Epidemiology of uterine fibroids: a systematic review

Conventional magnetic resonance imaging combined with three-dimensional ultrasound for preoperative prediction of immediate ablation rate in high-intensity focused ultrasound treatment of uterine fibroids

OBJECTIVE

This study aimed to assess the effectiveness of conventional magnetic resonance imaging (MRI) combined with three-dimensional (3D) ultrasound for the preoperative prediction of nonperfused volume ratio (NPVR) in uterine fibroids after high-intensity focused ultrasound (HIFU) ablation.

MATERIALS AND METHODS

In total, 178 patients who had undergone HIFU ablation therapy for uterine fibroids between July 2021 and August 2023 were enrolled. Baseline clinical, MRI, and 3D ultrasound parameters collected before and after HIFU ablation were analyzed. Multiple linear regression models were constructed for conventional MRI parameters alone and for combined MRI-3D ultrasound parameters to predict NPVR. Paired-sample t-tests and Pearson's correlation were employed to assess relationships between predicted and actual NPVR values. The prediction efficacy of both models was statistically compared.

RESULTS

The combined MRI-3D ultrasound model outperformed the conventional MRI model, with adjusted R2 values of 0.597 and 0.553, respectively, both statistically significant (p < 0.05). The combined model revealed that signal intensity on T2-weighted imaging, degree of enhancement on contrast-enhanced T1-weighted imaging, maximum distance between the fibroid's dorsal surface and the skin, uterine fibroid vascular network, and fibroid vascularization negatively affected NPVR. The predicted NPVR was significantly correlated with the actual NPVR (p < 0.001).

CONCLUSIONS

3D ultrasound provided essential information for screening fibroids and predicting NPVR before HIFU ablation, serving as a valuable supplement to MRI. The combined MRI-3D ultrasound model shows promise for the preoperative prediction of NPVR in patients with uterine fibroids treated with HIFU and may offer substantial clinical value.

Nomogram for predicting the efficacy of high-intensity focused ultrasound ablation for uterine fibroids based on oxytocin experimentation and ultrasonographic features: a retrospective single-center study

OBJECTIVE

To develop and validate a nomogram for predicting the effectiveness of high-intensity focused ultrasound (HIFU) ablation for uterine fibroids based on oxytocin experiments combined with sonographic features.

METHODS

Sixty patients with uterine fibroids treated with HIFU combined with oxytocin for uterine fibroids were retrospectively analyzed. Before HIFU treatment, all patients underwent abdominal ultrasonography and oxytocin testing for classification. Predictive factors were selected through univariate and multivariate logistic regression analyses. A predictive model for the clinical efficacy of HIFU treatment of uterine fibroids was established using the R language. The model was visualized by a nomogram, and its discriminative ability, calibration, and clinical value were evaluated.

RESULTS

Types of myomas, classification of blood flow around the myomas, location of the myomas, and classification of oxytocin were selected as the final predictive factors to construct the model. The calibration curve of the nomogram demonstrated good consistency between actual observations and nomogram predictions, with an absolute error of 0.066. The model's discriminative ability was evaluated by the area under the curve, which was 0.887 (95% CI: 0.818-0.955). The sensitivity and specificity were 84.4% and 78.8%, respectively, indicating that the model had a good predictive value for the ablation situation. Decision curve analysis showed that the model had high clinical applicability, with the maximum net benefit threshold probability interval ranging from 12.0% to 80.5%.

CONCLUSION

The prediction model for HIFU treatment of uterine fibroids, based on ultrasound characteristics and oxytocin test, shows strong predictive ability and may help clinicians choose suitable patients for treatment.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Risk Factors of Complications After Uterine Artery Embolisation for Symptomatic Fibroids: A Case-Control Study

OBJECTIVE

We aim to clarify potential risk factors of complications after uterine artery embolisation (UAE).

SETTING

Complications after uterine artery embolisation (UAE) for symptomatic fibroids are rare, but failure of treatment occurs for approximately 13%-24% of patients at 10 years.

DESIGN

We conducted a case-control study including all complications post UAE over 15 years in our specialised unit.

POPULATION

All Grade 2 complications (or worse) for the Society of Interventional Radiology Standards of Practice Committee complications post UAE were considered. One thousand one hundred seventy-two UAE were performed.

METHODS

Complications were divided into two groups: early (< 1 month) or late (≥ 1 month) to differentiate complications from failure of procedure. Multinomial analysis was conducted to assess links between complications and potential risk factors.

RESULTS

Sixty-nine (0.06%) complications were found: 24.6% hospitalisation for pain (n = 17/69), 30.4% for infection (n = 21/69) and 2.9% expulsion of fibroid (n = 2/69). Overall, 31 patients underwent a second procedure (45%).

MAIN OUTCOME MEASURES

Intra-uterine device and multiple fibroids were strongly related to early complications (ORearly = 4.44, IC 95%: 1.5-13.3 and ORearly = 3.7, IC 95%: 1.2-11.3, respectively). The only factor that appeared to be associated with risk of early and late complications was the major fibroid's diameter (for an increased size of 25 mm, ORearly = 1.7, IC 95%: 1.1-2.6; ORlate = 1.5, IC 95%: 1.04-2.2).

