Donnez
- Université Catholique de Louvain, Ottignies-Louvain-la-Neuve, Belgium; Society for Research into Infertility (SRI), Brussels, Belgium.
| | - Hugh S Taylor
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
| | - Louis Marcellin
- Département de Gynécologie Obstétrique II et Médecine de la Reproduction, Université Paris Cité, Assistance Publique-Hôpitaux de Paris (AP-HP), Centre Hospitalier Universitaire (CHU) Cochin, Hôpital Universitaire Paris Centre (HUPC), Paris, France
| | - Marie-Madeleine Dolmans
- Pôle de Recherche en Gynécologie, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain (UCL), Brussels, Belgium; Gynecology Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
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Chen MJ, Marroum P, Chiu YL, Neenan M, Mostafa NM, Shebley M. Bioequivalence of Elagolix/Estradiol/Norethindrone Acetate Fixed-Dose Combination Product: Phase 1 Results in Healthy Pre- and Postmenopausal Women. Clin Pharmacol Drug Dev 2024; 13:601-610. [PMID: 38593267 DOI: 10.1002/cpdd.1399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 02/26/2024] [Indexed: 04/11/2024]
Abstract
Fixed-dose combination (FDC) therapies can enhance patient convenience and adherence to prescribed treatment regimens. Elagolix is a novel oral gonadotropin-releasing hormone receptor antagonist approved for management of moderate to severe pain associated with endometriosis and heavy menstrual bleeding associated with uterine fibroids. Hormonal add-back therapy can attenuate the reversible hypoestrogenic effects of elagolix. An FDC formulation containing elagolix/estradiol (E2)/norethindrone acetate (NETA) 300/1/0.5 mg as the morning dose and an elagolix 300 mg capsule as the evening dose, were evaluated in 2 bioequivalence studies including the effects of food. Study 1 in premenopausal women assessed the bioavailability of the elagolix 300-mg capsule relative to the commercially available elagolix 300-mg tablet. Study 2 in postmenopausal women, elagolix/E2/NETA (300 mg/1 mg/0.5 mg) FDC capsule was assessed relative to the elagolix 300-mg tablet coadministered with E2/NETA 1-mg/0.5-mg tablet, the regimen that was studied in Phase 3 uterine fibroid studies. Under fasting conditions, the test elagolix 300-mg capsule was bioequivalent to the reference elagolix 300-mg tablet. Under fasting conditions, the elagolix/E2/NETA FDC capsule was bioequivalent to the coadministered elagolix 300-mg tablet and E2/NETA 1/0.5-mg tablet. Following administration of elagolix/E2/NETA FDC capsule after a high-fat breakfast, elagolix mean maximum concentration (Cmax) and area under the plasma concentration-time curve (AUC) were 38% and 28% lower, relative to fasting conditions. NETA mean Cmax was 51% lower and AUC from time 0 to infinity was 20% higher, while baseline-adjusted total estrone mean Cmax and AUC were 46% and 14% lower, respectively. No safety concerns were identified. These results enabled bridging the elagolix/E2/NETA FDC capsule.
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Affiliation(s)
- Mong-Jen Chen
- Clinical Pharmacology, AbbVie Inc., North Chicago, IL, USA
| | | | - Yi-Lin Chiu
- Data and Statistical Sciences, AbbVie Inc., North Chicago, IL, USA
| | - Melina Neenan
- Quantitative Translational ADME Sciences, AbbVie Inc., North Chicago, IL, USA
| | - Nael M Mostafa
- Clinical Pharmacology, AbbVie Inc., North Chicago, IL, USA
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Makary MS, Zane K, Hwang GL, Kim CY, Ahmed O, Knavel Koepsel EM, Monroe EJ, Scheidt MJ, Smolock AR, Stewart EA, Wasnik AP, Pinchot JW. ACR Appropriateness Criteria® Management of Uterine Fibroids: 2023 Update. J Am Coll Radiol 2024; 21:S203-S218. [PMID: 38823944 DOI: 10.1016/j.jacr.2024.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 02/28/2024] [Indexed: 06/03/2024]
Abstract
Uterine fibroids are the most common benign tumor in women of reproductive age and can present with symptoms including bleeding, bulk related symptoms, and infertility. Several treatment options are available for the management of uterine fibroids, including medical management, minimally invasive therapies such as uterine artery embolization and MR-guided focused ultrasound ablation, and surgical interventions ranging from laparoscopic myomectomy to open hysterectomy. Given this wide range of therapeutic interventions, it is important to understand the data supporting these interventions and to be able to apply it in different clinical settings. This document provides a summary of recent trials supporting various therapies for uterine fibroids, including recent evidence for MR-guided focused ultrasound ablation and a detailed discussion of fertility outcomes in myomectomy and uterine fibroid embolization. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
- Mina S Makary
- Ohio State University Wexner Medical Center, Columbus, Ohio.
| | - Kylie Zane
- Research Author, University of Chicago Hospitals, Chicago, Illinois
| | - Gloria L Hwang
- Stanford University School of Medicine, Stanford, California
| | - Charles Y Kim
- Panel Chair, Duke University Medical Center, Durham, North Carolina
| | | | | | | | | | - Amanda R Smolock
- Froedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Elizabeth A Stewart
- Mayo Clinic and Mayo Clinic Alix School of Medicine; American College of Obstetricians and Gynecologists
| | | | - Jason W Pinchot
- Specialty Chair, University of Wisconsin, Madison, Wisconsin
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Chang E, Shi YF, Liu JF, Wei W. Post-marketing safety concerns with elagolix: a disproportionality analysis of the FDA adverse event reporting system. Expert Opin Drug Saf 2024:1-8. [PMID: 38700323 DOI: 10.1080/14740338.2024.2351451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 03/01/2024] [Indexed: 05/05/2024]
Abstract
OBJECTIVE Elagolix is approved for the treatment of moderate-to-severe pain associated with endometriosis. However, the long-term safety of elagolix in a large sample of real-world patients is unknown. METHODS The U.S. Food and Drug Administration Adverse Event Reporting System (FAERS) reports were collected and analyzed from January 2019 to June 2023. Disproportionality analyses, including the reporting odds ratio (ROR), the proportional reporting ratio (PRR), the Bayesian confidence propagation neural network (BCPNN), and the multi-item gamma Poisson shrinker (MGPS) algorithms, were employed in data mining to quantify the signals of elagolix-related adverse events (AEs). RESULTS After removing the non-drug-related AE signals, we detected several AE signals such as hot flushes, bone pain, suicidal ideation, depression, and increased liver enzymes, which were known during the clinical trial phase. In addition to this, we detected several unexpected important AEs that were not mentioned in the drug insert, including cystitis interstitial, parosmia, and epiploic appendagitis. The median onset time of elagolix-associated AEs was 28.5 days. CONCLUSION Our study provides a comprehensive picture of the safety of elagolix in the post-marketing setting, while also identifying potential new AE signals. These findings emphasize the importance of continued monitoring of the potential risks of elagolix.
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Affiliation(s)
- En Chang
- Department of Pharmacy, People's Hospital of Zhongjiang County, Deyang, Sichuan, China
| | - Yong-Fang Shi
- College of Pharmacy, Heze University, Heze, Shandong, China
| | - Jin-Feng Liu
- Department of Pharmacy, People's Hospital of Zhongjiang County, Deyang, Sichuan, China
| | - Wei Wei
- Department of Pharmacy, People's Hospital of Zhongjiang County, Deyang, Sichuan, China
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Evangelisti G, Ferrero S, Perrone U, Gustavino C, Volpi E, Izzotti A, Barra F. Experimental and new investigational drugs for the treatment of uterine fibroids. Expert Opin Investig Drugs 2024; 33:497-508. [PMID: 38618931 DOI: 10.1080/13543784.2024.2343786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Accepted: 04/12/2024] [Indexed: 04/16/2024]
Abstract
INTRODUCTION Uterine fibroids, the most prevalent benign tumors among reproductive-age women, pose treatment challenges that range from surgical interventions to medical therapies for symptom control. Progestins and estroprogestins effectively manage uterine bleeding by suppressing dysfunctional endometrium over fibroids. While GnRH agonists represent a crucial milestone in symptom treatment, their prolonged use results in menopausal-like symptoms and irreversible bone mineral density loss. Advancements in understanding fibroid pathophysiology have prompted the exploration of new compounds to overcome current therapy limitations. AREAS COVERED This manuscript offers an updated overview of investigational drugs for symptomatic uterine fibroids. EXPERT OPINION Despite ulipristal acetate's well-established efficacy as a selective progesterone receptor modulator (SPRM) in fibroid treatment, its prescription has declined due to the rare but severe risk of liver damage. Oral GnRH antagonists, like elagolix, relugolix, and linzagolix, with their novel pharmacodynamic properties, are gaining traction in fibroid management, inducing a dose-dependent reduction in circulating sex hormone levels. Ongoing research on natural compounds, such as vitamin D and epigallocatechin gallate (EGCG), presents emerging options for treating uterine fibroids. This evolving landscape reflects the ongoing efforts to improve therapeutic outcomes for individuals with symptomatic uterine fibroids.
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Affiliation(s)
- Giulio Evangelisti
- Unit of Obstetrics and Gynecology, San Paolo Hospital - ASL2, Savona, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
| | - Simone Ferrero
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Umberto Perrone
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Claudio Gustavino
- Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Eugenio Volpi
- Unit of Obstetrics and Gynecology, San Paolo Hospital - ASL2, Savona, Italy
| | - Alberto Izzotti
- Unit of Mutagenesis and Cancer Prevention, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Experimental Medicine (DIMES), University of Genoa, Genoa, Italy
| | - Fabio Barra
- Unit of Obstetrics and Gynecology, P.O. "Ospedale del Tigullio"- ASL4, Chiavari, Genoa, Italy
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
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de Lange ME, Semmler A, Clark TJ, Mol BWJ, Bet PM, Huirne JAF, Hehenkamp WJK. Considerations on implementation of the newest treatment for symptomatic uterine fibroids: Oral GnRH antagonists. Br J Clin Pharmacol 2024; 90:392-405. [PMID: 37653680 DOI: 10.1111/bcp.15897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 08/22/2023] [Accepted: 08/23/2023] [Indexed: 09/02/2023] Open
Abstract
Novel gonadotrophin releasing hormone (GnRH) antagonist treatments have recently been developed in combination with hormonal add-back therapy, as an oral treatment option for women suffering from uterine fibroids. Registration trials assessing the GnRH antagonist combination preparations with relugolix, elagolix and linzagolix have assessed treatment efficacy for fibroid-related heavy menstrual blood loss in comparison to placebo. Marketing authorization has been granted by several agencies including those in Europe, the United Kingdom and the United States. While the registration trials report a robust effect on the reduction of heavy menstrual blood loss and improvement in quality of life scores, reticence is advised before widespread prescription. In this review, we demonstrate limitations in the trial data, namely a lack of generalizability due to the restricted study population, the lack of transparency in the distribution of disease-level characteristics limiting the predictability of treatment success in the real-world diverse population, and the absence of any comparison to current alternative treatment methods. Importantly, no clinically meaningful volume reductions were found with GnRH antagonist combination preparations, and long-term safety data, particularly concerning modest but stable bone mineral density decline, need further addressing. Symptoms related to uterine fibroids adversely affect many women's quality of life and effective medical treatments are lacking. However, despite the urgent need for conservative treatments, it is vitally important that novel drugs, like combination oral GnRH antagonists, undergo sufficiently rigorous evaluation of safety, effectiveness and cost-effectiveness in a representative population and are compared with alternative treatment methods before introduction into mainstream clinical practice.
