Uterine fibroids: current perspectives

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

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

The Mediator Complex Subunit 12 (MED-12) Gene and Uterine Fibroids: a Systematic Review

Uterine leiomyomas are the most common tumor of reproductive-age women worldwide. Although benign, uterine fibroids cause significant morbidity and adversely impact the quality of life for affected women. Somatic mutations in the exon 2 of the mediator complex subunit 12 (MED-12) gene represent the most common single gene mutation associated with uterine leiomyomas. The objective of this review was to evaluate the current role of MED-12 mutation in the pathophysiology of uterine fibroids, to assess the prevalence of MED-12 mutation among different populations, and to identify the most common subtypes of MED-12 mutations found in uterine fibroids. A comprehensive search was conducted using Pubmed, Embase, Scopus, and the Web of Science. English-language publications that evaluated MED-12 mutation and uterine fibroids in humans, whether experimental or clinical, were considered. We identified 380 studies, of which 23 were included, comprising 1353 patients and 1872 fibroid tumors. Of the total number of tumors analyzed, 1045 (55.8%) harbored a MED-12 mutation. Among the 23 studies included, the frequency of MED-12 mutation varied from 31.1 to 80% in fibroid samples. The most common type of MED-12 mutation was a heterozygous missense mutation affecting codon 44 of exon 2, specifically the nucleotide 131. Studies reported that MED-12 mutation acts by increasing levels of AKT and disrupting the cyclin C-CDK8/19 kinase activity. The overall average prevalence of MED-12 mutation in uterine fibroids was found to be 55.8% across the global population, though the frequency varied greatly among different countries.

Relugolix combination therapy in Black/African American women with symptomatic uterine fibroids: LIBERTY Long-Term Extension study

BACKGROUND

In the LIBERTY Long-Term Extension study, once-daily relugolix combination therapy (40 mg relugolix, estradiol 1 mg, norethindrone acetate 0.5 mg) substantially improved uterine fibroid-associated heavy menstrual bleeding throughout the 52-week treatment period in the overall study population.

OBJECTIVE

Black or African American women typically experience a greater extent of disease and symptom burden of uterine fibroids vs other racial groups and have traditionally been underrepresented in clinical trials. This secondary analysis aimed to assess the efficacy and safety of relugolix combination therapy in the subgroup population of Black or African American women with uterine fibroids in the LIBERTY Long-Term Extension study.

STUDY DESIGN

Black or African American premenopausal women (aged 18-50 years) with uterine fibroids and heavy menstrual bleeding who completed the 24-week randomized, placebo-controlled, double-blind LIBERTY 1 (identifier: NCT03049735) or LIBERTY 2 (identifier: NCT03103087) trials were eligible to enroll in the 28-week LIBERTY Long-Term Extension study (identifier: NCT03412890), in which all women received once-daily, open-label relugolix combination therapy. The primary endpoint of this subanalysis was the proportion of Black or African American treatment responders: women who achieved a menstrual blood loss volume of <80 mL and at least a 50% reduction in menstrual blood loss volume from the pivotal study baseline to the last 35 days of treatment by pivotal study randomized treatment group. The secondary outcomes included rates of amenorrhea and changes in symptom burden and quality of life.

RESULTS

Overall, 241 of 477 women (50.5%) enrolled in the LIBERTY Long-Term Extension study self-identified as Black or African American. In Black or African American women receiving continuous relugolix combination therapy for up to 52 weeks, 58 of 70 women (82.9%; 95% confidence interval, 72.0%-90.8%) met the treatment responder criteria for reduction in heavy menstrual bleeding (primary endpoint). A substantial reduction in menstrual blood loss volume from the pivotal study baseline to week 52 was demonstrated (least squares mean percentage change: 85.0%); 64.3% of women achieved amenorrhea; 59.1% of women with anemia at the pivotal study baseline achieved a substantial improvement (>2 g/dL) in hemoglobin levels; and decreased symptom severity and distress because of uterine fibroid-associated symptoms and improvements in health-related quality of life through 52 weeks were demonstrated. The most frequently reported adverse events during the cumulative 52-week treatment period were hot flush (12.9%), headache (5.7%), and hypertension (5.7%). Bone mineral density was preserved through 52 weeks.

CONCLUSION

Once-daily relugolix combination therapy improved uterine fibroid-associated heavy menstrual bleeding in most Black or African American women who participated in the LIBERTY Long-Term Extension study. The safety and efficacy profile of relugolix combination therapy in Black or African American women was consistent with previously published results from the overall study population through 52 weeks. Findings from this subanalysis will assist shared decision-making by helping providers and Black or African American women understand the efficacy and safety of relugolix combination therapy as a pharmacologic option for the management of uterine fibroid-associated symptoms.

Association between serum vitamin D status and uterine leiomyomas: a case-control study

OBJECTIVE

Uterine leiomyoma is a common gynecological condition that negatively affects women's quality of life. Vitamin D plays an important role in tumor development and progression. However, clinical studies comparing serum vitamin D levels between women with and without uterine leiomyomas are limited and inconclusive. This study aimed to compare serum vitamin D levels in women with and without uterine leiomyomas.

METHODS

This hospital-based case-control study included 150 women who visited a gynecological clinic. The cases included 75 women with uterine leiomyoma, whereas the controls included 75 age-and parity-matched participants without uterine leiomyoma. Serum vitamin D levels were measured in each participant and volumes of the uterine leiomyomas were determined using the water displacement method following myomectomy. The statistical significance was inferred at P<0.05.

RESULTS

The mean serum vitamin D level was 15.26±4.96 ng/mL and 22.45±6.93 ng/mL for the case and control groups, respectively. The difference was statistically significant (t-value -7.302 and P<0.001). Within the fibroid group, nine (12.0%), 49 (65.33%), and 17 (22.67%) participants had vitamin D deficiency, insufficiency, and sufficiency, respectively; and in the control group, two (2.67%), 24 (45.33%), and 39 (52.0%) participants had vitamin D deficiency, insufficiency, and sufficiency, respectively. There was significant negative correlation between the fibroid volume and the serum vitamin D level (r=-0.591, P<0.001).

CONCLUSION

Women with uterine leiomyoma had lower vitamin D levels than women in the control group. Lower vitamin D levels were associated with larger fibroid masses. Therefore, vitamin D supplementation may reduce fibroid growth and development.

Risk of hysterectomy at the time of myomectomy: an underestimated surgical risk

OBJECTIVE

To evaluate the risk of hysterectomy at the time of myomectomy and the associated 30-day postoperative morbidity.

DESIGN

Cohort study.

PATIENTS

Patients who underwent myomectomies identified from the American College of Surgeons' National Surgical Quality Improvement Program from 2010 to 2021.

INTERVENTION

Unplanned hysterectomy at the time of a myomectomy procedure.

MAIN OUTCOME MEASURES

The Current Procedural Terminology codes were used to identify myomectomies performed with or without concurrent hysterectomy. Preoperative characteristics and morbidity outcomes were obtained. The univariate analysis was performed using the chi-square and Fisher exact tests, as appropriate. Multivariate logistic regression reported risk factors for individuals who underwent hysterectomy at the time of myomectomy. P values of <.05 were considered statistically significant.

RESULTS

A total of 13,213 individuals underwent myomectomy, and 399 (3.0%) had a hysterectomy performed during myomectomy. Concurrent hysterectomy was most frequently performed with the laparoscopic approach (7.1%), followed by the abdominal (3.2%) and hysteroscopic (1.9%) approaches. Age ≥43 years, obesity class II and higher, American Society of Anesthesiologists (ASA) class greater than II, tobacco use, longer operative time (>85 minutes), and laparoscopic approach were associated with a significantly increased risk of hysterectomy. When adjusting for age, body mass index, race, ASA class, case type, surgical approach, operative time, preoperative transfusion, preoperative hematocrit, and high fibroid burden, an increased odds of hysterectomy was noted for white race, longer operative time, ASA class III or higher, obesity, laparoscopic approach, and low fibroid burden. Patients who underwent concurrent hysterectomy had a longer median length of hospital stay (2 vs. 1 day), longer median operative time (161 vs. 126 minutes), increased intraoperative/postoperative blood transfusions (14.5% vs. 9.0%), and higher rates of organ/space surgical site infections (1.5% vs. 0.5%) and return to surgery (2.0% vs. 0.7%) than those who did not (P<.05). The risk of a major complication within 30 days of myomectomy increased in patients who underwent concurrent hysterectomy after adjusting for relevant confounders (adjusted odds ratio, 2.4; 95% confidence interval, 1.8-3.2).

