Uterine fibroid management: from the present to the future

Awareness, burden and treatment of uterine fibroids: a web-based Italian survey

Uterine fibroids (UFs) are the most common benign tumors in women of reproductive age and one of the leading causes of hysterectomy in Italy. This survey aimed to report how Italian women perceive and approach UFs, in order to raise healthcare professionals (HCPs)', institutions' and women's awareness of UFs and their treatment options. 1508 Italian women aged 30-50 years completed a web-based survey, answering a structured questionnaire focused on UF prevalence, symptomatology and impact, management and awareness. UF self-reported prevalence was 28.8%. Most UF-diagnosed women had symptom(s) before diagnosis (79.0%), and more than a half of UF-diagnosed participants were symptomatic post-diagnosis (55.8%). The most common symptoms after diagnosis were heavy menstrual bleeding (73.1%), dysmenorrhea (50.4%) and pelvic pain (36.8%). UFs negatively affected the quality of life of most symptomatic women, as well as sexuality and employment. Private gynecologists were the key reference HCPs for consultation and UF diagnosis. The most common UF treatments for symptomatic women were surgery (49.2%), followed by oral contraceptives (39.3%). Surgery was also performed for 22.9% of asymptomatic participants. UF-diagnosed participants were not involved in therapeutic choices in 37.6% of cases. Women's knowledge about UFs was mostly superficial (58.7% of all participants), with gynecologists and family/friends as main information sources. Patient-physician communication was rather unsatisfactory, especially about UF therapeutic options and disease impact on sexuality, fertility and lifestyle. This survey highlights that there is still a need to promote patient's knowledge about UFs and empowerment in treatment decision.

Retrospective case control study on the evaluation of the impact of augmented reality in gynecological laparoscopy on patients operated for myomectomy or adenomyomectomy

The objective of this study is to evaluate the safety of using augmented reality (AR) in laparoscopic (adeno)myomectomy, defined as an increase in operating time shorter than 15 min. A total of 17 AR cases underwent laparoscopic myomectomy or adenomyomectomy with the use of AR and 17 controls without AR for the resection of (adeno)myomas. The non-inferiority assumption was defined by an operative overtime not exceeding 15 min, representing 10% of the typical operative time. The 17 AR cases were matched to 17 controls. The criteria used in matching the two groups were the type of lesions, the size and the placement. The mean operative time was 135 ± 39 min for AR cases and 149 ± 62 min for controls. The margin of non-inferiority was expressed as a difference in operative time of 15 min between the case and control groups. The mean difference observed between AR cases and controls was -14 min with 90% CI [-38.3;11.3] and was significantly lower than the non-inferiority margin of 15 min (p = 0.03). This negative time difference means that the operative time is shorter for the AR cases group. Intraoperative data revealed a volume of bleeding ≤200 mL in 82.3% of AR cases and in 75% of controls (p = 0.62). No intra or postoperative complications were reported in the groups. The use of augmented reality in laparoscopic (adeno)myomectomy does not introduce additional constraints for the surgeon. It appears to be safe for the patients, with an absence of additional adverse events and of significantly prolonged operative time.

Evaluation of the clinical and cost-effectiveness of transcervical ultrasound-guided radiofrequency ablation of leiomyomas (ESONATA): a prospective comparative cohort study

OBJECTIVE

Intrauterine ultrasound-guided radiofrequency ablation with the Sonata® System is a minimally invasive option for uterine fibroids. Currently, comparative studies and cost-effectiveness data are lacking. This three-arm study aims to evaluate the clinical and cost-effectiveness of the Sonata® system versus laparoscopic or laparotomic myomectomy and laparoscopic hysterectomy.

DESIGN/SETTING/PARTICIPANTS/INTERVENTIONS

A single-center prospective comparative cohort study of 96 participants was conducted with 18 months of follow-up. Participants were allocated, based on patient preference, to Sonata treatment, myomectomy, or hysterectomy. The primary outcome was return to work (RTW). Secondary outcomes included symptom severity score (SSS), health-related quality of life (HRQoL), reintervention or redo rate, complications, satisfaction, and recommendation. For the economic evaluation, HRQoL, resource use and costs were evaluated after 12 months.

RESULTS

Median RTW after Sonata treatment was 3.0 days (IQR 1.2-4.8), compared to 47.0 days (IQR 42.3-51.7) for myomectomy and 45.0 days (IQR 36.5-53.5) for hysterectomy. At 12 months SSS decreased by 22.2, 24.9, and 47.2 points for Sonata, myomectomy, and hysterectomy respectively. Correspondingly, HRQoL increased significantly by 31.1, 25.2, and 48.7 points. Surgical reintervention rates at 18 months were 27.3% for Sonata and 6.3% for myomectomy. Surgical redo rate following Sonata treatment was 24.2%. No complications were reported after Sonata, 11 complications were related to myomectomy and 2 to hysterectomy. After 18 months, satisfaction rates were slightly higher in the myomectomy (96%) and hysterectomy (97%) groups, compared to the Sonata group (85%). At 18 months, 97% of participants would recommend Sonata and hysterectomy, while 96% would recommend myomectomy. The economic evaluation showed the highest HRQoL gain after hysterectomy but at the highest cost. Conversely, myomectomy was less favorable than Sonata, as it yielded less HRQoL gain at a higher cost.

CONCLUSION

Sonata leads to faster RTW compared to myomectomy and hysterectomy. SSS and HRQoL significantly improve following all treatments. Sonata is a cost-effective option compared to myomectomy. Although Sonata yields less HRQoL gain than hysterectomy, it is a lower-cost, uterus-preserving option, making it particularly valuable for premenopausal women. Despite a higher reintervention and redo rate, Sonata achieves high levels of patient satisfaction and recommendation.

Drug likeliness, pharmacokinetics profiling and efficacy of Polyscias fulva bioactive compounds in the management of uterine fibroids; An integrative in silico and in vivo approach

Polyscias fulva is traditionally used in Uganda for the management of Uterine fibroids (UF). However, there is paucity of data regarding its efficacy, biological targets and potential mechanisms of action hence prompting scientific validation process through insilico and invivo approaches. In this study, we utilized network pharmacology, molecular docking, molecular dynamic simulations and invivo assays to investigate the drug likeliness, pharmacokinetics and efficacy of Polyscias fulva against Uterine fibroids. Four Polyscias fulva bioactive compounds; pinoresinol, lichexanthone, methyl atarate, β-sitosterol exhibited drug likeness properties with moderate safety profiles. Forty-eight (48) uterine fibroid targets were identified as potential targets for the eleven Polyscias fulva compounds. Protein-protein interaction (PPI) analysis revealed four key targets (HIF1A, ESR1, EGFR, and CASP3). The KEGG pathway and GO enrichment analyses revealed that these key targets play significant roles in regulating the positive regulation of cyclin-dependent protein serine/threonine kinase activity, positive regulation of nitric-oxide synthase activity and positive regulation of transcription, DNA-templated. β-sitosterol demonstrated the strongest binding affinity with the four targets, showing particularly strong affinities for EGFR (-9.75 kcal/mol) and HIF1A (-9.21 kcal/mol). Molecular dynamics (MD) simulations revealed high stability in these protein-ligand complexes, with CASP3 displaying the lowest deviation and most consistent RMSD (0.14 nm) of the protein, followed by EGFR (0.25), HIF1A (0.29), and ESR1 (0.79). In-vivo evaluation on female Wistar rats with Polyscias fulva ethanolic extract showed an ameliorative effect of the extracts against monosodium glutamate-induced (MSG) UF. Treated animals exhibited a decrease in serum proteins, cholesterol, estrogen, and progesterone levels (P < 0.05) and the extract preserved uterine tissue histoachitecture as compared to controls. In conclusion, Polyscias fulva demonstrates potential ameliorative activity against UF with promising pharmacokinetic properties and safety profiles.

An update on selective estrogen receptor modulator: repurposing and formulations

The selective estrogen receptor modulator (SERM) raloxifene hydrochloride (RLH) is used extensively in the management and prevention of breast cancer and osteoporosis. Recent clinical studies show the repurposing of RLH in various diseases based on its structure and some clinical trials studies. Optimizing the clinical effectiveness of this important drug requires a thorough review of the formulation techniques, patent environment, and analytical procedures. The purpose of this study is to give a thorough understanding of dug repurposing with the most recent formulation strategies, patents, and analytical methods related to RLH. Highlighting recent developments, pointing out current issues, and suggesting future lines of inquiry and development are the objectives. A thorough literature analysis was carried out with an emphasis on repurposing of RLH for various diseases and analytical techniques employed in the measurement and quality control of RLH. These techniques included spectroscopic, chromatographic, and electrochemical approaches. Key advancements and trends were found by analyzing patent databases. The evaluation also looked into formulation techniques intended to improve the medicine's therapeutic efficacy and bioavailability, notably cutting-edge drug delivery methods. For the study of RLH, the review identifies several sophisticated analytical techniques that provide increased accuracy and robustness. Significant innovation has been revealed by the patent landscape, particularly in formulations targeted at enhancing solubility and bioavailability. Notable formulation techniques that overcome the drawbacks of conventional techniques include transdermal patches, nanoparticulate systems, and various drug delivery techniques.

Clinical Efficacy of Percutaneous Microwave Ablation in Treating Uterine Fibroids: A Comprehensive Systematic Review and Meta-Analysis

PURPOSE

The objective of this systematic review and meta-analysis was to assess the clinical efficacy of percutaneous microwave ablation (PMWA) therapy for treating uterine fibroids and to explore regional variations in its effectiveness.

METHODS

PubMed, Google Scholar, and CochraneLibrary were searched using keywords such as "leiomyoma," "fibroid," and "microwave ablation" to identify clinical trials and observational studies involving women with symptomatic uterine fibroids treated with PMWA therapy. Data on the outcomes of symptom severity, quality of life, fibroid volume, and hemoglobin concentration were extracted to calculate weighted mean differences (WMD) with 95% confidence intervals. Subgroup analyses based on study type and location were conducted. The quality and risk of bias of the included studies were evaluated using the National Institutes of Health quality assessment tools. Heterogeneity was assessed using Higgins I2 statistics.

RESULTS

Out of 1,068 initial records, 14 studies comprising 754 patients with symptomatic uterine fibroids were included. There was a significant reduction in symptom severity (WMD = -33.3; 95 %CI: -41.16, -25.46; p < 0.001; I2 = 99 %) and fibroid volume (WMD = -89.26 cm3; 95 % CI: -130.64, -47.87; p < 0.01; I2 = 99 %)., along with a significant improvement in quality of life (WMD = 27.21; 95 % CI:21.70,32.72; p < 0.01; I2 = 91 %) and hemoglobin concentration (WMD = 3.20 g/dl; 95 %CI:2.71,3.69; p < 0.01;I2 = 83 %). Subgroup analysis identified study location as a significant moderator for fibroid volume reduction, with Asian studies showing a greater decrease than European studies.

CONCLUSION

The analysis suggests that PMWA therapy is an efficacious treatment for uterine fibroids, with consistent outcomes in both Asian and European populations. However, high heterogeneity among the included studies limits the interpretation of results.

Clinical characteristic and risk factors for post-operative complications in women undergoing laparoscopy myomectomy

OBJECTIVE

To assess clinical characteristic and risk factors for post-operative complications in women undergoing laparoscopic myomectomy using the Clavien-Dindo classification system.

METHODS

A retrospective cohort study was conducted at Soroka University Medical Center, Beer Sheva, Israel, between 2010 and 2020, including women who underwent laparoscopic myomectomy. Postoperative adverse events were classified using the Clavien-Dindo system. The study population was divided into two groups: those with complications (Clavien-Dindo classification ≥ 1) and those without complications (Clavien-Dindo classification = 0). Risk factors were compared between the groups and analyzed for statistical significance using univariate and multivariate logistic regression.

RESULTS

A total of 111 women who underwent laparoscopic myomectomy were included. Of these, 26 experienced complications (study group) and 85 did not (comparison group); all complications were minor. Women in the study group had a higher incidence of pre-operative symptoms (76.9 % vs. 55.3 %). Additionally, the duration of surgery was significantly longer in the study group (137 min vs. 97 min, p < 0.01), and estimated blood loss was higher, with more frequent use of anti-adhesive agents. There was no significant difference in preoperative anemia between the groups. Estimated blood loss > 100 mL was found to be independently associated with complications (aOR 4.4, 95 % CI 1.5-12.5).