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Affiliation(s)
- Maria E de Lange
- Department of Obstetrics and Gynaecology, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - Annika Semmler
- Department of Obstetrics and Gynaecology, Amsterdam UMC, location Vrije Universteit MC, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - T Justin Clark
- Department of Obstetrics and Gynaecology, Birmingham Women's and Children's Hospital, Birmingham, UK
| | - Ben Willem J Mol
- Department of Obstetrics and Gynaecology, Monash University Monash Medical Centre, Clayton, Victoria, Australia
- Department of Obstetrics and Gynaecology, Aberdeen Centre for Women's Health Research, University of Aberdeen, Aberdeen, UK
- Department of Obstetrics and Gynaecology, University of Aberdeen, Aberdeen, UK
| | - Pierre M Bet
- Department of Clinical Pharmacology and Pharmacy, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Judith A F Huirne
- Department of Obstetrics and Gynaecology, Amsterdam UMC, location Vrije Universteit MC, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Wouter J K Hehenkamp
- Department of Obstetrics and Gynaecology, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
- Department of Obstetrics and Gynaecology, Amsterdam UMC, location Vrije Universteit MC, Amsterdam, The Netherlands
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Al-Hendy A, Venturella R, Arjona Ferreira JC, Li Y, Soulban G, Wagman RB, Lukes AS. LIBERTY randomized withdrawal study: relugolix combination therapy for heavy menstrual bleeding associated with uterine fibroids. Am J Obstet Gynecol 2023; 229:662.e1-662.e25. [PMID: 37666383 DOI: 10.1016/j.ajog.2023.08.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 08/08/2023] [Accepted: 08/29/2023] [Indexed: 09/06/2023]
Abstract
BACKGROUND In the pivotal LIBERTY 1 and 2 trials and long-term extension study, once-daily relugolix combination therapy (40 mg relugolix, 1 mg estradiol, 0.5 mg norethindrone acetate) reduced menstrual blood loss volume and pain among women with uterine fibroids. Relugolix combination therapy was well tolerated with preservation of bone mineral density through 52 weeks. OBJECTIVE This study aimed to report the 2-year relugolix combination therapy efficacy and safety results of the phase 3 LIBERTY randomized withdrawal study. STUDY DESIGN Women with uterine fibroid-associated heavy menstrual bleeding who completed the 24-week LIBERTY 1 or 2 trials, followed by the 28-week long-term extension study (up to 52 weeks total treatment), and who met the responder criteria (menstrual blood loss volume <80 mL and ≥50% reduction from pivotal study baseline at week 48 [week 24 of long-term extension]) were randomized in a 1:1 ratio to either blinded treatment with relugolix combination therapy or placebo for 52 weeks (total treatment period, 104 weeks). For women who had a relapse of heavy menstrual bleeding during the study (menstrual blood loss volume ≥80 mL), open-label relugolix combination therapy was offered. The primary endpoint was the proportion of women who maintained menstrual blood loss volume <80 mL through week 76 (week 24 of randomized withdrawal study). Secondary endpoints included time to menstrual blood loss volume ≥80 mL, proportion of women who maintained a menstrual blood loss volume of <80 mL through week 104 (over the 52-week randomized treatment period), the proportion of women who achieved or maintained amenorrhea at week 76 at the end of treatment, and the change in Uterine Fibroid Symptom-Quality of Life Bleeding and Pelvic Discomfort Scale and symptom severity scores. Analyses were performed for the modified intent-to-treat population, including all randomized women who received ≥1 dose of the study drug. RESULTS Of the 229 randomized women (relugolix combination therapy, n=115; placebo, n=114), 228 received the study drug and 175 (76.7%) completed the randomized withdrawal study. Through week 76, 78.4% of women on relugolix combination therapy maintained menstrual blood loss volume <80 mL vs 15.1% in the placebo group (difference, 63.4%; 95% confidence interval, 52.9%-73.9%; P<.0001). At week 104, 69.8% of women on relugolix combination therapy maintained menstrual blood loss volume <80 mL vs 11.8% in the placebo group (difference, 58.0%; 95% confidence interval, 47.0%-69.1%; P<.0001). Through week 104, 88.3% of women on placebo relapsed with heavy menstrual bleeding (median time to relapse, 5.9 weeks). Among the 89 women in the placebo group who relapsed and received open-label rescue treatment, 87 women responded to relugolix combination therapy with a menstrual blood loss volume <80 mL. The proportion of women who achieved or maintained amenorrhea were 57.4% vs 13.3% at week 76 (difference, 44.1%; 95% confidence interval, 33.10%-55.1%; P<.0001) and 58.3% vs 10.6% at week 104 (difference, 47.6%; 95% confidence interval, 37.0%-58.3%; nominal P<.0001) for relugolix combination therapy and the placebo group, respectively. Relugolix combination therapy was generally well tolerated; no new safety signals were identified, and the adverse event profile over the second year was consistent with that reported through the first year of treatment. Bone mineral density remained stable in women who received relugolix combination therapy from week 52 to week 104. In women continuously treated with relugolix combination therapy up to 2 years, bone mineral density was generally preserved. CONCLUSION After 2 years of treatment with relugolix combination therapy, there was evidence of durability of the effect in maintaining low menstrual blood loss volume in women with symptomatic uterine fibroids. Most women had return of heavy menstrual bleeding and associated symptoms after treatment cessation, which improved upon retreatment with relugolix combination therapy. Relugolix combination therapy was well tolerated, the adverse event profile remained consistent, and the mean bone mineral density was generally preserved through 2 years of treatment.
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Affiliation(s)
- Ayman Al-Hendy
- Obstetrics and Gynecology, University of Chicago, Chicago, IL.
| | - Roberta Venturella
- Department of Clinical and Experimental Medicine, University Magna Graecia, Catanzaro, Italy
| | | | - Yulan Li
- Myovant Sciences Inc., Brisbane, CA
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D'Angelo G, Ascione M, Morra I, Verrazzo P, Bifulco G, Giampaolino P, Della Corte L. What's new on the horizon for polycystic ovarian syndrome? Exploring emerging drugs in phase II. Expert Opin Emerg Drugs 2023; 28:149-152. [PMID: 37725478 DOI: 10.1080/14728214.2023.2260746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 09/15/2023] [Indexed: 09/21/2023]
Affiliation(s)
- Giuseppe D'Angelo
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Mario Ascione
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Ilaria Morra
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Paolo Verrazzo
- Hospital Santa Maria delle Grazie of Pozzuoli - ASL Napoli 2 Nord, Naples, Italy
| | - Giuseppe Bifulco
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | | | - Luigi Della Corte
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
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Selmi C, La Marca A. Oral hormonal therapy as treatment option for abnormal uterine bleeding. EUR J CONTRACEP REPR 2023; 28:285-294. [PMID: 37955241 DOI: 10.1080/13625187.2023.2270098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 10/08/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND abnormal uterine bleeding is a very frequent reason for referral to gynaecologists and can deeply influence the quality of life. Once organic causes requiring surgical treatment are ruled out, clinicians should be able to manage these patients conservatively in the most effective way. MATERIALS AND METHODS a search in PubMed/MEDLINE database was conducted in order to find relevant and recent meaningful sources for this narrative review. RESULTS LNG-IUS 52 mg is the first-line treatment for non-organic causes. Nevertheless, it could be contraindicated or declined by the patient. Combined oral contraceptives (COC) and progestin-only pills inhibit the hypothalamic-pituitary-ovarian axis, preventing ovulation, and induce endometrial atrophy. Consequently, they are effective in treating AUB. Moreover, brand new pills containing a combination of oestrogens, progestins and GnRH antagonists are now available for the management of AUB related to uterine fibroids. CONCLUSIONS In daily clinical practice, oral hormonal therapies are convenient and reversible tools to manage AUB when LNG-IUS 52 mg is contraindicated or turn down by the patient. Many oral hormonal therapies are prescribed to treat AUB, but only a few have been approved with this specific indication, therefore further large well-designed studies are necessary in order to compare the efficacy of different pills for treating AUB.
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Affiliation(s)
- Chiara Selmi
- Department of Medical and Surgical Sciences of the Mother, Children and Adults, University of Modena and Reggio Emilia, Modena, Italy
| | - Antonio La Marca
- Department of Medical and Surgical Sciences of the Mother, Children and Adults, University of Modena and Reggio Emilia, Modena, Italy
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Ali M, Ciebiera M, Wlodarczyk M, Alkhrait S, Maajid E, Yang Q, Hsia SM, Al-Hendy A. Current and Emerging Treatment Options for Uterine Fibroids. Drugs 2023; 83:1649-1675. [PMID: 37922098 DOI: 10.1007/s40265-023-01958-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2023] [Indexed: 11/05/2023]
Abstract
Uterine fibroids are the most common benign neoplasm of the female reproductive tract in reproductive age women. Their prevalence is age dependent and can be detected in up to 80% of women by the age of 50 years. Patients affected by uterine fibroids may experience a significant physical, emotional, social, and financial toll as well as losses in their quality of life. Unfortunately, curative hysterectomy abolishes future pregnancy potential, while uterine-sparing surgical and radiologic alternatives are variously associated with reduced long-term reproductive function and/or high tumor recurrence rates. Recently, pharmacological treatment against uterine fibroids have been widely considered by patients to limit uterine fibroid-associated symptoms such as heavy menstrual bleeding. This hormonal therapy seemed effective through blocking the stimulatory effects of gonadal steroid hormones on uterine fibroid growth. However, they are contraindicated in women actively pursuing pregnancy and otherwise effective only during use, which is limited because of long-term safety and other concerns. Accordingly, there is an urgent unmet need for safe, durable, and fertility-compatible non-surgical treatment options for uterine fibroids. In this review article, we cover the current pharmacological treatments for uterine fibroids including their comparable efficacy and side effects as well as emerging safe natural compounds with promising anti-uterine fibroid effects.
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Affiliation(s)
- Mohamed Ali
- Department of Obstetrics and Gynecology, University of Chicago, 5841 S. Maryland Ave, Chicago, IL, 60637, USA
- Clinical Pharmacy Department, Faculty of Pharmacy, Ain Shams University, Cairo, 11566, Egypt
| | - Michał Ciebiera
- Second Department of Obstetrics and Gynecology, Center of Postgraduate Medical Education, Warsaw, 00-189, Poland
| | - Marta Wlodarczyk
- Department of Obstetrics and Gynecology, University of Chicago, 5841 S. Maryland Ave, Chicago, IL, 60637, USA
- Department of Biochemistry and Pharmacogenomics, Faculty of Pharmacy, Medical University of Warsaw, Banacha 1B, Warsaw, 02-097, Poland
- Centre for Preclinical Research, Medical University of Warsaw, Warsaw, Poland
| | - Samar Alkhrait
- Department of Obstetrics and Gynecology, University of Chicago, 5841 S. Maryland Ave, Chicago, IL, 60637, USA
| | - Elise Maajid
- Department of Obstetrics and Gynecology, University of Chicago, 5841 S. Maryland Ave, Chicago, IL, 60637, USA
| | - Qiwei Yang
- Department of Obstetrics and Gynecology, University of Chicago, 5841 S. Maryland Ave, Chicago, IL, 60637, USA
| | - Shih-Min Hsia
- School of Nutrition and Health Sciences, College of Nutrition, Taipei Medical University, Taipei, 11031, Taiwan
| | - Ayman Al-Hendy
- Department of Obstetrics and Gynecology, University of Chicago, 5841 S. Maryland Ave, Chicago, IL, 60637, USA.
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Brown E, Kroll R, Li H, Ng J, Pinsky B, Rodriguez JW, Thomas J, Snabes MC. Low-Dose Elagolix for the Treatment of Heavy Menstrual Bleeding in Patients With Uterine Leiomyomas: A Randomized Controlled Trial. Obstet Gynecol 2023; 142:1068-1076. [PMID: 37769311 DOI: 10.1097/aog.0000000000005380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 05/04/2023] [Indexed: 09/30/2023]
Abstract
OBJECTIVE To evaluate the safety and efficacy of elagolix 150 mg once-daily monotherapy in patients with heavy menstrual bleeding associated with uterine leiomyomas. METHODS A phase 4, randomized, double-blind, placebo-controlled, 6-month treatment study was conducted in premenopausal patients aged 18-51 years with heavy menstrual bleeding (defined as menstrual blood loss greater than 80 mL during one menstrual cycle) associated with uterine leiomyomas. Patients were randomized 2:1 to receive elagolix 150 mg once daily or placebo. The primary endpoint was reduction in menstrual blood loss volume to less than 80 mL at the final month and at least a 50% reduction in menstrual blood loss volume from baseline to the final month. RESULTS Of 82 randomized patients, 54 received elagolix 150 mg and 28 received placebo. With elagolix, 49.4% (95% CI 35.1-63.8%) of patients met the primary endpoint, compared with 23.3% (95% CI 7.2-39.5%) of patients who received placebo ( P =.035). Statistically significant differences between elagolix and placebo in mean reduction of menstrual blood loss from baseline were seen as early as month 1 ( P <.05 for months 1-3 and 5). Significantly more patients receiving elagolix experienced suppression of bleeding compared with placebo ( P =.036). Greater improvements were observed in the elagolix group (vs placebo) in the proportion of patients with amenorrhea, in hemoglobin concentrations, and in health-related quality of life. No serious or severe adverse events were reported for elagolix, compared with 7.1% of participants in the placebo group having serious adverse events (coronavirus disease 2019 [COVID-19] n=1, enlarged uvula n=1). Three patients (5.6%) discontinued elagolix due to adverse events. CONCLUSION Elagolix 150 mg once-daily monotherapy significantly improved heavy menstrual bleeding associated with uterine leiomyomas compared with placebo in premenopausal patients. Treatment with elagolix 150 mg once daily was generally well-tolerated in this study, with no new safety signals. FUNDING SOURCE AbbVie Inc. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov , NCT03886220.
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Affiliation(s)
- Eric Brown
- Gyn-Care, Atlanta, Georgia; Seattle Clinical Research Center, Seattle, Washington; AbbVie, Chicago, Illinois; and GCP Clinical Research, Tampa, Florida
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Al-Hendy A, Zhou YF, Faustmann T, Groettrup-Wolfers E, Laapas K, Parke S, Seitz C. Efficacy and safety of vilaprisan in women with uterine fibroids: data from the ASTEROID 3 randomized controlled trial. F&S SCIENCE 2023; 4:317-326. [PMID: 37437885 DOI: 10.1016/j.xfss.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 06/15/2023] [Accepted: 06/30/2023] [Indexed: 07/14/2023]
Abstract
OBJECTIVE Vilaprisan is a highly potent selective progesterone receptor modulator shown to reduce heavy menstrual bleeding, induce amenorrhea, and diminish uterine fibroid volume in phase 2 studies. The objective of ASTEROID 3 was to demonstrate the superiority of vilaprisan compared with placebo in the treatment of heavy menstrual bleeding in women with uterine fibroids. DESIGN Randomized, double-blind, placebo-controlled, multicenter phase 3 study. SETTING Hospitals and medical centers. PATIENT(S) Women with ≥1 uterine fibroid of ≥3 cm and heavy menstrual bleeding of >80 mL/cycle. INTERVENTION(S) Women were randomly assigned to 1 of 4 treatment arms, which were planned to comprise 2 treatment periods of 12 weeks, each with vilaprisan (2 mg/d) or placebo that were continuous or separated by a break of one bleed. MAIN OUTCOME MEASURE(S) Amenorrhea (primary end point; <2 mL in the last 28 days of treatment) and heavy menstrual bleeding response (key secondary end point; <80 mL/cycle and >50% reduction in bleeding from baseline) were measured with the alkaline hematin method. Change in volume of the 3 largest fibroids from baseline to end of treatment was assessed by ultrasound. Safety was monitored throughout the study. RESULT(S) Overall, 75 women completed the first 12 weeks of treatment. Statistically significant and clinically meaningful differences were observed between the vilaprisan- and placebo-treated groups in both the full analysis and per-protocol sets. In the per-protocol set (n = 36 and n = 12 for the vilaprisan and placebo groups, respectively), amenorrhea was observed more frequently in women treated with vilaprisan than in those who received placebo (83.3% vs. 0%, P<.0001), with a median time to onset of 3 days in the vilaprisan group. Similarly, more vilaprisan- than placebo-treated women achieved a response in heavy menstrual bleeding (91.7% vs. 25.0%, P<.0001). Serious adverse events were reported for 22 (27.8%) of 79 women and were evenly distributed among the 4 groups receiving vilaprisan and/or placebo. None of these events led to study discontinuation or were related to the liver, and no new safety findings were identified compared with the earlier phase 2 ASTEROID studies. CONCLUSION(S) Vilaprisan is efficacious and well tolerated over 12 weeks in the treatment of heavy menstrual bleeding associated with uterine fibroids. Further investigations of the long-term efficacy and safety of vilaprisan are warranted. CLINICAL TRIAL REGISTRATION NUMBER NCT03400943 (ClinicalTrials.gov).