CONCLUSION

The risk of hysterectomy during a myomectomy is higher than previously reported. The patient age of ≥43 years, obesity, white race, ASA class III or higher, longer operative time, and laparoscopic approach were associated with higher odds of hysterectomy. Identification of patients with these risk factors can aid in patient counseling and surgical planning, which may help reduce the unexpectedly high rates of hysterectomy at planned myomectomy.

Assessment of a Digital Symptom Checker Tool's Accuracy in Suggesting Reproductive Health Conditions: Clinical Vignettes Study

BACKGROUND

Reproductive health conditions such as endometriosis, uterine fibroids, and polycystic ovary syndrome (PCOS) affect a large proportion of women and people who menstruate worldwide. Prevalence estimates for these conditions range from 5% to 40% of women of reproductive age. Long diagnostic delays, up to 12 years, are common and contribute to health complications and increased health care costs. Symptom checker apps provide users with information and tools to better understand their symptoms and thus have the potential to reduce the time to diagnosis for reproductive health conditions.

OBJECTIVE

This study aimed to evaluate the agreement between clinicians and 3 symptom checkers (developed by Flo Health UK Limited) in assessing symptoms of endometriosis, uterine fibroids, and PCOS using vignettes. We also aimed to present a robust example of vignette case creation, review, and classification in the context of predeployment testing and validation of digital health symptom checker tools.

METHODS

Independent general practitioners were recruited to create clinical case vignettes of simulated users for the purpose of testing each condition symptom checker; vignettes created for each condition contained a mixture of condition-positive and condition-negative outcomes. A second panel of general practitioners then reviewed, approved, and modified (if necessary) each vignette. A third group of general practitioners reviewed each vignette case and designated a final classification. Vignettes were then entered into the symptom checkers by a fourth, different group of general practitioners. The outcomes of each symptom checker were then compared with the final classification of each vignette to produce accuracy metrics including percent agreement, sensitivity, specificity, positive predictive value, and negative predictive value.

RESULTS

A total of 24 cases were created per condition. Overall, exact matches between the vignette general practitioner classification and the symptom checker outcome were 83% (n=20) for endometriosis, 83% (n=20) for uterine fibroids, and 88% (n=21) for PCOS. For each symptom checker, sensitivity was reported as 81.8% for endometriosis, 84.6% for uterine fibroids, and 100% for PCOS; specificity was reported as 84.6% for endometriosis, 81.8% for uterine fibroids, and 75% for PCOS; positive predictive value was reported as 81.8% for endometriosis, 84.6% for uterine fibroids, 80% for PCOS; and negative predictive value was reported as 84.6% for endometriosis, 81.8% for uterine fibroids, and 100% for PCOS.

CONCLUSIONS

The single-condition symptom checkers have high levels of agreement with general practitioner classification for endometriosis, uterine fibroids, and PCOS. Given long delays in diagnosis for many reproductive health conditions, which lead to increased medical costs and potential health complications for individuals and health care providers, innovative health apps and symptom checkers hold the potential to improve care pathways.

In-bag extraction of tissue through an incision in the posterior vaginal wall in laparoscopic myomectomy: a large retrospective study

BACKGROUND

Our purpose was to describe the outcomes of transvaginal in-bag tissue extraction tissue through an incision in the posterior vaginal wall the middle part incision of posterior vagina in laparoscopic myomectomy.

METHODS

This was a retrospective study of patients who received laparoscopic myomectomy and in-bag tissue extraction through an incision in the posterior vaginal wall between January 2016 and December 2022. Patient characteristics, intra- and post-operative complications, and outcomes were collected and analyzed.

RESULTS

A total of 511women were included in the analysis. The mean largest myoma diameter was 8.44 ± 3.56 cm; mean specimen weight was 789.23 ± 276.97 g; mean operative time was 129.01 ± 53.13minutes; and mean blood loss was 175.99 ± 210.96 mL. Within 30-days of surgery, no fever, infection, or vaginal bleeding was noted in any patient, and the vaginal incisions of all patients had healed well. There were no incisional hernias, pelvic infections, and vaginal adhesions noted at follow-up 3 months after the operation. There were 37 cases of vaginal delivery of the patients after surgery, and there were no lacerations of the posterior wall vaginal incision.

CONCLUSIONS

Transvaginal in-bag extraction though an incision in the posterior vaginal wall is feasible and safe for removing tissue after laparoscopic myomectomy.

Describing the Patient Journey of Women with Claims for Uterine Fibroids and Heavy Menstrual Bleeding Using a Commercial Database (2011-2020)

Introduction

This retrospective database claims analysis describes the clinical characteristics and treatment patterns of commercially insured United States women with uterine fibroids (UF) and heavy menstrual bleeding (HMB).

Methods

Women age 18-55 years with an incident UF diagnosis (index date) between 1/1/2012 and 12/31/2019 and ≥1 claim for HMB (UF-HMB), were identified from the Optum® Clinformatics® database. Outcomes included clinical characteristics, pharmacologic therapy use, and surgeries/procedures. Regression models were used to identify factors associated with time to post-diagnosis hormonal therapy and hysterectomy.

Results

A total of 85,428 women had UF-HMB (mean [SD] age, 43.7 [6.4] years). The median follow-up was 3.2 years. After HMB, the most common symptoms were pelvic pressure/pain (27.6%) and backache (17.5%). Within 6 months of UF diagnosis, 40.2% of patients had received only pharmacologic therapy; 25.5% had received no treatment; 24.3% had a hysterectomy, and 10.0% had other procedures. By the end of follow-up, 50.0% had received a hysterectomy. Multiple factors were predictive of a higher likelihood of receiving hormonal therapy (geographic region, infertility, pre-index pregnancy) or hysterectomy (older age, prior hormonal treatment, specific bulk symptoms, White race).

Conclusion

Within 6 months of UF diagnosis, fewer than one-half of women with UF-HMB had received hormonal therapy, one-quarter received no treatment, and one-quarter had received a hysterectomy or another gynecologic procedure. Patients who received a hysterectomy were more likely to be older, White, and to have bulk symptoms.

A subserosal uterine leiomyoma complicated with intra-abdominal haemorrhage: A case report

Uterine leiomyomas, or fibroids, are the most common benign tumours of the female genital tract. Although uterine fibroids are commonly associated with menorrhagia, dysmenorrhea, symptomatic anaemia, urinary or bowel symptoms and infertility, intra-abdominal haemorrhage is an exceedingly rare complication. Often, the diagnosis is poorly recognizable based on the patient's clinical presentation and alternative diagnoses such as ruptured ectopic pregnancy, ruptured ovarian cyst or perforated viscus are frequently considered. Herein, we describe a case of a 50-year-old perimenopausal woman who presented with acute, lower abdominal pain, evolving anaemia, hypovolaemic shock and haemoperitoneum with no discernable source. Emergency exploratory laparotomy confirmed the source of massive haemoperitoneum arising from a ruptured blood vessel supplying a large subserosal uterine leiomyoma and the patient subsequently underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy. Given the paucity of publications on this clinical entity, the aim of this report is to highlight a rare complication of uterine leiomyomas, its pathophysiological spectrum and its relevance to emergency physicians, general surgeons and gynaecologists.

Serum versican as a potential biomarker in patients with uterine fibroids: A study from Eastern India

Objective

Versican is a chondroitin sulphate proteoglycan with raised expression at site of inflammation, and uterine fibroids are associated with local inflammation. Hence, this study aimed to estimate serum Versican levels in pre-menopausal women with uterine fibroids to evaluate its diagnostic efficiency.

Materials and Methods

This case-control study included forty uterine fibroid cases and 40 healthy controls. Cases clinically evaluated with USG findings, that is number, location of fibroid and volume calculated by prolate ellipse formula a × b × c × 0.523 (a - height, b - width, c - depth). Biochemical investigations, that is serum Versican levels, were estimated by ELISA with total cholesterol, HDLc and LDLc. Triglycerides by fully automated chemistry analysers. Serum biochemical parameters were compared and correlated with volume of fibroid. Area under receiver operating characteristic curve was calculated along with cut-off value to determine diagnostic potential of Versican, differentiating women with fibroids.

