Tranexamic acid for the management of uterine fibroid tumors: A systematic review of the current evidence

ACR Appropriateness Criteria® Management of Uterine Fibroids: 2023 Update

Uterine fibroids are the most common benign tumor in women of reproductive age and can present with symptoms including bleeding, bulk related symptoms, and infertility. Several treatment options are available for the management of uterine fibroids, including medical management, minimally invasive therapies such as uterine artery embolization and MR-guided focused ultrasound ablation, and surgical interventions ranging from laparoscopic myomectomy to open hysterectomy. Given this wide range of therapeutic interventions, it is important to understand the data supporting these interventions and to be able to apply it in different clinical settings. This document provides a summary of recent trials supporting various therapies for uterine fibroids, including recent evidence for MR-guided focused ultrasound ablation and a detailed discussion of fertility outcomes in myomectomy and uterine fibroid embolization. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Current and Emerging Treatment Options for Uterine Fibroids

Uterine fibroids are the most common benign neoplasm of the female reproductive tract in reproductive age women. Their prevalence is age dependent and can be detected in up to 80% of women by the age of 50 years. Patients affected by uterine fibroids may experience a significant physical, emotional, social, and financial toll as well as losses in their quality of life. Unfortunately, curative hysterectomy abolishes future pregnancy potential, while uterine-sparing surgical and radiologic alternatives are variously associated with reduced long-term reproductive function and/or high tumor recurrence rates. Recently, pharmacological treatment against uterine fibroids have been widely considered by patients to limit uterine fibroid-associated symptoms such as heavy menstrual bleeding. This hormonal therapy seemed effective through blocking the stimulatory effects of gonadal steroid hormones on uterine fibroid growth. However, they are contraindicated in women actively pursuing pregnancy and otherwise effective only during use, which is limited because of long-term safety and other concerns. Accordingly, there is an urgent unmet need for safe, durable, and fertility-compatible non-surgical treatment options for uterine fibroids. In this review article, we cover the current pharmacological treatments for uterine fibroids including their comparable efficacy and side effects as well as emerging safe natural compounds with promising anti-uterine fibroid effects.

Oxytocin versus a combination of tranexamic acid and ethamsylate in reducing intraoperative bleeding during abdominal myomectomy: a randomized clinical trial

OBJECTIVE

Myomectomy is the preferred surgical approach to manage uterine fibroids. However, uterine fibroids are highly vascular tumors and, consequently, extremely susceptible to problems from myomectomy-related hemorrhage. Hence, we aim to compare oxytocin efficacy and safety profile versus tranexamic acid (TA) with ethamsylate for reducing bleeding during myomectomy.

METHODS

This randomized, double-blinded multicenter study was performed between 20th August 2020 and 20th October 2020 at El-Galaa Teaching Hospital, El Hussein University Hospital, Al-Azhar University Hospitals of Assiut, and Al-Azhar University Hospitals of Damietta. One hundred and eighty patients were enrolled and divided into three groups: group (1) received an injection of 30 IU of oxytocin in 500 ml of normal saline; group (2) received injections of 1 g of TA, 250 mg of Ethamsylate, and 110 ml of normal saline IV; and group (3) received an injection of 110 ml of normal saline IV just before surgical incision.

RESULTS

In 180 premenopausal women, oxytocin and TA with ethamsylate had no significant value in lowering intraoperative blood loss compared with the placebo for abdominal myomectomy (666.25 ± 183.03, 630.72 ± 145.83, and 646.67 ± 168.92, respectively (P = 0.506)). Non-significant trends were observed for a reduction in operation time (P = 0.760), intra/postoperative blood transfusion (P = 0.624), hospital stay (P = 0.986), postoperative fever (P = 0.659), and wound infection (P = 1).

CONCLUSION

Oxytocin and TA with ethamsylate had no significant value in lowering intraoperative blood loss compared with the placebo for abdominal myomectomy which opens a new question about the role of the use of the hemostatic drug during myomectomy especially in centers with limited resources and had higher rates.

