Current medical treatment of uterine fibroids

Comparison of uterine myometrial thickness at the site of myomectomy scar after surgery using laparoscopic and laparotomy methods

Fibroids are the most common benign tumours of the uterus, often requiring surgery when symptomatic. This study aims to investigate the impact of surgery using two methods, laparoscopy and laparotomy, on the thickness and vascularity of the uterine myometrium at the site of myomectomy scar (comparing sonographic features at the surgical scar site, including thickness, vascularity, and the extent of fibrotic tissue, in both open and laparoscopic surgical approaches). In this clinical trial, 100 women with type 2-5 fibroids and clinical symptoms, seeking surgery et al. Zahra Hospital, were enrolled in two groups: laparoscopy and laparotomy. Inclusion criteria were a maximum fibroid size of 8 cm and, in the case of multiple fibroids, a maximum of three, with the largest being 8 cm. 6 months post-surgery, sonographic assessments of the myomectomy scar site were compared between both groups. Participants showed no significant differences in demographic and obstetric factors. The most common clinical symptom (87%) in both groups was abnormal uterine bleeding (AUB). The mean hospital stay duration was statistically significantly lower in the laparoscopy group at 1.64 (SD 0.56) compared to 1.89 (SD 0.58) in the laparotomy group (p = 0.028). Additionally, the decrease in haemoglobin levels was 0.89 (SD 0.92) and 1.87 (SD 2.24) units, respectively, which showed a statistically significant difference (p = 0.003). The duration of surgery was significantly shorter in the laparotomy group (p = 0.001). Abdominal pressure was not observed in the laparoscopy group, while 12% of the laparotomy group reported complaints (p = 0.013). Based on the results obtained in this study, it can be concluded that there was no difference between these two methods in terms of improving uterine thickness and associated complications. However, the decrease in haemoglobin levels and the length of hospital stay were lower in patients undergoing laparoscopy.

Targeting the long non-coding RNA MIAT for the treatment of fibroids in an animal model

Our previous studies indicated that there is overexpression of MIAT in fibroids and MIAT is a sponge for the miR-29 family in these tumors. The objective of the present study was to determine if the knockdown of MIAT in fibroid xenografts will increase miR-29 levels and reduce the expression of genes targeted by this miRNA such as collagen and cell cycle regulatory proteins in a mouse model for fibroids. Ovariectomized CB-17 SCID/Beige mice bearing estrogen/progesterone pellets were implanted subcutaneously in the flank with equal weight of fibroid explants which had been transduced by lentivirus for either control (empty vector) or MIAT knockdown for four weeks (n=7). Knockdown of MIAT in fibroid xenografts resulted in a 30% reduction of tumor weight and a marked increase in miR-29a, -b, and -c levels in the xenografts. There was reduced cell proliferation and expression of cell cycle regulatory genes CCND1, CDK2, and E2F1 and no significant changes in apoptosis. The xenografts with MIAT knockdown expressed lower mRNA and protein levels of FN1, COL3A1, and TGF-β3, and total collagen protein. Targeting MIAT, which sponges the pro-fibrotic miR-29 family, is an effective therapy for fibroids by reducing cell proliferation and thereby, tumor growth and accumulation of ECM, which is a hallmark of these benign gynecologic tumors.

Currently Available Treatment Modalities for Uterine Fibroids

Uterine fibroids (leiomyomas and myomas) are the most common benign gynecological condition in patients presenting with abnormal uterine bleeding, pelvic masses causing pressure or pain, infertility and obstetric complications. Almost a third of women with fibroids need treatment due to symptoms.

OBJECTIVES

In this review we present all currently available treatment modalities for uterine fibroids.

METHODS

An extensive search for the available data regarding surgical, medical and other treatment options for uterine fibroids was conducted.

REVIEW

Nowadays, treatment for fibroids is intended to control symptoms while preserving future fertility. The choice of treatment depends on the patient's age and fertility and the number, size and location of the fibroids. Current management strategies mainly involve surgical interventions (hysterectomy and myomectomy hysteroscopy, laparoscopy or laparotomy). Other surgical and non-surgical minimally invasive techniques include interventions performed under radiologic or ultrasound guidance (uterine artery embolization and occlusion, myolysis, magnetic resonance-guided focused ultrasound surgery, radiofrequency ablation of fibroids and endometrial ablation). Medical treatment options for fibroids are still restricted and available medications (progestogens, combined oral contraceptives andgonadotropin-releasing hormone agonists and antagonists) are generally used for short-term treatment of fibroid-induced bleeding. Recently, it was shown that SPRMs could be administered intermittently long-term with good results on bleeding and fibroid size reduction. Novel medical treatments are still under investigation but with promising results.