CONCLUSION

Our study enlightens about the potential risk factors of UAE's complications and differentiate their impact between early and late complications.

Activation of FGFR genes by genetic and epigenetic alterations in uterine leiomyomas

BACKGROUND

Fibroblast growth factor 1-4 (FGFR1-4) are well-known oncogenic drivers in many cancer types. Here, we studied the role of FGFRs in uterine leiomyoma (UL) that is a benign neoplasm arising from the myometrium and the most common tumour in women. Although ULs can be classified to molecular subtypes based on genetic drivers, potential secondary drivers are not well characterised.

METHODS

We performed mutation analysis of RNA-sequencing data of ULs, followed by screening of FGFR alterations in our Finnish (n = 2677) and Swedish (n = 372) UL collections, utilising Sanger-, next-generation and Nanopore sequencing and SNP array data. The role of FGFR genes in UL predisposition was examined by GWAS.

RESULTS

We identified FGFR activation in a subset of ULs on both genetic and epigenetic levels. In addition to single-nucleotide mutations in FGFR1/2, we detected an FGFR2-ERC1 fusion gene, FGFR1 gains and hypomethylation of regulatory regions of FGFR2/3. FGFR alterations were enriched in molecularly similar HMGA2, HMGA1 and PLAG1 UL subtypes. We also unveil a UL predisposing variant upstream of FGFR4 associated with increased expression in both normal myometrium and ULs.

CONCLUSIONS

Our results establish the role of FGFR signalling in the genesis of UL.

Association between blood heavy metals exposure with uterine fibroids among American women: a cross-sectional analysis from NHANES data

BACKGROUND

Excessive exposure to heavy metals has been linked to various health problems, including organ damage, neurological disorders, and reproductive and developmental abnormalities. However, the relationship between heavy metals exposure and uterine fibroids remains uncertain. To explore this association, we conducted a cross-sectional study among American women.

METHODS

We utilized data from three cycles of the National Health and Nutrition Examination Survey (NHANES, 1999-2006) to evaluate the association between uterine fibroids and blood heavy metal levels, including lead (Pb), cadmium (Cd), and mercury (Hg). Weighted logistic regression, restricted cubic spline (RCS), Bayesian kernel machine regression (BKMR), and subgroup analyse were used to examine the potential relationships between blood heavy metals and uterine fibroids.

RESULTS

Of the 4502 American women studied, 542 (12.04%) had uterine fibroids. Elevated levels of all heavy metals were significantly more common in women with uterine fibroids (P < 0.001). Blood Hg levels were notably associated with uterine fibroid prevalence in the adjusted model (OR = 1.41, 95% CI: 1.06-1.89, p = 0.03). Similar patterns were partly observed for blood Pb and Cd. Age and marital status were significant interaction factors concerning Hg exposure (P for interaction < 0.05). A dose-response relationship with an inflection point at 7µmol/L was identified for Hg, and BKMR models indicated a positive association between mixed heavy metal exposure and uterine fibroid risk.

CONCLUSIONS

Exposure to blood heavy metals, particularly Hg, is significantly associated with an elevated risk of uterine fibroids. Further prospective studies are necessary to confirm these findings.

Differential Expression of Small Non-Coding RNAs in Uterine Leiomyomas

We performed next-generation sequencing (NGS) on RNA from 19 paired leiomyoma (Lyo) and myometrium (Myo) specimens, stratified by race/ethnicity (White: n = 7; Black: n = 12) and mediator complex subunit 12 (MED12) mutation status (mutated: n = 10; non-mutated: n = 9). Analysis identified 2,189 small non-coding RNAs (sncRNAs) with altered expression in Lyo compared to paired Myo (≥1.5-fold change), including small nuclear RNAs (snRNAs), small nucleolar RNAs (snoRNAs), microRNAs (miRNAs), and PIWI-interacting RNAs (piRNAs). Among these, 17 sncRNAs showed differential expression in the MED12-mutated group versus Myo, while minimal changes were observed in the non-mutated group. Additionally, 31 sncRNAs displayed differential expression in Black women compared to White women. For validation, five novel miRNAs (miR-19a-3p, miR-99a-5p, miR-3196, miR-499a-5p, and miR-30d-3p) and five piRNAs (piR-009295, piR-020326, piR-020365, piR-006426, and piR-020485) were analyzed in 51 paired Lyo samples using qRT-PCR. Reduced expression of the selected sncRNAs was confirmed in Lyo versus Myo, with miR-19a-3p, miR-3196, miR-30d-3p, piR-006426, and piR-020485 linked to MED12 status, while miR-499a-5p and miR-30d-3p were associated with race/ethnicity. These findings suggest that sncRNA dysregulation contributes to altered gene expression in Lyo, influenced by MED12 mutation and racial background.

The influence of uterine leiomyomatosis on the onset of psoriasis: a nationwide population-based study of 2.5 million Korean females

BACKGROUND

Uterine leiomyomatosis and psoriasis are prevalent conditions and shared pathophysiological factors indicate a potential association. However, a direct correlation has not been established. We investigated the relationship between uterine leiomyomatosis and the risk of new-onset psoriasis in Korean females of reproductive age.