TRIAL REGISTRATION

The study was registered on Pan African Clinical Trials Registry with the following number: PACTR202008739887429 and was approved on 24/08/2020.

Submucosal Uterine Fibroid in Grand Multipara Woman: A Case Report

Background: to report and analyze a case that diagnosed with submocous uterine fibroid in grand multiparity woman. Methods: Case Report Case: a 49 years woman, P7A0 came with chief complaints vaginal bleeding that has been experienced since one year ago getting worse in 2 months. Her general condition was within normal limit and there was no abnormality in physical examination, by vaginal examination there was blood in the vagina, origin from the External Uterine Orificium (EUO),bimanual examination showed anteflexion uterus with normal size, right and left adnexa within normal limits. From transvaginal ultrasound we found submucous uterine fibroid size 3 x 3 cm, we decided to perform Total Abdominal Hysterectomy. Conclusion: Hysterectomy is a progressive and definitive uterine fibroid procedure. For women who do not want to conceive and/or women over 40-50 years of age, in particular.

Adjunctive use of tranexamic acid to tourniquet in reducing haemorrhage during abdominal myomectomy - A randomized controlled trial

BACKGROUND

Uterine fibroids are the commonest tumour of the female genital tract; about one third are symptomatic and require management. The treatment of uterine fibroids may be medical, surgical, conservative or expectant. Myomectomy is the common surgical treatment option for women failing medical management and desiring to preserve fertility and/or their uterus. The tourniquet is shown to be effective in reducing blood loss during myomectomy and tranexamic to a less extent. However, the adjunctive use of tranexamic acid with tourniquet to further reduce blood loss has not been studied.

AIM

The aim of the study was to determine the efficacy of perioperative intravenous tranexamic acid in further reducing blood loss at abdominal myomectomy when used as an adjunct to tourniquet.

METHODS

The study was a randomized double-blind controlled study involving women who underwent abdominal myomectomy. Participants were randomized to either tourniquet plus intravenous tranexamic acid or tourniquet plus placebo groups using simple random sampling. The primary outcomes were the intra-operative blood loss, post-operative haematocrit values and need for intra-operative blood transfusion. The data was analyzed using the SPSS software version 23.0 and p value < 0.05 was significant.

RESULTS

The mean intra-operative blood loss (998.72 ± 607.21 ml vs 907.25 ± 529.85 ml, p = 0.475), intra-operative blood transfusion rate (45% vs. 30%; p = 0.166) and mean unit of blood transfused (1.13 ± 1.64 vs. 0.75 ± 1.28; p = 0.256) were higher for tourniquet plus placebo group compared to tourniquet plus tranexamic acid group. The estimated blood loss per 100 g of fibroid removed was reduced significantly in the tranexamic acid plus tourniquet group (139.80 ± 2.28 ml vs 104.09 ± 1.97 ml; p = 0.001).

STRENGTH AND LIMITATIONS

The strength of the study include randomization and blinding. The limitations included non-uniformity of sizes and locations of fibroids, as well as the different surgeons with possibly different skills, techniques and experiences, though they were statistically not significant.

CONCLUSION

The adjunctive use of tranexamic acid to tourniquet significantly further reduces intraoperative blood loss during abdominal myomectomy when compared to tourniquet alone.

RECOMMENDATIONS

Adjunctive use of tranexamic acid is recommended for further reducing intra-operative blood loss during abdominal myomectomy.

The Effectiveness of Tranexamic Acid at Reducing Blood Loss and Transfusion Requirement for Women Undergoing Myomectomy: A Systematic Review and Meta-analysis

BACKGROUND

The surgical removal of fibroids can be associated with excessive blood loss requiring transfusion.

OBJECTIVE

This review sought to determine the effectiveness of tranexamic acid (TA) in reducing perioperative blood loss in women undergoing myomectomy.

METHODS

Electronic bibliographic databases were searched from inception until June 3, 2017. The review included RCTs of women of reproductive age with uterine fibroids who were undergoing myomectomy and who received TA or a comparator. Two independent reviewers extracted relevant data, and meta-analysis was performed.