Results

In the present study, patients with fibroids had decreased levels of serum Versican (79.43 ± 18.60) as compared to healthy controls (101.81 ± 28.24, P < 0.001). There was a statistically significant negative correlation (r = - 0. 307, P = 0.04) between serum Versican level and volume of fibroid. Area under ROC was 0.726 (95% CI: 0.616-0.836; P = 0.001). The best cut-off value for serum Versican level was 96.90 ng/ml with 90% sensitivity and 48% specificity.

Conclusion

Serum Versican levels were found significantly lower in women with fibroid with a negative correlation with volume of fibroid uterus. Furthermore, extensive study would help in substantiating diagnostic potential of serum Versican in fibroid uterus patients.

Increased Risk of Breast Fibroadenomas Among Obese and Postmenopausal Women With Uterine Fibroids

Introduction Uterine fibroids and breast fibroadenomas are common female benign neoplasms that are similarly derived from a single clonal origin and are modulated by estradiol concentration in blood. However, the association between these neoplasms has not yet been explored. Hence, this study aims to investigate the relationship between uterine fibroids and breast fibroadenomas.  Methods A total of 199 women (cases: 72 women with uterine fibroids, control: 127 women without uterine fibroids) were included in this study. Ultrasound was used to screen for uterine fibroids, and both ultrasound and biopsy were utilized to diagnose breast fibroadenomas. Logistic regression analysis was used to investigate the association between uterine fibroids and breast fibroadenomas and the factors associated with the relationship. Results Women with uterine fibroids have more than two times higher odds of having breast fibroadenomas among older women (p=0.03), more than twofold increased odds of breast fibroadenomas among obese females (p=0.05), and higher odds of having breast fibroadenomas among postmenopausal transition participant groups (OR=9.6; 95% CI 1.98-30.14; p-value=0.005).  Conclusion The association between uterine fibroids and breast fibroadenomas is significantly pronounced among older, obese, and postmenopausal women. This relationship might be driven by the indirect stimulation of estrogen hormone receptors via adipose tissue or other lifestyle as well as genetic factors. Therefore, further larger prospective studies considering these factors are needed to replicate the current findings.

Contemporary approaches in the management of uterine leiomyomas

BACKGROUND

Leiomyomas (fibroids), the most common benign solid tumours in females, originate from the myometrium and are associated with poor quality of life for patients. The current management of uterine leiomyomas mainly includes surgical interventions such as hysterectomy and myomectomy, either by laparoscopy or laparotomy, which have several complications and are not ideal for preserving fertility. Therefore, there is a need to develop or repurpose medical treatments that do not require surgical intervention.

OBJECTIVE

Many drugs are used to treat the symptoms associated with uterine fibroids. The main objective of this systematic review is to give an up-to-date account of potential pharmacological agents (non-surgical methods) for the management of uterine leiomyomas.

SEARCH STRATEGY

PubMed was searched for scientific and clinical literature using the keyword 'uterine fibroids' along with the drug names described in each section. For example, 'uterine fibroids' and 'ulipristal acetate' were the keywords used to search for literature on ulipristal acetate (UPA).

RESULTS

Various preclinical and clinical studies have shown that some drugs and herbal formulations exhibit activity in the management of uterine leiomyomas. Recent studies found that drugs such as UPA, elagolix, EC313, asoprisnol, nutritional supplements and herbal preparations were helpful in treating the symptoms associated with uterine leiomyomas.

CONCLUSION

Many drugs show efficacy in patients with symptomatic uterine fibroids. UPA is one of the most studied and prescribed medicines for uterine fibroids; however, its usage has been restricted due to a few recent incidences of hepatic toxicity. Herbal drugs and natural supplements have also shown promising effects on uterine fibroids. The synergistic effects of nutritional and herbal supplements have been reported in certain cases, and should be studied in detail. Further research is warranted to identify the mode of action of the drugs, and to determine the precise conditions that would explain the causes of toxicity in some patients.

Rare clinical entity of huge leiomyoma uteri in a 17-year-old adolescent managed with a fertility-sparing procedure: Case report and literature review

INTRODUCTION AND IMPORTANCE

The most frequent benign uterine tumor is uterine fibroids. Approximately, 20 to 30 % of women between the ages of 30 and 50 have them. Teenagers do, however, rarely experience them; the prevalence is less than 1 % in general population.

CASE PRESENTATION

We present a 17-year-old nulliparous female who was admitted to the hospital due to gradually increasing abdominopelvic pain. Transabdominal pelvic ultrasound showed massive uterine enlargement, with a heterogenous structure within the fundus measuring 9.8 cm in diameter. Pelvic MRI revealed an enlarged uterus with a heterogeneous complex mass measuring 10.78 cm by 8 cm that seemed to be compressing but was not attached to the endometrium The findings from the radiology review were concerning for leiomyoma. Intraoperative findings showed a 13-cm anterior intramural mass with normally appearing fallopian tubes and ovaries bilaterally. Resection of the mass was done, and the entire specimen was sent to pathology which confirmed the diagnosis of leiomyoma.

DISCUSSION

Occurrence of uterine fibroids in the young and adolescent age is extremely rare with an estimated prevalence of less than 1 %. Leiomyosarcoma is a less frequent diagnosis to take into account, but it can be identified histologically. Therefore, a myomectomy that preserves fertility enables a diagnostic chance to rule out a probable cancer.

CONCLUSION

When young women present with steadily worsening abdominopelvic discomfort, it is crucial to include leiomyomas in the differential diagnosis despite the rarity of leiomyomas in adolescents.

Diagnosis and management of uterine fibroids: current trends and future strategies

Uterine fibroids (UFs), leiomyomas or myomas, are a type of malignancy that affects the smooth muscle of the uterus, and it is most commonly detected in women of reproductive age. Uterine fibroids are benign monoclonal growths that emerge from uterine smooth muscle cells (myometrium) as well as fibroblasts. Uterine fibroid symptoms include abnormal menstrual bleeding leading to anaemia, tiredness, chronic vaginal discharge, and pain during periods. Other symptoms include protrusion of the abdomen, pain during intercourse, dysfunctions of bladder/bowel leading to urinary incontinence/retention, pain, and constipation. It is also associated with reproductive issues like impaired fertility, conceiving complications, and adverse obstetric outcomes. It is the leading cause of gynaecological hospitalisation in the American subcontinent and a common reason for the hysterectomy. Twenty-five percent of the reproductive women experience the symptoms of uterine fibroids, and among them, around 25% require hospitalization due to the severity of the disease. The frequency of the disease remains underestimated as many women stay asymptomatic and symptoms appear gradually; therefore, the condition remains undiagnosed. The exact frequency of uterine fibroids varies depending on the diagnosis, and the population investigated; nonetheless, the incidence of uterine fibroids in reproductive women ranges from 5.4 percent to 77 percent. The uterine fibroid treatment included painkillers, supplementation with iron, vitamin D3, birth control, hormone therapy, gonadotropin-releasing hormone (GnRH) agonists, drugs modulating the estrogen receptors, and surgical removal of the fibroids. However, more research needed at the level of gene to get a keen insight and treat the disease efficiently.

Ovarian Fibroma Presents As Uterine Leiomyoma in a 61-Year-Old Female: A Case Study

Uterine leiomyoma should be considered when a female patient reports symptoms of abdominal pressure and abnormal vaginal bleeding. However, the symptoms of a uterine leiomyoma are vast and overlap with other possible diseases that are difficult to distinguish even with imaging studies. This is why it is important for physicians and healthcare providers to keep an open mind and have a broad differential diagnosis.  In this case study, we present a 61-year-old postmenopausal female patient who presented to the emergency department with complaints of pelvic and abdominal pain, as well as vomiting and diarrhea. She was admitted for observation. A complete blood count (CBC), comprehensive metabolic panel (CMP), and urinalysis revealed no abnormalities; a pelvic ultrasound and CT scan reported possible adnexal torsion. The patient remained stable and the pain had subsided when she was seen the next morning by her gynecologist (GYN) who discharged her to follow-up in the office. Subsequent examinations that aided in the diagnosis included, but were not limited to pelvic and transvaginal ultrasounds, an abdominal and pelvic CT, and a pelvic MRI. In this case, the MRI revealed an 11-cm mass that could represent a torsioned pedunculated necrotic fibroid originating from the uterus. Radiology recommended surgical removal. Upon removal and review of the pathology of the mass, it was revealed to be a torsioned, partially necrotic fibroma that had originated from the ovary and not from the uterus, as imaging had originally suggested.