METHODS

This nationwide population-based study used data from the Korean National Health Insurance System database. Data from 2,755,790 Korean females 20-39 years of age who underwent health check-ups from 2009 to 2012 were analyzed. Monitoring began at the initial national health assessment within the time frame and continued until either the diagnosis of emerging psoriasis or until December 2018.

RESULTS

Among 2,503,769 females included, 1.96% were diagnosed with psoriasis and 0.72% with uterine leiomyomatosis. The incidence ratio for new-onset psoriasis was higher in uterine leiomyomatosis patients (3.13 per 1,000) than in subjects without uterine leiomyomatosis (2.72 per 1,000). The hazard ratio for psoriasis occurrence was 1.18 (1.07-1.31) in uterine leiomyomatosis patients, 1.22 (1.08-1.37) in subjects who did not undergo myomectomy, and 1.12 (0.94-1.33) in patients who underwent myomectomy.

CONCLUSIONS

Uterine leiomyomatosis patients, especially those not undergoing myomectomy, showed an increased risk of psoriasis. Lifestyle modifications and surgical intervention for uterine leiomyomatosis may also be beneficial for psoriasis occurrence.

Navigating diagnostic challenges: case reports on differentiating uterine fibroids from leiomyosarcoma through imaging and clinical evaluation

BACKGROUND

Differentiating between uterine fibroids and leiomyosarcoma poses significant challenges, particularly in cases of atypical fibroid degeneration. Accurate diagnosis is crucial for appropriate treatment and patient outcomes.

METHODS

We present two case reports to illustrate the complexities involved in distinguishing these conditions. Both cases involved patients with similar clinical presentations and imaging findings. The diagnostic process included trans-abdominal and trans-vaginal ultrasound, CT scans, and histopathological examination.

RESULTS

In Case 1, the patient presented with worsening abdominal pain and imaging revealed multiple myomas. Histological examination confirmed benign fibroids following surgery. Case 2 involved a patient with an abdominal mass and CT findings suggestive of a fibroid. However, ultrasound characteristics raised suspicion of malignancy, and subsequent histopathological analysis confirmed leiomyosarcoma.

CONCLUSION

These case reports underscore the importance of combining clinical evaluation with advanced imaging techniques for accurate differentiation between uterine fibroids and leiomyosarcoma. While ultrasound plays a critical role, its effectiveness is enhanced by the experience of the sonographer and the integration of other diagnostic modalities. Future multicenter studies should focus on refining these diagnostic approaches to improve accuracy and patient outcomes.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

2025 SWHR Women's Health Research Agenda: Prioritizing Uterine Fibroids, Lupus, and Metabolism

Women face unique and multifaceted challenges throughout their lifespans, shaped by biological, societal, and health care-related factors. These challenges have led to gender disparities in disease burden, access to care, and representation in medical research, underscoring the need to increase targeted investments in women's health. Historically, research on diseases that disproportionately affect women has been underfunded, hindering progress in closing gender health gaps. In March 2024, the President of the United States signed an Executive Order on Women's Health Research and Innovation, signaling a new commitment by the federal government to prioritize women's health research and address these disparities. The Society for Women's Health Research (SWHR) has consistently led the charge to identify research gaps and advocate for evidence-based initiatives to improve the health and well-being of women. In celebration of its 35th anniversary, SWHR introduces a 2025 Women's Health Research Agenda, which outlines key priorities in the areas of uterine health, autoimmune disease, and cardiometabolic health. This agenda serves as a strategic roadmap for stakeholders to engage with critical areas of women's health, fostering collaboration and accelerating research to address the unmet needs of women across the lifespan.

Caesarean myomectomy in pregnant women with uterine fibroids

RATIONALE

Postpartum haemorrhage, defined as a blood loss of 500 mL or more within 24 hours of birth, is the leading global cause of maternal morbidity and mortality. Uterine fibroids are non-cancerous growths that develop in or around the uterus, and affect an increasing number of women. Caesarean myomectomy is the surgical removal of fibroids during a caesarean section. Traditionally, obstetricians have avoided this procedure given the risk of uncontrollable haemorrhage. There is also the risk of longer operating time and more days in the hospital. However, there could be potential benefits in removing uterine fibroids for improved fertility, and caesarean section may provide an effective and efficient opportunity to perform this procedure. Given the link between removal of uterine fibroids and postpartum haemorrhage, it is prudent to evaluate current literature and assess the benefits and harms of caesarean myomectomy in pregnant women with uterine fibroids.

OBJECTIVES

To assess the benefits and harms of caesarean myomectomy in pregnant women with uterine fibroids undergoing caesarean section.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, Global Index Medicus, ICTRP portal, and ClinicalTrials.gov; performed supplementary searches of references and citations; and contacted study authors on 2 February 2024.

ELIGIBILITY CRITERIA

We included published randomised and quasi-randomised controlled trials, and observational controlled studies that assessed the impact of myomectomy on maternal health outcomes in pregnant women with fibroids undergoing caesarean birth. We excluded qualitative studies, case reports or series, conference abstracts, opinion papers, letters, and book chapters. There were no restrictions on ethnicity, race, socioeconomic status, education level, or place of residence.

OUTCOMES

Critical outcomes were requirement for blood transfusion, risk of haemorrhage, change in haemoglobin, length of hospitalisation, length of operation, major surgery at time of procedure, fertility outcome, and postpartum fever.