CONCLUSION

Laparoscopic myomectomy is a safe and effective surgical option for women, with a low rate of minor complications. Although longer surgeries and increased blood loss were associated with complications, the overall risk remains minimal. Proper identification of risk factors such as pre-operative symptoms and intraoperative blood loss can help optimize patient outcomes. Future research should further explore the relationship between anemia and surgical outcomes, as no significant differences in anemia were observed in this study.

Impact of definitive uterine artery occlusion on ovarian reserve markers in laparoscopic myomectomy: a randomized controlled trial with 2-year follow-up

STUDY QUESTION

Does definitive occlusion of uterine arteries have a short- or long-term impact on ovarian reserve markers in reproductive-age women undergoing laparoscopic myomectomy?

SUMMARY ANSWER

Preventive definitive uterine artery occlusion (UAO) during laparoscopic myomectomy reduces intraoperative blood loss but does not impact serum AMH levels after short- and long-term follow-up in reproductive-age women.

WHAT IS KNOWN ALREADY

Uterine leiomyomas are the most common benign tumours in women of reproductive age. For symptomatic women willing to retain their uterus, especially for a future pregnancy, the current gold standard is surgical myomectomy for subserous/intramural leiomyoma. Temporary or definitive occlusion of uterine arteries can be performed to control bleeding during surgery but its impact on ovarian reserve markers is still unclear. A single randomized trial with a 1-year follow-up demonstrated that temporary bilateral UAO during laparoscopic myomectomy slightly decreased AMH levels at postoperative day 2 but has no significant impact at 3, 6, and 12 months after surgery.

STUDY DESIGN, SIZE, DURATION

We conducted a randomized controlled trial with a 2-year follow-up evaluating the effect of definitive occlusion of uterine arteries on ovarian reserve markers via sequential measures of AMH levels and AFC by ultrasound assessment. The study included 58 women with symptomatic leiomyoma type FIGO 3 to 6 scheduled for laparoscopic myomectomy between July 2015 and October 2021. Patient allocation was disclosed to the surgeon just before starting the procedure; women were blinded to group allocation throughout the study.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Patients were randomized in two groups: the UAO group (laparoscopic myomectomy with preventive occlusion of uterine arteries) (n = 29 women) and the no-UAO group (laparoscopic myomectomy without occlusion of uterine arteries but with intra-myometrial injection of vasoconstrictive agents) (N = 29 women). Serum AMH levels and AFC were evaluated at baseline (T0) and followed at 1 month (T1), 3 months (T3), 6 months (T6), 12 months (T12), and 24 months (T24) after surgery. Intraoperative blood loss, evolution of uterine bleeding and pain symptoms, and leiomyoma recurrence were also evaluated as secondary outcomes. Pregnancies and live births were monitored.

MAIN RESULTS AND THE ROLE OF CHANCE

Women in both groups did not differ in their baseline characteristics in terms of age, body mass index, ethnicity, parity, wish to become pregnant, hormonal treatment, leiomyoma number and size, baseline haemoglobin levels, uterine bleeding symptoms, baseline serum AMH levels, and AFC. The mean operative time was similar between both groups. Mean blood loss during surgery was on average 138 (±104) ml in the UAO group versus 436 (±498) ml in controls (P < 0.001). In the UAO group, 0% had an intraoperative blood loss >500 ml versus 32.1% in the no-UAO group (P < 0.01). Regarding clinical symptoms, most patients in both groups had decreased menstrual flow at the last follow-up visit (24 months) compared to baseline and improvement of dysmenorrhea followed the same trend with a reduction in pain levels in both groups. The risk of leiomyoma recurrence was similar between both groups. Serum AMH levels did not differ between the groups at any time (T1, T3, T6, T12, and T24) and non-inferiority of preventive occlusion was demonstrated with a non-inferiority margin of [-3.5 pmol/l]. Differences between means and 95% CI (in parentheses) were as follows: at T1 -0.11 (-2.14 to 2.40), at T3 -0.25 (-2.36 to 2.21), at T6 0.81 (-2.69 to 3.84), at T12 -0.95 (-3.15 to 1.33), and at T24 1.18 (-1.95 to 3.82). AFC did not differ between the groups at any time, however, non-inferiority of preventive occlusion could not be demonstrated, presumably due to a large variability in this measurement.

LIMITATIONS, REASONS FOR CAUTION

Our sample size was calculated to detect a clinically relevant difference of at least two-thirds of the SD in serum AMH levels, but we cannot exclude that a larger sample size might have revealed a smaller impact on serum AMH.

WIDER IMPLICATIONS OF THE FINDINGS

Preventive UAO during laparoscopic myomectomy does not compromise ovarian reserve markers and can be used safely to improve perioperative bleeding control in women of reproductive age. Incorporating UAO as a preventive measure during laparoscopic myomectomy may enhance the safety of the procedure.

STUDY FUNDING/COMPETING INTEREST(S)

Funded by the Department of Paediatrics, Gynecology and Obstetrics of the Geneva University Hospitals. There are no competing interests to declare.

TRIAL REGISTRATION NUMBER

NCT02563392.

TRIAL REGISTRATION DATE

9 July 2015.

DATE OF FIRST PATIENT’S ENROLMENT

July 2015.

Near-Infrared Spectroscopy Mapping for Uterine Cancer and Fibroid Detection

Endometrial cancer and uterine leiomyomas (fibroid) are common uterine pathologies that require early diagnosis to improve a patient's symptoms and increase the success rate of interventional procedures. In this work, we report on near-infrared spectroscopy (NIRS) spectral features of uterine cancer and fibroids from 69 surgical specimens obtained from 24 patients following hysterectomies. Normal uterus, cancer, and fibroid tissue were identified by NIR spectral contrast parameters based on the differences in spectrum morphology. Using the significant optical features and spectral principal components, a classification model was able to classify uterus tissue with a prediction accuracy higher than 70%, identifying cancer specimens with 70% sensitivity and 93% specificity, and fibroid samples with 86% sensitivity and 83% specificity. These results demonstrated NIRS mapping has promise as a complementary method for gynecologic imaging.

Outlier data in volume calculations of uterine fibroids comparing ellipsoid formula and voxel-based segmentation

BACKGROUND

The ellipsoidal formula is the most common method used to determine the volume of fibroids on MR images. Labor-intensive manual segmentation provides the opportunity to measure the volume of a given lesion on a voxel basis. The aim of this study is to compare the volume of the uterine fibroid calculated using voxel-based segmentation and the ellipsoid formula.

METHODS

In this study, pretreatment MRI scans of patients who underwent uterine artery embolization due to symptomatic fibroids were retrospectively collected between 2016 and 2022. The volume data of the largest fibroids was determined by segmentation (group S) as the reference standard. In addition, the largest diameters of the fibroids in three planes (D1/D2/D3) were also measured and the volumes were also estimated by using the ellipsoidal formula (D1*D2*D3*0.5233) (group E). The interobserver reproducibility of the diameter measurements was tested. The volume values (median, IQR) were compared; in addition, the differences between the segmented and ellipsoidal volumes were recorded. Statistical analysis was performed using the Kruskal-Wallis test, Wilcoxon's two-sided signed rank test, intraclass correlation (ICC) analysis, and Bland-Altman plots.

RESULTS

Pretreatment MRI scans of 113 patients were identified. Fibroids where the interobserver difference of diameter-based ellipsoidal volumes reached 30% were excluded resulting in 99 patients in the final dataset. The volumes of group S and group E showed no significant differences with 134.1 (257.3) cm3 and 133.5 (269.1) cm3, respectively, with an average difference of 3.47 cm3 (0.25%; p = 0.377). The agreement between the two methods was excellent (ICC = 0.979), without difference across fibroid locations. In 46 cases (46.5%), group S values were larger, and in 53 fibroids (53.5%), group E volume values were larger. However, volume difference was outside the ± 20% range in 21 cases (21.2%) and outside the ± 30% range in 10 cases (10.1%); the largest difference was approximately 56.5% (156.5 cm3).

CONCLUSIONS

The ellipsoid formula-based and the voxel-based volume calculation showed no significant difference for the group as a whole. However, there was a difference of > 20% in 21.2% of cases and > 30% in 10.1% of cases. In the era of personalized medicine, it is not only the average difference between the two methods that need to be considered but also cases where there is a 20% or 30% difference in results should be highlighted, as these may change the treatment plan in individual cases. This methodology should also be tested for other tumor-type volume calculations.

Laparoscopic two-port myomectomy-A retrospective case series of a novel minimally invasive approach

OBJECTIVE

This study presents a novel two-port technique for laparoscopic myomectomy, examining perioperative outcomes from 87 cases DESIGN: Retrospective case series.

SETTING

Tertiary academic hospital in Norfolk, Virginia.

PARTICIPANTS

Patients who underwent two-port laparoscopic myomectomy over a six-year period, performed by a single fellowship-trained surgeon. Cases were identified via current procedural terminology (CPT) codes for laparoscopic myomectomy.

INTERVENTIONS

The two-port technique uses a multi-port system at the umbilicus, a 45-degree bariatric laparoscope, and a 5-mm trocar in the right lower quadrant. This method reduces abdominal incisions, improves traction for fibroid removal, enhances triangulation for laparoscopic suturing, and expedites specimen extraction.

RESULTS

Eighty-seven patients were included, with a mean age of 37.5 years (±5.2). The most common fibroid type was FIGO type 2-5. An average of 3.6 fibroids (±3.1) were removed per case. The mean dominant fibroid diameter was 5.2 cm (±2.3), and the mean total fibroid weight removed was 139.8 grams (±114.4). The mean EBL and operative time were 128 mL (±138.9) and 153 minutes (±45.9), respectively. Fibroid number and weight correlated with increasing operative time, while fibroid weight significantly correlated with higher EBL. No conversions to laparotomy occurred. Most patients (74.7%) were discharged on the same day.

CONCLUSION

Two-port laparoscopic myomectomy is a safe and effective option for a variety of fibroid types, with outcome data comparable to previously reported data on conventional laparoscopic methods. This technique combines the benefits of traditional triangulation with improved cosmesis of single-site surgery, while providing a dedicated specimen extraction site. Candidates for two-port myomectomy are those eligible for a conventional laparoscopic approach; however, challenges may arise with intramural fibroids >10 cm, multiple fibroids (≥4), or need for multiple hysterotomy incisions, requiring careful patient selection and surgeon discretion.

SUMMATION

For properly selected patients, a two-port laparoscopic myomectomy technique is safe, effective, and associated with favorable outcomes, including a high same-day discharge rate and minimal complications.

Ablation of symptomatic uterine fibroids with the Mirabilis system for rapid noninvasive ultrasound-guided high-intensity focused ultrasound (HIFU): a prospective observational clinical study

OBJECTIVES

Uterine fibroids often lead to symptoms that negatively impact health-related quality of life (HRQOL). High-intensity focused ultrasound (HIFU) has emerged as a promising noninvasive treatment for reducing fibroid size and symptoms. The Mirabilis system for ultrasound (US)-guided HIFU introduces a novel technique known as 'shell ablation'. This study evaluates the feasibility and efficacy of Mirabilis in a clinical setting, focusing on clinical outcomes.

MATERIALS AND METHODS

Sixteen patients with 23 uterine fibroids were treated with the Mirabilis system. Follow-up assessments included US and MRI at baseline, 6 weeks, 3, 6 and 9 months, and 1 year after HIFU. Changes in symptoms and QOL were evaluated using the Uterine Fibroid Symptom and HRQOL Questionnaire.

RESULTS

A significant reduction in fibroid volume was observed after HIFU (baseline 182.1 ± 49.3 ml; 1 year: 76.0 ± 37.9 ml, p < 0.001). The symptom severity score significantly declined (baseline 57.2 ± 3.8; 1 year: 30.2 ± 4.9, p < 0.001), correlating with a significant improvement in HRQOL (baseline 47.0 ± 3.9, 1 year: 71.8 ± 5.3, p < 0.001).