Treatment Patterns in Patients with Uterine Fibroids With and Without a Diagnosis of Heavy Menstrual Bleeding: Results from a Large U.S. Claims Database

Background: This retrospective database analysis describes clinical characteristics and treatment patterns of U.S. women with a diagnosis for uterine fibroids (UF), both with and without heavy menstrual bleeding (HMB). Materials and Methods: Two cohorts aged 18-50 years with an incident UF diagnosis, comprising women with and without claims for HMB (UF-HMB and UF-only), were identified from the IQVIA PharMetrics® Plus database (January 1, 2010-December 31, 2019). The index date was the first UF claim following diagnosis; treatment patterns were documented for postindex years 1 and 2 and the full duration of postindex follow-up. Also identified were claims for symptoms or signs potentially associated with UF. Outcomes were the proportion of patients treated with pharmacologic therapies of interest and gynecologic procedures. Logistic regression was used to identify factors associated with postdiagnosis hysterectomy and hormonal therapy. Results: A total of 66,313 (71.8%) women were included in the UF-HMB cohort (mean age [standard deviation]) 42.6 [5.4] years), and 26,068 (28.2%) in the UF-only cohort (41.8 [6.3]). Median follow-up was ∼4 years. Pain was the most common symptom (42.7% in patients with UF-HMB and 36.6% with UF-only); also common were abnormal bleeding (15.6%, 11.5%) and fatigue (22.2%, 15.5%). Within 1 year of UF diagnosis, 28.8% and 49.2% of women with UF-HMB and UF-only, respectively, had no claims for relevant pharmacologic or surgical treatment. In logistic regression, multiple factors were associated with a higher likelihood of receiving hysterectomy or hormonal therapy. Conclusions: Patients with UF-HMB were more likely to receive UF treatment, either surgical or pharmacologic, than women with UF-only. Apart from HMB, pain was the most commonly documented symptom of UF.

"I think people should be more aware:" Uterine fibroid experiences among women living in Indiana, USA

OBJECTIVE

To understand healthcare experiences among patients with uterine fibroids (fibroids) across the continuum of care, from early symptoms through diagnosis, treatment, and management, while also investigating health disparities.

METHODS

We conducted 20 semi-structured interviews with patients with fibroids. Interviews were transcribed verbatim and qualitatively analyzed using thematic analysis. Eligible participants were women aged 18 and over, residing within 75 miles of one of the two recruitment locations (Tippecanoe or Marion County) in Indiana, USA.

RESULTS

Women experienced myriad physical symptoms, which often manifested into psychological and sexual disturbances and infiltrated all aspects of daily life. Internet searches were frequently mentioned as their main information source. Fertility became a prominent factor in deciding treatment options. However, health disparities prevented some from receiving quality fibroids healthcare. Some women reported staying home during COVID-19 pandemic facilitated the management of physical symptoms. Overall, participants advocated for greater fibroids awareness and education.

CONCLUSION

Results highlight barriers and facilitators to fibroids-related decisions, behaviors, and outcomes. Translation of research to practice was guided by a combined Social-Ecological Model and social determinants of health framework for development of strategic interventions.

PRACTICE IMPLICATIONS

Interventions should aim to improve fibroids healthcare access, education and awareness, and patient-provider communication for minority, rural, and low socioeconomic status communities disproportionately impacted by fibroids.

Accidental Morcellation of Uterine Leiomyosarcoma Influences Relapse Free Survival but Does Not Negatively Influence Overall Survival

Background: Uterine leiomyosarcoma (LMS) is a rare entity amongst malignant gynaecological tumours and is mostly diagnosed after surgery for benign leiomyoma (LM) of the uterus. As minimal invasive surgery is widely used, the morcellation of LM and the uterus is rather common. As there is little known about the impact of the morcellation of LMS on local and distant metastases, as well as overall survival, we carried out a large-scale retrospective study. Methods: A total of 301 LMS cases from the German Clinical Competence Centre for Genital Sarcomas and Mixed Tumours were analysed. We distinguished morcellated and non-morcellated LMS from pT1 and >pT1 tumours. Fine−Gray competing risks regressions and cumulative incidence rates were computed for the time to local recurrence, distant metastases, and patient death. Results: The recurrence free interval in pT1 LMS was significantly lower in the morcellation group with a 2-year cumulative incidence rate of 49% vs. 26% in non-morcellated LMS (p = 0.001). No differences were seen in >pT1 tumours. Distant metastases were more frequently found in non-morcellated pT1 LMS compared to the morcellated cases (5-year cumulative incidence: 54% vs. 29%, p < 0.001). There was no significant difference in time to death between both groups neither in the pT1 stages nor in >pT1 disease. Subdistribution hazard ratios estimated by multivariable competing risks regressions for the morcellation of pT1 LMS were 2.11 for local recurrence (95% CI 1.41−3.16, p < 0.001) and 0.52 for distant metastases (95% CI 0.32−0.84, p = 0.008). Conclusions: Tumour morcellation is not associated with OS for pT1 tumours. The morcellation of pT1 LMS seems to prolong the time to distant metastases whereas local recurrence is more likely to occur after the morcellation of pT1 LMS.

Genetic Contribution of the Adrenergic, Cholinergic, and Serotonergic Systems to Leiomyoma Development and Treatment

The link between the autonomic nervous system and tumor biology is being unfold. We aim to study the contribution of genes of the adrenergic (ADBR2 - rs1042713, NM_000024.6:c.46G>A, NP_000015.2:p. Gly16Arg), cholinergic (CHRNA5 - rs16969968, NM_000745.3:c.1192G>A, NP_000736.2:p.Asp398Asn), and serotonergic systems (SLC6A4 - 5-HTTVNTR-intron2, HTR2A - rs6313, NM_000621.5:c.102C>T, NP_ 001365853 .1: p. Ser 34=) to gynecological tumorigenesis and their treatment by embolization. A total of 517 DNA samples from women were analyzed. Samples were genotyped by PCR, PCR-RFLP and EndPoint genotyping. Results show a statistically significant association between the AA genotype of the ADBR2 gene and GG genotype of the CHRNA5 gene with leiomyoma (OR = 2.311; p = 0.003 and OR = 2.165; p = 0.001, respectively), and the epistatic interaction between genotypes increases the risk (OR = 2.458; p= 0.043). The GG genotype (CHRNA5) shows a lower reduction of the volume of the main leiomyoma after treatment (p=0.015). Combination of the genotypes 12/12-AA (SLC6A4 - ADBR2) increases the risk to leiomyoma (OR = 2.540, p= 0.030). TT genotype of HTR2A gene in combination with any of the two risk genotypes (of ADBR2 or CHRNA5) increases substantially the risk (OR = 5.266, p = 0.006; OR = 6.364, p=0.007, respectively). We conclude that ADBR2 and CHRNA5 genes have a relevant role that is enhanced by the epistatic relationship with the genes HTR2A and SLC6A4. CHRNA5 gene may also be a modulator of the success of embolization. We confirm the contribution of the genetics of Autonomous Nervous System to tumor biology.

Assessment of the Clinical Presentations and Ultrasonographic Features of Uterine Fibroids in Adult Africans: A Retrospective Study

Objectives

We sought to determine the clinical presentations and ultrasonographic features of uterine fibroids in adult Ghanaians.

Methods

Between 1 January 2018 and 31 December 2021, 4279 ultrasound-confirmed cases of uterine fibroids were retrieved. The data obtained, which included age, clinical presentations, and sonographic features were analyzed. A chi-squared test was done to assess for possible associations between the clinical indications, age distribution, and ultrasonographic features of uterine fibroids.

Results

The mean age of the patients diagnosed with uterine fibroids was 37.1±11.5 years (range = 16-69 years). Routine checkup (n = 1310, 28.1%), menorrhagia (n = 1104, 23.7%), and lower abdominal mass (n = 801, 17.2%) were the leading clinical indications. Dysmenorrhea, amenorrhea, menorrhagia, and routine checkup were significantly noted in the younger patients (p ≤ 0.001). The majority of the fibroid nodules had smooth regular outline (n = 4125, 96.4%) and were mostly heterogeneous (n = 3282, 76.7%). The echo pattern of the nodules was predominantly hypoechoic (n = 3358, 51.1%) followed by hyperechoic nodules (n = 2554, 38.9%). Degenerative changes accounted for less than one-third of the total fibroid nodules, with the least recorded degenerative change being nodules with cystic areas (n = 55, 5.4%) and the most observed degenerative feature being nodules with rim of calcification and areas of calcified degeneration (n = 965, 94.6%). Almost all the sonographic features were significantly seen in the 30-44 years age category.

