Clinical utility of ulipristal acetate for the treatment of uterine fibroids: current evidence

Sacral injury and influencing factors after ultrasonic ablation of uterine fibroids ≤30 mm from the sacrum

PURPOSE

To study sacral injuries and influencing factors after ultrasonic ablation of uterine fibroids no more than 30 mm from the sacrum.

METHODS

A total of 406 patients with uterine fibroids who underwent percutaneous ultrasound ablation were analyzed retrospectively. All patients underwent contrast-enhanced magnetic resonance imaging (MRI) scans before and after high-intensity focused ultrasound. The abnormal signal intensity (low signal intensity on T1WI and high signal intensity on T2WI) on the postoperative MRIs was indicative of a sacral injury. The patients were divided into a sacrum injury group and a sacrum non-injury group. The relationship between fibroid characteristics, ultrasound ablation parameters, and injury was analyzed using univariate and multivariate analyses.

RESULTS

There were 139 cases of sacral injury (34.24%). When the distance from the fibroid's dorsal side to the sacrum was 0-10 mm, the risk assessment showed that the danger of sacral injury increased by 1.85 times and 3.03 times compared with that at a distance of 11-20 or 21-30 mm. Furthermore, the risk of sacral injury increased by 1.89 times and 3.23 times when the therapeutic dose (TD) of a fibroid was >500 KJ compared with that of a fibroid with TD= 250-500 KJ and <250 KJ.

CONCLUSION

A distance of 10 mm or less and a TD of >500 KJ were significantly correlated with sacral injury. The distance from the fibroid's dorsal side to the sacrum and the TD were the main causes of injury to the sacrum. A distance of 10 mm or less and a TD of >500 KJ carried higher injury risks, while a distance of 21-30 mm and a TD of <250 KJ were the most appropriate circumstances to reduce the risk of sacral injury.

The Effect of Vitamin D Deficiency on Overgrowth of Uterine Fibroids: A Blinded Randomized Clinical Trial

Background

To evaluate the effects of vitamin D (vitD) supplement on uterine fibroid growth.

Materials and Methods

A randomized blinded clinical trial was conducted at a tertiary university-based hospital from August 2017 to September 2018. Totally, 204 women were enrolled into the study. They had at least one uterine fibroid >10 mm on transvaginal ultrasound and their vitD level was insufficient (i.e. 20-30 ng/ml). The intervention group was treated with vitD 50000 U supplements for two months. After 2 months, ultrasound screening and vitD level measurement was done in both groups.

Results

At first, the mean serum vitD levels in intervention and control group were 23.62 and 23.20 ng/ml, respec- tively. After 8 weeks, the mean serum vitD levels in the control and intervention group were 22.72 and 28.56 ng/ml respectively (P<0.05). Also, mean fibroma diameter in the intervention group before and after 8 weeks of vitD supple- mentation was 43 ± 4.68 and 42.6 ± 1.31 mm, respectively. Mean uterine fibroid diameter in the control group which did not receive vitD supplements, before and after 8 weeks was 41.98 ± 5.25 and 47.81 ± 3.42 mm, respectively. The variation in the mean size of the uterine fibroid between the control and intervention group which was respectively about 5.83 mm increase and 0.48 mm decrease, was significant (P<0.001).

Conclusion

Our results showed that vitD supplementation prevents fibroid growth. It seems that vitD supple- ment is a simple, safe and inexpensive modality for leiomyoma growth prevention (Registration number: IRCT201703122576N15).

Effect of HIFU on endometrial receptivity and sex hormone level in uterine fibroid patients and analysis of influencing factors for its treatment rate

Effect of high intensity focused ultrasound (HIFU) uterine fibroid ablation on the endometrial receptivity and sex hormone level in uterine fibroid patients and the influencing factors for treatment rate were investigated. A retrospective analysis of 266 uterine fibroid patients admitted to the Department of Gynaecology in the Jining Maternity and Child Care Hospital from October 2013 to October 2016 was performed. Among them, observation group was treated with HIFU ablation (n=143), control group with myomectomy (n=123). The pulsatility index (PI) and the resistance index (RI) of the uterine arterial blood flow were measured during the luteal phase of menstruation by transvaginal ultrasonography. The serum luteinizing hormone (LH), follicle stimulating hormone (FSH) and estradiol (E₂) were detected by chemical immunofluorescence. The relationship between HIFU treatment rate and clinical pathology of uterine fibroid patients was analyzed, and univariate/multivariate regression analysis was used to analyze the influencing factors for HIFU treatment rate. There was no significant difference in preoperative and postoperative PI and RI between the two groups (P>0.05); no significant difference between preoperative and postoperative PI/RI in the same group (P>0.05). There was no significant difference in preoperative and postoperative LH, FSH and E₂ between the two groups (P>0.05); no significant difference between preoperative LH and postoperative LH in the same group (P>0.05), neither FSH or E₂ (P>0.05). Results of multivariate analysis showed that fibroid location and ultrasound contrast intensity were independent influencing factors for HIFU treatment rate (P<0.05). Treatment of uterine fibroid with HIFU has no effect on the patient's endometrial receptivity and sex hormone level. Fibroid location and ultrasound contrast intensity are independent risk factors for HIFU treatment rate. This study provides guidance for the clinical optimization of treatment methods and is more conducive to the promotion of HIFU ablation therapy.

