A study evaluating the effect of mifepristone (RU-486) for the treatment of leiomyomata uteri

Mifepristone in Fibroids: Comparative Study of Safety and Efficacy of Biweekly Dosage Vs Daily Dosage Schedule

Background

Leiomyomas are the most prevalent benign tumors of the uterus and are seen more with increasing age. 50 mg biweekly dose was compared with 25 mg daily dose in terms of efficacy and safety in symptomatic women as the biweekly dose maybe an economically better alternative. Two different dosages of mifepristone for medical management of fibroids were compared in terms of efficacy and safety in symptomatic women.

Materials and Methods

Ninety-two women were recruited who fulfilled the criteria after informed consent and were randomized in two groups. Sample size was calculated on the basis of earlier literature, for response in terms of reduction in fibroid volume, assuming 1% level of significance and 95 % power of study, the optimum sample size came out to be minimum 27 in each group. Assuming loss to follow up of few patients, we took 45 patients in group 1 and 47 patients in group 2. Group 1 was given mifepristone in a dose of 25 mg once a day and Group 2 was given mifepristone 50 mg biweekly for 3 months. Fibroid volume, uterine volume, endometrial thickness, pictorial blood loss assessment chart score, hemoglobin levels, and liver transaminases were recorded at the beginning and at the end of treatment. Side effects were noted at the end of the treatment.

Results

Both the dosages lead to improvement in symptoms of the patients. Mifepristone significantly reduced fibroid volume in both the groups, but the difference between the groups was not significant (P = 0.99). Mifepristone treatment significantly reduced bleeding and increased hemoglobin levels in both the groups. The side effects were mild and tolerable.

Conclusion

Mifepristone in both dosages is highly efficacious in causing amenorrhea, improving anemia, and enhancing the quality of life, and hence 50 mg biweekly dosage shows potential for being cost efficient.

A prospective interventional study to evaluate the effects of medical therapy (Mifepristone 25 mg) on the management of uterine fibroids

Background and Objectives:

In India, the uterine fibroid is a common indication of hysterectomy. An effective option for medical treatment may decrease the morbidity associated with hysterectomy. We aimed to evaluate the effect of mifepristone (25 mg), progesterone antagonist, on uterine fibroids in perimenopausal women.

Methods:

Fifty-four perimenopausal women of age ≥18 years having symptomatic uterine fibroids were selected from Gynecology OPD and given 25 mg mifepristone once daily continuously for 2–4 cycles of 3 months each. Variables such as baseline fibroid size, position, and hemoglobin were measured and followed at 3, 6, 9, and 12 months. The data were entered in MS EXCEL spreadsheet and analysis was done using Statistical Package for Social Sciences (SPSS) version 21.0. A P value of <0.05 was considered statistically significant.

Results:

Majority were intramural fibroids (70.37%) followed by submucosal in 16.67%. Size of fibroids ranged from <3 to >7 cm; the majority of fibroids were in 5–7 cm size. No significant association of location with the size of fibroid was found. Out of 54 cases included in the study, change in size in uterine fibroids was observed in 98.14% cases. There was an increase in hemoglobin, from 8.6 g% at baseline to 9.7 g% at 12 months.

Conclusion:

Mifepristone resulted in a reduction in uterine fibroids size and an increase in hemoglobin at the end of 12 months. It may be an option for uterine leiomyoma treatment, as it is given orally, cost-effective and has minimal side effects.