RISK OF BIAS

We assessed risk of bias for non-randomised controlled studies using the Risk Of Bias In Non-randomised Studies of Interventions (ROBINS-I) tool.

SYNTHESIS METHODS

We conducted a meta-analysis for each outcome when more than one study provided data. If it was not possible to analyse data via meta-analysis, we synthesised results narratively using Synthesis Without Meta-analysis (SWiM) guidance. We used GRADE to assess certainty of evidence for each critical and important outcome.

INCLUDED STUDIES

We included 23 non-randomised studies with 7504 women. Most studies were conducted in high-income or upper-middle-income countries. Five studies enrolled women with singleton pregnancies and one study was restricted to women with a twin pregnancy. Most studies did not report whether the caesarean section was elective or emergent. Thirteen studies diagnosed fibroids prior to operation.

SYNTHESIS OF RESULTS

Blood transfusion The evidence is very uncertain about whether caesarean myomectomy affects the risk of requiring blood transfusion compared to caesarean section alone (risk ratio (RR) 1.34, 95% confidence interval (CI) 1.01 to 1.79; I2 = 33%; 18 non-randomised studies, 6897 women; very low-certainty evidence). Haemorrhage The evidence is very uncertain about the effect of caesarean myomectomy on the risk of haemorrhage (RR 1.12, 95% CI 0.84 to 1.50; I2 = 0%; 9 non-randomised studies, 1729 women; very low-certainty evidence). Change in haemoglobin Sixteen studies reported change in postpartum haemoglobin. Meta-analysis was not possible due to statistical heterogeneity, and the evidence for this outcome was very low certainty. Length of hospitalisation The evidence is very uncertain about the effect of caesarean myomectomy on length of hospitalisation (mean difference (MD) 0.30 days, 95% CI 0.10 to 0.51; I2 = 93%; 15 non-randomised studies, 2955 women; very low-certainty evidence). The significant heterogeneity was explained by two outlying studies; once we removed these studies, the effect size remained consistent but heterogeneity reduced (MD 0.24 days, 95% CI 0.15 to 0.33; I2 = 40%; 2760 women). Length of operation The evidence is very uncertain about the effect of caesarean myomectomy on length of operation (MD 11.17 minutes, 95% CI 8.78 to 13.56; I2 = 91%; 19 non-randomised studies, 4289 women; very low-certainty evidence). Major surgery at time of procedure The evidence is very uncertain about the effect of caesarean myomectomy on risk of major surgery at the time of procedure (RR 1.94, 95% CI 0.67 to 5.63; I2 = 0%; 5 non-randomised studies, 1165 women; very low-certainty evidence). Four of the studies followed the pooled direction of effect. Fertility outcome No studies reported data on future fertility outcomes. Postpartum fever The evidence is very uncertain about the effect of caesarean myomectomy on risk of postpartum fever (RR 1.13, 95% CI 0.88 to 1.44; I2 = 0%; 13 non-randomised studies, 2735 women; very low-certainty evidence). It was possible to assess the certainty of evidence for seven of the eight priority outcomes using GRADE; the evidence for all outcomes was very low certainty.

AUTHORS' CONCLUSIONS

The available evidence for all critical outcomes is very low certainty. As such, it is not possible to draw conclusions about the effects of caesarean myomectomy on the risk of requiring blood transfusion, risk of haemorrhage, length of hospitalisation, length of operation, risk of major surgery at time of procedure, and risk of postpartum fever. Data retrieved on mean change in haemoglobin were too heterogenous to be pooled. There were no data on fertility outcomes.

FUNDING

This Cochrane review had no dedicated funding.

REGISTRATION

The review was registered with PROSPERO (CRD42024554215) and available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42024554215.

Licochalcone A Induces Uterine Leiomyoma Cell Apoptosis via the ROS-Mediated JNK Activation of the GRP78/NRF2 Pathway In Vitro and In Vivo

Licochalcone A (LicoA) possesses anti-tumor properties. However, the potential therapeutic effect of LicoA on uterine leiomyomas (ULs) remains unknown. In this study, the effects of LicoA on the proliferation of ULs and its underlying mechanism were explored. LicoA treatment significantly decreased the viability of uterine smooth muscle cells (UtSMCs) and ELT3 cells in a dose-dependent manner. The induction of ELT3 cell apoptosis by LicoA was accompanied by the increased generation of reactive oxygen species (ROS), elevated endoplasmic reticulum (ER) stress (GRP78/IRE1α/ATF6/CHOP), and the increased expression of proapoptotic proteins (c-caspase-3, c-caspase-9, and c-PARP). The ability of Z-VAD-FMK (a caspase inhibitor) and n-acetylcysteine (NAC; a cell membrane permeable antioxidant) to reverse LicoA-induced ROS-mediated ER stress pathways also observed. Furthermore, GRP78 or JNK knockdown was involved in LicoA-induced ROS-mediated ER stress and apoptosis in ELT3 cells. In immunodeficient mice, LicoA significantly suppressed the growth of ELT3 tumor cells, without toxicity. This study is the first to show that LicoA exerts anti-leiomyoma effects via the modulation of ROS-mediated ER stress-induced apoptosis through the JNK/GRP78/NRF2 signaling pathway.