RESULTS

Three studies included women undergoing abdominal myomectomy. TA significantly reduced intraoperative blood loss by a mean difference of 213.1 mL (95% CI -242.4 to -183.7) and postoperative blood loss by a mean difference of 56.3 mL (95% CI -67.8 to -44.8) compared with control arms. However, no significant differences were seen in blood transfusion requirement (relative risk 0.58; 95% CI 0.33-1.00). In one study for women undergoing hysteroscopic myomectomy, TA was not associated with improved outcomes in transfusion requirement and resulted in reduced postoperative hemoglobin levels compared with oxytocin.

CONCLUSION

Among women undergoing abdominal myomectomy, TA is effective at reducing perioperative blood loss compared with no treatment or placebo. For women undergoing hysteroscopic myomectomy, TA compared with oxytocin is not associated with improved outcomes in transfusion requirement and resulted in reduced postoperative hemoglobin levels.

Alternatives to excisional therapy: a clinical review of our current options to conservatively manage symptomatic leiomyomas

PURPOSE OF REVIEW

This article provides a clinical review of the alternatives to traditional excisional surgical therapies for uterine leiomyomas, such as myomectomy or hysterectomy.

RECENT FINDINGS

In this review, currently available hormonal medications will be briefly discussed. Then, nonhormonal medical therapy will be addressed with respect to mechanism of action, safety, and efficacy. Finally, the risk-benefit profile of nonexcisional procedures for management of leiomyomas will be addressed.

SUMMARY

This provides an update on the information available for more conservative options for symptomatic leiomyoma management.

ACR Appropriateness Criteria® Radiologic Management of Uterine Leiomyomas

Uterine fibroids, also known as leiomyomas, are the most common benign tumor in women of reproductive age. When symptomatic, these patients can present with bleeding and/or bulk-related symptoms. Treatment options for symptomatic uterine leiomyomas include medical management, minimally invasive treatment such as uterine artery embolization, and surgical options, such as myomectomy. It is important to understand the role of these treatment options in various clinical scenarios so that appropriate consultation is performed. Furthermore, patients should be presented with the outcomes and complications of each of these treatment options. A summary of the data and clinical trials of the treatment options for symptomatic uterine leiomyomas is outlined in this article. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Updated approaches for management of uterine fibroids

Uterine anatomy and uterine fibroids (UFs) characteristics have been classically considered as almost a unique issue in gynecology and reproductive medicine. Nowadays, the management of UF pathology is undergoing an important evolution, with the patient's quality of life being the most important aspect to consider. Accordingly, surgical techniques and aggressive treatments are reserved for only those cases with heavy symptomatology, while the clinical diagnostic based on size and number of UFs remains in a second plane in these situations. Moreover, the development of several noninvasive surgical techniques, especially the appearance of ulipristal acetate as a medical etiological treatment, has substantially changed the clinical indications. As a consequence, after almost 2 decades without relevant updates, it has been necessary to update the protocols for the management of UFs in the Spanish Society of Gynecology and Obstetrics twice. Accordingly, we believe that it is necessary to translate our experience to protocolize the medical care for patients with UFs, incorporating these new therapeutic options, and selecting the best treatment for them. We highlight the importance of achieving the patient's goals and decisions by improving the clinical diagnosis for these type of pathologies, allowing enhanced personalized treatments, as well as the reduction of potential risks and unnecessary surgeries.

Non-surgical Management of Myomas

Uterine myomas are a common condition and the leading cause of hysterectomy. Clinically, myomas can be challenging because they range from asymptomatic to causing severe, debilitating symptoms and occur in many women before childbearing is complete. Thus, women often seek uterine-conserving and nonsurgical management of their myomas. In this review the available uterine-conserving treatment options from medical management through minimally invasive procedures are discussed. To the extent of research available, the sustainability of symptom improvement and the effects on future fertility are reviewed. Future research may lead to therapies that reduce the risks of major surgery, decrease side effects, and offer primary or secondary prevention options.