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Affiliation(s)
- Ayman Al-Hendy
- Department of Obstetrics and Gynecology, University of Chicago, Chicago, Illinois
| | - Ying F Zhou
- Department of Obstetrics and Gynecology, Peking University First Hospital, Xicheng District, Beijing, People's Republic of China
| | | | | | | | | | - Christian Seitz
- Bayer AG, Berlin, Germany; Institute of Clinical Pharmacology and Toxicology, Universitätsmedizin Berlin, Berlin, Germany.
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Agarwal SK, Stokes M, Kung T, Tilney R, Lickert C. Describing the Patient Journey of Women with Claims for Uterine Fibroids and Heavy Menstrual Bleeding Using a Commercial Database (2011-2020). Int J Womens Health 2023; 15:1561-1575. [PMID: 37867928 PMCID: PMC10588720 DOI: 10.2147/ijwh.s420612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 09/26/2023] [Indexed: 10/24/2023] Open
Abstract
Introduction This retrospective database claims analysis describes the clinical characteristics and treatment patterns of commercially insured United States women with uterine fibroids (UF) and heavy menstrual bleeding (HMB). Methods Women age 18-55 years with an incident UF diagnosis (index date) between 1/1/2012 and 12/31/2019 and ≥1 claim for HMB (UF-HMB), were identified from the Optum® Clinformatics® database. Outcomes included clinical characteristics, pharmacologic therapy use, and surgeries/procedures. Regression models were used to identify factors associated with time to post-diagnosis hormonal therapy and hysterectomy. Results A total of 85,428 women had UF-HMB (mean [SD] age, 43.7 [6.4] years). The median follow-up was 3.2 years. After HMB, the most common symptoms were pelvic pressure/pain (27.6%) and backache (17.5%). Within 6 months of UF diagnosis, 40.2% of patients had received only pharmacologic therapy; 25.5% had received no treatment; 24.3% had a hysterectomy, and 10.0% had other procedures. By the end of follow-up, 50.0% had received a hysterectomy. Multiple factors were predictive of a higher likelihood of receiving hormonal therapy (geographic region, infertility, pre-index pregnancy) or hysterectomy (older age, prior hormonal treatment, specific bulk symptoms, White race). Conclusion Within 6 months of UF diagnosis, fewer than one-half of women with UF-HMB had received hormonal therapy, one-quarter received no treatment, and one-quarter had received a hysterectomy or another gynecologic procedure. Patients who received a hysterectomy were more likely to be older, White, and to have bulk symptoms.
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Affiliation(s)
| | | | - Tiffany Kung
- Myovant Sciences, Inc (now known as Sumitomo Pharma America, Inc), Marlborough, MA, USA
| | | | - Cassandra Lickert
- Myovant Sciences, Inc (now known as Sumitomo Pharma America, Inc), Marlborough, MA, USA
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16
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Goitia M, Estadella J. [Emerging therapies in the medical treatment of uterine fibroids]. Med Clin (Barc) 2023; 161 Suppl 1:S32-S37. [PMID: 37923512 DOI: 10.1016/j.medcli.2023.06.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 05/29/2023] [Accepted: 06/15/2023] [Indexed: 11/07/2023]
Affiliation(s)
- Mikel Goitia
- Servicio Ginecología y Obstetricia, Hospital Universitario Cruces, Barakaldo, Bizkaia, España.
| | - Josep Estadella
- Servicio de Ginecología, Hospital de la Santa Creu i Sant Pau, Barcelona, España
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17
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Huerga López C, Gutiérrez Alagüero A, Cristóbal García I. Management of uterine fibroids: Approach to medical treatment. Med Clin (Barc) 2023; 161 Suppl 1:S15-S21. [PMID: 37923509 DOI: 10.1016/j.medcli.2023.06.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 06/03/2023] [Accepted: 06/27/2023] [Indexed: 11/07/2023]
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18
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Xin L, Ma Y, Ye M, Chen L, Liu F, Hou Q. Efficacy and safety of oral gonadotropin-releasing hormone antagonists in moderate-to-severe endometriosis-associated pain: a systematic review and network meta-analysis. Arch Gynecol Obstet 2023; 308:1047-1056. [PMID: 36656435 PMCID: PMC10435625 DOI: 10.1007/s00404-022-06862-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 11/15/2022] [Indexed: 01/20/2023]
Abstract
PURPOSE The aim of this NMA is to comprehensively analyze evidence of oral GnRH antagonist in the treatment of moderate-to-severe endometriosis-associated pain. METHODS Literature searching was performed to select eligible studies published prior to April 2022 in PubMed, Cochrane, Embase and Web of Science. Randomized controlled trials involving patients who suffered from moderate-to-severe endometriosis-associated pain and treated with oral nonpeptide GnRH antagonists or placebo were included. RESULTS Elagolix 400 mg and ASP1707 15 mg were most efficient in reducing pelvic pain, dysmenorrhea and dyspareunia. Relugolix 40 mg was best in reducing the analgesics use. The rates of any TEAEs and TEAEs-related discontinuation were highest in relugolix 40 mg and elagolix 250 mg, respectively, while rates of hot flush and headache were highest in relugolix 40 mg and elagolix 150 mg. Significantly decreased spinal BMD was observed in elagolix 250 mg. CONCLUSION Oral GnRH antagonists were effective in endometriosis-associated pain in 12w, and most of the efficiency and safety outcomes were expressed in a dose-dependent manner, but linzagolix 75 mg was an exception.
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Affiliation(s)
- Lingli Xin
- Department of Obstetrics and Gynecology, PLA Rocket Force Characteristic Medical Center, Xinjiekou Outer Street 16#, Xicheng District, Beijing, 100088, China.
| | - Yinghao Ma
- Department of Quality Management, PLA Rocket Force Characteristic Medical Center, Xinjiekou Outer Street 16#, Xicheng District, Beijing, 100088, China
| | - Mei Ye
- Department of Obstetrics and Gynecology, PLA Rocket Force Characteristic Medical Center, Xinjiekou Outer Street 16#, Xicheng District, Beijing, 100088, China
| | - Ling Chen
- Department of Obstetrics and Gynecology, PLA Rocket Force Characteristic Medical Center, Xinjiekou Outer Street 16#, Xicheng District, Beijing, 100088, China
| | - Fuzhou Liu
- Department of Orthopaedics, PLA Rocket Force Characteristic Medical Center, Xinjiekou Outer Street 16#, Xicheng District, Beijing, 100088, China
| | - Qingxiang Hou
- Department of Obstetrics and Gynecology, PLA Rocket Force Characteristic Medical Center, Xinjiekou Outer Street 16#, Xicheng District, Beijing, 100088, China.
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19
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Sim-Ifere O, Aref-Adib M, Odejinmi F. Oral gonadotrophin-releasing hormone (GnRH) antagonists: the continuing search for the ideal nonsurgical therapy of uterine fibroids with a cautionary tale. Curr Opin Obstet Gynecol 2023; 35:460-465. [PMID: 37560806 DOI: 10.1097/gco.0000000000000907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/11/2023]
Abstract
PURPOSE OF REVIEW Uterine fibroids are very common with a prevalence of over 70%. They present a significant economic and psychological burden. A variety of nonsurgical treatments exist for its management encompassing hormonal and nonhormonal methods. Gonadotrophin-releasing hormone (GnRH) antagonists are a novel treatment for uterine fibroids. They cause a rapid reduction in endogenous GnRH, leading to a dose-dependent reduction in levels of oestradiol and progesterone, thus reduction in bleeding. The addition of hormones, estrogen, and progesterone, known as add-back therapy, helps curb the menopausal side effects. As such, they pose a potential long-term nonsurgical therapy for management of symptomatic fibroids. RECENT FINDINGS There are various uses of GnRH antagonists and the results from the clinical trials are promising. Caution needs to be taken when new treatment options are introduced with audit and data collection tools in place to assess effectiveness as well as any side effects. SUMMARY This article highlights the uses of GnRH antagonists in practice and reflects on previous novel treatments for fibroids with a focus on Ulipristal acetate. It states the importance of using audit tools and multiinstitutional databases to prevent and allow early discovery of issues such as those that encumbered Ulipristal.
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Affiliation(s)
| | | | - Funlayo Odejinmi
- Whipps cross university hospital Barts Health NHS Trust, London, UK
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20
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Ciebiera M, Madueke-Laveaux OS, Feduniw S, Ulin M, Spaczyński R, Zgliczyńska M, Bączkowska M, Zarychta E, Łoziński T, Ali M, Al-Hendy A. GnRH agonists and antagonists in therapy of symptomatic uterine fibroids - current roles and future perspectives. Expert Opin Pharmacother 2023; 24:1799-1809. [PMID: 37602464 DOI: 10.1080/14656566.2023.2248890] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 07/12/2023] [Accepted: 08/14/2023] [Indexed: 08/22/2023]
Abstract
INTRODUCTION Uterine fibroids are the most common noncancerous tumors in women of childbearing age. This review was developed to evaluate the current role of gonadotropin-releasing hormone (GnRH) agonists and antagonists in the therapy of symptomatic uterine fibroids. AREAS COVERED There is a great need for alternative methods for surgical treatment of uterine fibroids. Hormonal therapy remains the first-line treatment option for most patients. GnRH analogs (agonists and antagonists) modulate the pulsatile release of GnRH. This review summarizes the available literature concerning pharmacologic principles underlying the mechanism of action of GnRH and its analogs, as well as individual therapeutic applications to which these drugs have been applied. EXPERT OPINION In many cases, it is possible to try to treat uterine fibroids pharmacologically. Both groups of GnRH analogs are used in therapy, agonists instead as a preparation for surgery, and antagonists as a drug for long-term use. It is essential to develop this path further and look for at least long-term-release systems or new methods of administering these drugs. It is also important from the patient's perspective to search for possible drugs that may have an additive effect of decreasing side effects when combined with GnRH analogs.
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Affiliation(s)
- Michał Ciebiera
- Second Department of Obstetrics and Gynecology, Centre of Postgraduate Medical Education, Warsaw, Poland
- Warsaw Institute of Women's Health, Warsaw, Poland
- Development and Research Center of Non-Invasive Therapies, Pro-Familia Hospital, Rzeszów, Poland
| | | | - Stepan Feduniw
- Department of Gynecology, University Hospital Zurich, Zurich, Switzerland
| | - Mara Ulin
- Department of Obstetrics and Gynecology, Mount Sinai Hospital, Chicago, IL, USA
| | - Robert Spaczyński
- Obstetrics and Infertility Treatment Pastelova, Center for Gynecology, Poznan, Poland
| | - Magdalena Zgliczyńska
- Department of Obstetrics, Perinatology and Neonatology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Monika Bączkowska
- Second Department of Obstetrics and Gynecology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Elżbieta Zarychta
- Second Department of Obstetrics and Gynecology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Tomasz Łoziński
- Department of Obstetrics and Gynecology, Pro-Familia Hospital, Rzeszow, Poland
- Department of Gynecology and Obstetrics, College of Medical Sciences, Institute of Medical Sciences, University of Rzeszow, Rzeszow, Poland
| | - Mohamed Ali
- Department of Obstetrics and Gynecology, University of Chicago Medicine, Chicago, IL, USA
| | - Ayman Al-Hendy
- Department of Obstetrics and Gynecology, University of Chicago Medicine, Chicago, IL, USA
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Lee S, Stewart EA. New treatment options for nonsurgical management of uterine fibroids. Curr Opin Obstet Gynecol 2023; 35:288-293. [PMID: 37144584 PMCID: PMC10330353 DOI: 10.1097/gco.0000000000000880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
PURPOSE OF REVIEW Uterine fibroids is a common problem in reproductive-age individuals, frequently causing abnormal uterine bleeding, bulk symptoms, and adverse reproductive outcomes. Traditionally, almost half of the women with symptomatic fibroids received surgery for definitive treatment. There are a growing number of nonsurgical options for treatment that have become available for patients who desire conservative treatment or those with contraindications to surgery. RECENT FINDINGS The introduction of oral gonadotropin-releasing hormone antagonists in combination with low-dose physiologic hormonal therapy demonstrated improvement in heavy menstrual bleeding, pain, and quality of life with preservation of bone density and a modest reduction in uterine volume with few hypogonadal side effects. Magnetic resonance-guided focused ultrasound surgery and uterine artery embolization continue to be minimally invasive procedural alternatives to hysterectomy that are safe and effective. SUMMARY As more options for conservative management of uterine fibroids became available, it is important to counsel patients on possible options based on the size, location, and number of the fibroids as well as severity of the symptoms, plans for pregnancy, how close they are to menopause and their treatment goals.
