Epidemiology of uterine fibroids: a systematic review

Exploring Self-Reported Symptoms for Developing and Evaluating Digital Symptom Checkers for Polycystic Ovarian Syndrome, Endometriosis, and Uterine Fibroids: Exploratory Survey Study

BACKGROUND

Reproductive health conditions such as polycystic ovary syndrome (PCOS), endometriosis, and uterine fibroids pose a significant burden to people who menstruate, health care systems, and economies. Despite clinical guidelines for each condition, prolonged delays in diagnosis are commonplace, resulting in an increase to health care costs and risk of health complications. Symptom checker apps have the potential to significantly reduce time to diagnosis by providing users with health information and tools to better understand their symptoms.

OBJECTIVE

This study aims to study the prevalence and predictive importance of self-reported symptoms of PCOS, endometriosis, and uterine fibroids, and to explore the efficacy of 3 symptom checkers (developed by Flo Health UK Limited) that use self-reported symptoms when screening for each condition.

METHODS

Flo's symptom checkers were transcribed into separate web-based surveys for PCOS, endometriosis, and uterine fibroids, asking respondents their diagnostic history for each condition. Participants were aged 18 years or older, female, and living in the United States. Participants either had a confirmed diagnosis (condition-positive) and reported symptoms retrospectively as experienced at the time of diagnosis, or they had not been examined for the condition (condition-negative) and reported their current symptoms as experienced at the time of surveying. Symptom prevalence was calculated for each condition based on the surveys. Least absolute shrinkage and selection operator regression was used to identify key symptoms for predicting each condition. Participants' symptoms were processed by Flo's 3 single-condition symptom checkers, and accuracy was assessed by comparing the symptom checker output with the participant's condition designation.

RESULTS

A total of 1317 participants were included with 418, 476, and 423 in the PCOS, endometriosis, and uterine fibroids groups, respectively. The most prevalent symptoms for PCOS were fatigue (92%), feeling anxious (87%), BMI over 25 (84%); for endometriosis: very regular lower abdominal pain (89%), fatigue (85%), and referred lower back pain (80%); for uterine fibroids: fatigue (76%), bloating (69%), and changing sanitary protection often (68%). Symptoms of anovulation and amenorrhea (long periods, irregular cycles, and absent periods), and hyperandrogenism (excess hair on chin and abdomen, scalp hair loss, and BMI over 25) were identified as the most predictive symptoms for PCOS, while symptoms related to abdominal pain and the effect pain has on life, bleeding, and fertility complications were among the most predictive symptoms for both endometriosis and uterine fibroids. Symptom checker accuracy was 78%, 73%, and 75% for PCOS, endometriosis, and uterine fibroids, respectively.

CONCLUSIONS

This exploratory study characterizes self-reported symptomatology and identifies the key predictive symptoms for 3 reproductive conditions. The Flo symptom checkers were evaluated using real, self-reported symptoms and demonstrated high levels of accuracy.

Modifiable prognostic factors in uterine fibroid development: a systematic review of literature

BACKGROUND

Many risk factors in uterine fibroid development have been identified, but women and their physicians are less aware of the influence of lifestyle on uterine fibroid development. The objective of this systematic review is to investigate and summarize modifiable prognostic factors associated with uterine fibroid development.

METHODS

Pubmed and Embase were searched for relevant articles according to PRISMA guidelines. References from included articles were screened and when relevant also included. Human in vivo studies on modifiable factors in fibroid development were included. Studies on non-modifiable factors and treatment, in vitro studies and animal studies were excluded. 607 articles were screened and 33 articles were included. Two independent investigators collected data from the report.

RESULTS

The strongest risk factor for fibroid development was a high BMI, while the strongest protective factors were a high fruit and vegetable intake and high vitamin D intake.

CONCLUSION

More high-quality studies are necessary to better understand the impact of the abovementioned factors as well as the role they play in the growth of already existing fibroids.

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.

Systemic Estrogen Therapy and Thrombosis: A Call for Individualized Clinical Decision Making in the Acute Care Setting

Systemic estrogen therapies (SETs) are integral to health care, playing critical roles in reproductive rights, managing heavy menstrual bleeding (HMB), alleviating menopausal symptoms, and supporting gender-affirming hormone therapy (GAHT) for transwomen. However, SETs are associated with an increased risk of venous thromboembolism (VTE), posing a challenge in the acute care setting. Here, we explore the nuanced management of SETs in patients who present with a hormone-related VTE in the acute care setting. The prevailing practice of discontinuing SETs in this setting may lead to significant adverse effects, including exacerbation of HMB, unintended pregnancy, menopausal symptoms, and psychological distress from interrupted GAHT or hormone replacement therapy. The discontinuation of SETs can severely affect patients' health, quality of life, and adherence to anticoagulation therapy in the case of HMB, increasing the risk of VTE recurrence. We challenge the practice of broadly discontinuing SETs in the acute care setting, advocating for a patient-centered approach that considers the underlying reasons for SET use, potential adverse effects of abrupt cessation, and individual patient needs. We underscore the importance of shared decision making and individualized care, particularly for historically marginalized groups in health care, cis women, transwomen, and individuals with HMB, to ensure safe, equitable, and affirming health care. A tailored approach to managing SETs in the acute care setting will enhance health care delivery and reduce health inequities. Lastly, we highlight the need for further research, particularly regarding GAHT-related VTE for transwomen.

Preoperative identification from occult leiomyosarcomas in laparoscopic hysterectomy and laparoscopic myomectomy: accuracy of the ultrasound scoring system (PRESS-US)

PURPOSE

To assess the diagnostic performance and inter-observer agreement of a PREoperative sarcoma scoring based on ultrasound (PRESS-US) in differentiating uterine leiomyosarcoma (uLMS) from leiomyoma (LM).

METHODS

We conducted a retrospective evaluation of patients who underwent surgery and received standardized ultrasound examinations due to the presence of uterine myoma-like masses. Histological diagnosis was used as the reference standard. The masses were analyzed using morphological uterus sonographic assessment criteria, and the diagnostic accuracy of PRESS-US was evaluated using ROC curve analysis. Kappa (κ) statistics were used to assess the inter-observer agreement between a less experienced and an expert radiologist.

RESULTS

Among the 646 patients, 632 (97.8%) were diagnosed with LM, and 14 (2.2%) had uLMS. The malignancy rates for low-risk and high-risk patients were 0.35% and 13.48%, respectively. The optimal PRESS-US cutoff was 17.5, resulting in an AUC of 89.7% (95% CI, 0.79-1.00), with a sensitivity of 85.7% and a specificity of 87.8%. The inter-observer agreement between a less experienced and an expert radiologist was excellent (κ = 0.811, P < 0.001).

CONCLUSIONS

PRESS-US provides effective risk stratification for uLMS for radiologists with different levels of experience, with high reliability. Subgrouping high-risk patients helps in better risk stratification.

Relation of Endocan Serum Levels with Patient Characteristics and Morphological Features of Uterine Fibroids: A Case-Control Study

OBJECTIVES

This study aimed to compare the serum endocan levels of patients with uterine fibroids and the healthy control group.

DESIGN

A case-control study was designed. Participants/Materials: The study group includes women diagnosed with uterine fibroids, and the control group includes healthy women.

SETTING

The study was conducted at a tertiary education and research hospital with 130 women (uterine fibroid group, n = 65; control group, n = 65).

METHODS

Serum endocan levels were determined in the study and control groups using the ELISA method. The number of uterine fibroids was identified, and the volume of uterine fibroids was calculated with ellipsoid formula by ultrasonography. The primary outcome parameter was serum endocan levels in patients with uterine fibroids and healthy control groups. Second, it is aimed to determine the distribution of the serum endocan level of patients according to uterine fibroid number, volume, and clinical presentation.

RESULTS

The mean serum endocan level of patient with uterine fibroid was 145.18 ± 169.86 (median: 94.10; Q25-Q75%: 54.50-116.50) pg/mL; it was 88.94 ± 54.21 (median: 76.9; Q25-Q75%: 64.20-152.65) pg/mL in the control group (p = 0.016). According to ROC analysis, cutoff value of the endocan level for uterine fibroid was determined as ≥133.1 pg/mL. For the cutoff value of 133.1 pg/mL, sensitivity was 36.92%, specificity was 89.23%, positive predictive value was 77.40%, and negative predictive value was 58.60%. Above this cutoff value, a 4.8-fold increased significant risk (OR) for uterine fibroid was detected.

LIMITATIONS

The major limitation of the study is the lack of histopathological examination.

CONCLUSION

Serum endocan levels were found to be higher in women with uterine fibroids compared to the control group, so endocan may be considered as a significant serum marker.

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 two 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 <0.0001). 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 0.02) and an increased incidence of miscarriage in pregnancies (53.5% UAE group vs. 22.3% non-UAE group, p-value=0.01). 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=0.03).

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.

Predictive value of contrast-enhanced MRI for the regrowth of residual uterine fibroids after high-intensity focused ultrasound treatment

OBJECTIVES

To investigate whether the signal intensity (SI) ratio of residual fibroid (RF) to myometrium using Contrast-Enhanced Magnetic Resonance Imaging (CE-MRI) could predict fibroid regrowth after high-intensity focused ultrasound (HIFU) treatment.

MATERIALS AND METHODS

A retrospective analysis was conducted among 164 patients with uterine fibroids who underwent HIFU. To predict the RF regrowth, the SI perfusion parameters were quantified using the RF-myometrium SI ratio on CE-MRI on day 1 post-HIFU and then compared with the fibroid-myometrium SI ratio on the T2-weighted image (T2WI) and Funaki classification 1 year later. Thirty cases from another center were used as an external validation set to evaluate the performance of RF-myometrium SI ratio.