Conclusions

Sonographically, uterine fibroids were mostly hypoechoic heterogeneous nodules with a smooth regular outline with a predominant occurrence within women in the fourth to fifth decade of life.

Pain, Nausea, and Hospital Admission after Uterine Fibroid Embolization: A Comparison of 2 Protocols

Uterine fibroid embolization (UFE) procedures performed from 2013 to 2019 were reviewed. Seventy-two patients were treated with a standard protocol consisting of sedation, ketorolac, ondansetron, and overnight parenteral analgesics and antiemetics. Ninety-six patients were treated with a new protocol, which added transdermal scopolamine, lorazepam, and intravenous acetaminophen. Outpatient uterine fibroid embolization (OP-UFE) not requiring hospitalization was successful in 81.4% and 2.7% of patients treated with the new and old protocols, respectively (odds ratio [OR], 141.4; P < .0001). Procedural fentanyl doses were lower with the new protocol than with the old one (mean, 148 vs 186 mcg; P = .0016). In the new protocol subset, patients were 1.01 times more likely to fail OP-UFE for every microgram increase in procedural fentanyl (OR, 0.99, P = .009), and those presenting with pain were less likely to succeed with OP-UFE than those with bleeding or bulk symptoms (OR, 0.31, P = .04). In conclusion, decreasing the opioid dose while increasing the antiemetic and nonopioid analgesic medications improves the chances of same day discharge after UFE.

Long term follow-up of uterine fibroids treated with microwave ablation: an up to 3-year observational study of volume, regrowth, and symptoms

OBJECTIVE

To study long-term effects in patients treated with microwave ablation (MWA) for symptomatic uterine fibroids and investigate fibroid characteristics predictive of successful treatment.

METHOD

Women who received MWA treatment for uterine fibroids in a previous study were included. A total of 16 patients underwent contrast enhanced MRI before treatment, postoperatively at 6 months and at long-term follow-up, to assess volumes of treated fibroids (n = 42). Long-term MRI was performed between 16 and 36 months after treatment [median 22 months, interquartile range (IQR) 18.5-27]. Validated questionnaires for evaluation of uterine fibroid symptoms and menstrual bleeding (UFS-QoL and PBAC) were used to assess long-term effects on symptoms. The degree of shrinkage was correlated to vascularization and T2 signal intensity (SI) at preoperative MRI and location of fibroids according to the FIGO classification, using the Mann-Whitney U test.

RESULTS

Most patients (82%) reported improvement up to 3 years after treatment. Out of 42 treated fibroids, 35 (83%) continued to shrink over time with median relative volume reduction of 77% (IQR 39-95). For eight fibroids (19%) which showed low vascularization on the pretreatment MRI, there was less shrinkage compared to well-vascularized fibroids (p = 0.01). Most fibroids (79%) showed iso- to hyperintense T2 signal on preoperative MRI and showed a higher grade of shrinkage than hypointense fibroids (p = 0.02).

CONCLUSION

After microwave treatment improvement is maintained for most patients up to 36 months and most fibroids showed continuous shrinkage. Preoperative vascularization, high T2 SI and submucosal location predicted continuous volume reduction. However, to confirm this, larger studies are needed.

Histotripsy for the Treatment of Uterine Leiomyomas: A Feasibility Study in Ex Vivo Uterine Fibroids

Uterine fibroids (leiomyomas), the most common benign tumors in women of reproductive age, are a frequent cause of abnormal vaginal bleeding and other reproductive complaints among women. This study investigates the feasibility of using histotripsy, a non-invasive, non-thermal focused ultrasound ablation method, to ablate uterine fibroids. Human fibroid samples (n = 16) were harvested after hysterectomy or myomectomy procedures at Carilion Memorial Hospital. Histotripsy was applied to ex vivo fibroids in two sets of experiments using a 700-kHz clinical transducer to apply multicycle histotripsy pulses and a prototype 500-kHz transducer to apply single-cycle histotripsy pulses. Ultrasound imaging was used for real-time treatment monitoring, and post-treatment ablation was quantified histologically using hematoxylin and eosin and Masson trichrome stains. Results revealed that multicycle histotripsy generated diffuse cavitation in targeted fibroids, with minimal cellular ablative changes after treatment with 2000 pulses/point. Single-cycle pulsing generated well-confined bubble clouds with evidence of early coagulative necrosis on histological assessment in samples treated with 2000 pulses/point, near-complete ablation in samples treated with 4000 pulses/point and complete tissue destruction in samples treated with 10,000 pulses/point. This study illustrates that histotripsy is capable of fibroid ablation under certain pulsing parameters and warrants further investigation as an improved non-invasive ablation method for the treatment of leiomyomas.

Emerging Polymer Materials in Trackable Endovascular Embolization and Cell Delivery: From Hype to Hope

Minimally invasive endovascular embolization is a widely used clinical technique used for the occlusion of blood vessels to treat various diseases. Different occlusive agents ranging from gelatin foam to synthetic polymers such as poly(vinyl alcohol) (PVA) have been commercially used for embolization. However, these agents have some drawbacks, such as undesired toxicity and unintended and uncontrolled occlusion. To overcome these issues, several polymer-based embolic systems are under investigation including biocompatible and biodegradable microspheres, gelling liquid embolic with controlled occlusive features, and trackable microspheres with enhanced safety profiles. This review aims to summarize recent advances in current and emerging polymeric materials as embolization agents with varying material architectures. Furthermore, this review also explores the potential of combining injectable embolic agents and cell therapy to achieve more effective embolization with the promise of outstanding results in treating various devastating diseases. Finally, limitations and challenges in developing next-generation multifunctional embolic agents are discussed to promote advancement in this emerging field.

Uterine artery embolization technique for treatment of a huge multi myomatous uterus in a virgin woman

Introduction

Uterine artery embolization is a non-surgical method performed for large and numerous fibroids to preserve the fertility.

Case presentation

The patient is a 36-year-old virgin woman with menometrorrhagia, abdominal pressure, constipation, bilateral abdominal pain, frequent urination and a compressive effect on the intestines was reported to our center. She was diagnosed with uterine fibroids.

Discussion

Because the type of uterine masses and possibility of uncontrollable bleeding during myomectomy and hysterectomy, uterine vascular embolization by supra selective angiography to preserve the uterus was performed. Due to fever, pain and vaginal discharge, she was hospitalized again and hysterotomy was performed without any reported complications.

Conclusion

Uterine artery embolization is a safe method, however reduction and loss in ovarian function can be seen with the treatment. Measurement of follicle stimulating hormone and anti-Müllerian hormone before and after the treatment is important.

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Fibroids are very common, occur individually or in multiple myometrial smooth muscle cells.

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The patient is a 36-year-old virgin woman with menometrorrhagia, abdominal pressure.

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she was hospitalized again and hysterotomy was performed without any reported complications.

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It is also recommended to use egg storage with existing methods if possible, to maintain future fertility.

Human Myometrial and Uterine Fibroid Stem Cell-Derived Organoids for Intervening the Pathophysiology of Uterine Fibroid

Uterine fibroids (UFs) (leiomyomas or myomas) are the most common clonal neoplasms of the uterus in women of reproductive age worldwide. UFs originate from myometrium consist of smooth muscle and fibroblast components, in addition to a substantial amount of fibrous extracellular matrix which all contribute to the pathogenetic process. Current treatments are primarily limited to surgical and interventional. Here, we have established a novel and promising organoid model from both normal and patient myometrial stem cells (MMSCs). MMSCs embedded in Matrigel in stem cell media swiftly formed organoids which successfully proliferate and self-organized into complex structures developing a sustainable organoid culture that maintain their capacity to differentiate into the different cell types recapitulating their tissue of origin and shows responsiveness to the reproductive hormones (estrogen and progesterone). Gene expression analysis and structural features indicated the early onset of uterine fibrosis led to the accumulation of extracellular matrix suggesting the potential use of this model in better understanding of the pathophysiology associated with UFs and inventing novel therapeutics for the treatment of UFs.

Effects of total laparoscopic hysterectomy on the clinical outcomes of patients with uterine fibroids

OBJECTIVE

To clarify the effects of total laparoscopic hysterectomy (TLH) on sex hormone levels, quality of life (QOL) and complications such as lower-extremity deep vein thrombosis (DVT) in patients with uterine fibroids (UFs).