CONCLUSIONS

Treatment of fibroids must be individualized based on the presence and severity of symptoms and the patient's desire for definitive treatment or fertility preservation.

The Role of Nanomedicine in Benign Gynecologic Disorders

Nanomedicine has revolutionized drug delivery in the last two decades. Nanoparticles appear to be a promising drug delivery platform in the treatment of various gynecological disorders including uterine leiomyoma, endometriosis, polycystic ovarian syndrome (PCOS), and menopause. Nanoparticles are tiny (mean size < 1000 nm), biodegradable, biocompatible, non-toxic, safe, and relatively inexpensive materials commonly used in imaging and the drug delivery of various therapeutics, such as chemotherapeutics, small molecule inhibitors, immune mediators, protein peptides and non-coding RNA. We performed a literature review of published studies to examine the role of nanoparticles in treating uterine leiomyoma, endometriosis, PCOS, and menopause. In uterine leiomyoma, nanoparticles containing 2-methoxyestradiole and simvastatin, promising uterine fibroid treatments, have been effective in significantly inhibiting tumor growth compared to controls in in vivo mouse models with patient-derived leiomyoma xenografts. Nanoparticles have also shown efficacy in delivering magnetic hyperthermia to ablate endometriotic tissue. Moreover, nanoparticles can be used to deliver hormones and have shown efficacy as a mechanism for transdermal hormone replacement therapy in individuals with menopause. In this review, we aim to summarize research findings and report the efficacy of nanoparticles and nanotherapeutics in the treatment of various benign gynecologic conditions.

Network-based drug repositioning of linagliptin as a potential agent for uterine fibroids targeting transforming growth factor-beta mediated fibrosis

Uterine fibroid is the most common non-cancerous tumor with no satisfactory options for long-term pharmacological treatment. Fibroblast activation protein-α (FAP) is one of the critical enzymes that enhances the fibrosis in uterine fibroids. Through STITCH database mining, we found that dipeptidyl peptidase-4 inhibitors (DPP4i) have the potential to inhibit the activity of FAP. Both DPP4 and FAP belong to the dipeptidyl peptidase family and share a similar catalytic domain. Hence, ligands which have a binding affinity with DPP4 could also bind with FAP. Among the DPP4i, linagliptin exhibited the highest binding affinity (Dock score = -8.562 kcal/mol) with FAP. Our study uncovered that the differences in the S2 extensive-subsite residues between DPP4 and FAP could serve as a basis for designing selective inhibitors specifically targeting FAP. Furthermore, in a dynamic environment, linagliptin was able to destabilize the dimerization interface of FAP, resulting in potential inhibition of its biological activity. True to the in-silico results, linagliptin reduced the fibrotic process in estrogen and progesterone-induced fibrosis in rat uterus. Furthermore, linagliptin reduced the gene expression of transforming growth factor-β (TGF-β), a critical factor in collagen secretion and fibrotic process. Masson trichrome staining confirmed that the anti-fibrotic effects of linagliptin were due to its ability to reduce collagen deposition in rat uterus. Altogether, our research proposes that linagliptin has the potential to be repurposed for the treatment of uterine fibroids.

The Hangman's Tourniquet: A Safe and Practical Approach for Reducing Blood Loss During Uterine Myomectomy

STUDY OBJECTIVES

The application of a pericervical uterine artery tourniquet is a useful method of reducing intraoperative haemorrhage during abdominal myomectomy. However, the utilization of a single combined pericervical uterine artery and infundibulopelvic ligament tourniquet is a more effective and influential method of temporarily occluding the uterine vasculature to decrease intraoperative blood loss, reducing the requirement for blood products, the risk of conversion to hysterectomy, and patient morbidity and mortality during fertility-sparing leiomyoma surgery. Our objective of this retrospective review was to assess the effectiveness of the combined uterine artery and infundibulopelvic ligament tourniquet, which we coin as the "Hangman's uterine tourniquet", in reducing intraoperative blood loss during abdominal myomectomy, thereby reducing the need for blood products.

METHODS

This retrospective study included 39 patients diagnosed with symptomatic subserosal, intramural, and/or submucosal uterine leiomyoma (>3 cm) who underwent an abdominal myomectomy between January 2021 and December 2022.