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Affiliation(s)
- SiWon Lee
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Mayo Clinic, Rochester, Minnesota
| | - Elizabeth A. Stewart
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Mayo Clinic, Rochester, Minnesota
- Mayo Clinic Alix School of Medicine, Rochester, Minnesota
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22
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MacGregor B, Munro MG, Lumsden MA. Therapeutic options for the management of abnormal uterine bleeding. Int J Gynaecol Obstet 2023; 162 Suppl 2:43-57. [PMID: 37538018 DOI: 10.1002/ijgo.14947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Just as the investigation of abnormal uterine bleeding (AUB) is approached systematically using the two FIGO systems for AUB in the reproductive years, treatment options can be considered similarly. Therapeutic options fall into two categories-medical and surgical-and while medical management is typically regarded as first-line therapy, there are several exceptions defined by the presenting cause or causes, mainly when infertility is a concurrent issue. In the early 1990s, up to 60% of women underwent a hysterectomy for the symptom of heavy menstrual bleeding (HMB), but this figure has decreased. The number of women undergoing a hysterectomy for benign disorders continues to decline, along with an increase in hysterectomies performed using minimally invasive techniques. Discussions about therapeutic options are tailored to the individual patient, and we include the risks and benefits of each option, including no management, to enable the patient to make an informed choice. The different types of treatment options and the factors affecting decision-making are considered in this article.
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Affiliation(s)
| | - Malcolm G Munro
- Department of Obstetrics and Gynecology, David Geffen School of Medicine at the University of California, Los Angeles, California, USA
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23
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Singh S, Kumar P, Rathore SS, Singh Y, Garg N. Contemporary approaches in the management of uterine leiomyomas. Eur J Obstet Gynecol Reprod Biol 2023; 287:195-210. [PMID: 37385088 DOI: 10.1016/j.ejogrb.2023.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 04/24/2023] [Accepted: 06/20/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND Leiomyomas (fibroids), the most common benign solid tumours in females, originate from the myometrium and are associated with poor quality of life for patients. The current management of uterine leiomyomas mainly includes surgical interventions such as hysterectomy and myomectomy, either by laparoscopy or laparotomy, which have several complications and are not ideal for preserving fertility. Therefore, there is a need to develop or repurpose medical treatments that do not require surgical intervention. OBJECTIVE Many drugs are used to treat the symptoms associated with uterine fibroids. The main objective of this systematic review is to give an up-to-date account of potential pharmacological agents (non-surgical methods) for the management of uterine leiomyomas. SEARCH STRATEGY PubMed was searched for scientific and clinical literature using the keyword 'uterine fibroids' along with the drug names described in each section. For example, 'uterine fibroids' and 'ulipristal acetate' were the keywords used to search for literature on ulipristal acetate (UPA). RESULTS Various preclinical and clinical studies have shown that some drugs and herbal formulations exhibit activity in the management of uterine leiomyomas. Recent studies found that drugs such as UPA, elagolix, EC313, asoprisnol, nutritional supplements and herbal preparations were helpful in treating the symptoms associated with uterine leiomyomas. CONCLUSION Many drugs show efficacy in patients with symptomatic uterine fibroids. UPA is one of the most studied and prescribed medicines for uterine fibroids; however, its usage has been restricted due to a few recent incidences of hepatic toxicity. Herbal drugs and natural supplements have also shown promising effects on uterine fibroids. The synergistic effects of nutritional and herbal supplements have been reported in certain cases, and should be studied in detail. Further research is warranted to identify the mode of action of the drugs, and to determine the precise conditions that would explain the causes of toxicity in some patients.
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Affiliation(s)
- Shikha Singh
- Department of Prasuti Tantra, Faculty of Ayurveda, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Praveen Kumar
- Department of Medicinal Chemistry, Faculty of Ayurveda, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Saurabh Singh Rathore
- Department of Biotechnology, Mahatma Gandhi Central University, Raghunathpur, Motihari, East Champaran, Bihar, India
| | - Yashasvi Singh
- Department of Urology, CSSB, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Neha Garg
- Department of Medicinal Chemistry, Faculty of Ayurveda, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India.
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Saleh FL, Taylor HS. Clinical applications of gonadotropin-releasing hormone analogues: a broad impact on reproductive medicine. F S Rep 2023; 4:83-87. [PMID: 37223759 PMCID: PMC10201293 DOI: 10.1016/j.xfre.2023.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 01/21/2023] [Indexed: 02/04/2023] Open
Abstract
Gonadotropin-releasing hormone (GnRH) is central to the control of the entire hypothalamic-pituitary-gonadal axis. Manipulation of GnRH, in turn, regulates pituitary response and ovarian hormone production. Gonadotropin-releasing hormone analogues have revolutionized assisted reproductive technology and gynecologic practice. The recent advent of oral GnRH antagonists with an inherent rapid onset of action continues to transform the treatment options available for several common gynecologic conditions, including endometriosis and fibroids. Herein, we review neuroendocrine GnRH activity and discuss modulation of the reproductive axis by GnRH analogues for diverse clinical applications.
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Affiliation(s)
- Farrah L. Saleh
- Section of Reproductive Endocrinology and Infertility, Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
| | - Hugh S. Taylor
- Section of Reproductive Endocrinology and Infertility, Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
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25
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Whitaker LH, Middleton LJ, Daniels JP, Williams AR, Priest L, Odedra S, Cheed V, Stubbs CE, Clark TJ, Lumsden MA, Hapangama DK, Bhattacharya S, Smith PP, Nicholls EP, Roberts N, Semple SI, Saraswat L, Walker J, Chodankar RR, Critchley HO. Ulipristal acetate versus levonorgestrel-releasing intrauterine system for heavy menstrual bleeding (UCON): a randomised controlled phase III trial. EClinicalMedicine 2023; 60:101995. [PMID: 37251622 PMCID: PMC10209678 DOI: 10.1016/j.eclinm.2023.101995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 04/16/2023] [Accepted: 04/19/2023] [Indexed: 05/31/2023] Open
Abstract
Background Heavy menstrual bleeding affects one in four women and negatively impacts quality of life. Ulipristal acetate is prescribed to treat symptoms associated with uterine fibroids. We compared the effectiveness of ulipristal acetate and the levonorgestrel-releasing intrauterine system at reducing the burden of heavy menstrual bleeding, irrespective of the presence of fibroids. Methods This randomised, open-label, parallel group phase III trial enrolled women over 18 years with heavy menstrual bleeding from 10 UK hospitals. Participants were centrally randomised, in a 1:1 ratio, to either three, 12-week treatment cycles of 5 mg ulipristal acetate daily, separated by 4-week treatment-free intervals, or a levonorgestrel-releasing intrauterine system. The primary outcome, analysed by intention-to-treat, was quality of life measured by the Menorrhagia Multi-Attribute Scale at 12 months. Secondary outcomes included menstrual bleeding and liver function. The trial is registered with ISRCTN, 20426843. Findings Between June 5th, 2015 and February 26th, 2020, 236 women were randomised, either side of a recruitment suspension due to concerns of ulipristal acetate hepatoxicity. Subsequent withdrawal of ulipristal acetate led to early cessation of recruitment but the trial continued in follow-up. The primary outcome substantially improved in both groups, and was 89, (interquartile range [IQR] 65 to 100, n = 53) and 94, (IQR 70 to 100, n = 50; adjusted odds ratio 0.55, 95% confidence interval [CI] 0.26-1.17; p = 0.12) in the ulipristal and levonorgestrel-releasing intrauterine system groups. Rates of amenorrhoea at 12 months were higher in those allocated ulipristal acetate compared to levonorgestrel-releasing intrauterine system (64% versus 25%, adjusted odds ratio 7.12, 95% CI 2.29-22.2). Other outcomes were similar between the two groups and there were no cases of endometrial malignancy or hepatotoxicity due to ulipristal acetate use. Interpretation Our findings suggested that both treatments improved quality of life. Ulipristal was more effective at inducing amenorrhoea. Ulipristal has been demonstrated to be an effective medical therapeutic option but currently its use has restrictions and requires liver function monitoring. Funding UK Medical Research Council and National Institute of Health Research EME Programme (12/206/52).
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Affiliation(s)
- Lucy H.R. Whitaker
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - Lee J. Middleton
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Jane P. Daniels
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | | | - Lee Priest
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Smita Odedra
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Versha Cheed
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Clive E. Stubbs
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | | | - Mary-Ann Lumsden
- Reproductive & Maternal Medicine, University of Glasgow, Glasgow, UK
| | - Dharani K. Hapangama
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
| | | | - Paul P. Smith
- Birmingham Women's and Children's Hospital, Birmingham, UK
| | | | - Neil Roberts
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - Scott I. Semple
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | | | - Jane Walker
- Department of Clinical Radiology, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Rohan R. Chodankar
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | | | - UCON Collaborative
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
- Division of Pathology, University of Edinburgh, Edinburgh, UK
- Birmingham Women's and Children's Hospital, Birmingham, UK
- Reproductive & Maternal Medicine, University of Glasgow, Glasgow, UK
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
- University of Aberdeen, Aberdeen, UK
- Adcal H.R. Consultancy, UK (PPI representative)
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
- Department of Clinical Radiology, Royal Infirmary of Edinburgh, Edinburgh, UK
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26
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Islam MS, Parish M, Brennan JT, Winer BL, Segars JH. Targeting fibrotic signaling pathways by EGCG as a therapeutic strategy for uterine fibroids. Sci Rep 2023; 13:8492. [PMID: 37231028 DOI: 10.1038/s41598-023-35212-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 05/15/2023] [Indexed: 05/27/2023] Open
Abstract
Fibrosis is characterized by excessive accumulation of extracellular matrix, which is a key feature of uterine fibroids. Our prior research supports the tenet that inhibition of fibrotic processes may restrict fibroid growth. Epigallocatechin gallate (EGCG), a green tea compound with powerful antioxidant properties, is an investigational drug for uterine fibroids. An early phase clinical trial showed that EGCG was effective in reducing fibroid size and its associated symptoms; however, its mechanism of action(s) has not been completely elucidated. Here, we probed effects of EGCG on key signaling pathways involved in fibroid cell fibrosis. Viability of myometrial and fibroid cells was not greatly affected by EGCG treatment (1-200 µM). Cyclin D1, a protein involved in cell cycle progression, was increased in fibroid cells and was significantly reduced by EGCG. EGCG treatment significantly reduced mRNA or protein levels of key fibrotic proteins, including fibronectin (FN1), collagen (COL1A1), plasminogen activator inhibitor-1 (PAI-1), connective tissue growth factor (CTGF), and actin alpha 2, smooth muscle (ACTA2) in fibroid cells, suggesting antifibrotic effects. EGCG treatment altered the activation of YAP, β-catenin, JNK and AKT, but not Smad 2/3 signaling pathways involved in mediating fibrotic process. Finally, we conducted a comparative study to evaluate the ability of EGCG to regulate fibrosis with synthetic inhibitors. We observed that EGCG displayed greater efficacy than ICG-001 (β-catenin), SP600125 (JNK) and MK-2206 (AKT) inhibitors, and its effects were equivalent to verteporfin (YAP) or SB525334 (Smad) for regulating expression of key fibrotic mediators. These data indicate that EGCG exhibits anti-fibrotic effects in fibroid cells. These results provide insight into mechanisms behind the observed clinical efficacy of EGCG against uterine fibroids.
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Affiliation(s)
- Md Soriful Islam
- Division of Reproductive Sciences and Women's Health Research, Department of Gynecology and Obstetrics, Johns Hopkins Medicine, 720 Rutland Ave, Ross Building, Room 624, Baltimore, MD, 21205, USA.
| | - Maclaine Parish
- Division of Reproductive Sciences and Women's Health Research, Department of Gynecology and Obstetrics, Johns Hopkins Medicine, 720 Rutland Ave, Ross Building, Room 624, Baltimore, MD, 21205, USA
| | - Joshua T Brennan
- Division of Reproductive Sciences and Women's Health Research, Department of Gynecology and Obstetrics, Johns Hopkins Medicine, 720 Rutland Ave, Ross Building, Room 624, Baltimore, MD, 21205, USA
| | - Briana L Winer
- Division of Reproductive Sciences and Women's Health Research, Department of Gynecology and Obstetrics, Johns Hopkins Medicine, 720 Rutland Ave, Ross Building, Room 624, Baltimore, MD, 21205, USA
| | - James H Segars
- Division of Reproductive Sciences and Women's Health Research, Department of Gynecology and Obstetrics, Johns Hopkins Medicine, 720 Rutland Ave, Ross Building, Room 624, Baltimore, MD, 21205, USA.