METHODS

In this retrospective study, 136 patients with UFs treated in Hainan General Hospital from March 2018 to December 2020 were collected as research participants, of which 65 patients received total abdominal hysterectomy (TAH) were included in the control group and 71 patients who received TLH were assigned to the research group. The two groups were compared regarding the following items: response rate, surgical indexes, rehabilitation indicators, changes in sex hormone levels and QOL, and the occurrence of lower-extremity DVT.

RESULTS

The research group showed a significantly higher response rate, and better indicators of surgical treatment and rehabilitation than the control group (P<0.05). The sex hormones in the research group were more stable than that in the control group. The QOL was also significantly better and the incidence of total complications was statistically lower in the research group compared with the control group (both P<0.05).

CONCLUSIONS

TLH is a feasible and safe alternative than traditional TAH for UFs, as it can effectively improve patients' sex hormone levels and QOL, and reduce the incidence of complications, which is worthy of clinical promotion.

Vaginal leiomyoma mimicking a Cystocele (report case)

Introduction and importance

Case presentation

Clinical discussion

Conclusion

A Case Report of the Largest Submucosal Uterine Leiomyoma Removed by Single-Session Hysteroscopic Myomectomy in the Caribbean

Minimally invasive gynecological surgery is rapidly evolving in the Caribbean. Hysteroscopic myomectomy is the procedure of choice for the removal of submucosal uterine leiomyomas. In Trinidad and Tobago, advancements in minimally invasive surgery have allowed submucosal myomectomies to be performed hysteroscopically with results that are on par with international standards of care. This report highlights a successful hysteroscopic myomectomy performed for the largest submucosal uterine leiomyoma documented in the Caribbean.

The Burden of Uterine Fibroids from the Perspective of US Women Participating in Open-Ended Interviews

BACKGROUND

Research on women's perspective of uterine fibroids (UF) experiences using their own words is limited. This study aimed to provide new insights on the symptoms experienced and their impacts on daily life.

METHODS

Interview substudy in 30 US women with heavy menstrual bleeding (HMB) associated with UF who completed one of two phase 3, randomized, double-blind, placebo-controlled trials (LIBERTY 1 and 2; ClinicalTrials.gov identifiers: NCT03049735, NCT03103087). Women who consented to participate in this substudy were interviewed after their last clinical trial study visit. Concepts (i.e., symptoms and impacts) of importance to women were determined via open-ended questions, and the frequency of symptoms and their impacts, including the relationship between pain and menstruation, were assessed. Data were analyzed using established qualitative research methods, including grounded theory and constant comparative methods, and concept saturation was assessed.

RESULTS

Fifteen unique symptoms of UF emerged: the most commonly reported were HMB (n = 30, 100.0%), pelvic pain (n = 28, 93.3%), and passing of blood clots (n = 24, 80.0%). In total, 25 unique impacts were identified across eight concepts: physical impacts, activities of daily living, sleep, emotional impacts, sex life, social impacts, work and school, and financial impacts. Concept saturation was achieved for both symptoms and impacts.

CONCLUSION

This study provides data on the symptoms experienced by women with HMB associated with UF, as well as the negative impacts of these symptoms as reported using their own words. The study findings confirm the significant burden associated with symptomatic UF.

Historical Perspectives and Evolution of Menstrual Terminology

Abnormal uterine bleeding (AUB) in the reproductive years in non-pregnant women comprises a group of symptoms that include abnormal frequency and the irregular onset of flow as well as prolonged and heavy menstrual bleeding. It is a common, chronic, and debilitating condition affecting women worldwide with an adverse impact on their quality of life. Until the last decade, the “menstrual” terminology used to describe both normal and abnormal uterine bleeding and its underlying causes was inconsistent, creating considerable confusion. Using standardized terminology may potentially improve clinical management as well as help designing and interpreting basic, translational, epidemiological, and clinical research in women with menstrual problems. In this article, we explore the history and evolution of menstrual terminology and discuss the two International Federation of Gynecology and Obstetrics (FIGO) systems on i.e., (A) menstrual terminology and definitions (B) and the causes of AUB, achieved through international consensus of relevant stakeholders through a long multistage journey.

Ultrasound guided microwave ablation compared to uterine artery embolization treatment for uterine fibroids - a randomized controlled trial

OBJECTIVE

To evaluate the efficacy, feasibility and acceptability of microwave ablation (MWA) compared to uterine artery embolization (UAE) as treatment for uterine fibroids.

METHOD

A randomized controlled superiority trial, including premenopausal women 30-55 years, with symptomatic uterine fibroids without any single fibroid exceeding mean diameter of eight centimeters. Patients were randomized to receive microwave ablation, performed abdominally or vaginally, or to uterine artery embolization. The primary outcome was volume difference of the three largest fibroids at 6 months post treatment evaluated by magnetic resonance imaging (MRI) by a blinded radiologist analyzed by Mann-Whitney U-test. Secondary outcomes included symptom severity score (SSS), health related quality of life (HR-QoL), amount of menstrual bleeding, postoperative pain, length of hospitalization, need for additional treatment, adverse events and if patients would recommend the treatment to a friend.

RESULTS

Patients were recruited from 30 January 2017 to 12 September 2019, with a total of 17 patients treated in each group from May 2017 to December 2019. Superiority of MWA could not be established. The volume reduction was 41.8% (Interquartile range, IQR, 14-63) in the MWA group compared to 62.2% (IQR 34.9-80.1) in the UAE group (p = 0.29). Effects on symptoms, HR-QoL and acceptability did not differ between groups. Days of hospitalization and sick leave were significantly fewer in the MWA group (p < 0.001 and p = 0.001).

CONCLUSIONS

Although superiority of MWA could not be established, it is a promising technique for treating uterine fibroids. It was well tolerated and associated with lower use of health care resources. Trial registration: NCT02942537, www.clincialtrials.gov.

Spinal Cord Compression Secondary to Benign Metastasizing Leiomyoma

Benign metastasizing leiomyoma is an extremely rare disease characterized by the presence of extrauterine spread of smooth muscle cells with histological, molecular, and immunological patterns similar to those of benign uterine leiomyomas. Benign metastasizing leiomyoma is often asymptomatic, and it presents as an incidental radiology finding of well-defined multiple pulmonary nodules with varying sizes. It is more frequent in premenopausal women, and a previous history of uterine leiomyomas resected in the past is found in most of the cases. There are very few case reports of benign metastasizing leiomyoma causing spinal cord compression. The authors report an uncommon case of a premenopausal woman with spinal cord compression one year after the diagnosis of benign metastasizing leiomyoma to the lung. Given that spinal cord compression is an oncologic neurosurgical emergency, rapid diagnosis and management are essential to prevent irreversible neurological deficits.

Successful Laparoscopic-Assisted Supracervical Hysterectomy in a 14-Week-Sized Fibroid Uterus: An Autobiographical Case Report

Uterine leiomyomas are a very common gynecological condition. This case report describes the author’s experience pursuing definitive treatment of a 14-week-sized fibroid uterus, the associated menometrorrhagia, and bulk symptoms. Barriers still remain if women of reproductive age prefer ovary-sparing hysterectomy. Laparoscopic supracervical hysterectomy with contained morcellation remains a well-tolerated and low-risk option dependent on surgeon expertise and informed patient consent. Literature review reveals the psychosocial and financial burden of uterine leiomyomas may present multiple challenges, affecting the quality of life.

The association between vitamin D and uterine fibroids: A mendelian randomization study

Uterine fibroids (UFs), the most common benign gynecological tumor, can bring severe negative impacts on a woman's life quality. Vitamin D, is thought to play an important role in regulating cell proliferation and differentiation. In recent years, several studies suggested that higher level of vitamin D has a negative effect on the occurrence of UFs, but the results of studies on the relationship between them are conflicting and further evidence needs to be studied. Here in, we used a two-sample Mendelian Randomization (2SMR) study to explore the causal relationship between genetically predicted vitamin D levels and the risk of UFs. The exposure data comes from a genome-wide association study (GWAS) summary dataset consisting of 441,291 individuals, which includes datasets from United Kingdom Biobank, FinnGen Biobank and the corresponding consortia. Single-nucleotide polymorphisms (SNPs) associated with vitamin D at a significant level of p < 5 × 10^-8 and low linkage disequilibrium (LD) level (r² < 0.01) were selected. The outcome data comes from a GWAS dataset of IEU analysis of United Kingdom Biobank phenotypes consisting of 7,122 UFs cases and 455,811 controls. Our inverse-variance weight (IVW) analysis results support the causal association of genetically predicted vitamin D with the risk of UFs (OR = 0.995,95% CI = 0.990-0.999, p = 0.024). In addition, heterogeneity and pleiotropy were not observed in statistical models. In summary, our results indicate that elevated serum vitamin D levels are in strong relationship with reduction of the risk of UFs, which indicates that the clinical treatment of UFs may have a new and excellent option.