Polyethylene Glycol microspheres for uterine artery embolization for the treatment of symptomatic uterine fibroids

BACKGROUND

Uterine fibroids are prevalent benign pelvic tumors, often causing debilitating symptoms that impair quality of life. Uterine fibroid embolization (UFE) is a consolidated minimally invasive treatment option. The purpose of this study is to report our experience with polyethylene glycol microspheres (HydroPearl) in UFE for symptomatic patients.

METHODS

This single-center retrospective study evaluated 37 consecutive patients with symptomatic uterine fibroids referred to our institution since November 2016 to February 2020 for UFE with HydroPearl microspheres. All patients included completed a comprehensive pre-UFE clinical assessment and underwent a magnetic resonance imaging (MRI) pre- and post-procedure. Technical success, procedure-related complications, clinical outcomes, follow-up MRI findings, and patient satisfaction were evaluated.

RESULTS

A technical success rate of 97% with complete bilateral uterine artery embolization was achieved. Significant improvements were observed in menorrhagia, bulk-type symptoms, abdominal pain, and urinary dysfunctions after UFE. Post-procedural MRI assessments demonstrated reductions in uterine and dominant fibroid volumes, indicating successful devascularization. No immediate procedural complications were reported. Symptoms interfering with everyday activities significantly improved after the procedure. Patient satisfaction was high, with 89% expressing satisfaction with the treatment and 84% indicating purpose to repeat the procedure if necessary.

CONCLUSIONS

Uterine artery embolization with HydroPearl is a safe and effective treatment option for symptomatic uterine fibroids. A significant improvement in menorrhagia and bulk-type symptoms after the procedure was observed correlated by a reduction in diameters and volumes of both the uterus and the main fibroid in post-procedural MRI.

Impact of Uterine Leiomyomas on Cardiovascular Disease Risk in Young Reproductive-Aged Women: A Nationwide Population-Based Cohort Study

Background/Objectives: Uterine leiomyomas are the most common benign gynecological tumors in women of reproductive age and are often associated with localized symptoms. However, emerging evidence suggests a link between uterine leiomyomas and systemic conditions such as cardiovascular disease (CVD), particularly myocardial infarction (MI) and ischemic stroke (IS). This study aimed to investigate the relationship between uterine leiomyomas and the risk of CVD events in young women aged 20-39 years using a large, nationwide, population-based cohort. Methods: This retrospective cohort study analyzed data from the National Health Insurance Service database of South Korea of 2,581,700 women aged 20-39 years who underwent health screening between 2009 and 2012. Uterine leiomyomas were identified using International Code of Disease, 10th Edition codes. CVD events (MI and IS) were defined according to hospital claims and radiological data. Multivariate hazard ratios (HRs) were calculated to evaluate the association between leiomyomas and CVD after adjusting for confounders (age, lifestyle factors, comorbidities, and body mass index). Results: In all, 58,812 were diagnosed with uterine leiomyomas, and 25,063 underwent surgical treatment. During the follow-up period, MI occurred in 115 women (0.21%) and IS in 82 women (0.15%) in the leiomyoma group, compared with 3107 cases of MI (0.12%) and 2240 cases of IS (0.09%) in the non-leiomyoma group. The leiomyoma group demonstrated a higher incidence rate of CVD (IR: 0.63 vs. 0.39 per 1000 person-years). After adjusting for confounding factors such as age, lifestyle, comorbidities, and body mass index (BMI), the hazard ratio (HR) for MI was 1.32, indicating a statistically significant increase in cardiovascular risk. The risk of CVD was lower in women who underwent surgical treatment; however, when specifically analyzing the occurrence of MI and IS, no statistically significant differences were observed between the two groups. Conclusions: Uterine leiomyomas are associated with an increased risk of MI and IS in young women. Surgical treatment itself may be associated with additional cardiovascular risks. Further research is needed to develop strategies to mitigate these risks and elucidate the underlying mechanisms.

Epidemiological features of uterine fibroid-associated imaging changes in Chinese women of reproductive age: a retrospective study

OBJECTIVES

To investigate uterine fibroid (UF)-associated imaging changes, and their prevalence, incidence and potential risk factors in the Chinese population.

DESIGN

This was a retrospective observational study using health examination data.

SETTING

A physical examination centre in Nanchong, China, between October 2017 and December 2020.

PARTICIPANTS

A total of 33 915 Chinese women older than 15 years of age underwent uterine imaging during the study period.

PRIMARY AND SECONDARY OUTCOME MEASURES

This study identified entries of UF-associated imaging changes through a two-round expert consultation and calculated prevalence and incidence of UF-associated imaging changes. Logistic regression estimated the association (OR, 95% CI of body mass index, high blood pressure (HBP), blood lipid profile, and fasting blood glucose level) with UF-associated imaging changes. Age-stratified (≤40 years and >40 years) risks were ascertained.

RESULTS

Besides the entry 'Potential UF', 17 other entries of UF-associated imaging changes screened by the expert consultation were included, involving a total of 46 864 records (n=33 915), and crude prevalence=25.18%; crude incidence density/1000-woman-years=63.28. Incidence and prevalence increased with age during reproductive age (15-49 years) and decreased thereafter. The greatest burden was in women aged 40-54 years, the prevalence was 38.60%-45.38% and the incidence was 14.73%-17.96%. In the incident younger population (age ≤40 years), overweight (OR: 1.48, 95% CI 1.03 to 2.14) and HBP (OR: 2.16, 95% CI 1.10 to 4.24) were associated with a higher risk for UF-associated imaging changes; in the >40 years group, no association was observed.