CONCLUSION

HIFU with the portable Mirabilis system is a feasible and safe noninvasive treatment for symptomatic uterine fibroids in an outpatient setting. This approach allows efficient and rapid ablation even for large fibroids, significantly reducing fibroid volume and symptoms.

AMH and Kisspeptin Receptor Expression in Rare Hydropic Leiomyoma: A Case Study

BACKGROUND Leiomyomas are common benign uterine tumors (BUMTs) with diverse histopathological subtypes and variable clinical presentations. While most are asymptomatic, some cause significant morbidity, including abnormal uterine bleeding, infertility, and pain. Hydropic leiomyomas (HLMs) are rare variants histopathologically characterized by zonal edema and may pose diagnostic challenges, particularly when located in atypical sites such as the retroperitoneal space. This report presents a case of a retroperitoneal HLM with strong expression of anti-Müllerian hormone (AMH) and its receptor (AMHR2), and kisspeptin (KISS1) and its receptor (KISS1R), suggesting potential new therapeutic targets. CASE REPORT A 44-year-old woman presented with acute lower abdominal pain. Magnetic resonance imaging (MRI) revealed a well-circumscribed, pedunculated retroperitoneal mass originating posteriorly from the uterine body-cervix junction. MRI findings suggested a benign mesenchymal tumor but could not exclude malignancy. Surgical excision was performed, and histopathological examination confirmed HLM. Immunohistochemical analysis demonstrated strong nuclear and cytoplasmic expression of AMH, AMHR2, KISS1, and KISS1R in tumor cells, making this the first reported case of such expression in HLM. The patient had an uneventful postoperative course, and no recurrence was observed during a 2-year follow-up. CONCLUSIONS This case underscores the diagnostic complexity of retroperitoneal HLMs and the importance of MRI in differentiating BUMTs from malignancies. Strong AMH, AMHR2, KISS1, and KISS1R expression suggests a potential role of these regulatory proteins in HLM pathophysiology. Further research on targeted modulation of these pathways may provide novel therapeutic approaches for BUMTs, particularly in cases where conventional treatments are limited.

Exploring the Recurrence Risk Factors and Development of a Nomogram Prediction Model for Uterine Fibroid Patients Post-Myomectomy Based on Patient Medical Records

Objective

This study aims to investigate the risk factors contributing to the recurrence of uterine fibroids in patients undergoing laparoscopic myomectomy, providing a basis for clinical treatment.

Methods

A retrospective analysis was conducted on 378 patients who underwent laparoscopic myomectomy between January 2022 and August 2023 and were subsequently followed up. Based on the recurrence status 6 months post-operation, patients were divided into a recurrence group (43 cases) and a non-recurrence group (335 cases). Clinical data of both groups were analyzed using univariate analysis, and factors statistically significant in univariate analysis were further evaluated through multivariate logistic regression to identify independent risk factors for recurrence post-laparoscopic myomectomy.

Results

Univariate analysis indicated that the proportion of patients with ≥2 fibroids, intramural fibroids, and preoperative serum C-reactive protein (CRP) levels ≥4.67 mg/L was significantly higher in the recurrence group (all P<0.05). Multivariate logistic regression analysis revealed that having ≥2 fibroids, a uterine size ≥14 gestational weeks, intramural fibroids, and preoperative serum CRP levels ≥4.67 mg/L were independent risk factors for recurrence post-laparoscopic myomectomy (OR=1.855, 1.038, 1.917, 1.208, 1.154, respectively; all P<0.05).

Conclusion

The presence of ≥2 fibroids, intramural fibroids, and preoperative serum CRP levels ≥4.67 mg/L are identified as independent risk factors for the recurrence of uterine fibroids post-laparoscopic myomectomy. Regular follow-ups should be conducted for patients with these risk factors to timely detect potential recurrence risks and implement preventive and therapeutic measures accordingly. The number of fibroids, their location, and preoperative serum CRP level have a strong predictive ability for recurrence after laparoscopic myomectomy, effectively identifying patients with recurrence while excluding those without recurrence.

The efficacy and safety of Chinese herbal medicine Shugan Sanjie decoction in the treatment of uterine fibroids: a systematic review and meta-analysis

Background

Shugan Sanjie Decoction (SGSJ) is a commonly used Chinese medicine prescription for the treatment of uterine fibroids (UFs). However, there is still a lack of evidence for its effects and safety. To systematically assess the efficacy and safety of SGSJ in conjunction with Mifepristone [MFP] or Leuprolide acetate [LA] for the treatment of UFs, thereby providing a reference for clinical medication.

Objective

To systematically assess the efficacy and safety of SGSJ in combination with MFP or LA for the treatment of UFs, thereby providing a basis for clinical medication decisions.

Methods

Eight digital medical databases were systematically searched to identify randomized controlled trials (RCTs) evaluating the use of SGSJ combined with MFP or LA for the treatment of UFs. The search spanned from the inception of each database to July 2024. Risk of Bias (ROB) 2.0 and RevMan 5.3 software were utilized for systematic review and meta-analysis. Eligible studies comprised RCTs comparing SGSJ plus MFP or LA with MFP or LA alone. The primary outcome was the Clinical Effective Rate (CER). Secondary outcomes included (1) Uterine Fibroid Volume (UFV) (2), Uterine Volume (UV) (3), Serum Sex Hormone Levels [Follicle-Stimulating Hormone (FSH), Luteinizing Hormone (LH), Estradiol (E2), Progesterone (P)], and (4) Traditional Chinese Medicine Syndrome Scores (TSS).

Results

The meta-analysis comprised 12 RCTs with 952 participants. The results of meta-analysis showed that the total effective rate of SGSJ or combined with MFP or LA in the treatment of UFs [RR = 1.26, 95% CI (1.19, 1.34), P < 0.00001], which was statistically significant compared with the MFP or LA group and superior to the MFP or LA group (P < 0.05).

Conclusion

At present, there are evidence shows that SGSJ combined with MFP or LA improves CER, reduces UFV, and modulates sex hormone levels. However, due to the poor methodological quality and high heterogeneity of the included trials, our conclusions should be interpreted with caution. Future studies should prioritize rigorous RCTs with standardized treatment protocols, extended follow-up, and comprehensive safety assessments to identify SGSJ as a reliable treatment option for UFs.

Systematic Review registration

https://www.crd.york.ac.uk/PROSPERO/view/CRD42024506017.

Preoperative medical therapy before surgery for uterine fibroids

BACKGROUND

Uterine fibroids occur in up to 40% of women over 35 years of age. Up to 50% of uterine fibroids cause symptoms that warrant treatment: anaemia caused by heavy menstrual bleeding, pelvic pain, dysmenorrhoea, infertility and poor quality of life. Surgery is the first choice of treatment, but medical therapies have been used prior to surgery to improve outcomes. Gonadotropin-hormone-releasing analogues (GnRHa) induce a low-oestrogen state that shrinks fibroids, but they have unacceptable side effects if used long-term. Other potential hormonal treatments include progestins and selective progesterone-receptor modulators (SPRMs). This updates a Cochrane review published in 2017.

OBJECTIVES

To assess the benefits and risks of medical treatments prior to surgery for uterine fibroids.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility Group Specialized Register, CENTRAL, MEDLINE, Embase, PsycINFO and CINAHL on 8 August 2024. We also searched trials registers (ClinicalTrials.gov; WHO ICTRP), theses and dissertations, and grey literature, as well as handsearching reference lists of retrieved articles and contacting pharmaceutical companies.

SELECTION CRITERIA

We included randomised controlled trials of premenopausal women receiving medical therapy before myomectomy, hysterectomy or hysteroscopic resection for uterine fibroids versus placebo, no pretreatment or another medical therapy.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. We assessed the certainty of the evidence using GRADE.

MAIN RESULTS

We included 41 RCTs, which involved 3982 women. Thirty-six studies evaluated GnRHa: the comparators were no pretreatment (19 studies), placebo (9 studies), or other medical pretreatments (progestin, SPRMs, selective oestrogen receptor modulators (SERMs), dopamine agonists, oestrogen receptor antagonists) (8 studies). Five studies evaluated SPRMs versus placebo. Most results provided low-certainty evidence due to poor reporting of randomisation procedures, lack of blinding, imprecision and inconsistency. Some outcomes were not measured or did not have usable data. The use of ulipristal acetate (an SPRM) is suspended at this time (March 2025) because of an association with cases of liver failure. GnRHa versus placebo or no pretreatment before surgery for uterine fibroids GnRHa pretreatment may reduce uterine volume (mean difference (MD) -175.34 mL, 95% confidence interval (CI) -219.04 to -131.65; 13 studies, 858 participants; I² = 67%; low-certainty evidence) and fibroid volume (MD range 5.7 mL to 155.4 mL; 5 studies to heterogeneous to pool, 427 participants; low-certainty evidence), and probably increases preoperative haemoglobin (MD 0.88 g/dL, 95% CI 0.68 to 1.08; 10 studies, 834 participants; I² = 0%; moderate-certainty evidence). However, there is probably a greater likelihood of adverse events with GnRHa (odds ratio (OR) 2.78, 95% CI 1.77 to 4.36; 5 studies, 755 participants; I² = 28%; moderate-certainty evidence). No usable data were available for preoperative bleeding. Hysterectomy Duration of hysterectomy may be reduced amongst women who receive GnRHa treatment (-10.11 minutes, 95% CI -16.96 to -3.25; 6 studies, 617 participants; I² = 57%; low-certainty evidence). Results are uncertain for intraoperative blood loss (4 heterogeneous studies, 258 participants; MD range 25 mL to 148 mL, in favour of GnRHa; very low-certainty evidence). There are probably fewer blood transfusions with GnRHa (OR 0.54, 95% CI 0.29 to 1.01; 6 studies, 601 participants; I² = 0%; moderate-certainty evidence) and less postoperative morbidity (OR 0.54, 95% CI 0.32 to 0.91; 7 studies, 772 participants; I² = 28%; moderate-certainty evidence). Myomectomy There is uncertainty about the effects of GnRHa pretreatment on surgery duration (7 heterogeneous studies, 443 participants) (very low-certainty evidence) and intraoperative blood loss during myomectomy (11 studies too heterogenous to pool, 549 participants; very low-certainty evidence). GnRHa may make little to no difference to blood transfusions (OR 0.85, 95% CI 0.26 to 2.75; 4 studies, 121 participants; I² = 0%; low-certainty evidence) or postoperative morbidity (OR 1.07, 95% CI 0.43 to 2.64; I² = 0%; 5 studies, 190 participants; low-certainty evidence). Hysteroscopic resection GnRHa treatment before hysteroscopic resection of uterine myomas may result in little to no difference in surgery duration (2 studies,123 participants; low-certainty evidence). One study reported no cases of postoperative morbidity in either group (84 participants; low-certainty evidence). GnRHa versus other medical therapies before surgery - preoperative outcomes GnRHa may be associated with a greater reduction in uterine volume than other medical therapies (-47% compared to -20% and -22% with 5 mg and 10 mg ulipristal acetate, respectively; low-certainty evidence). There may be little to no difference in bleeding reduction (ulipristal acetate 5 mg: OR 0.71, 95% CI 0.30 to 1.68; 1 study, 199 participants; low-certainty evidence), and there is probably little to no difference in preoperative haemoglobin (MD -0.02, 95% CI -0.41 to 0.37; 242 participants; moderate-certainty evidence). We are uncertain whether there is any difference in fibroid volume between GnRHa and cabergoline (MD 12.71 mL, 95% CI -5.92 to 31.34; 2 studies, 110 participants; I² = 0%; low-certainty evidence). Adverse events such as hot flushes may be more likely with GnRHa (OR 2.83, 95% CI 1.68 to 4.77; 6 studies, 507 participants; I² = 59%; low-certainty evidence). SPRMs versus placebo before surgery - preoperative outcomes SPRMs (mifepristone, CDB-2914, ulipristal acetate and asoprisnil) before surgery probably reduce uterine volume (2 heterogenous studies, 275 participants; moderate-certainty evidence) and may reduce fibroid volume (5 heterogeneous studies, 451 participants; low-certainty evidence). SPRMs probably increase preoperative haemoglobin (MD 0.93 g/dL, 95% CI 0.52 to 1.34; 2 studies, 173 participants; I² = 0%; moderate-certainty evidence), and they may reduce bleeding before surgery (ulipristal acetate 5 mg: OR 41.41, 95% CI 15.26 to 112.38; 1 study, 143 participants; asoprisnil: MD -166.9 mL; 95% CI -277.60 to -56.20; 1 study, 22 participants; low-certainty evidence). Results were very imprecise for adverse events (low-certainty evidence).