RESULTS

The predictive performance of the RF-myometrium SI ratio on CE-MRI on day 1 post-HIFU (Area Under Curve, AUC: 0.869) was superior to that of the preoperative and postoperative fibroid-myometrium SI ratios on the T2WI (AUC: 0.724, 0.696) and Funaki classification (AUC: 0.663, 0.623). Multivariate analysis showed that the RF- myometrium SI ratio and RF thickness were independent factors. The RF-myometrium SI ratio reflects the long-term rate of re-intervention (r = 0.455, p < 0.001).

CONCLUSION

The RF-myometrium SI ratio on CE-MRI exhibits greater accuracy in predicting RF regrowth compared to the SI classification and the SI ratio on T2WI.

CRITICAL RELEVANCE STATEMENT

The ratio of residual uterine fibroid to myometrial signal intensity on contrast-enhanced (CE)-MRI can reflect residual blood supply, predict regrowth of fibroids, and thus reflect long-term re-intervention rate and recovery situation of clinical high-intensity focused ultrasound (HIFU) treatment.

KEY POINTS

Contrast-enhanced (CE)-MRI can indicate the blood supply of residual uterine fibroids after high-intensity focused ultrasound (HIFU) treatment. The predictive capability of CE-MRI ratio surpasses T2WI ratio and the Funaki. Residual fibroids can serve as a measure of the long-term efficacy of HIFU.

Use of Uterine Artery Embolization for the Treatment of Uterine Fibroids: A Comparative Review of Major National Guidelines

OBJECTIVE

Fibroids cause significant morbidity, including anemia, pelvic pain, and infertility. It is imperative that healthcare providers are well-versed in the varying treatments available for fibroids. Specifically, uterine artery embolization (UAE) is a treatment that improves anemia, pelvic pain, and quality of life. The purpose of this article is to compare international guidelines on UAE to offer best practices to healthcare providers.

DATA SOURCES

Guidelines from the American College of Obstetrics and Gynecology, The Royal College of Obstetricians and Gynaecologists and the Royal College of Radiologists, National College of French Gynecologists and Obstetricians, The Royal Australian and New Zealand College of Obstetricians and Gynaecologists, the Society of Obstetricians and Gynaecologists of Canada, and the National Institute for Health and Care Excellence were reviewed alongside peer-reviewed PubMed articles.

METHOD OF STUDY SELECTION

A comparative review of major international guidelines was conducted to encompass potential geographical, cultural, and societal variances with UAE.

TABULATION, INTEGRATION, AND RESULTS

Review of data revealed guidelines agree with many constituents surrounding treatment of fibroids with UAE. Guidelines diverge regarding offering UAE for small fibroids, intracavitary/submucosal fibroids, and pedunculated serosal fibroids with variations on suggested imaging. Most agree that an experienced care team, including a gynecologist and interventional radiologist, should be included. Preoperative antibiotics and intrauterine device removal may be recommended. UAE for patients who desire fertility remains an option after counseling within most guidelines.

CONCLUSIONS

UAE is a safe, efficacious, and cost-effective alternative to hysterectomy and myomectomy. Including UAE as a treatment option during the patient counseling process is critical. Guidelines vary based on data interpretation and are based on clinical research and expert opinion. Due to mixed data and lack of randomized controlled trials, organizations differ when offering UAE to patients who wish to preserve fertility. It is vital to note emerging studies supporting the safety of UAE for subsequent pregnancy.

A novel nomogram for predicting non-infectious fever in patients following laparoscopic myomectomy

This study aimed to develop and validate a novel nomogram to predict the risk of non-infectious fever (NIF) in patients following laparoscopic myomectomy. A retrospective analysis was conducted on data from patients who underwent laparoscopic myomectomy between 2019 and 2023. Pertinent variables before, during, and after surgery were collected. Multivariate logistic regression analysis identified independent risk factors for postoperative NIF, from which a nomogram was constructed. The study included 576 patients, among whom 64 (11.1%) developed postoperative NIF. Multivariate analysis identified leiomyoma size, number of leiomyomas, preoperative hemoglobin levels, operative time, and estimated blood loss as independent risk factors for postoperative NIF. A predictive nomogram model incorporating these factors demonstrated good accuracy following internal validation. The developed nomogram represents the first tool tailored for predicting NIF after laparoscopic myomectomy. Its implementation can assist clinicians in early identification of high-risk patients, facilitating timely preventive and management strategies.

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 Smooth Muscle Tumors: An Overview

Uterine smooth muscle tumors are a heterogeneous group of mesenchymal neoplasms with multiple histologic variants and distinct biological behaviors. Pathologic classification (benign, uncertain malignant potential, malignant) relies on the evaluation of mitotic index, necrosis, and degree of cytologic atypia, with different thresholds based on each subtype. Immunohistochemistry and other ancillary studies may be necessary to establish the diagnosis in a subset of cases, given the morphologic overlap with other mesenchymal neoplasms, including low-grade and high-grade endometrial stromal tumors, inflammatory myofibroblastic tumors, and PEComa. Recent advances in molecular diagnostics have refined the classification of smooth muscle tumors, but most cases are diagnosed purely on histologic grounds.

Risk Factors and Prediction Nomogram of Local Regeneration After Ultrasound-Guided Microwave Ablation of Uterine Fibroids

STUDY OBJECTIVE

To explore the risk factors associated with local regeneration of the treated uterine fibroids (UFs) after microwave ablation (MWA) and to develop a nomogram model for predicting the risk of local regeneration.

DESIGN

Retrospective study.

SETTING

The Eighth Affiliated Hospital of Sun Yat-Sen University.

PATIENTS

Patients with UFs who underwent MWA at our hospital between October 2020 and April 2023 were included.

INTERVENTION

MWA was used for the treatment of UFs.

MEASUREMENTS AND MAIN RESULTS

A total of 47 patients with 68 fibroids were included into this study. Over a median follow-up of 13 months (interquartile range, 8-22 months), local regeneration occurred in 11 UFs. The clinical and imaging characteristics of these patients were recorded and compared. Risk factors for local regeneration were determined through univariate and multivariate Cox regression analysis. Multivariate analysis revealed that the fertility desires, larger size of UFs (≥95.3 cm3), and hyperenhancement of UFs on contrast-enhanced ultrasound were independent risk factors for local regeneration after MWA. A predictive nomogram was constructed to predict the local regeneration after MWA of UFs. The concordance index (C-index) (C-index, 0.924; internal validation C-index, 0.895) and the 1- and 2-year area under the curve values (0.962, 0.927) all indicated that the nomogram had good predictive performance. Calibration and decision curve analysis curves further confirmed the model's accuracy and clinical utility.

CONCLUSION

Fertility desires, larger size of UFs, and hyperenhancement on contrast-enhanced ultrasound were independent predictors of UFs local regeneration after MWA in our study. The nomogram constructed based on the abovementioned independent risk factors may help predict which UFs will develop local regeneration after MWA.

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.

Magnetic Resonance-Guided Focused Ultrasound Surgery for Gynecologic Indications

Magnetic resonance-guided focused ultrasound surgery (MRgFUS) appears to be an effective and safe treatment for uterine fibroids and adenomyosis, particularly in women who wish to preserve fertility. In abdominal wall endometriosis and painful recurrent gynecologic malignancies, MRgFUS can relieve pain, but more research is needed. There is no widespread reimbursement due to the lack of large prospective or randomized controlled trials comparing MRgFUS with standard therapy.

Pilot study on the impact of HIFU treatment on miRNA profiles in vaginal secretions of uterine fibroids and adenomyosis patients

BACKGROUND

High intensity focused ultrasound (HIFU) ablation treatment for uterine fibroids and adenomyosis has been long developed. The aim of this study is to investigate miRNA profile changes in vaginal secretions after HIFU treatment and their clinical relevance.

METHODS

We prospectively collected vaginal secretions samples from 8 patients (1 with adenomyosis and 7 with fibroids) before and after HIFU treatment. RNA was isolated and miRNA profiles were analyzed using next-generation sequencing (NGS) sequencing.

RESULTS

Our study showed miRNA profile change in vaginal secretion samples after HIFU treatment for uterine fibroids/adenomyosis, with 33 miRNAs upregulated and 6 downregulated overall. In fibroid cases, 31 miRNAs were upregulated and 7 downregulated, while in adenomyosis case, 41 miRNAs were upregulated and 71 downregulated. Four miRNAs (hsa-miR-7977, hsa-miR-155-5p, hsa-miR-191-5p, hsa-miR-223-3p) showed significant differences after HIFU treatment in fibroid cases, except in case 5 with the lowest treatment sonications (425 sonications) and energy input (170000 J). hsa-miR-7977 consistently showed downregulation after HIFU treatment. hsa-miR-155-5p were downregulated in case 4 with lowest treatment efficiency (2439.64 J/cm3), while they were upregulated in other cases. hsa-miR-191-5p and hsa-miR-223-3p were downregulated in cases 4 and 7, with case 7 influenced by high sonication and energy due to multiple fibroids.

CONCLUSIONS

HIFU treatment altered miRNA profiles in fibroids/adenomyosis patients. Notably, hsa-miR-7977, hsa-miR-155-5p, hsa-miR-191-5p, and hsa-miR-223-3p showed significant changes in fibroid cases, except in low-energy treatments. hsa-miR-7977 consistently decreased post-treatment, while hsa-miR-155-5p decreased in the least efficient cases. Further research is needed for validation.

Body Mass Index and Uterine Fibroid Development: A Prospective Study

OBJECTIVE

Fibroids are hormonally dependent uterine tumors. The literature on adiposity and fibroid prevalence is inconsistent. Previous work usually combined all those with a body mass index (BMI) ≥30 kg/m2 into a single category and relied on clinically diagnosed fibroids, which misclassifies the many women with undiagnosed fibroids. We used a prospective cohort design with periodic ultrasound screening to investigate associations between repeated measures of BMI and fibroid incidence and growth assessed at each follow-up ultrasound.