CONCLUSION

UF incidence and prevalence in Asians were higher than previously reported, showed age-related increase in reproductive age, and UF incidence increased with overweight and HBP in ≤40-year-old participants. Variation in UF burden and factors with higher risk noted in different age ranges, and the correlations identified in younger women make it possible for early preventive measures for women with a higher risk of UF.

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

OBJECTIVE

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

DESIGN

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

SUBJECTS

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

INTERVENTION

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSION

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

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.

Hair Straightener Use in Relation to Prevalent and Incident Fibroids in the Sister Study with a Focus on Black Women

BACKGROUND

Uterine fibroids disproportionately affect Black women, and exposure to chemicals from hair relaxers or straighteners ("straighteners") may contribute to fibroid development.

OBJECTIVES

We examined the association between straightener use and prevalent young-onset uterine fibroids (diagnosed before age 36 y), as well as incident fibroids (diagnosed age 36-60 y), with a focus on Black women. We also examined differences in associations across birth cohorts as proxies for formulation changes.

METHODS

Data from 4,162 Black women in the Sister Study, a prospective cohort of women 35-74 y of age (enrolled 2003-2009), were analyzed. We used logistic regression to estimate odds ratios (ORs) for the association of straightener use at 10-13 y of age and self-reported young-onset fibroids. We used Cox regression to assess hazard ratios (HRs) for straightener use (age 10-13 y and in 12 months before enrollment) and incident fibroids among 779 premenopausal Black women. Similar analyses were conducted in 40,782 non-Hispanic White women.

RESULTS

Over 70% of Black women used straighteners. In comparison with no use, any [OR = 1.15 ; 95% confidence interval (CI): 0.96, 1.36] and frequent use (OR = 1.18 ; 95% CI: 0.99, 1.42) of straighteners at 10-13 y of age were associated with young-onset fibroids. This association was most apparent among those born between 1928 and 1945 (OR = 1.78 ; 95% CI: 1.15, 2.74) and 1965-1974 (OR = 1.64 ; 95% CI: 0.82, 3.29). Fibroid incidence from 36 to 60 y of age was modestly associated with use of straighteners at 10-13 y of age [hazard ratio ( HR ) = 1.14 ; 95% CI: 0.81, 1.63] and in the 12 months prior to enrollment (HR = 1.32 ; 95% CI: 0.88, 2.00). Among non-Hispanic White women, straightener use at 10-13 y of age was similarly associated with young-onset fibroids (OR = 1.23 ; 95% CI: 1.03, 1.47) despite lower use (≤ 5 % ) of straighteners. Sensitivity analyses indicated a potential for bias due to fibroid misclassification, with an overestimation of the effect likely if nulliparous women or women from households with lower education reported their fibroid status less accurately.

DISCUSSION

Hair straightener use may be positively associated with fibroid risk. https://doi.org/10.1289/EHP14493.

Complicated Sigmoid Diverticulitis Mimicking Pelvic Pain in a Patient With Giant Uterine Fibroids: A Case Report

This report describes the case of a woman in her late forties with a history of large uterine fibroids who presented to the Emergency Department with colicky suprapubic pain and urinary symptoms. Initial computed tomography (CT) showed uncomplicated acute diverticulitis but despite antibiotic treatment, her condition worsened, and a follow-up CT revealed sigmoid perforation, requiring high anterior resection and subtotal hysterectomy. The case highlights how large fibroids exert external pressure on the colon, impairing motility and increasing the risk of diverticula formation. Alterations in the gut microbiome may contribute to colonic mucosal inflammation, commonly seen in diverticular disease. Patients with uterine fibroids have altered microbiome composition, which could further increase the risk of diverticular disease. These findings provide a pathway for future research into the influence of uterine fibroids on the pathophysiology of diverticular disease.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Homeopathic Management of Bulky Uterus with Uterine Fibroid in a 40-year-old Patient: An Evidence-Based Case Report

BACKGROUND

 Uterine fibroids are benign gynecological tumours that arise in the uterine smooth muscle tissue and are characterized by the production of excessive quantities of extracellular matrix. Various therapeutic options, from medical management to surgical intervention, exist for uterine fibroids, for which homeopathy has emerged as a promising therapeutic option in patient-centered care.

CASE HISTORY

 A 40-year-old woman presented with complaints of heavy menstrual bleeding, with pain in the pelvic region and back. She was diagnosed as a case of bulky uterus with uterine fibroid. The patient opted for homeopathic management and was prescribed Thuja occidentalis based on individualization, miasmatic analysis and repertorial totality.

RESULTS

 After treatment, there was regression in size of the fibroid within 5 months, with complete resolution and restoration of the uterus to normal size within 9 months. Changes were validated through ultrasonography, which added objective evidence to the positive outcome. The Modified Naranjo Criteria for Homeopathy (MONARCH) inventory total score was +9, which indicated causal attribution of clinical outcome to the homeopathic intervention.