AUTHORS' CONCLUSIONS

Pretreatment with gonadotropin-hormone-releasing analogues may reduce uterine and fibroid volume and probably increases preoperative haemoglobin levels, but probably also increases the number of adverse events. Blood transfusions and operation time during hysterectomy may be reduced, with fewer women experiencing postoperative morbidity. SPRMs, such as ulipristal acetate, seem to offer similar advantages: they probably reduce uterine volume and increase haemoglobin level before surgery, and may reduce fibroid volume and fibroid-related bleeding. However, replication of these studies is advised as the certainty of the evidence is moderate to low.

Torsion of a large pedunculated subserosal fibroid led to ovarian torsion and ipsilateral hydroureteronephrosis

Torsion of uterine leiomyoma is a rare, albeit life-threatening surgical emergency. A 55-year-old woman presented with right iliac fossa pain persisting for the past 15 days, accompanied by nausea and vomiting. Imaging revealed a torsed subserosal pedunculated uterine leiomyoma, which caused ovarian torsion and ipsilateral ureterohydronephrosis. The case was managed surgically, and the diagnosis confirmed intraoperatively as well as through histopathology.

Long-term outcomes and re-intervention rates in women undergoing mri-guided focused ultrasound (mrgfus) for uterine fibroids: a 7-year follow-up study

PURPOSE

To assess the long-term outcomes of MR-guided focused ultrasound (MRgFUS) for treating uterine fibroids, focusing on re-intervention rates, pregnancy outcomes, and the onset of menopause over a 7-year follow-up period.

MATERIALS AND METHODS

We conducted a historical cohort study of 99 women with symptomatic uterine fibroids who underwent MRgFUS between 2013 and 2020 at a single tertiary medical center. Data collection included patient demographics, treatment details, and follow-up interviews. Re-intervention rates were evaluated using Kaplan-Meier curves and Cox regression analysis to identify predictors of further treatments, with a specific focus on age-related differences.

RESULTS

Over a median follow-up of 6.1 years, 33.1% of women required re-intervention for persistent fibroid symptoms. The median patient's age was 43 years old. Women aged ≤ 43 years had significantly higher re-intervention rates than those aged 44 + years (47.5% vs. 16.7%, p = 0.005). Multivariable Cox regression identified age as the sole significant predictor of re-intervention (HR44+vs. <43 0.303 95% CI 0.128-0.714, p = 0.006). Sixteen women conceived after MRgFUS, resulting in 21 pregnancies, with 72.2% live births and a spontaneous miscarriage rate of 22.2%. The mean age of menopause was 51.4 years, similar to global averages.

CONCLUSIONS

MRgFUS is a practical, noninvasive option for treating symptomatic uterine fibroids. Older women show lower re-intervention rates. Pregnancies post-MRgFUS are possible, and the procedure does not appear to affect the onset of menopause. Age remains a crucial predictor for further re-intervention.

Uterine Artery Embolization Before Myomectomy: Is It Worth the Trouble?

OBJECTIVES

This study compared patients who underwent myomectomy with preoperative uterine artery embolization (UAE) to those who underwent surgery without UAE. The primary objective was to analyze whether preoperative embolization reduces perioperative blood loss and other related complications. The secondary objective was to analyze the long-term outcomes of the 2 techniques in terms of fertility and obstetrical complications.

DESIGN

Observational cohort retrospective study approved by the Brugmann University Hospital's ethics committee (CE2023/79).

SETTING

The department of gynecology database was used to extract all myomectomy cases between January 2011 and December 2021. Hysteroscopic myomectomies were excluded.

PATIENTS

192 patients were included.

INTERVENTIONS

The population was divided according to the presence or absence of preoperative UAE. The UAE and myomectomy group comprised 95 cases between 2011 and 2020, while the myomectomy-only group consisted of 97 cases between 2014 and 2021.

MEASUREMENTS AND MAIN RESULTS

Blood loss was significantly lower when preoperative UAE was performed (175.9 [308.5] mL versus 623.3 [697.5] mL, p-value <.0001). However, there was no significant difference in postoperative haemoglobin, blood transfusion rate or emergent hysterectomy conversions compared to myomectomy as the only treatment. UAE was associated with complications that may result in infertility, such as adhesions (15.3% UAE group vs. 2.2% non-UAE group, p-value .02) and an increased incidence of miscarriage in pregnancies (53.5% UAE group vs. 22.3% non-UAE group, p-value = .01). Furthermore, in cases where a pregnancy did progress following UAE, later obstetrical complications such as abnormal placentation or uterine rupture were common in the series (21.7% UAE group vs. 0% non-UAE group, p-value = .03).

CONCLUSION

The findings of our study indicate that, other than a lower estimated blood loss (EBL), preoperative UAE does not appear to improve the outcome of myomectomies, while potentially increasing the risk of fertility and pregnancy related complications.

The Molecular and Cellular Mechanisms of Endometriosis: From Basic Pathophysiology to Clinical Implications

Endometriosis is a complex gynecological disorder characterized by endometrial-like tissue growing outside the uterus, leading to chronic pain, infertility, and reduced quality of life. Its pathophysiology involves genetic, epigenetic, immune, and molecular factors. Theories such as retrograde menstruation, coelomic metaplasia, and stem cell involvement explain lesion formation. Endometrial mesenchymal stem cells (eMSCs) and epithelial progenitors (eEPs) contribute to lesion establishment by adhering to peritoneal surfaces, proliferating, and differentiating into ectopic tissue. Aberrant adhesion molecules, inflammatory cytokines, and molecular pathways like PI3K/Akt and Wnt/β-catenin drive proliferation, angiogenesis, and resistance to apoptosis. Elevated estrogen levels and progesterone resistance further promote lesion growth and immune evasion. Immune dysfunction, including altered macrophage activity and reduced natural killer (NK) cell function, contributes to inflammation and lesion persistence. Pain is linked to prostaglandin E2 (PGE2) and nerve infiltration, emphasizing the need for targeted pain management. Current therapies, such as GnRH agonists, suppress ovarian hormone production but face limitations in long-term efficacy and side effects. Integrating molecular insights into clinical practice may advance diagnostics and treatment, with emerging approaches focusing on molecular pathways, immune modulation, and hormonal regulation for more effective, personalized therapies. Future research should unravel the complex mechanisms driving endometriosis to improve patient outcomes.

A Decade Long Analysis of Healthcare Disparities and Uterine Artery Embolization: An Exploration of Social Determinants of Health

PURPOSE

To determine the extent of impact that social determinants of health have on uterine artery embolization (UAE) utilization for treatment of symptomatic uterine fibroids.

MATERIALS AND METHODS

In this institutional review board (IRB)-exempt study, data from the 2011-2020 National Inpatient Sample were used to identify patients with International Classification of Diseases, 9th and 10th editions, codes of uterine fibroids who underwent UAE. Data collected included patient demographics (race/ethnicity, income, and insurance status) and procedure location (geographic region and hospital setting). Results are presented in percentage (UAE procedures per variable) and were analyzed using chi-square test.

RESULTS

UAE utilization by race/ethnicity demonstrated the following distribution: 45.6% non-Hispanic Blacks, 28.1% non-Hispanic Whites, 14.2% Hispanics, and 5.7% Asians. The lowest quartile for income experienced no change in utilization (27.8%), while the highest quartile gradually decreased across the decade (2011, 26.7%; 2020, 19.0%; P = .01). The Northeast region of the United States (49.0% in 2011) was superseded by the South (34.8% in 2020) as the dominant geographic region for UAE. The main insurance statuses were private (55.5%) and Medicaid (26.2%), with Medicaid rates increasing throughout the decade (2011, 18.2%; 2020, 28.6%; P < .001). Urban teaching hospitals accounted for the highest rates of total UAE (82.3%) compared with urban nonteaching (16.0%) and rural hospitals (1.2%).

CONCLUSIONS

Over the past decade, UAE has been performed in a relatively equitable fashion on the basis of income level, with improved utilization within the Medicaid population and throughout the geographic regions of the United States. When accounting for U.S. population representation and unequal disease burden, non-Hispanic Blacks demonstrated a greater-than-expected utilization of UAE compared with lower-than-expected rates among non-Hispanic Whites.

Reproductive tract microbiome dysbiosis associated with gynecological diseases

Female health and the microbiota of the reproductive tract are closely associated. The research scope on reproductive tract microbiota extends from the vaginal to the upper reproductive tract and from infectious diseases to various benign and malignant gynecological and obstetrical diseases. The primary focus of this paper was to evaluate the most recent findings about the role of reproductive tract microbiota in gynecological diseases, including endometrial polyps, uterine fibroids, endometriosis, adenomyosis, endometrial hyperplasia, and endometrial carcinoma. Different stages of gynecological diseases have diverse microbiota in the female reproductive tract, and some specific bacteria may help the disease progress. For example, Fusobacterium may exacerbate endometriosis, while treatments that target microbiota, such as antibiotics, probiotics, and flora transplantation, showed some efficacy in the experiment. These findings indicate the wonderful prospect of this field. Additionally, we have discussed how microbiome research can improve our understanding of the interactions between reproductive tract microorganisms and hosts, aid in the screening and diagnosis of gynecological diseases, and direct the development of preventive and therapeutic strategies aimed at maintaining and restoring a healthy reproductive tract microbiota when combined with other technologies like transcriptome and proteome, in vitro cultured cells, and animal models.

Ultrasound guided microwave ablation treatment of uterine fibroids: Clinical response and patient acceptability

INTRODUCTION

The objective of this study was to evaluate the effectiveness and acceptability of ultrasound guided microwave ablation for treating symptoms related to uterine fibroids.

MATERIAL AND METHODS

This was a prospective interventional study. Patients with symptomatic uterine fibroids were included at Danderyd Hospital, Sweden, from January 2020 to August 2023. All patients were treated with percutaneous or vaginal ultrasound guided microwave ablation. Primary outcome was reduction of fibroid symptoms evaluated by the validated uterine fibroid symptom and quality of life (UFS-QoL) questionnaire at 6 months post-treatment. Location of each fibroid was noted. Secondary outcomes included reduction of menstruation blood loss, change in hemoglobin, ferritin and Anti-Müllerian hormone, fibroid volume difference, hospitalization, acceptability, and postoperative pain. Clinical trials registration number NCT04240262.

RESULTS

Symptoms from uterine fibroids decreased by 37% (p < 0.001) on the symptom severity scale and health-related quality of life increased by 74% (p < 0.001). Menstrual blood loss decreased by 38% (p < 0.001) according to the Pictorial Bleeding Assessment Chart and median fibroid shrinkage of the three largest treated fibroids was 64% (p < 0.001). Highest median shrinkage rate (82) was seen in submucous fibroids. A total of 110 of 113 (97%) patients left the hospital on the day of treatment. We experienced one adverse event (0.8%) Clavien Dindo grade 3. Acceptability was high and postoperative pain was mild to moderate.

CONCLUSIONS

Microwave ablation is a highly acceptable minimally invasive method for treating symptoms related to uterine fibroids in patients who desire uterus preservation. Submucosal fibroids showed more favorable treatment results.

The Association Between Physical Activity and Uterine Leiomyoma and Its Symptoms: A Systematic Review and Meta-Analysis

Background and Aims

Although many studies have focused on the impact of physical activity on hormone-mediated tumors, its effect on uterine leiomyomas (UL) remains unclear. This systematic review synthesizes the scientific evidence on the role of physical activity in the occurrence and symptomatology of UL while putting forward a research agenda.

Methods

The PubMed, Scopus, Web of Science, SciELO, and Cochrane Library databases were searched for studies published up to January 10, 2025. The Newcastle‒Ottawa Scale was used to assess study quality, and the GRADE tool was used to determine evidence certainty. Dear-Simonian and Laird random effects models were used to estimate the pooled odds ratio (OR) and 95% confidence interval (CI) of the association between physical activity and UL. The PRISMA guidelines were followed.