Uterine fibroids: an update on current and emerging medical treatment options

Uterine fibroids are the most common gynecological disorder, classically requiring surgery when symptomatic. Although attempts at finding a nonsurgical cure date back to centuries, it is only around the middle of the last century that serious attempts at a medical treatment were carried out. Initially, both progestins and estrogen–progestin combinations have been utilized, although proof of their usefulness is lacking. A major step forward was achieved when peptide analogs of the GnRH were introduced, first those with superagonist properties and subsequently those acting as antagonists. Initially, the latter produced side effects preventing their routine utilization; eventually, this problem was overcome following the synthesis of cetrorelix. Because both types of analogs produce hypoestrogenism, their use is limited to a maximum of 6 months and, for this reason, today they are utilized as an adjuvant treatment before surgery with overall good results. Over the last decade, new, nonpeptidic, orally active GnRH-receptor blockers have also been synthesized. One of them, Elagolix, is in the early stages of testing in women with fibroids. Another fundamental development has been the utilization of the so-called selective progesterone receptor modulators, sometimes referred to as “antiprogestins”. The first such compound to be applied to the long-term treatment of fibroids was Mifepristone; today, this compound is mostly used outside of Western Countries, where the substance of choice is Ulipristal acetate. Large clinical trials have proven the effectiveness of Ulipristal in the long-term medical therapy of fibroids, although some caution must be exercised because of the rare occurrence of liver complications. All selective progesterone receptor modulators produce unique endometrial changes that are today considered benign, reversible, and without negative consequences. In conclusion, long-term medical treatment of fibroids seems possible today, especially in premenopausal women.

A randomized control trial to assess efficacy of Mifepristone in medical management of uterine fibroid

BACKGROUND

Fibroids are the most common benign tumours of uterus. Heavy menstrual bleeding is the commonest concern for which medical attention is sought. Hysterectomies for leiomyoma constitute a third of all hysterectomies. Thus, healthcare cost to society due to uterine leiomyomas is of considerable importance.

METHODS

A prospective study was conducted at tertiary care hospital of armed forces. 120 women in pre-menopausal age group with complaints of menorrhagia, Pictorial Bleeding Assessment Chart (PBAC) scoring ≥100 and at least one fibroid ≥2.5 cm in size were recruited in the study. Patients in Group 1 were given Tab Tranexemic acid (500 mg) and Tab Mefenemic acid (500 mg) three times a day during menstrual bleeding for a period of 6 months. Patients in Group 2 were given Tab Mifepristone 50 mg twice a week. They were followed up at 1, 3 and 6 months of starting the medicine. Results were statistically analysed using Microsoft Excel sheet and paired t-test.

RESULTS

The average age was 40 years in the Group 2 and 45 years in Group 1. A size reduction of 36.99% in intramural and 39.39% in submucosal fibroids after six months of treatment with Mifepristone resulted in marked clinical improvement. 10% patients had side effects. In 30% of patients symptoms reappeared during the follow up period.

CONCLUSION

Mifepristone when given in bi-weekly doses was found to be safe, efficacious, and cost effective as compared to treatment with tranexemic acid and mefenemic acid for management of fibroid uterus.

Efficacy of Use of Long-Term, Low-Dose Mifepristone for the Treatment of Fibroids

BACKGROUND

Fibroid or myoma is the commonest reported tumor of uterus, and is one of the important reasons for hysterectomy in our setting. Different drugs are available for medical management of fibroid uterus including mifepristone, a progesterone antagonist. Varying dosage regimen for mifepristone was studied as medical management of fibroid uterus. The aim of the project was to study the effect of mifepristone on the symptoms and size of fibroids, especially using a low-dose regimen for 6 months. In addition, any symptomatic improvement of menorrhagia and dysmenorrhea was also studied.

METHODS

The study was designed as an observational prospective "before-after" study. Women diagnosed with uterine fibroids attending OPD of a tertiary care hospital were selected according to the inclusion criteria. A total of 36 patients were enrolled in the study. Sample size was calculated to study changes in various parameters after 6 months treatment with mifepristone 50 mg once a week. Baseline investigations were performed and menstrual blood loss was assessed using pictorial blood assessment charts. Fifty milligrams of mifepristone weekly was used, and patient assessed at 1 and 6 month. They were also further followed up till 3 months after stopping the drug to observe the changes in menstrual pattern, fibroid volume, hemoglobin and liver function tests. Baseline endometrial biopsy and another at 6 month on cessation of drug therapy were done for all patients.