Uterine fibroids and incidence of depression, anxiety and self-directed violence: a cohort study

BACKGROUND

Depression and anxiety are prevalent among women with uterine fibroids (UF). The rate of mental health diagnoses in women with UF has not been studied.

METHODS

Women aged 18-50 years with diagnosed UF were identified in the Optum Clinformatics commercial insurance claims database (OptumInsight, Eden Prairie, Minnesota) from 1 May 2000 to 31 March 2020 (n=313 754) and were matched 1:2 on age and calendar time to women without (n=627 539). Cox proportional hazards models estimated HRs and 95% CIs between UF and diagnosed depression, anxiety and self-directed violence, adjusting for demographics and comorbidities. Among women with diagnosed UF, the association between hysterectomy and mental health outcomes was estimated.

RESULTS

After adjusting for confounders, women with diagnosed UF had a higher rate of depression (HR: 1.12; 95% CI 1.10 to 1.13), anxiety (HR: 1.12; 95% CI 1.10 to 1.13) and self-directed violence (HR: 1.46; 95% CI 1.29 to 1.64) than women without. Among women with pain symptoms and heavy menstrual bleeding, the HR comparing women with diagnosed UF to women without was 1.21 (95% CI 1.18 to 1.25) for depression, 1.18 (95% CI 1.15 to 1.21) for anxiety and 1.68 (95% CI 1.35 to 2.09) for self-directed violence. Among women with diagnosed UF, the HR comparing women who underwent a hysterectomy to women who did not was 1.22 (95% CI 1.17 to 1.27) for depression, 1.13 (95% CI 1.09 to 1.17) for anxiety and 1.86 (95% CI 1.39 to 2.49) for self-directed violence.

CONCLUSIONS

Rates of depression, anxiety and self-directed violence were higher among women with diagnosed UF, particularly among those who experienced pain symptoms or who underwent hysterectomy.

Benign metastasizing leiomyoma, a rare imposter of metastatic cervical cancer

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Differential for necrotic pelvic mass with pulmonary nodules.

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Benign metastasizing leiomyoma in woman with limited surgical history.

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Efficacy of estrogen depletion therapy for benign metastasizing leiomyoma.

Benign metastasizing leiomyoma (BML) is a rare variant of common benign smooth muscle neoplasm. We report a case of BML in a 45-year-old premenopausal woman with a significant smoking history and no previous history of cervical cancer screening. The patient presented with vaginal bleeding, abdominal pain, a necrotic mass in the vagina, and an incidental finding of diffuse pulmonary nodules on chest imaging. A total abdominal hysterectomy (TAH) and bilateral salpingo-oophorectomy (BSO) was performed for symptomatic management and adequate tissue sampling followed by fine needle biopsy of a pulmonary lesion. The pedunculated uterine mass and the pulmonary nodule were both consistent with smooth muscle neoplasm suggestive of myoma. Six-months following surgery, the patient is asymptomatic with partial regression of her lung nodules and no evidence of new or enlarging lesions while on treatment with Megestrol.

Arterial spin labeling assessment of myometrial perfusion changes in patients with uterine fibroid and its impact on fertility

Background

Fibroids are the most common uterine tumor in the reproductive age group. These tumors although benign, their relation to infertility is still controversial. The purpose of this study is to assess the fibroid impact on fertility using arterial spin labeling (ASL) technique.

Results

This prospective study included 40 cases (30 female patients having uterine fibroid and 10 age- and sex-matched control cases). The 30 patients were divided according to their fertility into 2 subgroups: fertile (n = 15) and infertile (n = 15). All cases underwent pelvic magnetic resonance imaging (MRI) examination with ASL technique. The perfusion values were measured in the uterine walls, fibroids, and in the gluteus maximus muscle as control. ASL demonstrated non-significant difference in the perfusion between anterior and posterior uterine walls in the control cases and revealed significant difference in the perfusion between fibroid positive and fibroid negative uterine walls in patients with uterine fibroid (p value < 0.04). Perfusion values of the fertile and infertile subgroups showed no statistically significant difference.

Conclusion

Arterial spin labeling is an evolving technique that can be used to evaluate the myometrial perfusion changes in patients with uterine fibroid without using contrast media. Uterine fibroids were associated with decreased perfusion but with no statistically significant impact on fertility.

Pregnancy outcomes of patients undergoing single-layer sutured laparoscopic myomectomy

AIM

In this study, we aimed to investigate the pregnancy outcomes of 102 patients who underwent laparoscopic myomectomy (LM) with single-layer suturing.

METHODS

This retrospective study included 102 women who underwent single-layer sutured LM in the obstetrics and gynaecology clinic of our hospital between September 2017 and April 2019.

RESULTS

A total of 102 patients underwent LM and colpotomy. Sixty-two patients were planning conception. Thirty-three (53.2%) of the sixty-two patients became pregnant until the study date. The mean age of the pregnant patients was 34 ± 8.2 years. In the pregnant patients, myoma localisation was anterior in 12 (50%), posterior in 7 (29%) and other in 5 (21%) patients. The mean duration between the operation and the first pregnancy was 10.2 months (2-24 months). Of the first pregnancies, 12 (50%) were between 0 and 6 months, and 12 (50%) were between 6 and 24 months to the operation. Twenty-four pregnant patients were delivered with caesarean section, six patients had a miscarriage and two patients resulted in intra-uterine pregnancy in the second trimester. Of these patients, eight were pregnant again, and eight were delivered by caesarean section. Curettage and dilatation were performed in six patients with miscarriage. None of the patients developed uterine rupture.

CONCLUSION

Single-layer closure of the uterine defect in LM is safe for subsequent pregnancies, and the risk of uterine rupture is low.

Nonenhanced MRI-based radiomics model for preoperative prediction of nonperfused volume ratio for high-intensity focused ultrasound ablation of uterine leiomyomas

OBJECTIVES

To develop and assess nonenhanced MRI-based radiomics model for the preoperative prediction of nonperfused volume (NPV) ratio of uterine leiomyomas after high-intensity focused ultrasound (HIFU) treatment.

METHODS

Two hundred and five patients with uterine leiomyomas treated by HIFU were enrolled and allocated to training (N =164) and testing cohorts (N = 41). Pyradiomics was used to extract radiomics features from T2-weighted images and apparent diffusion coefficient (ADC) map generated from diffusion-weighted imaging (DWI). The clinico-radiological model, radiomics model, and radiomics-clinical model which combined the selected radiomics features and clinical parameters were used to predict technical outcomes determined by NPV ratios where three classification groups were created (NPV ratio ≤ 50%, 50-80% or ≥ 80%). The receiver operating characteristic (ROC) curve, area under the curve (AUC), and calibration and decision curve analyses were performed to illustrate the prediction performance and clinical usefulness of model in the training and testing cohorts.

RESULTS

The multi-parametric MRI-based radiomics model outperformed T2-weighted imaging (T2WI)-based radiomics model, which achieved an average AUC of 0.769 (95% confidence interval [CI], 0.701-0.842), and showed satisfactory prediction performance for NPV ratio classification. The radiomics-clinical model demonstrated best prediction performance for HIFU treatment outcome, with an average AUC of 0.802 (95% CI, 0.796-0.850) and an accuracy of 0.762 (95% CI, 0.698-0.815) in the testing cohort, compared to the clinico-radiological and radiomics models. The decision curve also indicated favorable clinical usefulness of the radiomics-clinical model.

CONCLUSIONS

Nonenhanced MRI-based radiomics has potential in the preoperative prediction of NPV ratio for HIFU ablation of uterine leiomyomas.

Arterial hypertension as an inaugural sign of myomatous uterus

Uterine fibroids can be large enough to cause mechanical obstruction of pelvic ureters, which may result in hydroureters and hydronephrosis. Renal impairment frequently results in hypertension due to increased activity of the tubuloglomerular feedback system and renin-angiotensin-aldosterone axis. This process, however, seems reversible because normalisation of blood pressure is possible after the relief of renal obstruction. We report a rare case of a nulliparous woman with a myomatous uterus and an isolated initial complaint of high blood pressure. After proper diagnostic investigation, a uterine mass of 20 cm causing bilateral hydronephrosis was discovered. A successful myomectomy was conducted, which achieved an intact endometrium lining with posterior normalisation of blood pressure.