Results

Fifteen studies were included (three cross-sectional, 6 case-control, and 6 cohort studies), of which 11 were considered in the meta-analysis. The difference between women who did and did not regularly practice physical activity (OR = 0.93; 95% CI: 0.82, 1.05; I 2 = 77.6%, n = 8 studies) in the likelihood of having UL did not meet conventional levels of statistical significance. Moreover, those women who engaged in more intense physical activity were less likely to have UL (OR = 0.86; 95% CI: 0.75, 0.99; I 2 = 80.5%, n = 5 studies) than those who engaged in less intense physical activity.

Conclusion

Increased physical activity is associated with a slight decrease in the risk of UL and may provide relief from associated symptoms. Since current evidence is still limited to supporting specific physical activity recommendations, a research agenda is proposed for future studies on this subject.

PROSPERO Registration

CRD42021247505.

Suicide by Firearm and Hormonal Imbalances: A Forensic Case Report With Literature Review

Hormonal imbalances play a crucial role in the development of various diseases, with a significant impact on the gynecological system, especially in the onset of uterine fibroids (UFs). UFs, also known as myomas or leiomyomas, are noncancerous uterine growths commonly observed in women, particularly during their reproductive years. By age 50, many women experience fibroids, though the condition's prevalence varies significantly across different ethnic groups. While most fibroids remain asymptomatic, those that are symptomatic can lead to several issues, such as irregular bleeding, pelvic discomfort, and complications during pregnancy. Receiving a diagnosis of fibroids can be distressing, particularly when concerns arise about their potential link to more serious conditions. This distress can adversely affect a woman's quality of life and mental health, sometimes contributing to emotional distress, depressive symptoms, or even suicidal ideation. The management of UFs encompasses a spectrum of approaches, from careful monitoring to medical or surgical interventions, which are chosen based on the severity of symptoms and the patient's preferences. Psychological support can be valuable in helping women manage the anxiety and fears associated with the diagnosis and treatment process. Consequently, the impact of UFs on women's mental health warrants attention. This paper aims to review the existing scientific literature on the potential link between UFs, hormonal imbalances, and an increased risk of psychiatric disorders.

Factors affecting gasless reduced-port laparoscopic myomectomy (GRP-LM) using a subcutaneous abdominal wall lifting method: a retrospective analysis of a large cohort of 966 cases in Japan

OBJECTIVE

To evaluate the usefulness of gasless reduced-port laparoscopic myomectomy (GRP-LM) using a subcutaneous abdominal wall lifting method.

METHODS

In GRP-LM, after lifting the abdominal wall by a subcutaneous abdominal wall lifting method, a 1.5-cm incision is made in the lateral abdomen, Lap Protector® is placed. The operation is performed by two surgeons, one who inserts multiple forceps from the Lap Protector and performs the operation, and an assistant who operates the laparoscope and uterine manipulator. The surgical outcome of GRP-LM and the factors that affect it were investigated.

RESULTS

GRP-LM was performed in 966 patients. Complications (0.5%) and blood transfusions (0.3%) were remarkably rare, and there were no cases of conversion to open surgery. With regard to the correlation between the number of fibroids extracted and each factor, the number of fibroids extracted correlated with fibroid weight and operation time, but not with blood loss. The average number of sutures per case was 21, and the average suture and ligation time per suture was 77 s. Comparing the cost of GRP-LM with that of the conventional insufflation LM, a saving of $875 was possible with GRP-LM.

CONCLUSION

GRP-LM is a suitable for multiple fibroids, and is cosmetic and economical, because it allows rapid and reliable suture and ligation, despite having only one port for the procedure.

A systematic review and meta-analysis comparing the use of elagolix therapy alone or in combination with add-back therapy to treat women with uterine fibroid associated heavy menstrual bleeding

Background

Elagolix is an oral small molecule second-generation nonpeptide gonadotropin-releasing hormone (GnRH) antagonist drug that can quickly and reversibly inhibit female gonadotropins and ovarian sex hormones. Previous randomized controlled trials (RCTs) have evaluated the efficacy and safety of elagolix alone or in combination with add-back therapy to treat women with heavy menstrual bleeding (HMB) caused by uterine fibroids. Hence, this study sought to evaluate the safety and efficacy of elagolix alone or in combination with add-back therapy for the treatment of uterine fibroids with HMB.

Methods

The Cochrane Library, PubMed, Embase and ClinicalTrials.gov databases were searched for randomized controlled studies on the application of elagolix alone or with add-back therapy in patients with uterine fibroids and HMB from databases establishment to June 15, 2021. The outcomes reference menstrual blood loss (MBL), amenorrhea, uterine fibroid symptom quality of life (UFS-QoL), hemoglobin level, bone mineral density loss, and adverse events (AEs). The primary endpoint is MBL. Fixed/random effects models were used to calculate the risk ratio (RR)/mean difference (MD) and 95% confidence interval (CI) for each outcome.

Results

Two studies with four trials involving 1,217 patients were included in this meta-analysis. Compared with the placebo, when elagolix was used alone or given with additional therapy, the number of participants who satisfied the MBL was greater (MBL <80 mL and MBL was reduced by more than 50% in the last month), improved hemoglobin levels (increased by more than 2 g/dL from baseline to the final treatment month) criteria as well as triggered amenorrhea. Elagolix alone or in combination with add-back therapy improved the quality of life of patients. Compared with the elagolix treatment alone or with add-back therapy, the placebo was superior in terms of less bone mineral density change and a lower incidence of AEs.

Conclusions

This study indicated that elagolix alone or in use with add-back therapy can be considered as a satisfactory treatment plan for the majority of patients who are diagnosed with uterine fibroids and HMB; however, the specific treatment plan should also consider patients' physical condition and any adverse reactions to the drug, based on existing research.

Genetic association of lipid and lipid-lowing drug targets with uterine fibroids

Objective

Observational studies suggest that blood lipids are a risk factor for uterine fibroids (UFs) and that lipid-lowering drugs are beneficial for the treatment and prevention of UF; however, the conclusions are inconsistent. We aimed to determine the causal effects of lipids and lipid-lowering drugs on UFs using Mendelian randomization (MR).

Methods

Genetic variants from genome-wide association studies (GWAS) of lipid traits and variants in genes encoding lipid-lowering drug targets were extracted, and two independent UF GWAS were set as the outcome. Their effects on UF risk and related traits were estimated using the inverse variance weighted method.

Results

The MR analysis revealed that high density lipoprotein cholesterol (HDL-C, OR = 0.88, 95 % CI: 0.83-0.93, P = 3.58E-6) and triglycerides (TG, OR = 1.14, 95 % CI: 1.07-1.21, P = 6.83E-5) were protective factors and risk factors for UF, respectively. Drug-targeted MR analysis results indicated that genetically predicted inhibition of cholesteryl ester transfer protein (CETP) was associated with a lower UF risk (OR = 0.95, 95 % CI: 0.92-0.98, P = 7.83E-4), as well as reduced levels or risk of other UF-associated clinical traits, including estradiol level, excessive menstruation, abdominal and pelvic pain, myomectomy, and miscarriage.

Conclusions

Our study provides evidence that HDL-C and TG levels were causally associated with UF risk. Genetically proxied CETP inhibition may have a protective effect against UF, which warrants further investigation.

The feasibility of high-resolution organ-axial T2-weighted MRI when combined with federation of gynecology and obstetrics (FIGO) classification of uterine fibroid patients

PURPOSE

Correctly classifying uterine fibroids is essential for treatment planning. The objective of this study was to assess the accuracy and reliability of the FIGO classification system in categorizing uterine fibroids via organ-axial T2WI and to further investigate the factors associated with uterine compression.

METHODS

A total of 130 patients with ultrasound-confirmed fibroids were prospectively enrolled between March 2023 and May 2024. These patients underwent MR examinations, including body-axial T2W (sagittal and axial) and organ-axial T2W (high resolution with oblique coronal and double oblique axial). For postprocessing, the interobserver agreements between two radiologists and the interagreements between two MR examinations and operational descriptions were evaluated via kappa statistics. The accuracy of axial and organ-axial T2W assessments in the FIGO classification of uterine fibroids was compared when surgical outcomes were used as the gold standard. The Kruskal‒Wallis test was used to compare the differences in cavity deformation across various FIGO classifications. Spearman's rank correlation test was used to analyze the correlation between the FIGO classification and the parameters of uterine cavity deformation.

RESULTS

In total, 170 fibroids from 130 patients were included. Compared with body-axial T2WI, organ-axial T2WI showed better interobserver agreement and greater interagreements with operational descriptions, with kappa values of 0.877 (P = 0.04) and 0.932 (P = 0.037), respectively. The accuracy of the organ-axial T2WI assessment in determining the FIGO classification of uterine fibroids was greater than that of the body-axial T2WI assessment, with an accuracy of 92.9% (P < 0.01). Thirty-two (38.1%) fibroids showed cavity deformation according to organ-axial T2WI, including fibroids with FIGO types 0-7 and 2-5. Among these factors, the size of the fibroids (S), base width (B), depth of compression (D), D/B, D/S, and compression angle (A) significantly differed among the different FIGO types of fibroids (P < 0.05). Compression angle exhibited a linear correlation with the FIGO type (P < 0.001).

CONCLUSION

Compared with body-axial T2WI, organ-axial T2WI provides greater accuracy on the basis of the FIGO classification, which is more consistent with surgical outcomes. Given the excellent reliability and accuracy of the preoperative FIGO classification, organ-axial T2WI can contribute to treatment planning.

Gonadotropin Releasing Hormone Agonists Combined with Hormone Replacement Therapy Significantly Improves Reproductive Outcomes for Patients with Thin Endometrium and Intramural Fibroids in Frozen Embryo Transfer Cycles

Background

Both intramural myomas and thin endometrium exert a detrimental influence on the outcomes of assisted reproductive technology (ART). The downregulation of gonadotropin releasing hormone agonists (GnRH-a) is regarded as an effective approach to reducing the size of intramural fibroids and enhancing endometrial receptivity. Consequently, we conducted this study to assess whether the GnRH-a combined with hormone replacement therapy (GnRH-a-HRT) can improve reproductive outcomes in frozen embryo transfer cycles for patients with a thin endometrium (≤7 mm) and intramural fibroids.

Methods

This retrospective cohort study encompassed 360 patients who underwent frozen embryo transfer following in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) cycles. Patients were stratified into three groups based on the endometrial preparation protocol: the natural cycle (NC) group (n=96), the hormone replacement therapy (HRT) group (n=180), and the GnRH-a-HRT group (n=84). The live birth rate (LBR) was designated as the primary outcome, while clinical pregnancy rate (CPR), miscarriage rate, and ectopic pregnancy rate were classified as secondary outcomes.

Results

The LBR and CPR in the GnRH-a-HRT group were significantly higher than those in both the HRT group and the NC group (both P < 0.0001). A logistic regression model indicated that the LBR was significantly higher in the GnRH-a-HRT group compared to both the HRT group (odds ratio, 0.269; 95% confidence interval, 0.114-0.637; P = 0.003) and the NC group (odds ratio, 0.524; 95% confidence interval, 0.457-0.956; P = 0.023). Subgroup analyses based on the number and dimension of fibroids demonstrate the positive efficacy of the GnRH-a-HRT regimen.

Conclusion

Compared to NC and HRT protocol, improved reproductive outcomes were observed in the GnRH-a-HRT group. These findings provide valuable insights for exploration of the underlying mechanisms by which the GnRH-a-HRT protocol enhances reproductive outcomes in patients of thin endometrium with intramural fibroids.

Linzagolix rapidly reduces heavy menstrual bleeding in women with uterine fibroids: an analysis of the PRIMROSE 1 and 2 trials

OBJECTIVE

To study the timing of the effect of linzagolix, an oral gonadotropin-releasing hormone receptor antagonist, on significant reduction in heavy menstrual bleeding (HMB) in women with uterine fibroids.

