Hysterectomy for heavy menstrual bleeding

LIBERTY randomized withdrawal study: relugolix combination therapy for heavy menstrual bleeding associated with uterine fibroids

BACKGROUND

In the pivotal LIBERTY 1 and 2 trials and long-term extension study, once-daily relugolix combination therapy (40 mg relugolix, 1 mg estradiol, 0.5 mg norethindrone acetate) reduced menstrual blood loss volume and pain among women with uterine fibroids. Relugolix combination therapy was well tolerated with preservation of bone mineral density through 52 weeks.

OBJECTIVE

This study aimed to report the 2-year relugolix combination therapy efficacy and safety results of the phase 3 LIBERTY randomized withdrawal study.

STUDY DESIGN

Women with uterine fibroid-associated heavy menstrual bleeding who completed the 24-week LIBERTY 1 or 2 trials, followed by the 28-week long-term extension study (up to 52 weeks total treatment), and who met the responder criteria (menstrual blood loss volume <80 mL and ≥50% reduction from pivotal study baseline at week 48 [week 24 of long-term extension]) were randomized in a 1:1 ratio to either blinded treatment with relugolix combination therapy or placebo for 52 weeks (total treatment period, 104 weeks). For women who had a relapse of heavy menstrual bleeding during the study (menstrual blood loss volume ≥80 mL), open-label relugolix combination therapy was offered. The primary endpoint was the proportion of women who maintained menstrual blood loss volume <80 mL through week 76 (week 24 of randomized withdrawal study). Secondary endpoints included time to menstrual blood loss volume ≥80 mL, proportion of women who maintained a menstrual blood loss volume of <80 mL through week 104 (over the 52-week randomized treatment period), the proportion of women who achieved or maintained amenorrhea at week 76 at the end of treatment, and the change in Uterine Fibroid Symptom-Quality of Life Bleeding and Pelvic Discomfort Scale and symptom severity scores. Analyses were performed for the modified intent-to-treat population, including all randomized women who received ≥1 dose of the study drug.

RESULTS

Of the 229 randomized women (relugolix combination therapy, n=115; placebo, n=114), 228 received the study drug and 175 (76.7%) completed the randomized withdrawal study. Through week 76, 78.4% of women on relugolix combination therapy maintained menstrual blood loss volume <80 mL vs 15.1% in the placebo group (difference, 63.4%; 95% confidence interval, 52.9%-73.9%; P<.0001). At week 104, 69.8% of women on relugolix combination therapy maintained menstrual blood loss volume <80 mL vs 11.8% in the placebo group (difference, 58.0%; 95% confidence interval, 47.0%-69.1%; P<.0001). Through week 104, 88.3% of women on placebo relapsed with heavy menstrual bleeding (median time to relapse, 5.9 weeks). Among the 89 women in the placebo group who relapsed and received open-label rescue treatment, 87 women responded to relugolix combination therapy with a menstrual blood loss volume <80 mL. The proportion of women who achieved or maintained amenorrhea were 57.4% vs 13.3% at week 76 (difference, 44.1%; 95% confidence interval, 33.10%-55.1%; P<.0001) and 58.3% vs 10.6% at week 104 (difference, 47.6%; 95% confidence interval, 37.0%-58.3%; nominal P<.0001) for relugolix combination therapy and the placebo group, respectively. Relugolix combination therapy was generally well tolerated; no new safety signals were identified, and the adverse event profile over the second year was consistent with that reported through the first year of treatment. Bone mineral density remained stable in women who received relugolix combination therapy from week 52 to week 104. In women continuously treated with relugolix combination therapy up to 2 years, bone mineral density was generally preserved.

CONCLUSION

After 2 years of treatment with relugolix combination therapy, there was evidence of durability of the effect in maintaining low menstrual blood loss volume in women with symptomatic uterine fibroids. Most women had return of heavy menstrual bleeding and associated symptoms after treatment cessation, which improved upon retreatment with relugolix combination therapy. Relugolix combination therapy was well tolerated, the adverse event profile remained consistent, and the mean bone mineral density was generally preserved through 2 years of treatment.

Low-Dose Elagolix for the Treatment of Heavy Menstrual Bleeding in Patients With Uterine Leiomyomas: A Randomized Controlled Trial

OBJECTIVE

To evaluate the safety and efficacy of elagolix 150 mg once-daily monotherapy in patients with heavy menstrual bleeding associated with uterine leiomyomas.