METHODS

The Study of Environment, Lifestyle & Fibroids followed 1693 Black/African American women, ages 23 to 35 years from Detroit, Michigan, with ultrasound every 20 months for 5 years. Measured height and repeated weight measures were used to calculate BMI. Fibroid incidence was modeled using Cox models among those who were fibroid free at the enrollment ultrasound. Fibroid growth was estimated for individual fibroids matched across visits as the difference in log-volume between visits and was modeled using linear mixed models. All models used time-varying BMI and adjusted for time-varying covariates.

RESULTS

Compared with BMI <25 kg/m2, those with BMI 30 to <35 kg/m2 had increased fibroid incidence (adjusted hazard ratio, 1.37; 95% CI, 0.96-1.94), those with BMI ≥40 kg/m2 had reduced incidence (adjusted hazard ratio, 0.61; 95% CI, 0.41-0.90). Fibroid growth had mostly small magnitude associations with BMI.

CONCLUSION

BMI has a nonlinear association with fibroid incidence, which could be driven by effects of BMI on inflammation and reproductive hormones. More detailed measures of visceral and subcutaneous adiposity and their effects on hormones, DNA damage, and cell death are needed.

Spatially restricted ecto-5'-nucleotidase expression promotes the growth of uterine leiomyomas by modulating Akt activity

Found in as many as 80% of women, uterine leiomyomas are a frequent cause of abnormal uterine bleeding, pelvic pain, and infertility. Despite their significant clinical impact, the mechanisms responsible for driving leiomyoma growth remain poorly understood. After obtaining IRB permission, expression of ecto-5'-nucleotidase (NT5E, CD73) was assessed in matched specimens of myometrium and leiomyoma by real-time qPCR, Western blot, and immunohistochemistry (IHC). Adenosine concentrations were measured by enzyme-linked assay. Primary cultures were used to assess the impact of adenosine and/or adenosine receptor agonists on proliferation, apoptosis, and patterns of intracellular signaling in vitro. When compared to matched specimens of healthy myometrium, uterine leiomyomas were characterized by reduced CD73 expression. Largely limited to thin-walled vascular structures and the pseudocapsule of leiomyomas despite diffuse myometrial distribution. Restricted intra-tumoral CD73 expression was accompanied by decreased levels of intra-tumoral adenosine. In vitro, incubation of primary leiomyoma cultures with adenosine or its hydrolysis-resistant analog 2-chloro-adenosine (2-CL-AD) inhibited proliferation, induced apoptosis, and reduced proportion of myocytes in S- and G2-M phases of the cell cycle. Decreased proliferation was accompanied by reduced expression of phospho-Akt, phospho-Cdk2-Tyr15, and phospho-Histone H3. Enforced expression of the A2B adenosine receptor (ADORA2B) and ADORA2B-selective agonists similarly suppressed proliferation and inhibited Akt phosphorylation. Collectively, these observations broadly implicate CD73 and reduced extracellular concentrations of adenosine as key regulators of leiomyoma growth and potentially identify novel strategies for clinically managing these common tumors.

Phthalate exposure as a hidden risk factor for uterine leiomyoma in adult women: Accumulated evidence from observational studies

BACKGROUND

There is evidence that exposure to phthalate in women may increase the risk of uterine leiomyomas. Whereas, the association between exposure to phthalate and the incidence of uterine leiomyoma remained inconclusive.

METHODS

A meta-analysis was performed to evaluate their relationship. Literature eligible for inclusion was found in PubMed, EMBASE, Web of Science, and WanFang Medical Database. Pooled odds ratio (OR) with 95 % confidence interval (CI) was calculated to assess the risk for effect estimate for each phthalate.

RESULTS

A total of fourteen observational studies with 5777 subjects of adult women were included in this study. In the pooled analysis, we found an elevated risk of uterine leiomyoma among women who were exposed to higher levels of di-2-ethylhexyl phthalate (DEHP) (OR 1.61, 95 % CI: 1.18-2.20), as estimated indirectly from the molar summation of its urinary metabolite concentrations. In addition, a positive association was observed between the occurrence of uterine leiomyoma and exposure to low molecular weight phthalate mixture (OR 1.08, 95 % CI: 1.00-1.15), as well as high molecular weight phthalate mixture (OR 1.08, 95 % CI: 1.01-1.15), as quantified by integrating the effect estimates of individual metabolite from each study. Urinary levels of DEHP metabolites, monobenzyl phthalate, mono-(3-carboxypropyl) phthalate, mono-isobutyl phthalate, mono-n-butyl phthalate, monoethyl phthalate, and monomethyl phthalate were not appreciably correlated with the risk of uterine leiomyoma.

CONCLUSION

Our results indicated that exposure to DEHP, and co-exposure to high or low molecular weight phthalate mixture might be potential risk factors for uterine leiomyoma in adult women. Owing to the indirect estimation of association, when interpreting these findings, cautions should be taken.

Thinking in context: Fibroids-to-uterine volume ratio in pre-surgical fertility evaluation for intramural fibroids

OBJECTIVE

To explore the utility of the total fibroids-to-uterine volume (FTUV) ratio as a simple, preoperative tool to assist in counseling patients seeking pregnancy who are undergoing myomectomy for intramural (IM) fibroids.

STUDY DESIGN

This is an historical cohort study on reproductive-aged patients seeking pregnancy who underwent laparotomic myomectomy for intramural fibroids from January 2017 to December 2021. Only G3 to G5 fibroids, according to the 2011 International Federation of Gynecology and Obstetrics (FIGO) classification, were included. Pre-operative transvaginal ultrasound (TVUS) was performed to measure the volume of intramural myomas (diameter1*diameter2*diameter3*0.52) and to calculate their total volume. The total fibroids-to-uterine volume (FTUV) ratio was calculated as the proportion of the uterine volume occupied by the sum of IM fibroids volumes.

RESULTS

A total of 166 women with pre-surgical TVUS evaluation of IM fibroids were included, with a mean age of 36.22 ± 5.15 years. The FTUV ratio was identified as a positive predictor of clinical pregnancy after surgery (adjOR, 1.04; 95 % CI, 1.02-1.06; p = 0.0001), whereas age showed a negative association (adjOR, 0.90; 95 % CI, 0.83-0.98; p = 0.012). Endometrial cavity distortion prior to surgery was also positively associated with pregnancy post-surgery (adjOR, 3.50; 95 % CI, 1.51-8.08; p = 0.003). Consistent results were found for live births, with the FTUV ratio being a significant positive predictor of live birth after surgery (adjOR, 1.03; 95 % CI, 1.01-1.05; p = 0.001) and age showing a negative association (adjOR, 0.88; 95 % CI, 0.80-0.96; p = 0.004). Parity prior to surgery also positively impacted live birth post-surgery (adjOR, 2.65; 95 % CI, 1.30-5.40; p = 0.007). An FTUV ratio threshold of 53.39 % accurately predicted clinical pregnancy in 68.46 % of cases (sensitivity of 71.70 % and specificity of 66.67 %). For live births, a higher FTUV ratio threshold of 59.21 % predicted outcomes accurately in 69.13 % of cases (sensitivity of 65.85 % and specificity of 70.37 %).

CONCLUSION

The use of the FTUV ratio in pre-operative ultrasound evaluation of IM fibroids may improve counseling for patients desiring to conceive after myomectomy. By providing a personalized assessment of the amount of myometrial volume occupied by fibroids, the FTUV ratio can help predict fertility outcomes after surgery, enabling better-informed decisions and treatment planning.

Radiofrequency Ablation for the Treatment of Uterine Fibroids: A Systematic Review and Meta-Analysis by the AAGL Practice Committee

OBJECTIVE

To systematically review clinical and patient-reported outcomes after radiofrequency ablation (RFA) for the treatment of uterine fibroids.

DATA SOURCES

We searched Medline, EMBASE, Cochrane Registry of Controlled Trials (CENTRAL) on September 8, 2023, and requested additional data from industry sources. We included published, peer-reviewed studies of patient-centered outcomes of RFA when used for symptomatic fibroids. Abstracts and potentially relevant full-text articles were screened and data were extracted regarding study characteristics, arms, outcomes, and results, together with risk of bias assessment.

METHODS OF STUDY SELECTION

We included 30 studies published in 49 articles (3 randomized controlled trials, 1 nonrandomized comparative study, and 26 single-group studies, as well as 4 publications from the TRUST Study) with variable risks of bias.

TABULATION, INTEGRATION, AND RESULTS

The study populations were demographically diverse and clinically heterogeneous. Across studies, RFA treatment was associated with fibroid volume reduction of 46.0% (95% confidence interval [CI] 52.1, 40.0; 11 studies) at 3 months and 65.4% (95% CI 74.7, 56.1; 10 studies) at 12 months. All studies reported a decrease in proportion of patients experiencing abnormal, heavy, or prolonged menstrual bleeding, with the most substantial improvement within the first 3 months. Meta-analyses of health-related quality of life scores demonstrated significant improvements in scores from baseline for Uterine Fibroid Symptoms and Quality of Life (53.4, 95% CI 48.2, 58.5; 19 studies), EuroQol-5 dimension (71.6, 95% CI 65.0, 78.1; 4 studies), and Symptom Severity Score (52.2, 95% CI 46.4, 58.1; 17 studies), with a peak at 6 months on the Uterine Fibroid Symptoms and Quality of Life scale (88.0, 95% CI 83.0, 92.9; 11 studies), a peak at 24 months on the EuroQol-5 dimension scale (88.3, 95% CI 86.0, 90.6; 2 studies), and a trough at 12 months for Symptom Severity Score (12.8, 95% CI 7.0, 18.6; 11 studies). Studies mostly demonstrated return to work and normal activities within 2 weeks. Reported unplanned hospitalizations were infrequent, and durations of hospital stay were generally short. Postprocedure complications were inconsistently reported but assessed overall to be infrequent. Long-term need for medical and surgical re-intervention varied. Post-RFA hysterectomy rates ranged from 2/205 (1.0%) to 15/62 (24.1%) with variable follow-up periods ranging from 45 days to 74 months. Most studies did not include patients who desired to maintain fertility; thus, reproductive data are insufficient for interpretation.