DESIGN

The study used pooled data from PRIMROSE 1 and PRIMROSE 2, two double-blind, similar placebo-controlled trials of linzagolix in the United States and Europe, respectively. Eligible participants were randomized equally across four treatment arms (linzagolix 100 mg and 200 mg, with and without concomitant hormonal add-back therapy [ABT] consisting of 1-mg estradiol and 0.5-mg norethisterone acetate) and one placebo arm. The cumulative incidence of achieving clinically significant HMB reduction and maintaining it to week 24 was compared between the linzagolix arms and the placebo arm using the Kaplan-Meier plots adjusted for confounding by race and study (PRIMROSE 1 vs. PRIMROSE 2).

SUBJECTS

The PRIMROSE trials randomized 1,012 women aged ≥18 years with ultrasound-confirmed uterine fibroids and HMB.

INTERVENTION

Linzagolix (100 mg and 200 mg, with and without hormonal ABT) vs. placebo.

MAIN OUTCOME MEASURES

The main outcome of this analysis was the time to achievement of clinically significant HMB reduction and its maintenance up to week 24.

RESULTS

The onset of action in achieving and maintaining clinically significant HMB reduction was significantly more rapid for the linzagolix treatment arms than for the placebo arm, with a median time of <4 weeks for most linzagolix doses (except 100 mg alone). The fastest onset was seen with linzagolix 200 mg with or without ABT doses, with a median time of only 3 days. The cumulative incidence of achieving clinically significant HMB reduction by week 4 and maintaining it to week 24 was also significantly higher for the linzagolix treatment arms than for the placebo arm. Specifically, across four linzagolix treatment arms, 23.2%-68.1% achieved clinically significant HMB reduction by week 4 and maintained it to week 24 vs. 7.8% for the placebo arm.

CONCLUSION

Linzagolix was associated with a quick effect on reducing clinically significant HMB compared with placebo. Linzagolix, thus, offers a novel noninvasive treatment approach for the rapid management of HMB symptoms in patients with uterine fibroids.

Uterine fibroids show evidence of shared genetic architecture with blood pressure traits

Uterine leiomyomata (fibroids, UFs) are common, benign tumors in females, having an estimated prevalence of up to 80%. They are fibrous masses growing within the myometrium leading to chronic symptoms like dysmenorrhea, abnormal uterine bleeding, anemia, severe pelvic pain, and infertility. Hypertension (HTN) is a common risk factor for UFs, though less prevalent in premenopausal individuals. While observational studies have indicated strong associations between UFs and HTN, the biological mechanisms linking the two conditions remain unclear. Understanding the relationship between HTN and UFs is crucial because UFs and HTN lead to substantial comorbidities adversely impacting female health. Identifying the common underlying biological mechanisms can improve treatment strategies for both conditions. To clarify the genetic and causal relationships between UFs and BP, we conducted a bidirectional, two-sample Mendelian randomization (MR) analysis and evaluated the genetic correlations across BP traits and UFs. We used data from a multi-ancestry genome-wide association study (GWAS) meta-analysis of UFs (44,205 cases and 356,552 controls), and data from a cross-ancestry GWAS meta-analysis of BP phenotypes (diastolic BP [DBP], systolic BP [SBP], and pulse pressure [PP], N=447,758). We evaluated genetic correlation of BP phenotypes and UFs with linkage disequilibrium score regression (LDSC). LDSC results indicated a positive genetic correlation between DBP and UFs (Rg=0.132, p<5.0x10-5), and SBP and UFs (Rg=0.063, p<2.5x10-2). MR using UFs as the exposure and BP traits as outcomes indicated a relationship where UFs increases DBP (odds ratio [OR]=1.20, p<2.7x10-3). Having BP traits as exposures and UFs as the outcome showed that DBP and SBP increase risk for UFs (OR =1.04, p<2.2x10-3; OR=1.00, p<4.0x10-2; respectively). Our results provide evidence of shared genetic architecture and pleiotropy between HTN and UFs, suggesting common biological pathways driving their etiologies. Based on these findings, DBP appears to be a stronger risk factor for UFs compared to SBP and PP.

Minimally Invasive Myomectomy with Temporary Bilateral Uterine Artery Blockage at Anterior Cul-de-Sac

Background and Objectives

Minimizing intraoperative bleeding is pivotal in myomectomy, and blockage of uterine arteries has been reported as an effective approach. We developed a novel technique to temporary occlude bilateral uterine arteries at the anterior cul-de-sac in minimally invasive myomectomy (MIS), including minilaparotomy, laparoscopic-assisted myomectomy, and laparoscopic myomectomy. This study aims to evaluate the intraoperative and postoperative outcomes of this technique in complicated myomectomy cases.

Methods

Twenty-seven patients underwent minimally invasive myomectomy by single minimally invasive surgeon using bilateral uterine arteries blockage. To match the complexity of myomectomy, 66 open cases performed by generalists were used for control.

Results

There were no significant differences in fibroid size, number, or weight between MIS and open myomectomy groups. For intraoperative outcomes, the MIS group showed longer operative time (271.3 ± 72.9 vs 179.9 ± 78.8 minutes, P < .05), but fewer cases of intraoperative blood transfusion (3% vs 17%, P < .05) and fewer intraoperative complications (0% vs 3%, P < .005). For postoperative outcomes, the MIS group demonstrated shorter hospital stay (70% vs 29% for 0-1 day; 11% vs 42% for 2 days; 19% vs 29% for 3 or more days, P < .05) and fewer postoperative complications (3% vs 9%, P < .05).

Conclusion

Temporary blockage bilateral uterine arteries enable the safe performance of complicated myomectomy via minimally invasive surgery.

Impact of serum lipid on recurrence of uterine fibroids: a single center retrospective study

BACKGROUND

We aimed to analyze the correlation between serum lipid levels [total cholesterol (TC), triglyceride (TG), low density lipoprotein cholesterol (LDL-C), high density lipoprotein cholesterol (HDL-C)] and recurrence after uterine fibroids (UF) resection, and explore the predictive value of serum lipid levels in determining recurrence after myomectomy.

METHODS

In this retrospective cohort study, 323 patients undergoing first myomectomy who came from Li Huili Hospital, Ningbo Medical Center between December 2019 and January 2023 were included. The primary endpoint was the recurrence of UF within 12 months following surgery. Univariate and multivariate logistic regression analyses were adopted to evaluate the association between four serum lipid parameters and the risk of UF recurrence. All included patients were randomly assigned to the training group for nomogram development and the testing group for nomogram validation, with a ratio of 7:3. Receiver operator characteristic, calibration curves, and decision curve analysis were used to assess the predicting performance of constructed nomograms.

RESULTS

Totally, 98 developed the recurrence of UF within 12 months following surgery. Multivariate logistic regression analyses indicated that high levels of TC [odds ratio (OR) = 9.98, 95% confidence interval (CI): 4.28-23.30], LDL-C (OR = 11.31, 95% CI: 4.66-27.47) and HDL-C (OR = 2.37, 95% CI: 1.21-4.64) were associated with recurrence of UF risk. The association between TG level and UF recurrence risk did not statistical significance (P > 0.05). Four online prediction nomograms by integrating serum lipid levels and clinical features for predicting the risk of recurrence of UF were developed (TC-model, TG-model, LDL-C-model and HDL-C-model). Through verification, these models may have good prediction performance for predicting the recurrence of UF risk.

CONCLUSION

This study developed and validated prediction nomograms for predicting the risk of UF recurrence. These nomograms can provide individual risk assessment for UF recurrence.

Conservative Treatment of Uterine Myomas: A Network Meta-analysis Of Randomized Controlled Studies

OBJECTIVE

To comparatively evaluate the effectiveness of uterine artery embolization (UAE), high-intensity focused ultrasound (HIFU), radiofrequency ablation treatment (RFT), and laparoscopic/laparotomic surgery in the conservative treatment of uterine fibroids.

DATA SOURCES

The research was performed via electronic databases PubMed, Embase, and Cochrane Library, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses standards.

METHODS OF STUDY SELECTION

The network included 10 randomized trials between 2000 and 2024 and 1002 randomized subjects.

TABULATION, INTEGRATIONS, AND RESULTS

The network meta-analysis was conducted with subroutine netmeta on R. The risk of bias was assessed using the Revised Cochrane risk-of-bias tool for randomized trials. The surface under the cumulative ranking curve (SUCRA) was computed by Bayesian network meta-analysis. Incidences of reintervention per 100 person/year of follow-up were 4.13 (range, 0-19.4), 16.1 (6.2-32.8), 14.3 (0-15.1), and 6 (4.3-6.7) for myomectomy, UAE, HIFU, and RFT, respectively. The incidence rate ratios compared with myomectomy were 2.45 (95% confidence interval [CI], 1.38-4.37), 5.23 (95% CI, 1.59-17.3), and 4.59 (95% CI, 0.77-27.3; p = .09) for UAE, HIFU, and RFT, respectively. RTF had the highest (SUCRA, 1.25% and 3%) whereas myomectomy had the lowest risk of reintervention (SUCRA, 98% and 95%) or hysterectomy during follow-up (median, 12 months; range, 3-24). The risk of major complications was significantly lower after UAE (odds ratio, 0.38; 95% CI, 0.17-0.85) than myomectomy. The procedure with the lowest likelihood of major complications was HIFU (SUCRA, 81.5%). Finally, in the evaluation of QoL at follow-up visits, there were no differences between the treatments studied, although the model was highly heterogeneous and inconsistent.

CONCLUSION

In the analysis of randomized trials, surgical myomectomy carried the least risk of reintervention and subsequent hysterectomy during a relatively short follow-up period. HIFU was the method with the lowest risk of major complications.

Risk factors associated with pregnancy outcomes in patients with recurrent pregnancy loss after treatment

BACKGROUND

The treatment for recurrent pregnancy loss (RPL) has been addressed in international guidelines. However, limited studies have investigated the risk factors associated with pregnancy and live birth outcomes in patients with RPL after treatment. The objective of this study was to offer a comprehensive assessment of the risk factors for pregnancy loss in patients with a history of RPL following therapeutic interventions.

METHODS

This retrospective cohort study involved 431 women in early pregnancy with a history of RPL who experienced treatment at the Department of Obstetrics and Gynecology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, between June 2018 and June 2020. The main outcome measures were the ongoing pregnancy ≥ 12 weeks and the live birth outcomes. Univariate and multivariate logistic regression analyses were conducted to identify the risk factors for pregnancy loss < 12 weeks and live birth outcomes.

RESULTS

Patient's age and the prevalence of uterine malformations were significantly different between the patients with and without ongoing pregnancy ≥ 12 weeks (32.64 ± 5.08 vs. 31.54 ± 4.34, P = 0.026; 34.70% vs. 24.60%, P = 0.035). The risk of pregnancy loss < 12 weeks was significantly increased with age and those with uterine abnormalities (adjusted OR: 1.48 [95% CI: 1.05 to 2.07], P = 0.025; adjusted OR:1.78 [95% CI 1.11 to 2.79], P = 0.016). The risk of non-live birth was significantly increased in couples with parental karyotype abnormalities (adjusted OR: 0.08 [95% CI 0.01 to 0.76], P = 0.029). No statistically significant differences were found between the patients with and without ongoing pregnancy ≥ 12 weeks and live birth regarding number of miscarriages, BMI, thyroid stimulating hormone, thyroid peroxidase antibody, thyroglobulin antibody, homa insulin-resistance, parental karyotype abnormality, B lymphocyte, NK cells, antinuclear antibody, antithrombin III activity, platelet aggregation function, anticardiolipin antibody, lupus anticoagulant, homocysteine, protein C, protein S, anti-β2 glycoprotein antibody, anti-phosphatidylserine and thromboelastograms.

CONCLUSIONS

In patients with RPL after treatment, age and uterine anomalies were identified as risk factors linked to pregnancy loss < 12 weeks, while parental karyotype abnormalities were recognized as an independent risk factor affecting live birth outcomes.

CLINICAL TRIAL NUMBER

Not applicable.

Large uterine fibroid causing DVT and PE: Successful management with mechanical aspiration thrombectomy and hysterectomy: A case report and literature review

RATIONALE

Uterine leiomyomas, though commonly benign, can occasionally lead to serious complications, including deep vein thrombosis (DVT) and pulmonary embolism (PE). This study aims to highlight the uncommon yet serious association between large uterine leiomyomas and thromboembolism, which is often overlooked in patients without traditional risk factors. It emphasizes the need for awareness, early diagnosis, and timely intervention to prevent complications in patients presenting with unexplained symptoms and pelvic masses.