METHODS

A phase 4, randomized, double-blind, placebo-controlled, 6-month treatment study was conducted in premenopausal patients aged 18-51 years with heavy menstrual bleeding (defined as menstrual blood loss greater than 80 mL during one menstrual cycle) associated with uterine leiomyomas. Patients were randomized 2:1 to receive elagolix 150 mg once daily or placebo. The primary endpoint was reduction in menstrual blood loss volume to less than 80 mL at the final month and at least a 50% reduction in menstrual blood loss volume from baseline to the final month.

RESULTS

Of 82 randomized patients, 54 received elagolix 150 mg and 28 received placebo. With elagolix, 49.4% (95% CI 35.1-63.8%) of patients met the primary endpoint, compared with 23.3% (95% CI 7.2-39.5%) of patients who received placebo ( P =.035). Statistically significant differences between elagolix and placebo in mean reduction of menstrual blood loss from baseline were seen as early as month 1 ( P <.05 for months 1-3 and 5). Significantly more patients receiving elagolix experienced suppression of bleeding compared with placebo ( P =.036). Greater improvements were observed in the elagolix group (vs placebo) in the proportion of patients with amenorrhea, in hemoglobin concentrations, and in health-related quality of life. No serious or severe adverse events were reported for elagolix, compared with 7.1% of participants in the placebo group having serious adverse events (coronavirus disease 2019 [COVID-19] n=1, enlarged uvula n=1). Three patients (5.6%) discontinued elagolix due to adverse events.

CONCLUSION

Elagolix 150 mg once-daily monotherapy significantly improved heavy menstrual bleeding associated with uterine leiomyomas compared with placebo in premenopausal patients. Treatment with elagolix 150 mg once daily was generally well-tolerated in this study, with no new safety signals.

FUNDING SOURCE

AbbVie Inc.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov , NCT03886220.

Characteristics of Submucous Myomas and the Risk of Anemia

Background and Objectives: Uterine fibroids still represent the most common indication for hysterectomy for benign pathologies. In the United States, more than 479,000 hysterectomies are performed annually, 46.6% for myomas and 47.7% in women aged from 18 to 44 years. By applying appropriateness criteria to this procedure, it has been estimated that overuse ranges from 16 to 70%. One of the main reasons that induce patients and gynecologists to consider hysterectomy is represented by severe anemia. Materials and Methods: This is a retrospective cohort study of 202 patients with uterine fibroids diagnosed by transvaginal ultrasound who underwent a hysteroscopic procedure. Myoma grade, size, location, and number were assessed by transvaginal scan and office hysteroscopy and correlated to the pre-treatment hemoglobin level. Results: Univariate analysis showed that anemia does not have a statistically significant association with myoma number and with age considered as a numerical predictor. In the patients with myoma type 0, there is a possibility of 81% having anemia regardless of menorrhagia. On the contrary, in patients with myoma type 1 or type 2, the possibility of having anemia varies according to the presence or absence of menorrhagia. If there is menorrhagia, the risk of moderate anemia is only present for myomas >60 mm. Conclusions: The results of this study may contribute to defining objective criteria for the management of submucous myomas and anemia. Our data suggest that submucosal myomas type 0 >10 mm should always be treated, putting patients at risk for anemia. Myomas type 2 and 3 should be treated for the risk of anemia in the presence of menorrhagia episodes or if > of 60 mm. Adequate management of anemia and myomas could reduce the rate of unnecessary hysterectomies.

Management of patients with elevated Self-BAT scores or other bleeding symptoms: Updated overview for primary care practitioners

OBJECTIVE

To provide recommendations for management of patients presenting with elevated self-administered bleeding assessment tool (Self-BAT) scores or other bleeding symptoms in a primary care setting.

SOURCES OF INFORMATION

Primary research sources, clinical review articles, and interviews with research staff, hematologists, and family physicians were used to create the poster tools and reference guide resources.

MAIN MESSAGE

Recommendations to manage a patient with an elevated Self-BAT score or other bleeding symptoms include reviewing the results of the Self-BAT to clarify relevant symptoms, performing initial diagnostic laboratory tests, and doing basic symptom management. Clinical judgment should be used when determining whether referral to a hematologist is necessary, but referral should be considered if the bleeding score is abnormal or if initial management options are ineffective. Some bleeding symptoms warrant evaluation by a gastroenterologist, obstetrician-gynecologist, or otolaryngologist.