CONCLUSION

 This case study has illustrated the clinical benefits of homeopathy in the management of a patient with uterine fibroids, reaffirming the need for further research to explore its value as a therapeutic option for individuals seeking alternative or complementary approaches for appropriate medical conditions.

Evaluation of the In Vivo Efficacy of the JAK Inhibitor AZD1480 in Uterine Leiomyomas Using a Patient-derived Xenograft Murine Model

Uterine leiomyomas are common noncancerous hormonally-dependent neoplasms comprised of uterine smooth-muscle cells and fibroblasts. Despite their significant impact on morbidity, effective non-hormonal medical treatments are lacking. In vitro studies have identified the Janus kinase/signal transducer and activator of transcription (JAK/STAT) signaling pathway as a promising target in leiomyoma cells. Our objective was to evaluate the efficacy of AZD1480, a JAK 1/2 inhibitor, in treating uterine leiomyomas using a patient-derived xenograft murine model. Ovariectomized immunodeficient mice received an estrogen and progesterone pellet and were subsequently implanted with human leiomyoma tissue surgically resected from premenopausal women not on hormonal medication. Mice were divided into treatment (n = 6) and vehicle control (n = 6) groups receiving either 50 mg/kg of AZD1480 or vehicle via oral gavage for 5 days/week for 28 days. Our results demonstrate a significant AZD1480-mediated reduction in both xenograft volume (59.5% vs. 0.3%; treated vs. control, p < .0001) and weight (56.0% vs. 31.2%; p = 0.03) compared to controls. Moreover, xenografts from the treated group exhibited a significant decrease in cell density(p = 0.01). Levels of pSTAT3-positive cells (4.1% vs. 10.3%), Ki67-positive cells (4.1% vs. 6.5%), and fibrillar collagen (19.8% vs. 29.5%) declined but did not reach statistical significance, whereas AZD1480 treatment significantly reduced blood vessel formation in the xenografts (20.1 vs 45.6 per FOV; p = 0.01). These findings suggest JAK inhibition as a potential treatment for uterine leiomyomas by targeting angiogenesis. However, further studies are warranted to explore alternative JAK inhibitors, examine downstream effects, optimize dosing, and establish clinical efficacy and safety.

Relugolix reduces leiomyoma extracellular matrix production via the transforming growth factor-beta pathway

OBJECTIVE

To determine if the oral gonadotropin-releasing hormone antagonist relugolix affects leiomyoma extracellular matrix production through the transforming growth factor-beta (TGF-β) pathway.

DESIGN

Laboratory study.

SUBJECTS

None.

EXPOSURE

Exposure of human leiomyoma cells to TGF-β and/or relugolix.

MAIN OUTCOME MEASURES

Production of TGF-β, pSMAD2/3, SMAD2/3, collagen 1A1 (COL1A1), fibronectin (FN1), and versican (VCAN) in treated and untreated leiomyoma cells.

RESULTS

Transforming growth factor-beta 3 production decreased at 24 hours with relugolix 10 nM (0.80 ± 0.09-fold) and 100 nM (0.86 ± 0.06-fold) and at 48 hours with relugolix 1 nM (0.86 ± 0.05-fold) and 100 nM (0.86 ± 0.06-fold). pSMAD2/3 production decreased at 24 hours with relugolix 1 nM (0.71 ± 0.01-fold), 10 nM (0.68 ± 0.01-fold), and 100 nM (0.41 ± 0.10-fold). Compared with relugolix treatment alone at the same concentration, combination treatment at 24 hours resulted in significantly increased COL1A1, FN1, and VCAN production with relugolix 1 nM, 10 nM, and 100 nM. At 48 hours, combination treatment resulted in significantly increased COL1A1, FN1, and VCAN production with relugolix 10 nM and 100 nM.

CONCLUSION

Relugolix regulated leiomyoma size by decreasing COL1A1, FN1, and VCAN production. This effect is at least partly through the TGF-β pathway.

The Burden of Pain Symptoms in Individuals with Uterine Fibroids-Results from a Prospective Observational Study in the USA

Purpose

To characterize the burden of uterine fibroids (UF) in individuals experiencing heavy menstrual bleeding (HMB) and moderate-to-severe UF-associated pain in terms of symptoms experienced, impact on work and activities, and pain medication use both on menstrual and non-menstrual days.

Patients and Methods

This prospective, real-world, observational study enrolled 350 participants in the USA with a self-reported UF diagnosis, HMB, and moderate-to-severe pain due to UF. Data collection took place from February 9 to July 19, 2021. Over 4 months, participants used an online platform to self-report daily menstrual status, bleeding intensity, UF-associated pain severity, and pain medication use, and to complete weekly work and productivity questionnaires. Results were analyzed descriptively and are reported for the overall population, by pain medication subgroups-defined based on the most potent medication taken-and menstrual versus non-menstrual days/weeks.

Results

The analysis population consisted of 307 participants with ≤5 consecutive missing days of daily survey responses or ≥75% completion rate of the daily surveys. Mean age of participants (standard deviation; SD) was 37.2 (6.3) years. At baseline, 54.1% of participants reported not currently taking medication for treatment of HMB. Over the study period, mean UF-associated pain scores (SD; scale range 0-10) were higher on menstrual days (3.5 [2.7]) than non-menstrual days (1.0 [1.8]), and this was consistent across medication use subgroups. Pain medications were used more frequently on menstrual days than non-menstrual days (22.9% versus 3.7% days of pain medication use, respectively). Participants reported 31.5% work impairment on menstrual weeks versus a 12.7% work impairment on non-menstrual weeks.