CONCLUSION

There is a paucity of comparative studies, and the small number of RCTs are limited by lack of blinding. Few studies had the long-term follow-up time required to draw definitive conclusions regarding the durability of symptom relief. However, despite these limitations, there is overall agreement on several important clinical measures following RFA, such as decreased fibroid volume, improved uterine bleeding, and improved quality of life. Future high-quality randomized controlled trials with standardized outcomes measures are required to better characterize the use of RFA among fibroid patients.

Social Determinants of Health and Dysmenorrhea: A Systematic Review

Social determinants of health play a key role in health disparities. Dysmenorrhea is a highly prevalent and impactful public health problem affecting reproductive-age females. Systematically examining social determinants of health (SDoH) in dysmenorrhea is important for identifying gaps in the literature and informing research, policy, and clinical practice to reduce the public health burden associated with dysmenorrhea. The purpose of this systematic review was to synthesize the literature on SDoH and dysmenorrhea. The review protocol was prospectively registered. We searched Medline, EMBASE, CINAHL, PsycINFO, Scopus, and Google Scholar through February 2024 using search strategies informed by the literature. Screening of the articles, data extraction, and risk-of-bias (RoB) assessment were conducted independently by at least 2 reviewers on the Covidence platform. Among 2,594 unique records screened, 166 met eligibility criteria and were included for data extraction and RoB assessment. Evidence suggests traumatic experiences, toxic environmental exposures, female genital mutilation, job-related stress, lack of menstrual education, and low social support were associated with worse dysmenorrhea outcomes. However, evidence was equivocal regarding the relationships between dysmenorrhea outcomes and SDoH factors, including socioeconomic status, geographical location, race/ethnicity, employment, and religion. Nearly all articles (99.4%) had a high or very high overall RoB. The relationships between SDoH and dysmenorrhea outcomes were often inconsistent and complicated by heterogeneous study populations and methodologies. More rigorous research examining SDoH in dysmenorrhea is needed to inform policy and clinical practice. PERSPECTIVE: This systematic review synthesizes evidence linking SDoH and dysmenorrhea. The relationships between SDoH and dysmenorrhea were often equivocal and complicated by heterogeneous study populations and methodologies. We identify directions for future research and SDoH factors that could be addressed clinically (eg, trauma, menstrual education, and occupational stress).

Altered extracellular matrix-related pathways accelerate the transition from normal to prefibroid myometrium in Black women

BACKGROUND

Black women experience a disproportionate impact of uterine fibroids compared to White women, including earlier diagnosis, higher frequency, and more severe symptoms. The etiology underlying this racial disparity remains elusive.

OBJECTIVE

The aim of this study was to evaluate the molecular differences in normal myometrium (fibroid-free uteri) and at-risk myometrium (fibroid-containing uteri) tissues in Black and White women.

STUDY DESIGN

We conducted whole-genome RNA-seq on normal and at-risk myometrium tissues obtained from both self-identified Black and White women (not Hispanic or Latino) to determine global gene expression profiles and to conduct enriched pathway analyses (n=3 per group). We initially assessed the differences within the same type of tissue (normal or at-risk myometrium) between races. Subsequently, we analyzed the transcriptome of normal myometrium compared to at-risk myometrium in each race and determined the differences between them. We validated our findings through real-time PCR (sample size range=5-12), western blot (sample size range=5-6), and immunohistochemistry techniques (sample size range=9-16).

RESULTS

The transcriptomic analysis revealed distinct profiles between Black and White women in normal and at-risk myometrium tissues. Interestingly, genes and pathways related to extracellular matrix and mechanosensing were more enriched in normal myometrium from Black than White women. Transcription factor enrichment analysis detected greater activity of the serum response transcription factor positional motif in normal myometrium from Black compared to White women. Furthermore, we observed increased expression levels of myocardin-related transcription factor-serum response factor and the serum response factor in the same comparison. In addition, we noted increased expression of both mRNA and protein levels of vinculin, a target gene of the serum response factor, in normal myometrium tissues from Black women as compared to White women. Importantly, the transcriptomic profile of normal to at-risk myometrium conversion differs between Black and White women. Specifically, we observed that extracellular matrix-related pathways are involved in the transition from normal to at-risk myometrium and that these processes are exacerbated in Black women. We found increased levels of Tenascin C, type I collagen alpha 1 chain, fibronectin, and phospho-p38 MAPK (Thr180/Tyr182, active) protein levels in at-risk over normal myometrium tissues from Black women, whereas such differences were not observed in samples from White women.

CONCLUSION

These findings indicate that the racial disparities in uterine fibroids may be attributed to heightened production of extracellular matrix in the myometrium in Black women, even before the tumors appear. Future research is needed to understand early life determinants of the observed racial differences.

First Australian estimates of incidence and prevalence of uterine fibroids: a data linkage cohort study 2000-2022

STUDY QUESTION

What is the estimated prevalence and incidence of uterine fibroids diagnosed in Australian women of reproductive age?

SUMMARY ANSWER

An estimated 7.3% of Australian women had a diagnosis of uterine fibroids by the age of 45-49 years, with age-specific incidence highest in women aged 40-44 years (5.0 cases per 1000 person-years).

WHAT IS KNOWN ALREADY

Uterine fibroids are associated with a high symptom burden and may affect overall health and quality of life. Studies in different countries show a wide variation in both the prevalence (4.5-68%) and incidence (2.2-37.5 per 1000 person-years) of uterine fibroids, which may be partly explained by the type of investigation, method of case ascertainment, or the age range of the study population, necessitating the reporting of country-specific estimates.

STUDY DESIGN, SIZE, DURATION

This observational prospective cohort study using self-report survey and linked administrative data (2000-2022) included 8066 women, born between 1973 and 1978, in the Australian Longitudinal Study on Women's Health.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A combination of self-report survey and linked administrative health data (hospital, emergency department, the Medicare Benefits Schedule, and the Pharmaceutical Benefits Scheme) were used to identify women with a report of a diagnosis of uterine fibroids between 2000 and 2022.

MAIN RESULTS AND THE ROLE OF CHANCE

Of the 8066 Australian women followed for 22 years, an estimated 7.3% of women (95% CI 6.9, 7.6) had a diagnosis of uterine fibroids by the age of 45-49 years. The incidence increased with age and was highest in women aged 40-44 years (5.0 cases per 1000 person-years, 95% CI 4.3, 5.7 cases per 1000 person-years). Women with uterine fibroids were more likely to experience heavy or painful periods. They were also more likely to report low iron levels, endometriosis, and poor self-rated health and to have two or more annual visits to their general practitioner.

LIMITATIONS, REASONS FOR CAUTION

Our estimates are based on self-report of doctor diagnosis or treatment for fibroids and/or data linked to treatment and procedure administrative records. This predominantly captures women with symptomatic fibroids, but has the potential for misclassification of asymptomatic women and an underestimate of overall prevalence and incidence. In addition, questions on fibroids were only asked in surveys when women were 37-42 years of age to 43-48 years of age, so cases at younger ages may have been underestimated (particularly in women with less severe symptoms) as these were only ascertained through data linkage.

WIDER IMPLICATIONS OF THE FINDINGS

These are the first population-based estimates of the prevalence and incidence of uterine fibroids in women of reproductive age in Australia. Establishing these first estimates will help inform health policy and health care provision in the Australian context.

STUDY FUNDING/COMPETING INTEREST(S)

The ALSWH is funded by the Australian Government Department of Health and Aged Care. L.FW. was supported by an Australian National Health and Medical Research Council (NHMRC) Centres for Research Excellence grant (APP1153420) and G.D.M. was supported by an NHMRC Leadership Fellowship (APP2009577). The funding bodies played no role in the design, the collection, analysis or interpretation of data, the writing of the manuscript, or the decision to submit the manuscript for publication. There are no competing interests.

TRIAL REGISTRATION NUMBER

N/A.

Impact of demographic and clinical factors on elagolix plus add-back therapy effects on patient-reported nonbleeding symptoms in women with heavy menstrual bleeding and uterine fibroids: a post hoc analysis of data from two clinical trials

Objective

To investigate the efficacy of elagolix plus add-back therapy (estradiol [1 mg] and norethindrone acetate [0.5 mg] once daily) on patient-reported nonbleeding symptoms and menstrual bleeding associated with uterine fibroids (UFs) across different subpopulations.

Design

Post hoc analysis of two phase 3 clinical trials-Elaris UF-1 and UF-2.

Setting

A total of 76 (UF-1) and 77 (UF-2) US clinical sites.

Patients

Women (N = 591) with UFs and heavy menstrual bleeding.

Interventions

Elagolix (300 mg) twice daily with add-back therapy (the indicated dose for UF-associated heavy menstrual bleeding) vs. placebo for 6 months.

Main Outcome Measures

"Very much improved" or "much improved" change in nonbleeding symptoms (abdominal/pelvic pain, abdominal/pelvic pressure/cramping, back pain, and abdominal bloating) and menstrual bleeding measured using a Patient Global Impression of Change scale. Improvements were assessed in subpopulations stratified using baseline characteristics (age, race [self-reported], body mass index, and International Federation of Gynecology and Obstetrics fibroid classification).