PATIENT CONCERN

A 38-year-old gravida 5, para 2 woman presented to the emergency room with left lower extremity swelling, pain, and discoloration, accompanied by dyspnea. She had no prior history of DVT or PE and did not have any known risk factors for venous thromboembolism.

DIAGNOSIS

The patient was diagnosed with DVT and PE, confirmed by venous duplex ultrasound and abdominal and pelvic computed tomography, which revealed thrombus extension to the left iliac vein. Chest computed tomography angiography confirmed a partially occlusive thrombus in the pulmonary arteries.

INTERVENTION

The patient underwent mechanical aspiration thrombectomy, followed by placement of a left iliac stent. Anticoagulation therapy with heparin was initiated post-thrombectomy. On the third day, a right supracervical hysterectomy was successfully performed. After surgery, anticoagulation was continued with heparin, and the patient was later discharged on apixaban for ongoing therapy.

OUTCOMES

The patient made full recovery with no recurrence of thromboembolic events at 11 months posttreatment.

LESSONS

This case highlights the rare but serious complication of DVT and PE in patients with uterine leiomyomas. Timely intervention with thrombectomy, stent placement, and hysterectomy was effective in resolving the thromboembolic events.

Unveiling the advantages of laparoscopic myomectomy: A comprehensive systematic review and meta-analysis of outcomes and complications compared with traditional open surgery

AIMS

To compare the outcomes of laparoscopic myomectomy (LM) and open myomectomy (OM) by reviewing the frequency, type and severity of complications reported by the Clavien-Dindo classification. In addition, this study evaluated differences in blood loss, length of operative time and hospital stay between these two surgical approaches.

METHODS

A systematic search of electronic databases was conducted from their inception to January 2024 to identify studies comparing LM and OM with detailed surgical complications reported. The random effect model was applied, and the odds ratio was used for the main outcomes, with effect sizes presented alongside 95 % confidence intervals (CI). A p-value < 0.05 was considered to indicate significance.

RESULTS

Of 296 studies identified, nine studies (total 224 patients) were included. LM was found to be associated with significantly lower rates of overall postoperative complications compared with OM. With no statistical heterogeneity between the studies (I2 = 0 %), the overall effect size was 0.67 (95 % CI 0.45-0.99), indicating a significant association between postoperative complications and open surgery (p = 0.04). Regarding Clavien-Dindo complications >grade 3, the overall effect size was 1.55 (95 % CI 0.47-5.08), indicating a non-significant association between grade 3 complications and surgical approach (p = 0.47). Despite superimposable operative time (effect size 1.40, 95 % CI 0.70-2.79; p = 0.342), LM showed significantly lower mean blood loss compared with OM, with an overall effect size of 0.34 (95 % CI 0.12-1.00; p = 0.049). The duration of hospital stay was significantly shorter in the LM group (2.0 vs 3.1 days), with an overall effect size of 0.09 (95 % CI 0.05-0.18), strongly associating the laparoscopic approach with reduced hospitalization stay (p < 0.001).

CONCLUSION

LM offers favourable outcomes compared with OM for the treatment of uterine myomas. Despite a slightly longer operative time, LM was found to be associated with lower rates of postoperative complications and reduced hospital stay. These findings support the preference for LM for the treatment of uterine myomas, highlighting its potential to improve patient outcomes and recovery.

The safety and efficacy of myomectomy in the treatment of recurrent uterine fibroids after HIFU

OBJECTIVE

To evaluate the safety and efficacy of myomectomy for recurrent uterine fibroids (UFs) after high-intensity focused ultrasound (HIFU) ablation.

METHODS

This was a retrospective study. Patients who underwent abdominal myomectomy (AM) and laparoscopic myomectomy (LM) from January 2018 to December 2021 at the Three Gorges Hospital of Chongqing University were included. Among them, 73 had undergone prior HIFU ablation (Group 1), while 120 had not undergone HIFU (Group 2). Outcome measures included operating time, estimated blood loss (EBL), blood transfusion, postoperative activity times (PAT), duration of hospital stay (DOHS), and complications.

RESULTS

The operating time was 90.0 min (70.5, 115.0) for Group 1 and 110.0 min (81.5, 130.0) for Group 2 (P < 0.05). During all AM pathways, there were no significant differences observed between the two groups in EBL, blood transfusion, PAT, DOHS, and complications; however, operating time was shorter in Group 1. The operating time, EBL, blood transfusion, PAT, DOHS, and complications were similar in both groups during LM pathway. During the follow-up 40 (range: 24-53) months, the rate of relief, recurrence, and reintervention in Groups 1 and 2 was 78.1% versus 74.1%, 14.6% versus 16.4%, and 3.7% versus 2.6%, respectively (P > 0.05).

CONCLUSION

Myomectomy is a safe and effective surgical method for treating recurrent UFs after HIFU. Myomectomy for treating recurrent UFs resulted in a shorter operative and hospital stay, reduced blood loss, faster postoperative recovery, and fewer complications, better symptom relief rates, and lower risk of recurrence or reintervention. These findings indicate that previous HIFU ablation does not worsen the outcomes of the subsequent myomectomy.

Vaginal myomectomy for a large intrastromal cervical fibroid: a case report

Fibroids affect up to two-thirds of women of reproductive age and can lead to significant symptoms, including abnormal uterine bleeding and reproductive dysfunction. Cervical fibroids are rare, with an incidence of only 0.6%. Currently, there is no consensus on the optimal surgical approach for management of cervical fibroids. Pedunculated extracervical fibroids are routinely removed vaginally. However, intrastromal (intracervical) fibroids often require a laparoscopic or laparotomic approach. We report a case of vaginal myomectomy for the management of a large cervical fibroid in a 43-year-old patient seeking fertility treatment. We discuss the feasibility of this surgical approach and its potential for enhanced recovery.

Predicting the Prognosis of HIFU Ablation of Uterine Fibroids Using a Deep Learning-Based 3D Super-Resolution DWI Radiomics Model: A Multicenter Study

RATIONALE AND OBJECTIVES

To assess the feasibility and efficacy of a deep learning-based three-dimensional (3D) super-resolution diffusion-weighted imaging (DWI) radiomics model in predicting the prognosis of high-intensity focused ultrasound (HIFU) ablation of uterine fibroids.

METHODS

This retrospective study included 360 patients with uterine fibroids who received HIFU treatment, including Center A (training set: N = 240; internal testing set: N = 60) and Center B (external testing set: N = 60) and were classified as having a favorable or unfavorable prognosis based on the postoperative non-perfusion volume ratio. A deep transfer learning approach was used to construct super-resolution DWI (SR-DWI) based on conventional high-resolution DWI (HR-DWI), and 1198 radiomics features were extracted from manually segmented regions of interest in both image types. Following data preprocessing and feature selection, radiomics models were constructed for HR-DWI and SR-DWI using Support Vector Machine (SVM), Random Forest (RF), and Light Gradient Boosting Machine (LightGBM) algorithms, with performance evaluated using area under the curve (AUC) and decision curves.

RESULT

All DWI radiomics models demonstrated superior AUC in predicting HIFU ablated uterine fibroids prognosis compared to expert radiologists (AUC: 0.706, 95% CI: 0.647-0.748). When utilizing different machine learning algorithms, the HR-DWI model achieved AUC values of 0.805 (95% CI: 0.679-0.931) with SVM, 0.797 (95% CI: 0.672-0.921) with RF, and 0.770 (95% CI: 0.631-0.908) with LightGBM. Meanwhile, the SR-DWI model outperformed the HR-DWI model (P < 0.05) across all algorithms, with AUC values of 0.868 (95% CI: 0.775-0.960) with SVM, 0.824 (95% CI: 0.715-0.934) with RF, and 0.821 (95% CI: 0.709-0.933) with LightGBM. And decision curve analysis further confirmed the good clinical value of the models.

CONCLUSION

Deep learning-based 3D SR-DWI radiomics model demonstrated favorable feasibility and effectiveness in predicting the prognosis of HIFU ablated uterine fibroids, which was superior to HR-DWI model and assessment by expert radiologists.

Exploring the gut-inflammation connection: A Mendelian randomization study on gut microbiota, inflammatory factors, and uterine fibroids risk

This study employs Mendelian randomization (MR) approach to investigate the potential causal association between genetic variants associated with gut microbiota, inflammatory factors, and the risk of uterine fibroids development. We extracted data on 211 types of gut microbiota, 91 inflammatory factors, and uterine fibroids occurrence from genome-wide association studies and applied the inverse-variance weighted (IVW) method for analysis. To further assess the robustness of our MR analysis, we conducted sensitivity tests including Cochrane's Q test, the MR-Egger intercept test, the MR-PRESSO global test, and a leave-one-out analysis. IVW analysis identified a potential causal association between 14 types of gut microbiota and 8 inflammatory factors with the risk of uterine fibroids. When using 91 inflammation-related proteins as the outcome variable, 13 proteins demonstrated a potential causal association with uterine fibroids risk (IVW, all P < .05). Additionally, the MR-Egger intercept and MR-PRESSO global tests indicated no evidence of horizontal pleiotropy (P > .05), and the leave-one-out analysis confirmed the robustness of the results. This MR approach suggests that specific gut microbiota and inflammatory factors may have a causal association with the development of uterine fibroids, shedding light on the pathogenesis of uterine fibroids and potentially identifying targets for future therapeutic interventions.

Acupuncture combined with Chinese herbs versus Chinese herbs alone to improve the clinical efficacy of uterine fibroids: a systematic review and meta-analysis

Objective

The objective of this study was to evaluate the clinical efficacy of acupuncture combined with Chinese herbs versus Chinese herbs alone in treating uterine fibroids.

Methods

A literature search of eight databases identified nine randomized controlled trials (RCTs) evaluating the clinical efficacy of acupuncture combined with Chinese herbs compared to Chinese herbs alone for treating uterine fibroids. Subsequently, data extraction and analysis were conducted to assess the methodological quality and risk of bias in the studies, followed by an analysis of the data from the randomized controlled trials.

Results

Nine randomized controlled trials involving 640 women were included. The results indicated that acupuncture combined with Chinese herbs significantly increased the overall clinical efficacy rate [Z=5.00, P=0.74, relative risk(RR)1.20, 95%CI 1.12 to 1.30, P<0.00001, I²=0%] and reduced the size of uterine fibroids [Z=2.95, P=0.003, SMD=-0.82, 95%CI -1.36 to -0.27, P<0.00001, I²=90%].

Conclusions

Studies have shown that acupuncture combined with Chinese herbs reduces uterine size, lowers hormone levels, and improves quality of life. According to the findings of this study, acupuncture combined with Chinese herbs has a more positive effect on the treatment of uterine fibroids than Chinese herbs alone. However, due to the limited number and quality of the included studies, these conclusions need to be validated by further high-quality research.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/#myprospero, identifier CRD42024507248.

Global and regional trends in the incidence and prevalence of uterine fibroids and attributable risk factors at the national level from 2010 to 2019: A worldwide database study

BACKGROUND

Uterine fibroids (UFs), the most common tumors in women worldwide, may reduce quality of life and daily activities and even lead to adverse fertility and general health events in patients, causing significant societal health and financial burdens. The objective of this study was to evaluate the global burden through epidemiological trends and examine the potential risk factors for UFs at the national level.

METHODS

Data on the incidence, prevalence, disability-adjusted life years (DALYs), age-standardized incidence rates (ASIRs), age-standardized prevalence rates (ASPRs), and age-standardized DALY rates for UFs were collected, and the associations with the Human Development Index (HDI) and fertility were evaluated. The age trends in the average annual percent change (AAPC) of the incidence and prevalence rates of UFs were evaluated by joinpoint regression analysis. The associations between lifestyle, metabolic, and socioeconomic factors and the ASIRs of UFs were examined using multivariable linear regression analysis.

RESULTS

The worldwide incidence and prevalence of UFs have been increasing in the past decade, with AAPCs of 0.27% in the incidence rate and 0.078% in the prevalence rate. During 2010-2019, significant increasing trends in UF ASIR were observed in 52 of 88 countries. The age-specific incidence and prevalence of UFs in most age groups showed increasing trends except for 45-54-year-old women which showed no significant trend. Ecological analysis demonstrated no relationship between the incidence of UFs and the HDI but an inverse association with fertility. The incidence of UFs was positively correlated with alcohol intake, hypertension, overweight, and obesity and negatively correlated with smoking.