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Yin K, Whitaker L, Hojo E, McLenachan S, Walker J, McKillop G, Stubbs C, Priest L, Cruz M, Roberts N, Critchley H. Measurement of changes in uterine and fibroid volume during treatment of heavy menstrual bleeding (HMB). Hum Reprod Open 2023; 2023:hoad021. [PMID: 37304815 PMCID: PMC10247393 DOI: 10.1093/hropen/hoad021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 03/28/2023] [Indexed: 06/13/2023] Open
Abstract
STUDY QUESTION Does application of an unbiased method for analysis of magnetic resonance (MR) images reveal any effect on uterine or fibroid volume from treatment of heavy menstrual bleeding (HMB) with three 12-week courses of the selective progesterone receptor modulator ulipristal acetate (SPRM-UPA)? SUMMARY ANSWER Application of an unbiased method for analysis of MR images showed that treatment of HMB with SPRM-UPA was not associated with a significant reduction in the volume of the uterus or in the volume of uterine fibroids. WHAT IS KNOWN ALREADY SPRM-UPA shows therapeutic efficacy for treating HMB. However, the mechanism of action (MoA) is not well understood and there have been mixed reports, using potentially biased methodology, regarding whether SPRM-UPA has an effect on the volume of the uterus and fibroids. STUDY DESIGN SIZE DURATION In a prospective clinical study (with no comparator), 19 women with HMB were treated over a period of 12 months with SPRM-UPA and uterine and fibroid size were assessed with high resolution structural MRI and stereology. PARTICIPANTS/MATERIALS SETTING METHODS A cohort of 19 women aged 38-52 years (8 with and 11 without fibroids) were treated with three 12-week courses of 5 mg SPRM-UPA given daily, with four weeks off medication in-between treatment courses. Unbiased estimates of the volume of uterus and total volume of fibroids were obtained at baseline, and after 6 and 12 months of treatment, by using the Cavalieri method of modern design-based stereology in combination with magnetic resonance imaging (MRI). MAIN RESULTS AND THE ROLE OF CHANCE Bland-Altman plots showed good intra-rater repeatability and good inter-rater reproducibility for measurement of the volume of both fibroids and the uterus. For the total patient cohort, two-way ANOVA did not show a significant reduction in the volume of the uterus after two or three treatment courses of SPRM-UPA (P = 0.51), which was also the case when the groups of women with and without fibroids were considered separately (P = 0.63). One-way ANOVA did not show a significant reduction in total fibroid volume in the eight patients with fibroids (P = 0.17). LIMITATIONS REASONS FOR CAUTION The study has been performed in a relatively small cohort of women and simulations that have subsequently been performed using the acquired data have shown that for three time points and a group size of up to 50, with alpha (Type I Error) and beta (Type II Error) set to 95% significance and 80% power, respectively, at least 35 patients would need to be recruited in order for the null hypothesis (that there is no significant reduction in total fibroid volume) to be potentially rejected. WIDER IMPLICATIONS OF THE FINDINGS The imaging protocol that we have developed represents a generic paradigm for measuring the volume of the uterus and uterine fibroids that can be readily incorporated in future studies of medical treatments of HMB. In the present study, SPRM-UPA failed to produce a significant reduction in the volume of the uterus or the total volume of fibroids (which were present in approximately half of the patients) after either two or three 12-week courses of treatment. This finding represents a new insight in respect of the management of HMB using treatment strategies that target hormone-dependence. STUDY FUNDING/COMPETING INTERESTS The UPA Versus Conventional Management of HMB (UCON) trial was funded by the EME Programme (Medical Research Council (MRC) and National Institutes of Health Research (NIHR)) (12/206/52). The views expressed in this publication are those of the authors and not necessarily those of the Medical Research Council, National Institute for Health Research, or Department of Health and Social Care.Medical Research Council (MRC) Centre grants to the Centre for Reproductive Health (CRH) (G1002033 and MR/N022556/1) are also gratefully acknowledged. H.C. has clinical research support for laboratory consumables and staff from Bayer AG and provides consultancy advice (All paid to Institution) for Bayer AG, PregLem SA, Gedeon Richter, Vifor Pharma UK Ltd, AbbVie Inc., and Myovant Sciences GmbH. H.C. has received royalties from UpToDate for an article on abnormal uterine bleeding. L.W. has received grant funding from Roche Diagnostics (Paid to Institution). All other authors have no conflicts to declare. TRIAL REGISTRATION NUMBER The study reported here is an embedded mechanism of action study (no comparator) within the UCON clinical trial (registration ISRCTN: 20426843).
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Affiliation(s)
- K Yin
- Edinburgh Imaging Facility QMRI, University of Edinburgh, Edinburgh, UK
| | - L Whitaker
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - E Hojo
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - S McLenachan
- Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK
| | - J Walker
- Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK
| | - G McKillop
- Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK
| | - C Stubbs
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - L Priest
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - M Cruz
- Departamento de Matemáticas Estadística y Computación, University of Cantabria, Santander, Spain
| | - N Roberts
- Edinburgh Imaging Facility QMRI, University of Edinburgh, Edinburgh, UK
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - H Critchley
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
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28
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Neblett MF, Stewart EA. Oral Gonadotropin-Releasing Hormone Antagonists for the Treatment of Uterine Leiomyomas. Obstet Gynecol 2023; 141:901-910. [PMID: 37103532 DOI: 10.1097/aog.0000000000005145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 10/27/2022] [Indexed: 04/28/2023]
Abstract
Uterine leiomyomas are common hormone-responsive neoplasms that frequently cause heavy menstrual bleeding, anemia, pelvic pressure, pain, and adverse reproductive outcomes. In this overview, the efficacy and safety of oral gonadotropin-releasing hormone (GnRH) antagonists, co-administered with menopausal replacement-level steroid hormones or used at doses to avoid complete hypothalamic suppression, are reviewed for the management of uterine leiomyomas. Oral GnRH antagonists provide rapid suppression of sex steroids and avoid the initial steroidal flare and resultant temporary worsening of symptoms typically seen with parenteral GnRH agonists. Oral GnRH antagonists are effective in reducing leiomyoma-associated heavy menstrual bleeding, with high rates of amenorrhea and improved anemia and leiomyoma-associated pain, and providing modest reduction in uterine volume when used in combination with menopausal replacement-level steroid hormones. This add-back therapy can reduce hypogonadal side effects, including hot flushes and bone mineral density loss, close to levels seen with placebo therapy. Currently, both elagolix 300 mg twice daily with once-daily estradiol (1 mg) and norethindrone (0.5 mg) and relugolix 40 mg once daily with estradiol (1 mg) and norethindrone (0.5 mg) combination therapy are approved for leiomyoma treatment by the U.S. Food and Drug Administration. Linzagolix is under investigation in the United States but approved at two does with and without steroid hormones in the European Union. The efficacy of these agents appears to be robust over a wide spectrum of clinical presentations, demonstrating that worse disease parameters at baseline do not appear to inhibit efficacy. Across clinical trials, participants largely reflected the population of individuals affected by uterine leiomyomas.
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Affiliation(s)
- Michael F Neblett
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, the Department of Physiology and Biomedical Engineering, the Division of Endocrinology, Department of Medicine, the Department of Surgery, and the Women's Health Research Center, Mayo Clinic, and Mayo Clinic Alix School of Medicine, Rochester, Minnesota
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29
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Combs A, Singh B, Nylander E, Islam MS, Nguyen HV, Parra E, Bello A, Segars J. A Systematic Review of Vitamin D and Fibroids: Pathophysiology, Prevention, and Treatment. Reprod Sci 2023; 30:1049-1064. [PMID: 35960442 DOI: 10.1007/s43032-022-01011-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 06/12/2022] [Indexed: 10/16/2022]
Abstract
Uterine fibroids are the most common tumor of reproductive-age women worldwide and cause significant morbidity in affected women. Vitamin D has emerged as a potential therapy for uterine fibroids based on experimental and epidemiologic evidence. The objective of this systematic review was to evaluate the role of vitamin D in the pathophysiology of uterine fibroids and its efficacy for prevention and treatment of fibroids. A comprehensive search was conducted of Cochrane Library, Embase, PubMed, Scopus, and Web of Science from inception to March 2022. English-language publications that evaluated vitamin D and uterine fibroids in humans, whether experimental or clinical, were considered. The search yielded 960 publications, and 89 publications met inclusion criteria: 23 preclinical studies, 25 clinical studies, and 41 review articles. Preclinical studies indicated that the vitamin D receptor was decreased in fibroid cells. Vitamin D treatment of fibroid cells decreased proliferation, extracellular matrix protein expression, and Wnt/β-catenin signaling. Fourteen clinical studies (n = 3535 participants) assessed serum vitamin D level in women with ultrasound-proven fibroids, and all found an inverse correlation between serum vitamin D level and presence of fibroids. Five clinical studies (n = 472 patients) evaluated treatment of fibroids with vitamin D. Four of five studies showed vitamin D significantly inhibited fibroid growth. One pilot study (n = 109 patients) of vitamin D for secondary prevention of fibroids demonstrated smaller recurrent fibroids in the treated group. These studies provide evidence for vitamin D as a therapy for uterine fibroids and underscore the need for well-designed, randomized, placebo-controlled clinical trials.
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Affiliation(s)
- Abigail Combs
- Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Bhuchitra Singh
- Division of Reproductive Sciences and Women's Health Research, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Ross Research Building, 720 Rutland AvenueRoom 624, Baltimore, MD, USA
| | - Elisabeth Nylander
- Welch Medical Library, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Md Soriful Islam
- Division of Reproductive Sciences and Women's Health Research, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Ross Research Building, 720 Rutland AvenueRoom 624, Baltimore, MD, USA
| | - Ha Vi Nguyen
- Division of Reproductive Sciences and Women's Health Research, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Ross Research Building, 720 Rutland AvenueRoom 624, Baltimore, MD, USA
| | - Elissa Parra
- Division of Reproductive Sciences and Women's Health Research, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Ross Research Building, 720 Rutland AvenueRoom 624, Baltimore, MD, USA
| | - Ameerah Bello
- Division of Reproductive Sciences and Women's Health Research, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Ross Research Building, 720 Rutland AvenueRoom 624, Baltimore, MD, USA
| | - James Segars
- Division of Reproductive Sciences and Women's Health Research, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Ross Research Building, 720 Rutland AvenueRoom 624, Baltimore, MD, USA.
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30
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Mukherjee D, Chen MJ, Shao X, Ju TR, Shebley M, Marroum P. Virtual Bioequivalence Assessment of Elagolix Formulations Using Physiologically Based Pharmacokinetic Modeling. AAPS J 2023; 25:30. [PMID: 36949256 DOI: 10.1208/s12248-023-00794-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 02/15/2023] [Indexed: 03/24/2023] Open
Abstract
In lieu of large bioequivalence studies and exposing healthy postmenopausal women to additional drug exposure for elagolix coadministered with hormonal add-back therapy, physiologically based pharmacokinetic (PBPK) modeling was used with in vitro dissolution data to test for virtual bioequivalence. For endometriosis, elagolix is approved at doses of 150 mg once daily and 200 mg twice daily as a tablet. As a combination therapy, two individual tablets, consisting of an elagolix tablet and an estradiol/norethindrone acetate 1/0.5 mg (E2/NETA) tablet, were utilized in Phase 3 endometriosis trials. However, the commercial combination drug products consist of a morning capsule (containing an elagolix tablet and E2/NETA tablet as a fixed-dose combination capsule, AM capsule) and an evening capsule (consisting of an elagolix tablet, PM capsule). In vitro dissolution profiles were dissimilar for the tablet and capsule formulations; thus, in vivo bioequivalence studies or a bioequivalence waiver would have been required. To simulate virtual cross-over, bioequivalence trials, in vitro dissolution data was incorporated into a previously verified PBPK model. The updated PBPK model was externally validated using relevant bioequivalence study data. Based on results of the virtual bioequivalence simulations, the commercial drug product capsules met the bioequivalence criteria of 0.80-1.25 when compared to the reference tablets. This was a novel example where PBPK modeling was utilized along with in vitro dissolution data to demonstrate virtual bioequivalence in support of a regulatory bioequivalence waiver.
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Affiliation(s)
- Dwaipayan Mukherjee
- Clinical Pharmacology, AbbVie, Inc., Building AP31-3, 1 North Waukegan Rd., North Chicago, Illinois, 60064, USA.
| | - Mong-Jen Chen
- Clinical Pharmacology, AbbVie, Inc., Building AP31-3, 1 North Waukegan Rd., North Chicago, Illinois, 60064, USA
| | - Xi Shao
- Analytical Research & Development, AbbVie, Inc., North Chicago, Illinois, 60064, USA
| | - Tzuchi R Ju
- Analytical Research & Development, AbbVie, Inc., North Chicago, Illinois, 60064, USA
| | - Mohamad Shebley
- Clinical Pharmacology, AbbVie, Inc., Building AP31-3, 1 North Waukegan Rd., North Chicago, Illinois, 60064, USA
| | - Patrick Marroum
- Clinical Pharmacology, AbbVie, Inc., Building AP31-3, 1 North Waukegan Rd., North Chicago, Illinois, 60064, USA
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Yang Q, Al-Hendy A. Update on the Role and Regulatory Mechanism of Extracellular Matrix in the Pathogenesis of Uterine Fibroids. Int J Mol Sci 2023; 24:5778. [PMID: 36982852 PMCID: PMC10051203 DOI: 10.3390/ijms24065778] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 02/22/2023] [Accepted: 03/08/2023] [Indexed: 03/30/2023] Open
Abstract
Uterine fibroids (UFs), also known as leiomyomas, are benign tumors of the myometrium affecting over 70% of women worldwide, particularly women of color. Although benign, UFs are associated with significant morbidity; they are the primary indication for hysterectomy and a major source of gynecologic and reproductive dysfunction, ranging from menorrhagia and pelvic pain to infertility, recurrent miscarriage, and preterm labor. So far, the molecular mechanisms underlying the pathogenesis of UFs are still quite limited. A knowledge gap needs to be filled to help develop novel strategies that will ultimately facilitate the development of therapies and improve UF patient outcomes. Excessive ECM accumulation and aberrant remodeling are crucial for fibrotic diseases and excessive ECM deposition is the central characteristics of UFs. This review summarizes the recent progress of ascertaining the biological functions and regulatory mechanisms in UFs, from the perspective of factors regulating ECM production, ECM-mediated signaling, and pharmacological drugs targeting ECM accumulation. In addition, we provide the current state of knowledge by discussing the molecular mechanisms underlying the regulation and emerging role of the extracellular matrix in the pathogenesis of UFs and in applications. Comprehensive and deeper insights into ECM-mediated alterations and interactions in cellular events will help develop novel strategies to treat patients with this common tumor.