Differences in the therapeutic effects of high-intensity focused ultrasound (HIFU) ablation on uterine fibroids with different shear wave velocity (SWV): a study of histopathological characteristics

OBJECTIVE

To explore correlations between the therapeutic effect of high intensity focused ultrasound (HIFU) and histopathological characteristics of uterine fibroids with different Shear Wave Velocity (SWV) values.

METHODS

A retrospective study was conducted on 36 women (43 fibroids) who had undergone high intensity focused ultrasound (HIFU) uterine fibroids ablation between January 2019 and January 2020. Preoperative fibroids tissue sections were obtained for histopathological examination. The pathological sections were stained with Masson-trichrome, and were observed and imaged under a Low-power microscope (4 × 10), while the smooth muscle cell (SMC) and collagen fiber content were semi-quantitatively measured. Preoperative fibroid SWV was measured using the Virtual Touch tissue quantification (VTQ) technique. Within one month after HIFU ablation, all patients had undergone a pelvic cavity MRI examination, which measured the size, volume, and non-perfused volume (NPV) of the fibroids. The formula: the ablation rate = NPV/target fibroid volume × 100% was used to calculate the ablation rate of the uterine fibroids. Correlation analysis of SWV values, HIFU ablation rate, along with the smooth muscle cell (SMC) and collagen fiber content, were conducted using the Spearman's correlation test.

RESULTS

The collagen fiber and SMC content of the preoperative fibroids were 32.09 ± 15.90%/view and 37.61 ± 15.32%/view, respectively. Preoperative fibroid SWV value was 3.56 ± 0.71 m/s. Preoperative fibroid SWV was negatively correlated with SMC content (r = -0.445, p = 0.003), but positively correlated with collagen fiber content (r = 0.454, p = 0.002). The ablation rate was negatively correlated with collagen fiber content (r = -0.377, p = 0.013), but positively correlated with SMC content (r = 0.402, p = 0.007).

CONCLUSION

Differences in histopathological characteristics may be important factors that induce differences in the therapeutic effects of HIFU ablation on uterine fibroids with different SWV values.

Comparison of High-Intensity Focused Ultrasound and Conventional Surgery for Patients with Uterine Myomas: A Systematic Review and Meta-Analysis

OBJECTIVE

Uterine myomas are one of the most common gynecologic tumors in premenopausal women. The conventional surgical treatments are myomectomy and hysterectomy, but high-intensity focused ultrasound (HIFU) is a new noninvasive treatment creating no surgical wound. The aim of this study was to evaluate the effectiveness and safety of HIFU treatment compared with conventional surgery for patients with uterine myomas.

DATA SOURCES

PubMed, Embase, and the Cochrane Library were searched for studies published before January 2021.

METHODS OF STUDY SELECTION

Studies comparing the outcome of HIFU and conventional surgery-myomectomy and hysterectomy-for patients with uterine myomas were included. We conducted meta-analyses by using a random effects model. Uterine myoma symptom score and quality-of-life score were analyzed using the mean difference (MD). The recovery time and frequency of major adverse events were also evaluated.

TABULATION, INTEGRATION, AND RESULTS

Ten studies were included. HIFU relieved uterine myoma symptoms significantly when compared with conventional surgery at 6 (MD -1.61; 95% confidence interval [CI], -2.88 to -0.33) and 12 (MD -2.44; 95% CI, -3.68 to -1.20) months after treatment. Similarly, HIFU group improve the quality-of-life score significantly at 6 (MD 2.14; 95% CI, 0.86-3.42) and 12 (MD 2.34; 95% CI, 0.82-3.86) months after treatment when compared with the surgery group.

CONCLUSION

HIFU could be an effective and safe treatment option for patients with uterine myomas. However, one of its side effects, skin burns, requires further research and discussion. Additional studies involving more randomized controlled trials are warranted.

A Systematic Review of the Treatment of Uterine Myomas Using Transcervical Ultrasound-Guided Radiofrequency Ablation with the Sonata System

OBJECTIVE

To evaluate the treatment success, possible side effects, and safety of radiofrequency ablation with the Sonata System.

DATA SOURCES

An electronic literature search in the PubMed and Medline databases was carried out from inception to August 2020.

METHODS OF STUDY SELECTION

The review was performed in accordance with the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. Keywords such as "Sonata," "transcervical ablation," and "uterine myoma" were used to identify all relevant articles independently by both authors. Full-text articles in English that reported at least 1 of the following outcomes were included in the study: reduction in perfused/total myoma volume, effect of treatment on bleeding intensity and myoma-related symptoms, number of surgical reinterventions, adverse events, return to activities of daily life, effects on surrounding tissue, and safety during pregnancy.

TABULATION, INTEGRATION, AND RESULTS

10 studies matching the inclusion criteria were identified and used for further analysis. A reduction in total and perfused myoma volume of 63.2% and 64.5% was achieved. One of the studies showed a 53.8 ± 50.5% (n = 48) reduction in Menstrual Pictogram Score, and another study showed a 51.1 ± 40.9% (n = 142) reduction in Pictorial Blood Loss Assessment Chart at 12 months. 87.2% (n = 190) of the patients reported a clinically meaningful reduction in menstrual blood loss after 12 months. While Symptom Severity Scores dropped by 28.8 ± 19.3, 23.3 ± 23.7, and 23.7 ± 19.4 points at 3, 6, and 12 months, respectively, Health-Related Quality of Life Scores increased to 77.5 ± 22.0, 82.8 ± 19.0, and 83.3 ± 20.5 points. One study had an 8% reintervention rate after 12 months, and another study showed a 0.7% and 5.2% rate after 12 and 24 months. After an average of 64 months after ablation, the reintervention rate was 11.8%. Time to return to activities of daily life was 2.9 ± 2.5 days. No related complications during pregnancy and delivery were reported.

CONCLUSION

Radiofrequency ablation with the Sonata System represents a minimally invasive, organ-preserving treatment option in patients with symptomatic uterine myomas, associated with clinically meaningful improvement of myoma-related symptoms.

Emerging Roles of Long Non-coding RNAs in Uterine Leiomyoma Pathogenesis: a Review

Uterine leiomyoma (UL), as the most prevalent type of women's health disorders, is a benign tumor that originates from the smooth muscle cell layer of the uterus. A great number of associated complications are observed including infertility, miscarriage, bleeding, pain, dysmenorrhea, menorrhagia, and dyspareunia. Although the etiology of UL is largely undefined, environmental and genetic factors are witnessed to engage in the UL development. As long non-coding RNAs (lncRNAs) are involved in various types of cellular functions, in recent years, a great deal of attention has been drawn to them and their possible roles in UL pathogenesis. Moreover, they have illustrated their potential to be promising candidates for UL treatment. In this review paper, firstly, an overview of UL pathogenesis is presented. Then, the regulation of lncRNAs in UL and their possible mechanisms in cancer development are reviewed. Eventually, therapeutic approaches targeting lncRNAs in various cancers and UL are explored.

Normalisation of human chorionic gonadotrophin (hCG) levels in a patient with partial molar pregnancy with a uterine mass without chemotherapy: impact of using herbal remedies

OBJECTIVES

Level of βhCG and the presence of any uterine mass of hydatidiform mole need a careful review or monitoring in order to prevent metastasis, provide an early treatment and avoid unnecessary chemotherapy.

CASE PRESENTATION

A 36-year old fifth gravida patient who had a missed abortion was diagnosed as having a molar pregnancy with beta human chorionic gonadotrophin (βhCG) level of 509,921 IU/L. Her lung field was clear and she underwent suction and curettage (S & C) procedure. However, after six weeks, AA presented to the emergency department with a massive bleeding, although her βhCG level had decreased to 65,770 IU/L. A trans-abdominal ultrasound indicated the presence of an intra-uterine mass (3.0 × 4.4 cm). Nevertheless, her βhCG continued to show a declining trend (8,426 IU/L). AA was advised to undergo a chemotherapy but she refused, citing preference for alternative medicine like herbs instead. She opted for an "at own risk" (AOR) discharge with scheduled follow up. Subsequently, her condition improved with her βhCG showing a downward trend. Surprisingly, at six months post S & C, her βhCG ameliorated to 0 IU/L with no mass detected by ultrasound.

CONCLUSIONS

Brucea javanica fruits, Pereskia bleo and Annona muricata leaves can potentially be useful alternatives to chemotherapy and need further studies.