Results

Across subpopulations, differences favored elagolix plus add-back therapy (vs. placebo) for most symptoms at month 1 and all symptoms at months 3 as well as 6. In patients with characteristics commonly associated with high disease burden (age >40 years, Black/African American), those treated with elagolix plus add-back therapy reported significantly greater improvements vs. placebo at months 1-6 (P<.05) for all nonbleeding and bleeding symptoms (P≤.05).

Conclusions

Premenopausal women with heavy menstrual bleeding and UFs receiving elagolix plus add-back therapy experienced significant improvements in nonbleeding as well as bleeding symptoms from months 1-6, regardless of baseline characteristics.

Clinical Trial Registration Number

NCT02654054 and NCT02691494.

Uterine fibroids and Black people of African descent globally: a scoping review protocol

INTRODUCTION

Evidence suggests that when adjusted for age and other factors such as Body Mass Index, age of first pregnancy, years since last pregnancy and alcohol consumption, Black women are three times more likely to suffer from fibroids compared with the general population. When compared with the general population, Black women experience larger uterine fibroids with an earlier onset and more frequent and severe symptoms debilitating symptoms. Reported symptoms include pelvic pain, bladder issues, and heavy and/or abnormal menstrual bleeding. For Black women in perimenopause or menopause, uterine fibroids are more likely to continue growing rather than slow or cease. To design empirical research that addresses the issue of uterine fibroids among Black people of African descent, it is important to understand the current state of literature on this issue. The objectives of this scoping review are to understand and describe the extent and type of literature available regarding Black people of African descent with uterine fibroids globally, to identify the gaps within existing literature, and to provide recommendations for future research.

METHODS AND ANALYSIS

This scoping review will be conducted in accordance with JBI scoping review methodology and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews Checklist. Eligibility criteria for this review include sources that involve Black people of African descent who have uterine fibroids. This review is global in context and does not include jurisdictional, geographical, regional or study setting restrictions. A comprehensive search strategy developed in collaboration with a health sciences librarian will be used to identify and retrieve relevant peer-reviewed and grey literature. Databases including CINAHL (EBSCO), MEDLINE (Ovid), Embase (Elsevier), Gender Studies Database (EBSCO), Scopus (Elsevier) and LILACS (VHL) will be searched from inception to January 2024. Unpublished studies and grey literature searches will include The Society for Women's Health Research, Black Women's Health Imperative, ProQuest Dissertations and Theses Global (ProQuest), Open Access Theses and Dissertations (OATD.org) and Google search. All relevant sources will be uploaded to Covidence and undergo title and abstract screening by two independent team members. Selected sources will then undergo full-text review by two independent team members. Sources meeting the eligibility criteria will undergo extraction by two independent team members. Thematic analysis will be used to classify the extracted data points into categories according to the purpose or objective of the source, the methods used, the geographical region or jurisdiction of the source, key findings and recommendations. The synthesis of results will align with the review objective and question using charts or tables where necessary.

ETHICS AND DISSEMINATION

This scoping review does not require ethical approval. Dissemination of the review results includes the publication of a full report in a peer-reviewed journal as well as presenting the review results at local, national and international conferences. The results of the scoping review will also be disseminated through community events and social media using infographics and brochures.

The value of multiparametric MRI-based habitat imaging for differentiating uterine sarcomas from atypical leiomyomas: a multicentre study

PURPOSE

To explore the feasibility of multiparametric MRI-based habitat imaging for distinguishing uterine sarcoma (US) from atypical leiomyoma (ALM).

METHODS

This retrospective study included the clinical and preoperative MRI data of 69 patients with US and 225 patients with ALM from three hospitals. At both the individual and cohort levels, the K-means and Gaussian mixture model (GMM) algorithms were utilized to perform habitat imaging on MR images, respectively. Specifically, T2-weighted images (T2WI) and contrast-enhanced T1-weighted images (CE-T1WI) were clustered to generate structural habitats, while apparent diffusion coefficient (ADC) maps and CE-T1WI were clustered to create functional habitats. Parameters of each habitat subregion were extracted to construct distinct habitat models. The integrated models were constructed by combining habitat and clinical independent predictors. Model performance was assessed using the area under the curve (AUC).

RESULTS

Abnormal vaginal bleeding, lactate dehydrogenase (LDH), and white blood cell (WBC) counts can serve as clinical independent predictors of US. The GMM-based functional habitat model at the cohort level had the highest mean AUC (0.766) in both the training and validation cohorts, followed by the GMM-based structural habitat model at the cohort level (AUC = 0.760). Within the integrated models, the K-means functional habitat model based on the cohort level achieved the highest mean AUC (0.905) in both the training and validation cohorts.

CONCLUSION

Habitat imaging based on multiparametric MRI has the potential to distinguish US from ALM. The combination of clinical independent predictors with the habitat models can effectively improve the performance.

Systematic review and meta-analysis of current evidence in uterine artery embolization vs myomectomy for symptomatic uterine fibroids

This review compares the efficacy of Uterine Artery Embolization (UAE) and Myomectomy (MYO) in managing symptomatic Uterine Fibroids (UFs) in women who do not want hysterectomy. A meta-analysis was performed on all available studies that evaluated the relative benefits and harms of MYO and UEA for the management of patients suffering from UFs. Outcomes evaluated reintervention, UFs scores for quality of life (QOL) and symptom severity, and other complications. To determine mean differences (MDs) or odds ratios (ORs) with 95% confidence intervals (CIs), a random or fixed-effects model was utilized. A meta-analysis of 13 studies (9 observational and 4 randomized controlled trials) was conducted. The results indicated that UAE had a higher reintervention rate (OR 1.84; 95% CI 1.62-2.10; P < 0.01; I2 = 39%), hysterectomy rate (OR 4.04; 95% CI 3.45-4.72; P < 0.01; I2 = 59%), and symptom-severity score (OR - 4.02; 95% CI 0.82, 7.22; P = 0.01; I2 = 0%) compared to MYO at a four-year follow-up. However, UAE was associated with a lower rate of early complications (OR 0.44; 95% CI 0.20-0.95; P = 0.04; I2 = 25%), and readmission rate (OR 1.16; 95% CI 1.01-1.33; P = 0.04; I2 = 0%) compared to MYO. Furthermore, both procedures had comparable improvement in pregnancy rates and abnormal uterine bleeding. In conclusion, UAE and MYO are effective in treating symptomatic UFs but they have different outcomes. The decision on which procedure to choose should be made based on individual preferences and the physician's expertise.

Functional evidence for two distinct mechanisms of action of progesterone and selective progesterone receptor modulator on uterine leiomyomas

OBJECTIVE

To study the specific mechanisms through which progesterone and selective progesterone receptor modulators impact the growth, synthesis, and accumulation of the extracellular matrix in uterine leiomyomas.

DESIGN

Laboratory study.

SETTING

Academic Research Institutions.

PATIENTS (S)

This study involved reproductive-age women diagnosed with infertility associated uterine leiomyomas who underwent myomectomy either after selective progesterone receptor modulator ulipristal acetate (UA) treatment or without any pharmacological pretreatment. Control samples included healthy myometrium tissue (n = 100). Specimens were obtained from the Department of Reproduction and Gynecological Endocrinology and Biobank, Medical University of Bialystok, Poland.

INTERVENTIONS

Daily (5 mg/d) UA treated for 2 months (n = 100) and untreated (n = 150) patients with uterine leiomyomas or normal healthy myometrium (n = 100) tissue samples immediately after surgery were collected for transcriptional analysis and assessments.

MAIN OUTCOME MEASURES

Progesterone-induced activation of the signaling pathways related to uterine leiomyomas extracellular matrix synthesis, deposition, and growth, as well as the expression profile of progesterone receptors in uterine leiomyomas, were assessed.

RESULTS

The results indicated that progesterone activated the transforming growth factor-β and SMAD3 signaling pathways and promoted proliferation, growth, and extracellular matrix remodeling in uterine leiomyomas by up-regulating SMAD3, transforming growth factor-β (TGF-β) receptor type 1 and II, Ras homolog A, vascular endothelial growth factor, or increasing the fibrosis-related gene collagen, type I, ɑ-1, and procollagen, type I, ɑ-1 production. In contrast, UA had inhibitory effects on these processes. The study also showed that both nuclear and membrane progesterone receptors play distinct roles in uterine leiomyoma pathobiology.

CONCLUSIONS

We showed that both nuclear and membrane progesterone receptors were relevant in the treatment of uterine leiomyomas, especially when combined with selective progesterone receptor modulators. Novel therapeutic approaches combining selective progesterone receptor modulators with or without direct and indirect extracellular matrix targeting through selected specifically TGF-β and SMAD3 (SMAD3, TGF-β receptor types 1 and II, Ras homolog A, vascular endothelial growth factor, collagen, type I, ɑ-1) signaling pathways could therefore be a treatment option for uterine leiomyomas.

Racial Disparities in Surgical Treatment of Uterine Fibroids During the COVID-19 Pandemic

Objective: Analyze the association between race and surgery performed for uterine fibroids during the coronavirus disease 2019 (COVID-19) pandemic. Methods: Retrospective exploratory cross-sectional study of patients with fibroids who underwent surgery during the COVID-19 pandemic. We compared the type of surgery performed (minimally invasive hysterectomy [MIH], uterine-sparing procedure [USP], or total abdominal hysterectomy [TAH]) by White versus non-White patients. Absolute percentage differences were estimated with multinomial logistic regression adjusting for age, body mass index (BMI), parity, comorbidities, and maximum fibroid diameter. Results: Of 350 subjects, the racial composition was 1.7% Asian, 23.4% Black, and 74.9% White. Non-White patients had greater fibroid burden by mean maximum fibroid diameter, mean uterine weight, and mean fibroid weight. Although MIH occurred more frequently among White patients (7.5% points higher [95% confidence interval (CI) = -3.1 to 18.2]), USP and TAH were more commonly conducted for non-White patients (3.4% points higher [95% CI = -10.4 to 3.6] and 4.2% points higher [95% CI = -13.2 to 4.8], respectively). The overall complication rate was 18.6%, which was 6% points lower (95% CI = -15.8 to 3.7) among White patients. Conclusion: During the COVID-19 pandemic at a single-site institution, non-White patients were more likely to undergo a uterine-sparing procedure for surgical treatment of uterine fibroids, abdominal procedures, including both hysterectomy and myomectomy, and experience surgery-related complications.