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Affiliation(s)
- Qiwei Yang
- Department of Obstetrics and Gynecology, University of Chicago, Chicago, IL 60637, USA;
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32
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Behandlung symptomatischer uteriner Myome mit oral aktiven Gonadotropin-Releasing-Hormon-Antagonisten und Add-back-Therapie. GYNAKOLOGISCHE ENDOKRINOLOGIE 2023. [DOI: 10.1007/s10304-023-00505-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023]
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Zhang Y, Xu Y, Zhang X, Zheng B, Hu W, Yuan G, Si G. 8Spheres conformal microspheres as embolic agents for symptomatic uterine leiomyoma therapy in uterine artery embolization (UAE): A prospective clinical trial. Medicine (Baltimore) 2023; 102:e33099. [PMID: 36862859 PMCID: PMC9981361 DOI: 10.1097/md.0000000000033099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/04/2023] Open
Abstract
To evaluate the treatment efficacy of uterine artery embolization (UAE) using 8Spheres conformal microspheres for symptomatic uterine leiomyoma. In this prospective observational study, 15 patients were enrolled and underwent UAE by 2 experienced interventionalists from September 1, 2018, to September 1, 2019. All patients underwent menstrual bleeding scores, the symptom severity domain of the Uterine Fibroid Symptom and Quality of Life questionnaire scores (with lower scores indicating mild symptoms), pelvic contrast-enhanced magnetic resonance imaging, ovarian reserve tests (estradiol, prolactin, testosterone, follicle-stimulating, luteinizing, and progesterone), and other appropriate preoperative examinations within 1 week before UAE. During follow-up, menstrual bleeding scores and the symptom severity domain of the Uterine Fibroid Symptom and Quality of Life questionnaire scores were recorded at 1, 3, 6, and 12 months after UAE to assess the efficacy of symptomatic uterine leiomyoma. Pelvic contrast-enhanced magnetic resonance imaging was performed 6 months after the interventional therapy. Biomarkers of ovarian reserve function were reviewed at 6 and 12 months after treatment. All 15 patients successfully underwent UAE, without severe adverse effects. Six patients experienced abdominal pain, nausea, or vomiting, all of which improved significantly after symptomatic treatment. The menstrual bleeding scores declined from baseline (350.2 ± 61.9 mL) to (131.8 ± 42.7 mL), (140.3 ± 42.4 mL), (68.0 ± 22.8 mL), and (64.43 ± 17.0 mL) at 1, 3, 6, and 12 months, respectively. The symptom severity domain scores at 1, 3, 6, and 12 months postoperatively were significantly lower and statistically significant compared to the preoperative scores. The uterus and dominant leiomyoma volumes decreased from baseline (340.0 ± 35.8 cm3), (100.6 ± 24.3 cm3) to (266.6 ± 30.9 cm3), (56.1 ± 17.3 cm3) at 6 months after UAE, respectively. Moreover, the ratio of leiomyoma volumes and uterus decreased from (27.4 ± 4.5%) to (18.7 ± 3.9%). At the same time, there was no significant effect on changes in the biomarkers of ovarian reserve levels. Only the changes in testosterone levels before and after UAE were statistically significant (P < .05). 8Spheres conformal microspheres are ideal embolic agents for UAE therapy. This study showed that 8Spheres conformal microsphere embolization for symptomatic uterine leiomyoma could effectively relieve heavy menstrual bleeding, improve the symptom severity of patients, reduce the volume of leiomyoma, and have no significant effect on ovarian reserve function.
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Affiliation(s)
- Yiwen Zhang
- Department of Interventional Radiology, The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, China
| | - Yanneng Xu
- Department of Interventional Radiology, The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, China
| | - Xun Zhang
- Department of Interventional Radiology, The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, China
| | - Bo Zheng
- Department of Interventional Radiology, The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, China
| | - Wei Hu
- Department of Interventional Radiology, The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, China
| | - Gang Yuan
- Department of Interventional Radiology, The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, China
| | - Guangyan Si
- Department of Interventional Radiology, The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, China
- *Correspondence: Guangyan Si, Department of Interventional Radiology, The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou 646000, China (e-mail )
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Stewart EA, Lukes AS, Venturella R, Li Y, Hunsche E, Wagman RB, Al-Hendy A. Quality of life with relugolix combination therapy for uterine fibroids: LIBERTY randomized trials. Am J Obstet Gynecol 2023; 228:320.e1-320.e11. [PMID: 36370871 DOI: 10.1016/j.ajog.2022.11.1278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 10/17/2022] [Accepted: 11/05/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Symptomatic uterine fibroids are burdensome to live with; they are associated with symptom-related distress, affect daily activities, and reduce health-related quality of life. The LIBERTY randomized clinical trials showed that oral relugolix combination therapy (40 mg relugolix, 1 mg estradiol, and 0.5 mg norethindrone acetate once daily) markedly improved fibroid-associated symptoms and conditions, including heavy menstrual bleeding, pain, and anemia, and was well-tolerated. OBJECTIVE This study aimed to evaluate the effect of relugolix combination therapy on the symptom burden and health-related quality of life among women with uterine fibroids. STUDY DESIGN Two replicate, multinational, double-blind, 24-week, randomized, placebo-controlled, phase 3 studies, LIBERTY 1 and LIBERTY 2, were conducted in premenopausal women with uterine fibroid-associated heavy menstrual bleeding (≥80 mL per cycle for 2 cycles or ≥160 mL during 1 cycle). The symptom burden and health-related quality of life were secondary endpoints and were assessed using the validated Uterine Fibroid Symptom and Quality of Life questionnaire, which the participants completed at baseline and at week 12 and 24 of treatment. For this secondary analysis, the pooled LIBERTY 1 and LIBERTY 2 data set was used. The Uterine Fibroid Symptom and Quality of Life questionnaire is made up of a Symptom Severity scale and a Health-Related Quality of Life scale, the latter of which includes 6 subscales focusing on the following aspects of daily life: concern, activities, energy or mood, control, self-consciousness, and sexual function. The Revised Activities subscale of the Health-Related Quality of Life scale addresses the impact of uterine fibroids on physical and social activities. Symptom burden was also assessed via the Bleeding and Pelvic Discomfort subscale, a patient-reported outcome measure derived from the Uterine Fibroid Symptom Severity scale that focuses on distress from key uterine fibroid symptoms, which was a key secondary endpoint. Least squares mean changes from baseline to week 24 in the Symptom Severity scale, Bleeding and Pelvic Discomfort subscale, overall Health-Related Quality of Life scale, and the respective subscales were compared between the relugolix combination therapy and placebo groups. Responder analyses of the proportion of women who experienced a clinically meaningful change from baseline to week 24 were conducted for the Bleeding and Pelvic Discomfort and the activity subscales. A stratified Cochran-Mantel-Haenszel test, adjusted for stratification factors (region [North America vs rest of world] and baseline menstrual blood loss volume), was used for treatment comparisons. RESULTS Across both trials, 509 women were randomized to the relugolix combination therapy or placebo groups (April 2017-December 2018). Participants on relugolix combination therapy showed a statistically significant reduction in symptom severity (-33.5 vs -12.1; nominal P<.0001) and the Bleeding and Pelvic Discomfort subscale from baseline to week 24 when compared with those on placebo treatment (-48.4 vs -17.4; nominal P<.0001). Overall, the total Health-Related Quality of Life scores improved significantly from baseline to week 24 in the relugolix combination therapy group when compared with the placebo (+37.6 vs +13.1; nominal P<.0001). Responder analyses demonstrated that more women treated with relugolix combination therapy reported a clinically meaningful reduction in the Bleeding and Pelvic Discomfort subscale and an improvement in physical and social activities when compared with those treated with the placebo (nominal P<.0001). CONCLUSION After 24 weeks of treatment with relugolix combination therapy, women with symptomatic uterine fibroids experienced substantial improvements in health-related quality of life with all subscales showing improvement, including emotional well-being, physical and social activities, and sexual function. In addition, women reported substantial reductions in the overall symptom burden and distress caused by key fibroid-associated symptoms.
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Affiliation(s)
- Elizabeth A Stewart
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology Mayo Clinic and Mayo Clinic Alix School of Medicine, Rochester, MN.
| | - Andrea S Lukes
- Carolina Women's Research and Wellness Center, Durham, NC
| | - Roberta Venturella
- Department of Clinical and Experimental Medicine, Unit of Obstetrics and Gynecology, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Yulan Li
- Myovant Sciences Inc, Brisbane, CA
| | | | | | - Ayman Al-Hendy
- Department of Obstetrics and Gynecology, University of Chicago, Chicago, IL
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McKain L, Edsall K, Dufour R, Lickert C. Treatment Patterns in Patients with Uterine Fibroids With and Without a Diagnosis of Heavy Menstrual Bleeding: Results from a Large U.S. Claims Database. J Womens Health (Larchmt) 2023; 32:332-340. [PMID: 36413048 PMCID: PMC9993160 DOI: 10.1089/jwh.2022.0056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background: This retrospective database analysis describes clinical characteristics and treatment patterns of U.S. women with a diagnosis for uterine fibroids (UF), both with and without heavy menstrual bleeding (HMB). Materials and Methods: Two cohorts aged 18-50 years with an incident UF diagnosis, comprising women with and without claims for HMB (UF-HMB and UF-only), were identified from the IQVIA PharMetrics® Plus database (January 1, 2010-December 31, 2019). The index date was the first UF claim following diagnosis; treatment patterns were documented for postindex years 1 and 2 and the full duration of postindex follow-up. Also identified were claims for symptoms or signs potentially associated with UF. Outcomes were the proportion of patients treated with pharmacologic therapies of interest and gynecologic procedures. Logistic regression was used to identify factors associated with postdiagnosis hysterectomy and hormonal therapy. Results: A total of 66,313 (71.8%) women were included in the UF-HMB cohort (mean age [standard deviation]) 42.6 [5.4] years), and 26,068 (28.2%) in the UF-only cohort (41.8 [6.3]). Median follow-up was ∼4 years. Pain was the most common symptom (42.7% in patients with UF-HMB and 36.6% with UF-only); also common were abnormal bleeding (15.6%, 11.5%) and fatigue (22.2%, 15.5%). Within 1 year of UF diagnosis, 28.8% and 49.2% of women with UF-HMB and UF-only, respectively, had no claims for relevant pharmacologic or surgical treatment. In logistic regression, multiple factors were associated with a higher likelihood of receiving hysterectomy or hormonal therapy. Conclusions: Patients with UF-HMB were more likely to receive UF treatment, either surgical or pharmacologic, than women with UF-only. Apart from HMB, pain was the most commonly documented symptom of UF.
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Affiliation(s)
- Laura McKain
- Medical Affairs, Myovant Sciences, Inc., Brisbane, California, USA
| | - Kaitlyn Edsall
- Life Sciences Practice, Charles River Associates, Boston, Massachusetts, USA
| | - Robert Dufour
- Medical Affairs, Myovant Sciences, Inc., Brisbane, California, USA
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Nagai K, Asano R, Sekiguchi F, Asai-Sato M, Miyagi Y, Miyagi E. MED12 mutations in uterine leiomyomas: prediction of volume reduction by gonadotropin-releasing hormone agonists. Am J Obstet Gynecol 2023; 228:207.e1-207.e9. [PMID: 36150519 DOI: 10.1016/j.ajog.2022.09.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 08/11/2022] [Accepted: 09/09/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND Gonadotropin-releasing hormone agonists are used to treat premenopausal uterine leiomyomas; however, leiomyoma volume reduction is not always achieved. The reduction rate after this treatment varies for each leiomyoma, even in the same patient. Therefore, an effective method for predicting uterine leiomyoma volume reduction is required to reduce the adverse hypoestrogenic effects and drug-related economic burden related to gonadotropin-releasing hormone agonists. OBJECTIVE This study aimed to determine the predictive use of MED12 mutations for evaluating the effect of gonadotropin-releasing hormone agonist treatment concerning reducing uterine leiomyoma volume and to predict the MED12 mutation status based on the findings of magnetic resonance imaging performed before treatment. STUDY DESIGN MED12 exon 2 mutation and erythropoietin expression in uterine leiomyomas were evaluated concerning volume reduction, as measured using magnetic resonance imaging. We developed a system for classifying leiomyomas according to T2-weighted magnetic resonance imaging signals to noninvasively predict the presence or absence of MED12 mutations in leiomyomas. Leiomyoma samples (>5 cm) were obtained from 168 patients during surgery (hysterectomy or myomectomy) between 2005 and 2021 at Yokohama City University Hospital. To analyze the rate of leiomyoma volume reduction, 41 patients had been preoperatively administered the gonadotropin-releasing hormone agonist (leuprorelin acetate 3.75 mg, monthly subcutaneous injection) for 3 months; magnetic resonance imaging was performed before and after treatment without contrast material. RESULTS Patients with MED12 exon 2 mutations had smaller volume reduction after treatment with the gonadotropin-releasing hormone agonist (P<.001, Mann-Whitney U test) and displayed lower signal intensity on T2-weighted images than those with leiomyomas expressing wild-type MED12 exon 2. The newly proposed magnetic resonance imaging-based classification system showed that MED12 exon 2 mutations were more frequent in the low-signal group than in the high-signal group, with nearly equal proportions of mutated and wild-type MED12 exon 2 leiomyomas noted in the intermediate group. The low-signal group had significantly lower erythropoietin expression levels than the high-signal group (P<.001, Kruskal-Wallis test with the Dunn posthoc analysis). CONCLUSION MED12 mutation status can be a candidate marker for predicting the effect of gonadotropin-releasing hormone agonists on uterine leiomyoma reduction. Magnetic resonance imaging findings can be used to determine MED12 mutation status as a noninvasive strategy to select patients who will most likely benefit from gonadotropin-releasing hormone agonist treatment.