CONCLUSION

Primary care providers should conduct a thorough review of the Self-BAT results and associated management recommendations when working with a patient presenting with an elevated score or other bleeding manifestations. A review consists of the clarification of relevant symptoms, appropriate initial laboratory workups, and patient education. Treatment options for symptom management should be explored while recognizing the threshold for referral to a hematologist.

Risk Factors for Impaired Patient-Reported Satisfaction and Increased Length of Hospital Stay Following Hysterectomy on Benign Indications in Premenopausal Women: a Study From the Swedish National Register for Gynecological Surgery

Introduction The aims of the study were to evaluate the impact of intra- and postoperative complications on satisfaction one year after hysterectomy for benign conditions, to determine risk factors for low patient satisfaction and to analyze whether complications were associated with the length of hospital stay. Material and Methods A retrospective study of 27 938 women from the Swedish National Register for Gynecological Surgery undergoing hysterectomy for benign conditions between January 2004 and June 2016. Data were obtained from prospectively collected pre-, peri- and postoperative forms. Statistical analyses were performed using multivariable logistic regression models. Crude and adjusted odds ratios and 95% confidence intervals are presented. Results More than 90% were satisfied with the hysterectomy. Dissatisfaction was associated with complications. Pelvic pain as indication, preoperatively having less expectations to get rid of symptoms or being alleviated from surgery, and current smoking were also risk factors for low patient satisfaction. Vaginal and abdominal subtotal hysterectomies were associated with high satisfaction. Occurrence of complications intra- and postoperatively before discharge was associated with increased length of hospital stay, as well as occurrence and severity of complications reported after discharge from hospital. Conclusions Complications were strongly associated with lower patient satisfaction. Preoperative expectations of surgery, indication, mode of surgery and life-style factors had impact on the satisfaction. Patient-centered information to ensure realistic expectations and prevention of complications seem to be essential to gain optimal patient satisfaction with surgery.

Cyclical progestogens for heavy menstrual bleeding

BACKGROUND

Heavy menstrual bleeding (HMB) is a menstrual blood loss perceived by women as excessive that affects the health of women of reproductive age, interfering with their physical, emotional, social and material quality of life. Whilst abnormal menstrual bleeding may be associated with underlying pathology, in the present context, HMB is defined as excessive menstrual bleeding in the absence of other systemic or gynaecological disease. The first-line therapy is usually medical, avoiding possibly unnecessary surgery. Of the wide variety of medications used to reduce HMB, oral progestogens were originally the most commonly prescribed agents. This review assesses the effectiveness of two different types and regimens of oral progestogens in reducing ovulatory HMB.This is the update of a Cochrane review last updated in 2007, and originally named "Effectiveness of cyclical progestagen therapy in reducing heavy menstrual bleeding" (1998).

OBJECTIVES

To determine the effectiveness, safety and tolerability of oral progestogen therapy taken either during the luteal phase (short cycle) or for a longer course of 21 days per cycle (long cycle), in achieving a reduction in menstrual blood loss in women of reproductive age with HMB.

SEARCH METHODS

In January 2019 we searched Cochrane Gynaecology and Fertility's specialized register, CENTRAL, MEDLINE, Embase, CINAHL and PsycInfo. We also searched trials registers, other sources of unpublished or grey literature and reference lists of retrieved trials. We also checked citation lists of review articles to identify trials.

SELECTION CRITERIA

Randomized controlled trials (RCTs) comparing different treatments for HMB that included cyclical oral progestogens were eligible.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, assessed trials for risk of bias and extracted data. We contacted trial authors for clarification of methods or additional data when necessary. We only assessed adverse events if they were separately measured in the included trials. We compared cyclical oral progestogen in different regimens and placebo or other treatments. Our primary outcomes were menstrual blood loss and satisfaction with treatment; the secondary outcomes were number of days of bleeding, quality of life, compliance and acceptability of treatment, adverse events and costs.