Conclusion

In this study, UF-associated pain symptoms coincided with a reduction in individuals' ability to take part in both work and non-work activities and an increase in pain medication use, particularly during menstrual weeks. These results highlight the need for improved diagnosis and pain management strategies in UF.

Multimodal MRI radiomics-based stacking ensemble learning model with automatic segmentation for prognostic prediction of HIFU ablation of uterine fibroids: a multicenter study

Objectives

To evaluate the effectiveness of an MRI radiomics stacking ensemble learning model, which combines T2-weighted imaging (T2WI) and contrast-enhanced T1-weighted imaging (CE-T1WI) with deep learning-based automatic segmentation, for preoperative prediction of the prognosis of high-intensity focused ultrasound (HIFU) ablation of uterine fibroids.

Methods

This retrospective study collected data from 360 patients with uterine fibroids who underwent HIFU treatment. The dataset was sourced from Center A (training set: N = 240; internal test set: N = 60) and Center B (external test set: N = 60). Patients were categorized into favorable and unfavorable prognosis groups based on the post-treatment non-perfused volume ratio. Automated segmentation of uterine fibroids was performed using a V-net deep learning models. Radiomics features were extracted from T2WI and CE-T1WI, followed by data preprocessing including normalization and scaling. Feature selection was performed using t-test, Pearson correlation, and LASSO to identify the most predictive features for preoperative prognosis Support Vector Machine (SVM), Random Forest (RF), Light Gradient Boosting Machine (LightGBM), and Multilayer Perceptron (MLP) were employed as base learners to construct base predictive models. These models were integrated into a stacking ensemble model, with Logistic Regression serving as the meta-learner to combine the outputs of the base models. The performance of the models was assessed using the area under the receiver operating characteristic curve (AUC).

Results

Among the base models developed using T2WI and CE-T1WI features, the MLP model exhibited superior performance, achieving an AUC of 0.858 (95% CI: 0.756-0.959) in the internal test set and 0.828 (95% CI: 0.726-0.930) in the external test set. It was followed by the SVM, LightGBM, and RF, which obtained AUC values of 0.841 (95% CI: 0.737-0.946), 0.823 (95% CI: 0.711-0.934), and 0.750 (95% CI: 0.619-0.881), respectively. The stacking ensemble learning model, which integrated these five algorithms, demonstrated a notable enhancement in performance, with an AUC of 0.897 (95% CI: 0.818-0.977) in the internal test set and 0.854 (95% CI: 0.759-0.948) in the external test set.

Conclusion

The DL based automatic segmentation MRI radiomics stacking ensemble learning model demonstrated high accuracy in predicting the prognosis of HIFU ablation of uterine fibroids.

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.

National Utilization Trends of Inpatient Procedures for Symptomatic Uterine Fibroids and Adenomyosis: A 10-Year Analysis

PURPOSE

The aim of this study was to determine changes in procedural utilization for symptomatic uterine fibroids and adenomyosis from 2011 to 2020.

METHODS

An institutional review board-exempt retrospective study of the National Inpatient Sample database from 2011 to 2020 was performed using International Classification of Diseases, Ninth Revision, and International Classification of Diseases, 10th Revision, diagnosis and procedural codes for uterine fibroids, adenomyosis, hysterectomy, myomectomy, uterine artery embolization (UAE), and endometrial ablation. Patients with endometriosis, uterine cancer, placenta accreta spectrum, pelvic inflammatory disease, and uterine prolapse were excluded. Data were analyzed using statistical process control and χ2 testing.

RESULTS

A total of 247,476 inpatient procedures were identified in women with fibroids and/or adenomyosis. Of those patients with only uterine fibroids (n = 212,532), 77.9% underwent hysterectomy, 18.9% underwent myomectomy, and 2.8% underwent UAE. The utilization of UAE remained stable over the decade, whereas an increased prevalence of myomectomy was offset by a decrease in hysterectomy (2011 versus 2020: hysterectomy, 81.4% versus 73.7%; myomectomy, 15.4% versus 24.0%; UAE, 2.9% versus 2.0%). Regarding adenomyosis only (n = 16,073), more women underwent hysterectomy (98.1%) compared with UAE (1.1%), with minimal change in these procedures across the decade. For combined fibroids and adenomyosis (n = 18,871), hysterectomy was the most utilized procedure, with its utilization declining from 92.0% to 85.2% during the time period.

CONCLUSIONS

The utilization of hysterectomy remains the dominant inpatient procedural intervention for the treatment of uterine fibroids and adenomyosis, but the proportion of myomectomy in the setting of fibroids is increasing. Utilization of UAE did not change from 2011 to 2020, and it remains relatively underutilized despite initiatives to increase utilization.

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 2 techniques in terms of fertility and obstetrical complications.

DESIGN

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

SETTING

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

PATIENTS

192 patients were included.

INTERVENTIONS

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

MEASUREMENTS AND MAIN RESULTS

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

CONCLUSION

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

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.

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).