Challenging Surgical Management of Giant Uterine Leiomyomas With Ileal Resection: A Clinical Case Study

Uterine fibroids, or leiomyomas, are common benign tumors of the uterus, generally asymptomatic but potentially causing severe symptoms and complications in some cases, as demonstrated in this report. This case presents significant management challenges due to the fibroids' size, number, and location, including an unusual complication involving adhesion to the ileum. A 40-year-old female with a history of P2L1D1 and no significant comorbidities presented with three months of progressive abdominal pain and a rapidly enlarging mass resembling a 30- to 32-week gravid uterus and heavy menstrual bleeding. Clinical findings included severe anemia with a hemoglobin level of 5.5 g/dL. Imaging studies revealed a bulky uterus with numerous multilobulated, well-defined, solid, hypoechoic fibroids subserosally and intramurally, raising suspicions of sarcomatous conversion. The patient underwent a laparotomy, which involved the resection of multiple large subserosal fibroids and a total abdominal hysterectomy, necessitated by extensive uterine distortion and the patient's preference against fertility preservation. A significant intraoperative discovery was the adhesion of fibroids to the ileum, which required bowel resection and anastomosis. This case emphasizes the complexity of managing extensive uterine fibroids, highlighting the need for thorough preoperative assessment, preparation for potential intraoperative complications, and the importance of a multidisciplinary surgical approach. The successful management and uneventful recovery underscore the effectiveness of proactive and comprehensive surgical intervention in cases with significant fibroid burden and associated anatomical challenges.

Uterine fibroids: current research on novel drug targets and innovative therapeutic strategies

INTRODUCTION

Uterine fibroids, the most common nonmalignant tumors affecting the female genital tract, are a significant medical challenge. This article focuses on the most recent studies that attempted to identify novel non-hormonal therapeutic targets and strategies in UF therapy.

AREAS COVERED

This review covers the analysis of the pharmacological and biological mechanisms of the action of natural substances and the role of the microbiome in reference to UFs. This study aimed to determine the potential role of these compounds in UF prevention and therapy.

EXPERT OPINION

While there are numerous approaches for treating UFs, available drug therapies for disease control have not been optimized yet. This review highlights the biological potential of vitamin D, EGCG and other natural compounds, as well as the microbiome, as promising alternatives in UF management and prevention. Although these substances have been quite well analyzed in this area, we still recommend conducting further studies, particularly randomized ones, in the field of therapy with these compounds or probiotics. Alternatively, as the quality of data continues to improve, we propose the consideration of their integration into clinical practice, in alignment with the patient's preferences and consent.

Preterm birth and uterine fibroid necrosis: The clinical presentation illustrated in a case series

OBJECTIVE

Uterine fibroids increase the risk of preterm birth. The current study highlights uterine fibroid necrosis as a possible cause of (extreme) preterm birth.

STUDY DESIGN

Retrospective cohort study in one Dutch academic hospital. Cases were selected from the 526 participants of the MyoFert study (Netherlands Trial Register, NL7990), which included patients who presented between 2004 and 2018 and were between the age of 18 and 45 years at the time of diagnosis of uterine fibroids. Of these participants, 414 women became pregnant. A retrospective chart review of the first pregnancies was performed. The main outcomes were (imminent) preterm birth and signs of fibroid necrosis on ultrasound. In women with signs of fibroid necrosis, the following data were collected systematically: fibroid characteristics, clinical presentation, pregnancy outcome, and postpartum period.

RESULTS

In total, 66 women had a preterm birth (16 %, 66/414), of which 25 pregnancies ended between 16 and <24 weeks (38 %, 25/66) and 41 pregnancies ended between 24 and <37 weeks of gestation (62 %, 41/66). Of all women with preterm birth and available ultrasound images, 15 % (7/48) had fibroid necrosis at the time of labour. These seven patients, supplemented with three patients with fibroid necrosis during their first pregnancy and at least one episode of imminent preterm birth, are described in more detail. In these ten patients, the fibroids increased substantially in size during the first and second trimester, leading to severe abdominal pain in all patients and hospital admission in seven patients. Ultrasound examination of the fibroids showed heterogenic changes and focal transonic areas in the fibroid, which are characteristics that indicate fibroid necrosis. In four patients, myomectomy was performed and necrosis was confirmed histologically.

CONCLUSION

Fibroid necrosis during pregnancy is likely associated with (imminent) preterm birth. Clinicians are advised to structurally evaluate the myometrium in pregnancy, specifically in women presenting with abdominal pain in the second trimester.

Advancing women's health: The imperative for public health screening of uterine fibroids for personalized care

Uterine fibroids represent the most prevalent genital tract tumours among women, with a disproportionately higher impact on ethnic minority groups, notably black women. These hormonally dependent monoclonal tumours, characterized by excessive extracellular matrix and influenced by genetic, epigenetic, and lifestyle factors, significantly affect women's quality of life and pose substantial economic burdens on healthcare systems. Recent advances in early detection and minimally invasive treatment options have shifted management paradigms towards personalized care, yet challenges in early diagnosis, education and access to treatment persist. This review synthesizes current knowledge on uterine fibroids, highlighting the impact of fibroids on women's health, risk factors, principles of screening, diagnostic tools, and treatment modalities. It emphasizes the importance of early screening and individualized management strategies in improving patient outcomes and reducing healthcare costs. The article also discusses the socio-economic and health disparities affecting the disease burden, underscoring the need for improved patient education, clinician training, and public health strategies to enhance fibroid management. This review proposes a pathway to not only ameliorate the quality of life for women with fibroids, but also to advance global women's health equity.

Retrospective case-control study on radiation dose for uterine artery embolization procedures

INTRODUCTION

Uterine artery embolization is performed in pre-menopausal women. Understanding the contribution of radiation dose at each stage of the procedure is important for potential dose reduction. The aim was to retrospectively analyse radiation dose on a per-procedural-stage basis, comparing digital subtraction angiography (DSA) and conventional roadmap (CRM).

METHODS

Group A consisted of 50 patients where DSA was used for road mapping at all stages: (I) Aortogram, (II) Left internal iliac artery (IIA) DSA, (III) Left uterine artery (UA) DSA, (IV) Right IIA DSA and (V) Right UA DSA. Group B included 50 patients, where CRM was used for road mapping at stages (II) and (IV).

RESULTS

For Group A, mean total dose-area product (DAP) was 39.7 Gy·cm2; mean DAP for each stage were (I) Aortogram = 3.4 Gy·cm2, (II) Left IIA DSA = 5.9 Gy·cm2, (III) Left UA DSA = 3.2 Gy·cm2, (IV) Right IIA DSA = 5.5 Gy·cm2 and (V) Right UA DSA = 3.0 Gy·cm2. For Group B, mean total DAP was 33.6 Gy·cm2, mean DAP for each stage were (I) Aortogram = 3.3 Gy·cm2, (II) Left IIA CRM = 1.5 Gy·cm2, (III) Left UA DSA = 3.3 Gy·cm2, (IV) Right IIA CRM = 1.5 Gy·cm2 and (V) Right UA DSA = 3.3 Gy·cm2. Fluoroscopy time was 10 and 9.4 min for Groups A and B, respectively.

CONCLUSION

The highest road-mapping radiation dose contribution was from bilateral IIA DSA. The use of CRM, intermittent fluoroscopy and elimination of the aortogram is recommended to further reduce procedural radiation dose.

Pathogenesis of uterine fibroids: current understanding and future directions

Fibroids are benign uterine tumors characterized by the proliferation of uterine smooth muscle cells, embedded in an abundant extracellular matrix. Their prevalence is estimated to be >50% in women aged >45 years. Fibroids represent a considerable health burden. It is time to acquire a deeper mechanistic understanding of uterine fibroid-related etiology and pathogenesis, which may help pinpoint new strategies and an individualized approach. There is a need to gather prospective data and conduct studies to compare alternative approaches and assess long-term outcomes with respect to quality of life, recurrence of symptoms (bleeding and bulk symptoms), fertility, and even complications The goal of this review was to evaluate the widely accepted pathogenesis and identify risks factors and future directions for clinical and basic research into fibroids.

A new missense mutation c.1240A>G in fumarate hydratase gene leads to uterine leiomyoma associated hereditary leiomyomatosis and renal cell cancer (HLRCC) syndrome in Chinese

OBJECTIVE

This study presents a detailed analysis of the clinical and genetic characteristics of uterine leiomyoma associated with Hereditary Leiomyomatosis and Renal Cell Cancer (HLRCC), combined with exploration of family history, pathology, and management procedures, supported by thorough evidence collection.

METHODS

Blood samples were collected from the proband, and the pathogenic variant was verified using Sanger sequencing. A comprehensive review of family history, FH deficiency pathology, FH and 2SC immunohistochemistry staining was conducted. Functional evidence was derived from clinical and genetic information, supplemented by a literature collection and mutation was reclassified based on ACMG/AMP guidelines.

RESULTS

The study successfully identifies a novel missense mutation (c.1240A>G; p.Lys414Glu) in exon 9 of FH, with no prior reports in existing databases. The patient's phenotype and family history, coupled with evidence collected from the literature, contribute to the preliminary determination of the variant as likely pathogenic. We also emphasize that the importance of combining FH-deficient morphology and immunohistochemical staining with 2SC for enhanced sensitivity.