CONCLUSION

With the increasing incidence and prevalence worldwide, effective targeted prevention and control of relevant risk factors at the national level should be encouraged to reduce the disease burden of UFs.

Uterine fibroids with heavy menstrual bleeding stratified by race in a commercial and Medicaid database

Background

Historically, the clinical characteristics and treatment pathways for patients with uterine fibroids and heavy menstrual bleeding have differed between White and Black women.

Objective

To provide a contemporary comparison of patient characteristics and treatment patterns among White and Black women with uterine fibroids and heavy menstrual bleeding in the United States.

Study Design

This retrospective cohort study included administrative claims data from 46,139 White and 17,297 Black women with uterine fibroids and heavy menstrual bleeding from the Optum Clinformatics database (January 2011-December 2020) and 7353 White and 16,776 Black women from the IBM MarketScan Multi-State Medicaid Insurance database (January 2010-December 2019). Patients were indexed at their initial uterine fibroid diagnosis claim and were required to have a claim for heavy menstrual bleeding and ≥12 months of continuous enrollment pre- and postindex. Patients were followed until the earliest of death, disenrollment, hysterectomy date, or end of study database. Outcomes were stratified by race and included patient demographics, clinical characteristics, pharmacologic treatment patterns, and surgeries/procedures. Pearson's Chi-square test for categorical variables and Student's t-test for continuous data were used to evaluate differences in baseline characteristics. Descriptive statistics were used to characterize treatment pathways for hormonal contraceptive use in women with ≥24 months of follow-up. Kaplan-Meier survival analysis was used to estimate time until hysterectomy, with log-rank testing to assess between-group differences.

Results

The mean (standard deviation) duration of follow-up was 44.6 (27.9) and 41.0 (24.9) months in the commercial and Medicaid databases, respectively. Mean (standard deviation) age at uterine fibroid diagnosis was lower for Black than White women in both databases (commercial: 42.3 [6.5] vs 44.4 [6.3] years; P<.0001; Medicaid: 39.6 [7.1] years vs 40.2 [7.2] years; P<.0001). Anemia was more prevalent in Black vs White women in both databases (commercial: 5.9% [1028/17,297] vs 3.6% [1648/46,139]; P<.0001; Medicaid: 7.0% [1180/16,776] vs 4.5% [331/7353]; P<.0001). In the commercial database, approximately one-half of women had claims for ≥1 bulk symptom, with no significant differences between groups. In the Medicaid database, significantly more White than Black women had claims for bulk symptoms (77.0% [5665/7353] vs 68.4% [11,477/16,776]; P<.0001). Approximately 40% of all patients received hormonal drug therapies as initial treatment, most commonly hormonal contraceptives. However, discontinuation of hormonal contraceptive therapy was nearly universal, with one-half discontinuing within a median treatment duration of ∼5 months. Most women stopped treatment after 1 or 2 agents (commercial: White, 89.9% [9757/10,857]; Black, 90.0% [3594/3993]; Medicaid: White, 92.2% [1635/1773]; Black, 94.2% [4454/4726]). Hysterectomy was the most common procedure, and was more common among White vs Black women (commercial: 43.9% [20,235/46,139] vs 37.8% [6536/17,297]; Medicaid: 46.8% [3444/7353] vs 32.0% [5364/16,776]).

Conclusions

Black women with UF-HMB were diagnosed at a younger age than White women, and White women had higher hysterectomy rates than Black women, representing a shift from earlier researched treatment patterns. Patients with UF-HMB were also highly reliant on hormonal contraceptives, followed by nearly universal therapeutic discontinuation.

Laparoscopic myomectomy without uterine manipulator for maintaining endometrial cavity integrity

Background

Preserving the integrity of the endometrial cavity is crucial, particularly for preserving fertility during laparoscopic myomectomy (LM). This study aimed to compare the uterine breaching rate and clinical outcomes of LM performed with and without a uterine manipulator.

Methods

Data from women who underwent LM at our hospital between January 2020 and June 2023 were retrospectively analyzed. The primary outcomes included endometrial cavity breaching rate, conversion rate, abdominal port count, operative time, hospitalization duration, and blood loss. The secondary outcomes included adverse events such as postoperative anemia and emphysema.

Results

We analyzed the data from 50 participants, comparing those with (n=30) and without (n=20) manipulators. No significant differences were observed in age, body mass index, surgical time, hospitalization, blood loss, or hemoglobin drop. However, the incidence of endometrial cavity breach was higher in the manipulator group (p=0.007). The manipulator group required fewer abdominal ports (p < 0.001) than the manipulator group. Increased myoma size was associated with increased blood loss and surgical time.

Conclusions

The clinical outcomes of LM without a uterine manipulator were comparable to those of LM with a manipulator. The absence of a manipulator may aid in preserving the integrity of the endometrial cavity. An increase in myoma size was associated with longer surgical time and greater blood loss, while uterine manipulator use was linked to fewer trocars.

Role of Pyroptosis in Endometrial Cancer and Its Therapeutic Regulation

Pyroptosis is an inflammatory cell death induced by inflammasomes that release several pro-inflammatory mediators such as interleukin-18 (IL-18) and interleukin-1β (IL-1β). Pyroptosis, a type of programmed cell death, has recently received increased interest both as a therapeutic and immunological mechanism. Numerous studies have provided substantial evidence supporting the involvement of inflammasomes and pyroptosis in a variety of pathological conditions including cancers, nerve damage, inflammatory diseases and metabolic conditions. Researchers have demonstrated that dysregulation of pyroptosis and inflammasomes contribute to the progression of endometriosis and gynecological malignancies. Current research also indicates that inflammasome and pyroptosis-dependent signaling pathways may further induce the progression of endometrial cancer (EC). More specifically, dysregulation of NLR family pyrin domain 3 (NLRP3) and caspase-1-dependent pyroptosis play a contributory role in the pathogenesis and development of EC. Therefore, pyroptosis-regulated protein gasdermin D (GSDMD) may be an independent prognostic biomarker for the detection of EC. This review presents the molecular mechanisms of pyroptosis-dependent signaling pathways and their contributory role and function in advancing EC. Moreover, this review offers new insights into potential future applications and innovative approaches in utilizing pyroptosis to develop effective anti-cancer therapies.

Quality of life after myomectomy according to the surgical approach and MED12 mutation status

OBJECTIVE

Molecular status of uterine leiomyomas has been shown to affect both tumor characteristics and treatment response. Mutations in mediator complex subunit 12 (MED12), the most prevalent alterations in leiomyomas, are associated with tumor size and number of leiomyomas. Myomectomy can be performed by laparoscopy or by open abdominal surgery, depending on the size and number of leiomyomas removed. The aim of this study was to examine the association between MED12 mutation status and surgical approach of myomectomy. We also evaluated myomectomy patients' quality of life after laparoscopic or abdominal surgery and according to the MED12 mutation status.

STUDY DESIGN

The prospective cohort study included 104 women who underwent laparoscopic or abdominal myomectomy at the Helsinki University Hospital during 2015-2019. Patients filled in the validated Uterine Fibroid Symptom and Quality of Life (UFS-QOL) questionnaire before the operation and 6 and 12 months after the operation. Medical records were reviewed to collect clinical data. Leiomyoma tissue samples were collected and screened for MED12 mutations.

RESULTS

Patients undergoing abdominal myomectomy had larger and more numerous leiomyomas compared to patients with laparoscopic myomectomy (10 cm vs 7.4 cm, p < 0.001 and 3 vs 1 leiomyomas, p < 0.001, respectively). A mean change of over 20 points was seen in UFS-QOL scores at 6 months after both laparoscopic and abdominal myomectomy (p < 0.001). MED12 mutations were detected in 178/242 (74 %) of leiomyomas. Of the patients, 45/97 (46 %) had only MED12 positive leiomyomas, while 39/97 (40 %) had only MED12 wild type leiomyomas. The number of leiomyomas removed was higher among patients with MED12 positive leiomyomas than in patients with MED12 wild type tumors (p < 0.001). Laparoscopic approach was equally common in both groups (62 % and 64 %), and there was no statistically significant difference in the UFS-QOL scores.

CONCLUSION

Both laparoscopic and abdominal myomectomy significantly improved the quality of life. While MED12 mutations were related with multiple leiomyomas and therefore potentially generated a greater leiomyoma burden, they were not associated with the surgical approach. Pre- and postoperative quality of life was comparable between patients regardless of MED12 status.

Robotic-assisted laparoscopic versus abdominal and laparoscopic myomectomy: A systematic review and meta-analysis

BACKGROUND

Myomectomy is the preferred treatment for women with uterine fibroids and fertility requirements. There are three modalities are used in clinical practice for myomectomy: abdominal myomectomy (AM), laparoscopic myomectomy (LM), and robot-assisted laparoscopic myomectomy (RLM).

OBJECTIVES

To compare the perioperative and postoperative outcomes of RLM, AM, and LM.

SEARCH STRATEGY

We searched PubMed, Web of Science, Embase, and Clinical Trials for relevant literature published between January 2000 and January 2023.

SELECTION CRITERIA

We included all studies reporting peri- and postoperative outcomes of myomectomy in patients with uterine myomas. Surgical treatments were classified as RLM, LM, or AM.

DATA COLLECTION AND ANALYSIS

Two or more authors selected studies independently, assessed risk of bias, and extracted data. We derived mean difference (MD) or odds ratio (OR) with 95% confidence intervals (CIs) for each outcome, subgrouping trials by the patient characteristics and myoma characteristics. We used the I2 statistic to quantify heterogeneity and the random-effects model for meta-analysis when appropriate. We used the funnel plot to assess the publication bias.

MAIN RESULTS

A total of 32 studies with 6357 patients were included, of which 1982 women had undergone RLM. The operating time was significantly longer (MD = 43.58, 95% confidence interval [CI]: 25.22-61.93, P < 0.001), and the incidence of cesarean section after myomectomy was significantly lower (OR = 0.27, 95% CI: 0.10-0.78, P = 0.02) in RLM than in LM. Compared with AM, the operation time, blood loss, blood transfusion rate, complication rate, total cost, length of hospital stay, and pregnancy rate of patients with RLM were significantly different.

CONCLUSIONS

The safety and effectiveness of RLM are superior to those of AM but inferior to those of LM.

Endometrial E-cadherin and N-cadherin Expression during the Mid-Secretory Phase of Women with Ovarian Endometrioma or Uterine Fibroids

BACKGROUND

Endometriosis and uterine fibroids are benign conditions frequently linked to subfertility/infertility. Recent research has highlighted the importance of epithelial-mesenchymal transition between embryonic and endometrial cells in the context of embryo implantation. Additionally, the adverse endometrial environment during implantation has been proposed as a mechanism contributing to infertility in endometriosis. Nevertheless, the role of cadherin molecule alterations in relation to endometrial receptivity and embryo invasion remains a subject of controversy.

METHODS

We investigated the expression patterns of E-cadherin and N-cadherin in the endometria of women with ovarian endometrioma or uterine fibroids and assessed whether they differed from those of healthy women. We enrolled 17 women with ovarian endometrioma, 16 with uterine fibroids, and 6 healthy women. Endometrial tissues were obtained at the mid-secretory phase on days 19-24 of the menstrual cycle. The E-cadherin and N-cadherin mRNA and protein expression levels were measured using quantitative reverse transcriptase polymerase chain reaction and Western blot analysis, respectively.

RESULTS

The E-cadherin and N-cadherin mRNA expression levels were higher and lower, respectively, in the endometrium of women with ovarian endometrioma than in those of the controls. In the endometrium of women with uterine fibroids, similar patterns with higher E-cadherin and lower N-cadherin levels were observed compared with that of the controls. Protein expression showed similar patterns.

CONCLUSIONS

Our findings revealed higher E-cadherin expression and lower N-cadherin expression in the endometria of women with infertility-related diseases than in those of healthy women in the mid-secretory phase. This suggests a resistance to endometrial receptivity, potentially reflecting mesenchymal-epithelial transition properties.