MAIN RESULTS

This review identified 15 randomized controlled trials (RCTs) with 1071 women in total. Most of the women knew which treatment they were receiving, which may have influenced their judgements about menstrual blood loss and satisfaction. Other aspects of trial quality varied among trials.We did not identify any RCTs comparing progestogen treatment with placebo. We assessed comparisons between oral progestogens and other medical therapies separately according to different regimens.Short-cycle progestogen therapy during the luteal phase (medroxyprogesterone acetate or norethisterone for 7 to 10 days, from day 15 to 19) was inferior to other medical therapy, including tranexamic acid, danazol and the progestogen-releasing intrauterine system (Pg-IUS (off of the market since 2001)), releasing 60 mcg of progesterone daily, with respect to reduction of menstrual blood loss (mean difference (MD) 37.29, 95% confidence interval (CI) 17.67 to 56.91; I2 = 50%; 6 trials, 145 women). The rate of satisfaction and the quality of life with treatment was similar in both groups. The number of bleeding days was greater on the short cycle progestogen group compared to other medical treatments. Adverse events (such as gastrointestinal symptoms and weight gain) were more likely with danazol when compared with progestogen treatment. We note that danazol is no longer in general use for treating HMB.Long-cycle progestogen therapy (medroxyprogesterone acetate or norethisterone), from day 5 to day 26 of the menstrual cycle, is also inferior to the levonorgestrel-releasing intrauterine system (LNG-IUS), releasing tranexamic acid and ormeloxifene, but may be similar to the combined vaginal ring with respect to reduction of menstrual blood loss (MD 16.88, 95% CI 10.93 to 22.84; I2 = 87%; 4 trials, 355 women). A higher proportion of women taking norethisterone found their treatment unacceptable compared to women having Pg-IUS (Peto odds ratio (OR) 0.12, 95% CI 0.03 to 0.40; 1 trial, 40 women). However, the adverse effects of breast tenderness and intermenstrual bleeding were more likely in women with the LNG-IUS. No trials reported on days of bleeding or quality of life for this comparison.The evidence supporting these findings was limited by low or very low gradings of quality; thus, we are uncertain about the findings and there is a potential that they may change if we identify other trials.

AUTHORS' CONCLUSIONS

Low- or very low-quality evidence suggests that short-course progestogen was inferior to other medical therapy, including tranexamic acid, danazol and the Pg-IUS with respect to reduction of menstrual blood loss. Long cycle progestogen therapy (medroxyprogesterone acetate or norethisterone) was also inferior to the LNG-IUS, tranexamic acid and ormeloxifene, but may be similar to the combined vaginal ring with respect to reduction of menstrual blood loss.

Intraoperative cervical treatment does not affect the prevalence of vaginal bleeding 1 year postoperatively after subtotal hysterectomy. A register study from the Swedish National Register for Gynecological Surgery

INTRODUCTION

The objectives were to establish the prevalence of persistent vaginal bleeding following subtotal hysterectomy, to analyze the effect of intraoperative cervical treatment on the occurrence of persistent vaginal bleeding, and to evaluate the impact of persistent vaginal bleeding on the patient-reported opinion concerning result of surgery and medical condition.

MATERIAL AND METHODS

Retrospective study with data from the Swedish National Register for Gynecological Surgery including 5240 women undergoing subtotal hysterectomy for benign conditions between January 2004 and June 2016. Demographic and clinical data were obtained from the pre- and perioperative forms. Data concerning occurrence of persistent vaginal bleeding, rating of medical condition and contentment with result of surgery were collected from the 1-year inquiry form. Statistical analyses were performed with multivariable logistic regression models. The results are presented as adjusted odd ratios and 95% confidence intervals.

RESULTS

Persistent vaginal bleeding occurred in 18.6%. Intraoperative cervical treatment did not affect the frequency of persistent vaginal bleeding (adjusted odds ratio 1.48; 95% confidence interval 0.93-2.37). More than 90% were satisfied with the result of the hysterectomy, but women with persistent vaginal bleeding were less content compared with those without persistent vaginal bleeding (adjusted odds ratio 0.42; 95% confidence interval 0.26-0.67). The self-perception of the medical condition did not differ between the women with and without persistent vaginal bleeding (adjusted odds ratio 1.16; 95% confidence interval 0.33-4.12).

CONCLUSIONS

Nearly two in ten women may expect persistent vaginal bleeding following subtotal hysterectomy, and cervical treatment intraoperatively did not affect this. More than 90% were satisfied with the result but women with persistent vaginal bleeding were less content. Preoperative information on this risk of persistent vaginal bleeding may be important when choosing hysterectomy technique.