CONCLUSION

This research adds a novel missense mutation to the repertoire of FH gene variants, emphasizing its likely pathogenic nature based on a multidimensional analysis of phenotype, family history, and literature evidence. The findings enhance our understanding of the genetic landscape associated with FH and underscore the importance of thorough characterization for accurate variant classification.

Clinical signs and diagnosis of fibroids from adolescence to menopause

The aim of this review was to provide an updated assessment of the present diagnostic tools and clinical symptoms and signs to evaluate uterine fibroids (UFs) on the basis of current guidelines, recent scientific evidence, and a PubMed and Google Scholar search for peer-reviewed original and review articles related to clinical signs and diagnosis of UFs. Approximately 50%-75% of UFs are considered nonclinically relevant. When present, the most common symptoms are abnormal uterine bleeding, pelvic pain and/or bulk symptoms, and reproductive failure. Transvaginal ultrasound is recommended as the initial diagnostic modality because of its accessibility and high sensitivity, although magnetic resonance imaging appears to be the most accurate diagnostic tool to date in certain cases. Other emerging techniques, such as saline infusion sonohysterography, elastography, and contrast-enhanced ultrasonography, may contribute to improving diagnostic accuracy in selected cases. Moreover, artificial intelligence has begun to demonstrate its ability as a complementary tool to improve the efficiency of UF diagnosis. Therefore, it is critical to standardize descriptions of transvaginal ultrasound images according to updated classifications and to individualize the use of the different complementary diagnostic tools available to achieve precise uterine mapping that can lead to targeted therapeutic approaches according to the clinical context of each patient.

The modern management of uterine fibroids-related abnormal uterine bleeding

Uterine fibroids (UFs) are the most common female benign pelvic tumors, affecting >60% of patients aged 30-44 years. Uterine fibroids are asymptomatic in a large percentage of cases and may be identified incidentally using a transvaginal ultrasound or a magnetic resonance imaging scan. However, in approximately 30% of cases, UFs affect the quality of life and women's health, with abnormal uterine bleeding and heavy menstrual bleeding being the most common complaints, along with iron deficiency (ID) and ID anemia. Medical treatments used for UFs-related abnormal uterine bleeding include symptomatic agents, such as nonsteroidal antiinflammatory drugs and tranexamic acid, and hormonal therapies, including combined oral contraceptives, gonadotropin-releasing hormone agonists or antagonists, levonorgestrel intrauterine systems, selective progesterone receptor modulators, and aromatase inhibitors. Nevertheless, few drugs are approved specifically for UF treatment, and most of them manage the symptoms. Surgical options include fertility-sparing treatments, such as myomectomy, or nonconservative options, such as hysterectomy, especially in perimenopausal women who are not responding to any treatment. Radiologic interventions are also available: uterine artery embolization, high-intensity focused ultrasound or magnetic resonance-guided focused ultrasound, and radiofrequency ablation. Furthermore, the management of ID and ID anemia, as a consequence of acute and chronic bleeding, should be taken into account with the use of iron replacement therapy both during medical treatment and before and after a surgical procedure. In the case of symptomatic UFs, the location, size, multiple UFs, or coexistent adenomyosis should guide the choice with a shared decision-making process, considering long- and short-term treatment goals expected by the patient, including pregnancy desire or wish to preserve the uterus independently of reproductive goals.

Impact of government-issued financial incentive to medical facilities on management of secondary dysmenorrhea

AIM

In April 2020, the Japanese government introduced a Specific Medical Fee for managing secondary dysmenorrhea (SD). This initiative provided financial incentives to medical facilities that provide appropriate management of SD with hormonal therapies. We aimed to assess how this policy affects the management processes and outcomes of patients with SD.

METHODS

Using a large Japanese administrative claims database, we identified outpatient visits of patients diagnosed with SD from April 2018 to March 2022. We used an interrupted time-series analysis and defined before April 2020 as the pre-introduction period and after April 2020 as the post-introduction period. Outcomes were the monthly proportions of outpatient visits due to SD and hormonal therapy among women in the database and the proportions of outpatient visits for hormonal therapy and continuous outpatient visits among patients with SD.

RESULTS

We identified 815 477 outpatient visits of patients diagnosed with SD during the pre-introduction period and 920 183 outpatient visits during the post-introduction period. There were significant upward slope changes after the introduction of financial incentives in the outpatient visits due to SD (+0.29% yearly; 95% confidence interval, +0.20% to +0.38%) and hormonal therapies (+0.038% yearly; 95% confidence interval, +0.030% to +0.045%) among the women in the database. Similarly, a significant level change was observed after the introduction of continuous outpatient visits among patients with SD (+2.68% monthly; 95% confidence interval, +0.87% to +4.49%).

CONCLUSIONS

Government-issued financial incentives were associated with an increase in the number of patients diagnosed with SD, hormonal therapies, and continuous outpatient visits.

An Unheard Variant of Leiomyoma Cotyledonoid Dissecting Leiomyoma: Case Report

Leiomyomas are benign smooth muscle tumor of the uterus with varied morphology that are well known to undergo secondary changes. A variety of other unusual patterns of uterine leiomyoma have been described, such as parasitic leiomyoma, cellular leiomyoma, symplastic or bizarre leiomyoma, epithelioid leiomyoma, intravenous leiomyomatosis, and leiomyoma with secondary changes. Some cotyledonoid dissecting leiomyoma (CDL) appears as large fungating masses with widespread extension into the broad ligament and pelvic cavity. Due to its rarity and a clinician's lack of familiarity, such tumors are sometimes misdiagnosed as malignancies. We present a rare case report of CDL. It is a diagnostic challenge for clinicians, pathologists, and radiologists and can be confused with malignancy due to its large size. After extensive literature research, we found 28 case reports of this variant. Little is known in the literature about this entity. We present here a case report of a 65-year-old female emphasizing its clinical, radiological, gross, and microscopic findings. A total hysterectomy was performed on the patient. This tumor does not have malignant potential, but clinicians and pathologists must be aware of its existence to avoid over-treating patients as malignancy.

Comparison of uterine myometrial thickness at the site of myomectomy scar after surgery using laparoscopic and laparotomy methods

Fibroids are the most common benign tumours of the uterus, often requiring surgery when symptomatic. This study aims to investigate the impact of surgery using two methods, laparoscopy and laparotomy, on the thickness and vascularity of the uterine myometrium at the site of myomectomy scar (comparing sonographic features at the surgical scar site, including thickness, vascularity, and the extent of fibrotic tissue, in both open and laparoscopic surgical approaches). In this clinical trial, 100 women with type 2-5 fibroids and clinical symptoms, seeking surgery et al. Zahra Hospital, were enrolled in two groups: laparoscopy and laparotomy. Inclusion criteria were a maximum fibroid size of 8 cm and, in the case of multiple fibroids, a maximum of three, with the largest being 8 cm. 6 months post-surgery, sonographic assessments of the myomectomy scar site were compared between both groups. Participants showed no significant differences in demographic and obstetric factors. The most common clinical symptom (87%) in both groups was abnormal uterine bleeding (AUB). The mean hospital stay duration was statistically significantly lower in the laparoscopy group at 1.64 (SD 0.56) compared to 1.89 (SD 0.58) in the laparotomy group (p = 0.028). Additionally, the decrease in haemoglobin levels was 0.89 (SD 0.92) and 1.87 (SD 2.24) units, respectively, which showed a statistically significant difference (p = 0.003). The duration of surgery was significantly shorter in the laparotomy group (p = 0.001). Abdominal pressure was not observed in the laparoscopy group, while 12% of the laparotomy group reported complaints (p = 0.013). Based on the results obtained in this study, it can be concluded that there was no difference between these two methods in terms of improving uterine thickness and associated complications. However, the decrease in haemoglobin levels and the length of hospital stay were lower in patients undergoing laparoscopy.

Comprehensive Review of Uterine Leiomyosarcoma: Pathogenesis, Diagnosis, Prognosis, and Targeted Therapy

Uterine leiomyosarcoma (uLMS) is the most common subtype of uterine sarcomas. They have a poor prognosis with high rates of recurrence and metastasis. The five-year survival for uLMS patients is between 25 and 76%, with survival rates approaching 10-15% for patients with metastatic disease at the initial diagnosis. Accumulating evidence suggests that several biological pathways are involved in uLMS pathogenesis. Notably, drugs that block abnormal functions of these pathways remarkably improve survival in uLMS patients. However, due to chemotherapy resistance, there remains a need for novel drugs that can target these pathways effectively. In this review article, we provide an overview of the recent progress in ascertaining the biological functions and regulatory mechanisms in uLMS from the perspective of aberrant biological pathways, including DNA repair, immune checkpoint blockade, protein kinase and intracellular signaling pathways, and the hedgehog pathway. We review the emerging role of epigenetics and epitranscriptome in the pathogenesis of uLMS. In addition, we discuss serum markers, artificial intelligence (AI) combined with machine learning, shear wave elastography, current management and medical treatment options, and ongoing clinical trials for patients with uLMS. Comprehensive, integrated, and deeper insights into the pathobiology and underlying molecular mechanisms of uLMS will help develop novel strategies to treat patients with this aggressive tumor.

Feasibility, safety and efficacy of high intensity focused ultrasound ablation as a preoperative treatment for challenging hysteroscopic myomectomy

PURPOSE

To investigate the feasibility, safety and efficacy of high intensity focused ultrasound ablation (HIFU) as a preoperative treatment for challenging hysteroscopic myomectomies.