RESULTS

Majority of the study population comprised of perimenopausal women, i.e., 41-45 years (44 %). Fifty percent of the patients were Para 2 and belonged to the perimenopausal age-group (18 out of 36). The dominant presenting symptom was menorrhagia associated with dysmenorrhea and pelvic pain. After 6 months of treatment with mifepristone, the mean fibroid volume reduced from 204.33 to 113.16 cm(3) (n = 33); p ≤ 0.001, and the percentage mean volume reduction of the fibroid in the study population was 44.57 % (range 1.10-100 %). Immediate reduction in bleeding PV was observed in 100 %, and 88.89 % (32/36) patients attained amenorrhea. The mean hemoglobin increased from 9.18 to 10.82 g/dl (p = 0.001). There was a transient rise in mean transaminases (AST/ALT) levels at 6 months which reverted to normal at 9 months follow-up.

CONCLUSION

To conclude, 6 months therapy with 50 mg of mifepristone given weekly is efficacious and acceptable for the treatment of symptomatic leiomyoma, especially in a select group of patients. Although its use as a primary medical therapy is limited due to recurrence of fibroid after stopping treatment, it is useful for perimenopausal women whose myoma would regress after menopause, and younger infertile patients with small-size deep intramural myomas not easily accessible to either hysteroscopic or laparoscopic surgery. It is also beneficial as a preoperative adjunct, in patients with preoperative severe anemia and large fibroids where surgery is technically difficult. Mode of surgery can be changed to a less-invasive vaginal hysterectomy rather than an abdominal procedure.

Selective progesterone receptor modulators: an update

INTRODUCTION

Several selective progesterone receptor modulators (SPRMs) show promise in several areas of medicine and this work has been summarized by us in 2008.

AREAS COVERED

Since the publication of our reviews, several developments have taken place in the field of reproductive medicine. The first is emergency contraception (EC). Two SPRMs are clinically utilized today: mifepristone (MFP) and ulipristal acetate (UPA). MFP is available for EC in up to 120 h following unprotected intercourse. A dose of 10 mg is significantly more effective than levonorgestrel (LNG). In a metanalysis of the use of UPA versus LNG up to 72 h after unprotected intercourse, failure rates of 1.4 versus 2.2% were reported. The second is contraception. A daily dose of 2 mg MFP can block ovulation and several MFP regimens are being tested, including a vaginal ring releasing MFP. The third is the preoperative administration in women harboring leiomyomas, where clinical testing of several SPRM has shown that they can decrease uterine leiomyomas' size and substantially reduce uterine bleeding. SPRM can induce unusual, specific endometrial appearances. Many believe that these changes should not cause concern, but the issue remains controversial.

EXPERT OPINION

SPRMs are very effective in EC and for the preoperative treatment of uterine leiomyomas.

Vaginal mifepristone for the treatment of symptomatic uterine leiomyomata: an open-label study

OBJECTIVE

To evaluate the efficacy and safety of 3 months of vaginal mifepristone treatment on leiomyoma volume and related symptoms.

DESIGN

Prospective, open-label, two tertiary centers, phase II clinical trial.

SETTING

Two tertiary medical centers in Israel.

PATIENT(S)

Thirty-three enrolled women, ages 30-53 years, diagnosed with symptomatic uterine fibroids.

INTERVENTION(S)

Patients received 10 mg mifepristone vaginally daily for 3 months.

MAIN OUTCOME MEASURE(S)

Reduction in uterine leiomyoma volume. Improvement in symptoms related to uterine fibroids was assessed with the use of the "Uterine Fibroid Symptoms Quality of Life Questionnaire" (UFS-QoL). The number of bleeding days, safety, and tolerability were secondary measures.

RESULT(S)

Mifepristone treatment significantly reduced leiomyoma volume from 135.3 ± 22.9 cc at enrollment to 101.2 ± 22.4 cc after 3 months of treatment. The UFS-QoL Score significantly decreased from 20.7 ± 0.7 at enrollment to 14.0 ± 0.8 after 3 months of treatment. The number of bleeding days significantly decreased by 3.5 days. Endometrial biopsies showed no evidence of endometrial hyperplasia or cellular atypia. There were no major side effects during the course of the study, and treatment was well tolerated.

CONCLUSION(S)

Vaginal mifepristone may offer an effective treatment option for women with symptomatic uterine leiomyoma and can improve the patients' quality of life.

CLINICAL TRIAL REGISTRATION NUMBER

NCT00881140.