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Affiliation(s)
- Koichi Nagai
- Department of Obstetrics, Gynecology and Molecular Reproductive Science, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Ryoko Asano
- Department of Obstetrics, Gynecology and Molecular Reproductive Science, Yokohama City University Graduate School of Medicine, Yokohama, Japan; Department of Gynecology, Yokohama City University Medical Center, Yokohama, Japan.
| | - Futoshi Sekiguchi
- Department of Obstetrics, Gynecology and Molecular Reproductive Science, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Mikiko Asai-Sato
- Department of Obstetrics and Gynecology, Nihon University School of Medicine, Tokyo, Japan
| | - Yohei Miyagi
- Molecular Pathology and Genetics Division, Kanagawa Cancer Center Research Institute, Yokohama, Japan
| | - Etsuko Miyagi
- Department of Obstetrics, Gynecology and Molecular Reproductive Science, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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Gonadotropin-Releasing Hormone Antagonists-A New Hope in Endometriosis Treatment? J Clin Med 2023; 12:jcm12031008. [PMID: 36769656 PMCID: PMC9918258 DOI: 10.3390/jcm12031008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 01/23/2023] [Accepted: 01/25/2023] [Indexed: 01/31/2023] Open
Abstract
Endometriosis is a chronic disease, in which endometrial-like tissue is found outside the uterine cavity. Lesions are typically located in the true pelvis but can be found, in addition to extragenital endometriosis, in the respiratory system, the diaphragm, the pleura or the pericardium. As the extrauterine endometrial lesions undergo the menstrual cycle, they cause many symptoms, including pain, and besides infertility, they all mostly affect the quality of the patient's life. Pharmacological management of endometriosis significantly increases in importance either as a first-line treatment or as a complementary therapy after surgery. Yet, current research on antagonists of the gonadotropin-releasing hormone (GnRH) has revealed their potential benefits in endometriosis treatment. Their mechanism of action is to down-regulate the hypothalamic-pituitary-gonadal axis and therefore induce a hypoestrogenic state. The resulting reduction of estrogen levels prevents disease progression and diminishes the recurrence rate after surgical removal of endometriosis. The present review summarizes recent reports of the role oral GnRH antagonists have as a significant treatment option for pain reduction in endometriosis patients.
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Sefah N, Ndebele S, Prince L, Korasare E, Agbleke M, Nkansah A, Thompson H, Al-Hendy A, Agbleke AA. Uterine fibroids - Causes, impact, treatment, and lens to the African perspective. Front Pharmacol 2023; 13:1045783. [PMID: 36703761 PMCID: PMC9871264 DOI: 10.3389/fphar.2022.1045783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 12/12/2022] [Indexed: 01/12/2023] Open
Abstract
Leiomyomas, or uterine fibroids as they are commonly known, are mostly seen in women of reproductive age. However, they can go undetected in most women, and approximately 25% of women show clinical symptoms. Although fibroids are a global burden impacting 80% of premenopausal women, they are more prevalent among Black women than among women of other races. Based on clinical diagnosis, the estimated cumulative incidence of fibroids in women ≤50 years old is significantly higher for black (>80%) versus white women (∼70%). The cause of leiomyomas is not clearly known, but studies have shown evidence of factors that drive the development or exacerbation of the disease. Evidence has linked risk factors such as lifestyle, age, environment, family history of uterine fibroids, and vitamin D deficiencies to an increased risk of uterine fibroids, which impact women of African descent at higher rates. Treatments may be invasive, such as hysterectomy and myomectomy, or non-invasive, such as hormonal or non-hormonal therapies. These treatments are costly and tend to burden women who have the disease. Sub-Saharan Africa is known to have the largest population of black women, yet the majority of uterine fibroid studies do not include populations from the continent. Furthermore, the prevalence of the disease on the continent is not well determined. To effectively treat the disease, its drivers need to be understood, especially with regard to racial preferences. This paper aims to review the existing literature and build a case for conducting future research on African women.
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Affiliation(s)
| | | | | | | | | | | | | | - Ayman Al-Hendy
- University of Chicago, Chicago, United States,*Correspondence: Ayman Al-Hendy, ; Andrews Akwasi Agbleke,
| | - Andrews Akwasi Agbleke
- Sena Institute of Technology, Penyi, Ghana,*Correspondence: Ayman Al-Hendy, ; Andrews Akwasi Agbleke,
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Mercorio A, Della Corte L, Boccia D, Palumbo M, Reppuccia S, Buonfantino C, Cuomo L, Borgo M, Zitiello A, De Angelis MC, Laganà AS, Bifulco G, Giampaolino P. Myomectomy in infertile women: More harm than good? Front Surg 2023; 10:1151901. [PMID: 37139194 PMCID: PMC10150951 DOI: 10.3389/fsurg.2023.1151901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 03/22/2023] [Indexed: 05/05/2023] Open
Abstract
Adhesion formation following gynecological surgery remains a challenge. The adoption of minimally invasive surgical approaches, such as conventional or robotic-assisted laparoscopy combined with meticulous microsurgical principles and the application of adhesion-reducing substances, is able to reduce the risk of de novo adhesion formation but do not eliminate it entirely. Myomectomy is the most adhesiogenic surgical procedure and postoperative adhesions can have a significant impact on the ability to conceive. Therefore, when surgery is performed as infertility treatment, attention should be paid to whether the benefits outweigh the risks. Among several factors, the size and the location of fibroids are the most accountable factors in terms of adhesion development and post surgical infertility; therefore, the search for effective strategies against adhesion formation in this setting is of paramount importance. The purpose of this review is to evaluate the incidence and factors of adhesion formation and the best preventive measures current available.
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Affiliation(s)
- Antonio Mercorio
- Department of Public Health, University of Naples Federico II, Naples, Italy
- Correspondence: Antonio Mercorio
| | - Luigi Della Corte
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Dominga Boccia
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Mario Palumbo
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Sabrina Reppuccia
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Cira Buonfantino
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Lara Cuomo
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Maria Borgo
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Antonio Zitiello
- Department of Woman Mother Child, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Antonio Simone Laganà
- Unit of Gynecologic Oncology, ARNAS “Civico-Di Cristina-Benfratelli”, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | - Giuseppe Bifulco
- Department of Public Health, University of Naples Federico II, Naples, Italy
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Actualización sobre las posibilidades de tratamiento médico hormonal para el sangrado menstrual abundante. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2023. [DOI: 10.1016/j.gine.2022.100819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Efficacy and Safety of Oral GnRh Antagonists in Patients With Uterine Fibroids: A Systematic Review. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2022; 44:1279-1288. [PMID: 36368594 DOI: 10.1016/j.jogc.2022.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 10/16/2022] [Accepted: 10/17/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVE This review aimed to assess the efficacy and safety of GnRH antagonists in patients with symptomatic uterine fibroids. DATA SOURCES A literature search was performed on PubMed, Web of Science, Embase, Cochrane, and ClinicalTrials.gov using the MeSH and Emtree terms "leiomyoma" and "gonadotropin-releasing hormone." STUDY SELECTION All clinical trials that provided efficacy and safety data in clinical terms (i.e., reduction in menstrual bleeding and discomfort, changes in the size of leiomyoma and uterine volume, etc.) were included. We excluded all preclinical studies, case reports, meta-analyses, review articles, and clinical studies irrelevant to the study question. DATA EXTRACTION AND SYNTHESIS Two authors extracted data from 9 clinical studies. The extracted data included the study's characteristics, participants' baseline characteristics, treatment drugs, efficacy measures, and toxicity. CONCLUSION Among oral GnRH antagonists, relugolix, elagolix, and linzagolix were safe in patients with uterine fibroids. These drugs, alone and in combination with E2/NETA (estradiol/norethindrone acetate), showed significantly better efficacy than placebo in improving bleeding, discomfort, uterine/leiomyoma sizes, and quality of life in premenopausal patients with symptomatic uterine fibroids. However, more randomized, double-blind, multicentre clinical trials are needed to confirm these results and to see long-term benefits.
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Al-Hendy A, Lukes AS, Poindexter AN, Venturella R, Villarroel C, McKain L, Li Y, Wagman RB, Stewart EA. Long-term Relugolix Combination Therapy for Symptomatic Uterine Leiomyomas. Obstet Gynecol 2022; 140:920-930. [PMID: 36357960 PMCID: PMC9665945 DOI: 10.1097/aog.0000000000004988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 08/19/2022] [Accepted: 08/25/2022] [Indexed: 11/13/2022]
Abstract
OBJECTIVE In the LIBERTY 1 and LIBERTY 2 placebo-controlled trials, once-daily relugolix combination therapy reduced menstrual blood loss volume and pain in women with heavy menstrual bleeding associated with uterine leiomyomas and was well tolerated, with preservation of bone mineral density (BMD) through 24 weeks. Here we report the long-term efficacy and safety of relugolix combination therapy treatment for up to 52 weeks. METHODS Women with uterine leiomyoma-associated heavy menstrual bleeding who completed any treatment arm in either the LIBERTY 1 or LIBERTY 2 trial were eligible to enroll in a 28-week long-term extension study. All participants received once-daily relugolix combination therapy (40 mg relugolix, estradiol 1 mg, norethindrone acetate 0.5 mg) in the extension study. The primary efficacy endpoint was the proportion of women who achieved or maintained a menstrual blood loss volume of less than 80 mL and a 50% or greater reduction in menstrual blood loss volume from LIBERTY study baseline to the last 35 days of treatment (defined as responders ). Analyses were conducted for all three randomized treatment groups from pivotal studies. RESULTS Overall, 477 women enrolled, 476 were treated, and 363 (76.1%) completed 52 weeks. Among patients treated with relugolix combination therapy through 52 weeks (n=163), sustained improvement in heavy menstrual bleeding was observed in 87.7% (responders). The least squares mean menstrual blood loss volume reduction was 89.9%, with 70.6% of patients achieving amenorrhea. At week 52, 59.0% of patients with anemia at baseline had improvements in hemoglobin concentration of greater than 2 g/dL. Distress due to uterine leiomyoma-associated symptoms measured by the BPD (Bleeding and Pelvic Discomfort) scale score was reduced by 51.3 points. Sustained reductions in uterine and uterine leiomyoma volume were observed. Bone mineral density was preserved through week 52. CONCLUSION Improvements in heavy menstrual bleeding and anemia and reduction of uterine leiomyoma-associated symptom burden were sustained through up to 52 weeks of treatment with relugolix combination therapy in women with uterine leiomyomas. No new safety concerns were identified, and BMD was maintained. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov , NCT03049735; NCT03103087; NCT03412890. FUNDING SOURCE Myovant Sciences GmbH.
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Affiliation(s)
- Ayman Al-Hendy
- University of Chicago, Chicago, Illinois; Carolina Woman's Wellness Center, Durham, North Carolina; Baylor College of Medicine and St. Luke's Episcopal Hospital, Houston, Texas; University Magna Graecia, Catanzaro, Italy; Instituto de Investigaciones Materno Infantil (IDIMI), University of Chile, Santiago, Chile; McKain Consulting, LLC, Las Vegas, Nevada; Myovant Sciences Inc., Brisbane, California; and Mayo Clinic and Mayo Clinic Alix School of Medicine, Rochester, Minnesota
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Gonadotropin-Releasing Hormone Antagonists Revolutionizing Gynecology. Obstet Gynecol 2022; 140:917-919. [PMID: 36357969 DOI: 10.1097/aog.0000000000005012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Beck D, Winzenborg I, Gao W, Mostafa NM, Chiuve SE, Owens C, Shebley M. Interdisciplinary model-informed drug development for extending duration of elagolix treatment in patients with uterine fibroids. Br J Clin Pharmacol 2022; 88:5257-5268. [PMID: 35695781 PMCID: PMC9796281 DOI: 10.1111/bcp.15440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/08/2022] [Accepted: 05/26/2022] [Indexed: 01/01/2023] Open
Abstract
AIM Elagolix, a gonadotropin-releasing hormone receptor antagonist, was recently approved for heavy menstrual bleeding associated with uterine fibroids (UF, Oriahnn) at a dose of 300 mg twice daily (BID) in combination with add-back therapy (oestradiol 1 mg/norethindrone acetate 0.5 mg [E2/NETA] once daily) for 24 months use. The limited duration of treatment is related to elagolix dose- and duration-dependent decrease in oestrogen that is mechanistically linked to changes in bone mineral density (BMD). The work herein supported the extended treatment duration of 24 months. METHODS An integrated exposure-response and epidemiological modelling framework of elagolix effects on femoral neck BMD (FN-BMD), informed by real-world data and phase 3 clinical trials data, was developed to predict the time course and magnitude of changes in BMD and its relation to risk of bone fracture in women with UF. RESULTS Model results indicated that women treated with elagolix 300 mg BID + E2/NETA in the long term (ie, >24 months) may experience less than 1% loss in FN-BMD per year, relative to placebo. The exposure-response model simulations and clinical risk factors were used to estimate 10-year risk of fractures using the clinically validated Fracture Risk Assessment Tool (FRAX). The impact of elagolix 300 mg BID + E2/NETA treatment on the 10-year risk of hip or major osteoporotic fractures estimated from the FRAX model was minimal compared to that of placebo. CONCLUSION The elagolix integrated exposure-BMD analysis and translation to fracture risk provided an interdisciplinary model-informed drug development framework for clinical benefit-risk evaluation and enabled approval of longer treatment duration to benefit the patient.
