Hysteroscopic and ultrasonographic evaluation of ulipristal acetate treatment for symptomatic myomas in premenopausal women: a prospective study

Factors associated with dysmenorrhoea and menorrhagia improvement in patients with adenomyosis after uterine artery embolisation

BACKGROUND

This study examined the improvement of dysmenorrhoea and menorrhagia after uterine artery embolisation (UAE) in women with symptomatic adenomyosis and identified factors that could predict the improvement of dysmenorrhoea and menorrhagia.

METHODS

This retrospective study included women with adenomyosis who underwent bilateral UAE between December 2014 and December 2016. The percentage of the volume of the absence of contrast enhancement on T1-weighted images was evaluated 5-7 days after UAE. A receiver operating characteristic (ROC) analysis was used to determine a cut-off point and predict the improvement of dysmenorrhoea and menorrhagia.

RESULTS

Forty-eight patients were included. At 24 and 36 months after UAE, the improvement rates for dysmenorrhoea and menorrhagia were 60.4% (29/48) and 85.7% (30/35), and the recurrence rates were 19.4% (7/36) and 9.1% (3/33), respectively. Only the percentage of the volume of the absence of contrast enhancement on T1-weighted images was associated with the improvement of dysmenorrhoea (p = 0.001, OR = 1.051; 95% CI: 1.02-1.08) and menorrhagia (p = 0.006, OR = 1.077; 95% CI: 1.021-1.136). When the cut-off value of the ROC analysis was 73.1%, sensitivity, specificity, positive predictive value, and negative predictive value for the improvement of dysmenorrhoea were 58.6%, 94.7%, 94.4%, and 60%, while they were 58.9%, 80%, 100%, 100%, and 45.5% for the improvement of dysmenorrhoea.

CONCLUSION

Bilateral UAE for symptomatic adenomyosis led to good improvement of dysmenorrhoea and menorrhagia. The percentage of the volume of the absence of contrast enhancement on T1-weighted images of the uterus in postoperative magnetic resonance imaging might be associated with the improvement of dysmenorrhoea and menorrhagia.

Contemporary approaches in the management of uterine leiomyomas

BACKGROUND

Leiomyomas (fibroids), the most common benign solid tumours in females, originate from the myometrium and are associated with poor quality of life for patients. The current management of uterine leiomyomas mainly includes surgical interventions such as hysterectomy and myomectomy, either by laparoscopy or laparotomy, which have several complications and are not ideal for preserving fertility. Therefore, there is a need to develop or repurpose medical treatments that do not require surgical intervention.

OBJECTIVE

Many drugs are used to treat the symptoms associated with uterine fibroids. The main objective of this systematic review is to give an up-to-date account of potential pharmacological agents (non-surgical methods) for the management of uterine leiomyomas.

SEARCH STRATEGY

PubMed was searched for scientific and clinical literature using the keyword 'uterine fibroids' along with the drug names described in each section. For example, 'uterine fibroids' and 'ulipristal acetate' were the keywords used to search for literature on ulipristal acetate (UPA).

RESULTS

Various preclinical and clinical studies have shown that some drugs and herbal formulations exhibit activity in the management of uterine leiomyomas. Recent studies found that drugs such as UPA, elagolix, EC313, asoprisnol, nutritional supplements and herbal preparations were helpful in treating the symptoms associated with uterine leiomyomas.

CONCLUSION

Many drugs show efficacy in patients with symptomatic uterine fibroids. UPA is one of the most studied and prescribed medicines for uterine fibroids; however, its usage has been restricted due to a few recent incidences of hepatic toxicity. Herbal drugs and natural supplements have also shown promising effects on uterine fibroids. The synergistic effects of nutritional and herbal supplements have been reported in certain cases, and should be studied in detail. Further research is warranted to identify the mode of action of the drugs, and to determine the precise conditions that would explain the causes of toxicity in some patients.

Surgical management of endocervical and decidual polyps during pregnancy: systematic review and meta-analysis

PURPOSE

To evaluate the impact of endocervical and decidual polypectomy on obstetrical outcomes of pregnant women.

METHODS

MEDLINE, Scopus, ClinicalTrials.gov, Scielo, EMBASE, Cochrane Library at the CENTRAL Register of Controlled Trials, and LILACS were searched from inception to April 2021. No language or geographical restrictions were applied. Inclusion criteria regarded observational studies concerning pregnant women with a cervical lesion who underwent cervical polypectomy. Co-primary outcomes were incidence of late pregnancy loss and preterm birth in women with endocervical or decidual polypectomy as well as polypectomy versus expectant management. Random effect meta-analyses to calculate risk ratio (RR) with 95% confidence interval (CI) were performed. Quality assessment of included papers was performed using Newcastle-Ottawa Scale criteria.

RESULTS

Three studies, with data provided for 3097 women, were included in quantitative analysis, with comparisons between endocervical and decidual polyps extracted from two studies and 156 patients. After a first trimester endocervical or decidual polypectomy, no significant differences were found for late pregnancy losses (RR 0.29 [95% CI 0.05, 1.80], I² = 11%). Risk for preterm birth was significantly higher for decidual polyps' removal (RR 6.13 [95% CI 2.57, 14.59], I² = 0%). One paper compared cervical polypectomy vs expectant management, with increased incidence of late pregnancy loss (4/142 vs 5/2799; p < 0.001) and preterm birth (19/142 vs 115/2799; p < 0.001) in women subjected to polypectomy.

CONCLUSIONS

Evidence regarding the removal of cervical polyps in pregnancy is extremely limited. However, the removal of either decidual or endocervical polyps seems associated with increased risk of pregnancy loss and preterm birth, with increased preterm birth risk following endocervical rather than decidual polypectomy.

Ultra-minimally invasive surgery in gynecological patients: a review of the literature

In the last decade, Ultra-minimally invasive surgery (UMIS) including both minilaparoscopic (MH) and percutaneous (PH) endoscopic surgery achieved widespread use around the world. Despite UMIS has been reported as safe and feasible surgical procedure, most of the available data are drawn from retrospective studies, with a limited number of cases and heterogeneous surgical procedures included in the analysis. This literature review aimed to analyze the most methodologically valid studies concerning major gynecological surgeries performed in UMIS. A literature review was performed double blind from January to April 2021. The keywords ‘minilaparoscopy’; ‘ultra minimally invasive surgery’; ‘3 mm’; ‘percutaneous’; and ‘Hysterectomy’ were selected in Pubmed, Medscape, Scopus, and Google scholar search engines. PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines were followed for the drafting of the systematic review. The systematic literature research provided 298 studies, of which 9 fell within the inclusion criteria. Two hundred ninety-six total patients were included, 148 for both PH and MH groups. Median age (48 years), BMI (24 kg/m²), OT (90 min), EBL (50 ml), time to discharge (1 day), self scar evaluation (10/10), and VAS (3/10) were reported. The most frequent intraoperative complication in both the PH and MH groups was surgical bleeding. The UMIS approaches were feasible and safe even for complex gynecological procedures. Operative times and complications were superimposable to the “classical” minimally invasive approaches reported in the literature. The reported results apply only to experienced surgeons.