Selective progesterone receptor modulators for fertility preservation in women with symptomatic uterine fibroids

Uterine fibroids (UFs, AKA leiomyoma) are the most important benign neoplastic threat to women's health, with costs up to hundreds of billions of health care dollars worldwide. Uterine fibroids caused morbidities exert a tremendous health toll, impacting the quality of life of women of all ethnicities, especially women of color. Clinical presentations include heavy vaginal bleeding, pelvic pain, bulk symptoms, subfertility, and obstetric complications. Current management strategies heavily lean toward surgical procedures; nonetheless, the choice of treatment is generally subject to patient's age and her desire to preserve future fertility. Women with UF who desire to maintain future fertility potential face a dilemma because of the limited treatment choices that are currently available to help them achieve that goal. Recently, ulipristal acetate the first of the promising family of oral selective progesterone receptor modulators has been approved for UF treatment in Europe, Canada, and several other countries and is under review for possible approval in the USA. In this review article, we discuss recent advances in the management options against UF with a bend toward oral effective long-term treatment alternatives who are particularly suited for those seeking to preserve their future fertility potential. We also explore the transformative concept of primary and secondary UF prevention using these new anti-UF agents. We envision a remarkable shift in the management of UF in future years from surgical/invasive treatment to orally administrated options; clearly, this potential shift will require additional intense clinical research.

Selective Progesterone Receptor Modulators for the Medical Treatment of Uterine Fibroids with a Focus on Ulipristal Acetate

Uterine fibroids are the most frequent benign tumours in women of child-bearing age. Their symptoms are diverse and the quality of life of the women affected can be significantly impaired. While treatment to date has been primarily by means of surgical intervention, selective progesterone receptor modulators (SPRMs) open up new medication-based treatment options. EMA's Pharmacovigilance Risk Assessment Committee (PRAC) has recently completed its review of ESMYA® (ulipristal acetate, 5 mg), following reports of serious liver injury, including liver failure leading to transplantation in postmarketing settings. We will provide some information on the PRAC's recommendations to minimize this risk. Nevertheless, the effectiveness and safety of the SPRM ulipristal acetate (UPA), both with regard to preoperative administration and with regard to an intermittent administration as long-term treatment for patients with symptomatic uterine fibroids, have been shown in several clinical studies (PEARL I-IV).

Proliferation and ovarian hormone signaling are impaired in normal breast tissues from women with BRCA1 mutations: benefit of a progesterone receptor modulator treatment as a breast cancer preventive strategy in women with inherited BRCA1 mutations

Women with inherited BRCA1 mutations have an elevated risk (40-80%) for developing breast and ovarian cancers. Reproductive history has been reported to alter this risk, suggesting a relationship between ovarian hormone signaling and BRCA1-related tumor development. BRCA1 interactions with estrogen receptor (ER) and progesterone receptor (PR) signaling were previously described in human breast cancer cell lines and mouse models. However, few studies have examined the effect of ovarian hormone regulation in normal human breast tissues bearing a heterozygous BRCA1 mutation. This study compares the proliferation level (Ki67) and the expression of ER, PR, and of the PR target gene, fatty acid synthase (FASN), in histologically normal breast tissues from women with BRCA1 mutations (BRCA1+/mut, n=23) or without BRCA1 mutations (BRCA1+/+, n=28). BRCA1+/mut tissues showed an increased proliferation and impaired hormone receptor expression with a marked loss of the PR isoform, PR-B. Responses to estradiol and progesterone treatments in BRCA1+/mut and BRCA1+/+ breast tissues were studied in a mouse xenograft model, and showed that PR and FASN expression were deregulated in BRCA1+/mut breast tissues. Progesterone added to estradiol treatment increased the proliferation in a subset of BRCA1+/mut breast tissues. The PR inhibitor, ulipristal acetate (UPA), was able to reverse this aberrant progesterone-induced proliferation. This study suggests that a subset of women with BRCA1 mutations could be candidates for a UPA treatment as a preventive breast cancer strategy.

Hypovitaminosis D and "small burden" uterine fibroids: Opportunity for a vitamin D supplementation

The aim of this study was to evaluate the effect of vitamin D supplementation in women with hypovitaminosis D and "small burden" uterine fibroids.This study focused on 208 women diagnosed with uterine fibroids and concomitant hypovitaminosis D, from January to December 2014. One hundred eight women of the initial study population were diagnosed with "small burden" uterine fibroids. Among them, those who underwent a proper vitamin D supplementation constituted the "study group" (n = 53), while women who spontaneously refused the therapy or did not perform it properly, constituted the "control group" (n = 55). The characteristics of uterine fibroids, the fibroid-related symptoms, and the vitamin D serum levels were evaluated 12 months after the initial diagnosis.In women with uterine fibroids, a negative correlation emerged between the baseline 25-hydroxy-cholecalciferol (25-OH-D3) concentration and both the volume of the largest fibroid (r = -0.18, P = 0.01) and the total volume of fibroids (r = -0.19, P = 0.01). No correlation was found between the baseline 25-OH-D3 levels and the number of fibroids per patient (r = -0.10, P = 0.16). In women of the "study group," a significant increase in the 25-OH-D3 serum level was observed after 12 months of supplementation, and a lower rate of surgical or medical treatment due to the "progression to extensive disease" was reported (13.2% vs 30.9%, P = 0.05).Supplementation therapy with 25-OH-D3 restores normal vitamin D serum levels in women with "small burden" fibroids. In these women, vitamin D supplementation seems to reduce the progression to an extensive disease, and thus the need of conventional surgical or medical therapy.