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Affiliation(s)
- Denise Beck
- Clinical Pharmacology and PharmacometricsAbbVie Deutschland GmbH & Co. KGLudwigshafen am RheinGermany
| | - Insa Winzenborg
- Clinical Pharmacology and PharmacometricsAbbVie Deutschland GmbH & Co. KGLudwigshafen am RheinGermany
| | - Wei Gao
- Analysis Group, Inc.BostonUSA
| | - Nael M. Mostafa
- Clinical Pharmacology and Pharmacometrics, AbbVieNorth ChicagoILUSA
| | | | - Charlotte Owens
- Clinical Development, General Medicine, AbbVieNorth ChicagoILUSA
| | - Mohamad Shebley
- Clinical Pharmacology and Pharmacometrics, AbbVieNorth ChicagoILUSA
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Xu Y, Hu W, Li J, Jiang X, Shi P, Shen K, Shen Y, Ma L, Cao Y. Safety, pharmacokinetics, and pharmacodynamics of SHR7280, an oral gonadotropin-releasing hormone antagonist in healthy premenopausal women. Front Pharmacol 2022; 13:1027648. [PMID: 36506562 PMCID: PMC9727091 DOI: 10.3389/fphar.2022.1027648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 11/10/2022] [Indexed: 11/24/2022] Open
Abstract
Background: Treatment with gonadotropin-releasing hormone (GnRH) antagonists is a powerful strategy to suppress gonadotropin activity in women with sex hormone-dependent disorders. Herein, we provide the safety, pharmacokinetics (PK), and pharmacodynamics (PD) profiles of SHR7280, an oral non-peptide GnRH antagonist in healthy premenopausal women. Methods: In this randomized, double-blinded, placebo-controlled, dose-ascending, phase 1 trial, healthy premenopausal women were randomized to receive SHR7280 or placebo orally. Four doses of SHR7280 (200, 300, 400, and 500 mg BID) were planned. Safety, PK, and PD parameters were evaluated. Results: SHR7280 presented tolerable toxicity and most adverse events were mild in severity. SHR7280 showed rapid onset of action (median Tmax ranged from 1.0 to 1.2 h for each dose), and plasma exposure was dose-dependent. PD results showed that SHR7280 300 mg BID and above suppressed estrogen concentration within the estradiol (E2) treatment window for endometriosis (20-50 pg/ml), inhibited the emergence of the peak of luteinizing hormone (LH) and the concentration of follicle stimulating hormone (FSH), and maintained the concentration of progesterone (P) in an anovulatory state (2 nmol/L). Conclusion: SHR7280 showed favorable safety, PK, and PD profiles in the dose range of 200-500 mg BID in healthy premenopausal women. This study supports the continued clinical development of SHR7280 as a GnRH antagonist for sex hormone-dependent disorders in women. Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT04554043, Identifier NCT04554043.
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Affiliation(s)
- Yi Xu
- Phase I Clinical Research Center, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Wei Hu
- Department of Clinical Pharmacology, The Second Hospital of Anhui Medical University, Hefei, China
| | - Jian Li
- Early Clinical Trial Centre, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xin Jiang
- Phase I Clinical Research Center, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Ping Shi
- Phase I Clinical Research Center, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Kai Shen
- Jiangsu Hengrui Pharmaceuticals Co., Ltd., Shanghai, China
| | - Yu Shen
- Jiangsu Hengrui Pharmaceuticals Co., Ltd., Shanghai, China
| | - Lingyu Ma
- Jiangsu Hengrui Pharmaceuticals Co., Ltd., Shanghai, China
| | - Yu Cao
- Phase I Clinical Research Center, The Affiliated Hospital of Qingdao University, Qingdao, China,*Correspondence: Yu Cao,
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Syed YY. Relugolix/Estradiol/Norethisterone (Norethindrone) Acetate: A Review in Symptomatic Uterine Fibroids. Drugs 2022; 82:1549-1556. [DOI: 10.1007/s40265-022-01790-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/26/2022] [Indexed: 11/06/2022]
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47
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Paul EN, Grey JA, Carpenter TJ, Madaj ZB, Lau KH, Givan SA, Burns GW, Chandler RL, Wegienka GR, Shen H, Teixeira JM. Transcriptome and DNA methylome analyses reveal underlying mechanisms for the racial disparity in uterine fibroids. JCI Insight 2022; 7:160274. [PMID: 36066972 PMCID: PMC9714787 DOI: 10.1172/jci.insight.160274] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 08/31/2022] [Indexed: 12/14/2022] Open
Abstract
Uterine fibroids (leiomyomas) affect Black women disproportionately compared with women of other races and ethnicities in terms of prevalence, incidence, and severity of symptoms. The causes of this racial disparity are essentially unknown. We hypothesized that myometria of Black women are more susceptible to developing fibroids, and we examined the transcriptomic and DNA methylation profiles of myometria and fibroids from Black and White women for comparison. Myometrial samples cluster by race in both their transcriptome and DNA methylation profiles, whereas fibroid samples only cluster by race in the latter. More differentially expressed genes (DEGs) were detected in the Black and White myometrial sample comparison than in the fibroid comparison. Leiomyoma gene set expression analysis identified 4 clusters of DEGs, including a cluster of 24 genes with higher expression in myometrial samples from Black women. One of the DEGs in this group, von Willibrands factor (VWF), was significantly hypomethylated in both myometrial samples from Black women and in all fibroids at 2 CpG probes that are near a putative enhancer site and that are correlated with VWF expression levels. These results suggest that the molecular basis for the disparity in fibroid disease between Black and White women could be found in the myometria before fibroid development and not in the fibroids themselves.
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Affiliation(s)
- Emmanuel N. Paul
- Department of Obstetrics, Gynecology and Reproductive Biology, College of Human Medicine, Michigan State University, Grand Rapids, Michigan, USA
| | - Joshua A. Grey
- Department of Obstetrics, Gynecology and Reproductive Biology, College of Human Medicine, Michigan State University, Grand Rapids, Michigan, USA
| | - Tyler J. Carpenter
- Department of Obstetrics, Gynecology and Reproductive Biology, College of Human Medicine, Michigan State University, Grand Rapids, Michigan, USA
| | - Zachary B. Madaj
- Bioinformatics and Biostatistics, Van Andel Institute, Grand Rapids, Michigan, USA
| | - Kin H. Lau
- Bioinformatics and Biostatistics, Van Andel Institute, Grand Rapids, Michigan, USA
| | - Scott A. Givan
- Bioinformatics and Biostatistics, Van Andel Institute, Grand Rapids, Michigan, USA
| | - Gregory W. Burns
- Department of Obstetrics, Gynecology and Reproductive Biology, College of Human Medicine, Michigan State University, Grand Rapids, Michigan, USA
| | - Ronald L. Chandler
- Department of Obstetrics, Gynecology and Reproductive Biology, College of Human Medicine, Michigan State University, Grand Rapids, Michigan, USA
| | - Ganesa R. Wegienka
- Department of Public Health Sciences, Henry Ford Hospital, Detroit, Michigan, USA
| | - Hui Shen
- Department of Epigenetics, Van Andel Institute, Grand Rapids, Michigan, USA
| | - Jose M. Teixeira
- Department of Obstetrics, Gynecology and Reproductive Biology, College of Human Medicine, Michigan State University, Grand Rapids, Michigan, USA
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Donnez J, Taylor HS, Stewart EA, Bradley L, Marsh E, Archer D, Al-Hendy A, Petraglia F, Watts N, Gotteland JP, Bestel E, Terrill P, Loumaye E, Humberstone A, Garner E. Linzagolix with and without hormonal add-back therapy for the treatment of symptomatic uterine fibroids: two randomised, placebo-controlled, phase 3 trials. Lancet 2022; 400:896-907. [PMID: 36116480 DOI: 10.1016/s0140-6736(22)01475-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 07/11/2022] [Accepted: 07/29/2022] [Indexed: 12/21/2022]
Abstract
BACKGROUND Uterine fibroids are common non-cancerous neoplasm that cause heavy menstrual bleeding and other signs. Linzagolix is an oral gonadotropin-releasing hormone receptor antagonist taken once per day that dose-dependently suppresses gonadal steroids and might reduce uterine-fibroid-associated signs. Two phase 3 trials were conducted to confirm the efficacy and safety of linzagolix at full-suppression (200 mg) and partial-suppression (100 mg) doses with or without hormonal add-back therapy (1 mg oestradiol and 0·5 mg norethisterone acetate) compared with placebo for the treatment of symptomatic uterine fibroids. METHODS PRIMROSE 1 and PRIMROSE 2 were identical 52-week, randomised, parallel, double-blind, placebo-controlled, phase 3 trials conducted at clinics in the USA (PRIMROSE 1) and Europe and the USA (PRIMROSE 2). Eligible women with uterine fibroid-associated heavy menstrual bleeding (menstrual blood loss >80 mL per cycle) were randomly assigned in a 1:1:1:1:1 ratio to one of five masked treatments: (1) placebo, (2) 100 mg linzagolix per day alone, (3) 100 mg linzagolix per day with once-per-day hormonal add-back therapy (1 mg oestradiol and 0·5 mg norethisterone acetate), (4) 200 mg linzagolix per day alone, or (5) 200 mg linzagolix per day with once-per-day hormonal add-back therapy (1 mg oestradiol and 0·5 mg norethisterone acetate). The primary endpoint was a response (menstrual blood loss ≤80 mL and ≥50% reduction from baseline) at 24 weeks in women who received at least one dose of treatment and did not meet any exclusion criteria based on predosing assessments. These trials are registered with ClinicalTrials.gov (NCT03070899 and NCT03070951). The trials have been completed. FINDINGS Between May, 2017, and October, 2020, in PRIMROSE 1, 574 women were enrolled, of which 48 discontinued and 15 were excluded; therefore, 511 women were included in the full analysis set; and in PRIMROSE 2, 535 women were enrolled, of which 24 did not receive the study drug and ten women were excluded from the study, resulting in 501 women being included in the full analysis set. In both trials, a significantly higher proportion of women had a reduction in heavy menstrual bleeding in all linzagolix (with or without add-back therapy) treatment groups compared with the placebo group (p≤0·003). In PRIMROSE 1, the response rates were 56·4% (95% CI 45·8-66·6%) in the 100 mg group, 66·4% (56·6-75·2%) in the 100 mg plus add-back therapy group, 71·4% (61·8-79·8%) in the 200 mg group, and 75·5% (66·0-83·5%) in the 200 mg plus add-back therapy group, compared with 35·0% (25·8-45·0%) in the placebo group. In PRIMROSE 2, the response rates were 56·7% (46·3-66·7%) in the 100 mg group, 77·2% (67·8-85·0%) in the 100 mg plus add-back therapy group, 77·7% (68·4-85·3%) in the 200 mg group, and 93·9% (87·1-97·7%) in the 200 mg plus add-back therapy group, compared with 29·4% (20·8-39·3%) with placebo. The most common adverse events up to 24 weeks were hot flushes (35% of participants in PRIMROSE 1 and 32% in PRIMROSE 2 with linzagolix [200 mg] alone and 3-14% in all other groups). INTERPRETATION Linzagolix (100 mg or 200 mg) with or without add-back therapy significantly reduced heavy menstrual bleeding. Partial suppression with once-per-day linzagolix (100 mg) without add-back therapy potentially provides a unique option for the chronic treatment of symptomatic uterine fibroids in women who cannot or do not want to take concomitant hormonal add-back therapy. FUNDING ObsEva.
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Affiliation(s)
- Jacques Donnez
- Société de Recherche pour l'infertilité, Catholic University of Louvain, Brussels, Belgium
| | - Hugh S Taylor
- Yale University School of Medicine, New Haven, CT, USA
| | - Elizabeth A Stewart
- Division of Reproductive Endocrinology, Mayo Clinic and Mayo Clinic Alix School of Medicine, Rochester, MN, USA
| | - Linda Bradley
- Department of Obstetrics and Gynecology, Cleveland Clinic, Cleveland, OH, USA
| | - Erica Marsh
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - David Archer
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Ayman Al-Hendy
- Department of Obstetrics and Gynecology, University of Chicago, Chicago, IL, USA
| | - Felice Petraglia
- Obstetrics and Gynecology, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Nelson Watts
- Mercy Health Osteoporosis and Bone Health Services, Cincinnati, OH, USA
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49
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Kelly B, Buttigieg E. Evaluation and Management of Heavy Vaginal Bleeding (Noncancerous). Obstet Gynecol Clin North Am 2022; 49:591-606. [PMID: 36122987 DOI: 10.1016/j.ogc.2022.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Heavy vaginal bleeding is a common, life-altering condition affecting around 30% of women at some point in their reproductive lives. Initial evaluation should focus on hemodynamic stability. A thorough history including the patient's menstrual cycle and personal and family bleeding history should be obtained. Causes are stratified using the structural and nonstructural International Federation of Gynecology and Obstetrics classification system. Further consideration of the patient's age is essential because this can help to narrow the differential diagnosis. Work-up includes laboratory and imaging studies. Treatment approach includes acute stabilization and long-term treatment with medical and surgical modalities.
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Affiliation(s)
- Bridget Kelly
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA; University of Wisconsin Obstetrics and Gynecology Clinic, 2402 Winnebago Street, Madison, WI 53704, USA
| | - Emily Buttigieg
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA; University of Wisconsin Obstetrics and Gynecology Clinic, 20 South Park, Madison, WI 53715, USA.
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50
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Evangelisti G, Barra F, Perrone U, Di Donato N, Bogliolo S, Ceccaroni M, Ferrero S. Comparing the pharmacokinetic and pharmacodynamic qualities of current and future therapies for uterine fibroids. Expert Opin Drug Metab Toxicol 2022; 18:441-457. [DOI: 10.1080/17425255.2022.2113381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Giulio Evangelisti
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Fabio Barra
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Southern Endometriosis Centre, Queen Alexandra Hospital, Portsmouth, UK
- Department of Obstetrics and Gynecology, Gynecology Oncology and Minimally-Invasive Pelvic Surgery, International School of Surgical Anatomy (ISSA), IRCCS Ospedale Sacro Cuore - Don Calabria, Via Don A. Sempreboni, 5, 37024, Negrar (Verona), Italy
| | - Umberto Perrone
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Nadine Di Donato
- Southern Endometriosis Centre, Queen Alexandra Hospital, Portsmouth, UK
| | - Stefano Bogliolo
- Department of Obstetrics and Gynecology, “P.O del Tigullio” Hospital-ASL4, Metropolitan Area of Genoa, Genoa, Italy
| | - Marcello Ceccaroni
- Department of Obstetrics and Gynecology, Gynecology Oncology and Minimally-Invasive Pelvic Surgery, International School of Surgical Anatomy (ISSA), IRCCS Ospedale Sacro Cuore - Don Calabria, Via Don A. Sempreboni, 5, 37024, Negrar (Verona), Italy
| | - Simone Ferrero
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
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