MATERIALS AND METHODS

A total of 75 patients diagnosed with types 0-III of uterine fibroids were enrolled. Based on the Size, Topography, Extension of the base, Penetration and lateral Wall position (STEPW) classification scoring system, 25 cases with a score ≥ 5 points were treated with HIFU followed by hysteroscopic myomectomy (HIFU + HM group), whereas 50 cases with a score < 5 points were treated with hysteroscopic myomectomy (HM group).

RESULTS

The median preoperative STEPW score was 7 in the HIFU + HM group and 2 in the HM group. The average non-perfused volume (NPV) ratio achieved in fibroids after HIFU was 86.87%. Patients in the HIFU + HM group underwent hysteroscopic myomectomy one to four days after HIFU, and downgrading was observed in 81.81% of fibroids. The operation time for patients in the HIFU + HM group was 73 min and the success rate of myomectomy in a single attempt was 60%. The volume of distention medium used during the operation was greater in the HIFU + HM group than in the HM group (15,500 ml vs. 7500 ml). No significant difference was observed between the two groups in terms of intraoperative blood loss, the incidence of intraoperative and postoperative complications, menstrual volume score, or uterine fibroid quality of life score.

CONCLUSION

HIFU can be utilized as a preoperative treatment for large submucosal fibroids prior to hysteroscopic myomectomy. HIFU offers a novel approach in the management of this subset of patients.

Risk factors affecting long-term efficacy of ultrasound-guided high-intensity focused ultrasound treatment for multiple uterine fibroids

OBJECTIVES

To investigate the long-term efficacy of ultrasound-guided high-intensity focused ultrasound (USgHIFU) for multiple uterine fibroids and the factors associated with recurrence.

MATERIALS AND METHODS

Five hundred and forty-nine patients with multiple uterine fibroids treated with USgHIFU from June 2017 to June 2019 were retrospectively analyzed. The Pictorial Blood Loss Assessment Chart (PBAC) was used to assess menstrual blood loss. The patients were asked to undergo pre- and post-USgHIFU magnetic resonance imaging (MRI) and complete routine follow-up after USgHIFU. Cox regression analysis was used to investigate the risk factors associated with recurrence.

RESULTS

The median number of fibroids per patient was 3 (interquartile range: 3-4), and a total of 1371 fibroids were treated. Among them, 446 patients completed 3 years follow-up. Recurrence, defined as PBAC score above or equal to 100 and/or the residual fibroid volume increased by 10%, was detected in 90 patients within 3 years after USgHIFU, with a cumulative recurrence rate of 20.2% (90/446). The multi-factor Cox analysis showed that age was a protective factor for recurrence. Younger patients have a greater chance of recurrence than older patients. Mixed hyperintensity of fibroids on T2WI and treatment intensity were risk factors for recurrence. Patients with hyperintense uterine fibroids and treated with lower treatment intensity were more likely to experience recurrence than other patients after USgHIFU. No major adverse effects occurred.

CONCLUSIONS

USgHIFU can be used to treat multiple uterine fibroids safely and effectively. The age, T2WI signal intensity and treatment intensity are factors related to recurrence.

Opportunities for change and levelling up: a trust wide retrospective analysis of 8 years of laparoscopic and abdominal myomectomy

Background

Laparoscopic myomectomy is increasingly considered the gold standard uterine preserving procedure and has well documented benefits over the open approach. Barriers that women have in accessing the most appropriate treatment need to be addressed to ensure optimal patient care and outcomes.

Objectives

To analyse rates of open and laparoscopic myomectomy at a large NHS trust and identify how many cases could potentially have been performed laparoscopically, and any variation between sites.

Materials and Methods

A retrospective review of preoperative imaging reports and a surgical database containing information for all myomectomies performed between 1st January 2015 and 31st December 2022.

Main outcome measures

Number of procedures suitable for alternative surgical approach; length of hospital stay; estimated blood loss; cost differences.

Results

846 myomectomies were performed; 656 by laparotomy and 190 by laparoscopy. 194/591 (32.8%) open myomectomies could have been performed laparoscopically and 26/172 (15.1%) laparoscopic myomectomies may have been better performed via an open approach. Length of hospital stay, and estimated blood loss were significantly higher in the open group. Had cases been performed as indicated by pre-operative imaging, the cost differences ranged from -£115,752 to £251,832.

Conclusions

There is disparity in access to the gold standard care of laparoscopic myomectomy. Due to multifactorial reasons, even at sites where the rate of laparoscopic myomectomy is high, there is still underutilisation of this approach. It is clear that there is scope for change and "levelling up" of this imbalance.

What is new?

Robust pathways and guidelines must be developed, and more laparoscopic surgeons should be trained to optimise care for women with fibroids.

Predicting the efficacy of high-intensity focused ultrasound (HIFU) ablation for uterine leiomyomas based on DTI indicators and imaging features

PURPOSE

To predict the efficacy of high-intensity focused ultrasound (HIFU) ablation for uterine leiomyomas based on diffusion tensor imaging (DTI) indicators and imaging features.

METHODS

Sixty-two patients with 85 uterine leiomyomas were consecutively enrolled in this retrospective study and underwent DTI scanning before HIFU treatment. Based on whether the non-perfused volume ratio (NPVR) was greater than 70%, all patients were assigned to sufficient ablation (NPVR ≥ 70%) or insufficient ablation (NPVR < 70%) groups. The selected DTI indicators and imaging features were incorporated to construct a combined model. The predictive performance of DTI indicators and the combined model were assessed using receiver operating characteristic (ROC) curves.

RESULTS

There were 42 leiomyomas in the sufficient ablation group (NPVR ≥ 70%) and 43 leiomyomas in the insufficient ablation group (NPVR < 70%). The fractional anisotropy (FA) and relative anisotropy (RA) values were higher in the sufficient ablation group than in the insufficient ablation group (p < 0.05). Conversely, the volume ratio (VR) and mean diffusivity (MD) values were lower in the sufficient ablation group than those in the insufficient ablation group (p < 0.05). Notably, the combined model composed of the RA and enhancement degree values had high predictive efficiency, with an AUC of 0.915. The combined model demonstrated higher predictive performance than FA and MD alone (p = 0.032 and p < 0.001, respectively) but showed no significant improvement compared with RA and VR (p > 0.05).

CONCLUSION

DTI indicators, especially the combined model incorporating DTI indicators and imaging features, can be a promising imaging tool to assist clinicians in predicting HIFU efficacy for uterine leiomyomas.

Uterine leiomyoma with RAD51B::NUDT3 fusion: a report of 2 cases

Three main uterine leiomyoma molecular subtypes include tumors with MED12 mutation, molecular aberrations leading to HMGA2 overexpression, and biallelic loss of FH. These aberrations are mutually exclusive and can be found in approximately 80-90% of uterine leiomyoma, in which they seem to be a driver event. Approximately 10% of uterine leiomyoma, however, does not belong to any of these categories. Uterine leiomyoma with HMGA2 overexpression is the most common subtype in cellular and second most common category of usual leiomyoma. In some of these tumors, rearrangement of HMGA2 gene is present. The most common fusion partner of HMGA2 gene is RAD51B. Limited data suggests that RAD51B fusions with other genes may be present in uterine leiomyoma. In our study, we described two cases of uterine leiomyoma with RAD51B::NUDT3 fusion, which occur in one case of usual and one case of highly cellular leiomyoma. In both cases, no other driver molecular aberrations were found. The results of our study showed that RAD51::NUDT3 fusion can occur in both usual and cellular leiomyoma. RAD51B may be a fusion partner of multiple genes other than HMGA2 and HMGA1. In these cases, RAD51B fusion seems to be mutually exclusive with other driver aberrations defining molecular leiomyoma subtypes. RAD51B::NUDT3 fusion should be added to the spectrum of fusions which may occur in uterine leiomyoma, which can be of value especially in cellular leiomyoma in the context of differential diagnosis against endometrial stromal tumors.

Non-persistent endocrine disrupting chemical mixtures and uterine leiomyomata in the study of environment, lifestyle and fibroids (SELF)

BACKGROUND

Results of studies investigating associations between individual endocrine-disrupting chemicals (EDCs) and incidence of uterine leiomyomata (UL), a hormone-dependent gynecological condition, have been inconsistent. However, few studies have evaluated simultaneous exposure to a mixture of EDCs with UL incidence.

METHODS

We conducted a case-cohort analysis (n = 708) of data from the Study of the Environment, Lifestyle and Fibroids (SELF), a prospective cohort study. Participants were aged 23-35 years at enrollment, had an intact uterus, and identified as Black or African American. We measured biomarker concentrations of 21 non-persistent EDCs, including phthalates, phenols, parabens, and triclocarban, in urine collected at baseline, 20-month, and 40-month clinic visits. We ascertained UL incidence and characteristics using ultrasounds at baseline and approximately every 20 months through 60 months. We used probit Bayesian Kernel Machine Regression (BKMR-P) to evaluate joint associations between EDC mixtures with cumulative UL incidence. We estimated the mean difference in the probit of UL incidence over the study period, adjusting for baseline age, education, years since last birth, parity, smoking status and body mass index. We converted probit estimates to odds ratios for ease of interpretation.

RESULTS

We observed that urinary concentrations of the overall EDC mixture were inversely associated with UL incidence in the overall mixtures model, with the strongest inverse associations at the 70th percentile of all biomarkers compared with their 50th percentile (odds ratio = 0.59; 95% confidence interval: 0.36, 0.96). Strongest contributors to the joint association for the mixture were bisphenol S (BPS), ethyl paraben (EPB), bisphenol F (BPF) and mono (2-ethyl-5-carboxypentyl) phthalate (MECPP), which each demonstrated inverse associations except for MECPP. There was suggestive evidence of an interaction between MECPP and EPB.

CONCLUSION

In this prospective ultrasound study, we observed evidence of an inverse association between the overall mixture of urinary biomarker concentrations of non-persistent EDCs with UL incidence.