RESULTS

Thirty-nine patients met the eligibility criteria for our study. The average patient age included in our study was 36 years. All myomectomies were completed with a mean intraoperative blood loss of 252.60 ml and the average number of fibroids removed was seven. The largest fibroid removed measured 27 x 20 cm in diameter while the most significant number of fibroids removed was 41. Moreover, the mean duration of the tourniquet application was 45.31 minutes, and the mean duration of operation was 80.44 minutes. Thirty-six patients (92.3%) had an estimated blood loss <500 ml. The number of fibroids removed was a statistically significant risk factor influencing estimated blood loss (p = 0.019). However, there was no statistical significance between estimated blood loss and the size of the largest fibroid removed (p = 0.178) nor estimated blood loss and a history of previous surgery (p = 0.412). The postoperative blood transfusion rate was 2.5% and no patients suffered grade III or higher surgical complications according to the Clavien-Dindo classification.

CONCLUSION

This study showed that the utilization of a temporary intraoperative combined pericervical uterine artery and infundibulopelvic ligament tourniquet is an effective, practical, and economical approach to limiting intraoperative blood loss during abdominal myomectomy.

Evidence-Based Approach for Secondary Prevention of Uterine Fibroids (The ESCAPE Approach)

Uterine fibroids (UFs) are common tumors in women of reproductive age. It is imperative to comprehend UFs' associated risk factors to facilitate early detection and prevention. Simple relying on surgical/pharmacological treatment of advanced disease is not only highly expensive, but it also deprives patients of good quality of life (QOL). Unfortunately, even if the disease is discovered early, no medical intervention is traditionally initiated until the disease burden becomes high, and only then is surgical intervention performed. Furthermore, after myomectomy, the recurrence rate of UFs is extremely high with the need for additional surgeries and other interventions. This confused approach is invasive and extremely costly with an overall negative impact on women's health. Secondary prevention is the management of early disease to slow down its progression or even halt it completely. The current approach of watchful observation for early disease is considered a major missed opportunity in the literature. The aim of this article is to present an approach named the ESCAPE (Evidence-Based Approach for Secondary Prevention) of UF management. It comprises simple, inexpensive, and safe steps that can arrest the development of UFs, promote overall reproductive health, decrease the number of unnecessary surgeries, and save billions of health care systems' dollars worldwide.

Robotic surgery in Gynecology: the present and the future

Since its introduction, laparoscopic surgery has been often preferred over open surgery in obstetrics and gynecology due to its advantages, such as less bleeding, lower incidence of adhesions, reduced postoperative pain, short hospital stay, and quick return to daily life. However, in the case of complex surgeries, laparoscopy presented some limitations. Nonetheless, since the 1980s, medical robots have been introduced to overcome the technical limitations of laparoscopy and start a new age for minimally invasive surgery. In this review, we explore the indications and advantages and disadvantages of robotic surgery in the field of gynecology, and try to assess the recent trend of robotic surgery.

Intravenous leiomyoma of the uterus extending to the pulmonary artery: A case report

BACKGROUND

Uterine intravenous leiomyomatosis is defined as leiomyoma tissue invading the vein outside the leiomyoma. Reports of extension to the right pulmonary artery are relatively rare.

CASE SUMMARY

We describe a 31-year-old woman with a benign leiomyoma that extended into the right ventricular lumen, causing mechanical obstruction and corresponding clinical symptoms. Tumors located in the pulmonary artery can cause pulmonary artery obstruction. After diagnosis, surgical treatment should be performed as soon as possible.

CONCLUSION

In this case, the uterine leiomyoma extended to the right pulmonary system, which is clinically rare.

Cysteine-rich intestinal protein 1 is a novel surface marker for human myometrial stem/progenitor cells

Myometrial stem/progenitor cells (MyoSPCs) have been proposed as the cells of origin for uterine fibroids, but the identity of the MyoSPC has not been well established. We previously identified SUSD2 as a possible MyoSPC marker, but the relatively poor enrichment in stem cell characteristics of SUSD2+ over SUSD2- cells compelled us to find better markers. We combined bulk RNA-seq of SUSD2+/- cells with single cell RNA-seq to identify markers for MyoSPCs. We observed seven distinct cell clusters within the myometrium, with the vascular myocyte cluster most highly enriched for MyoSPC characteristics and markers. CRIP1 expression was found highly upregulated by both techniques and was used as a marker to sort CRIP1+/PECAM1- cells that were both enriched for colony forming potential and able to differentiate into mesenchymal lineages, suggesting that CRIP1+/PECAM1- cells could be used to better study the etiology of uterine fibroids.

Comparison of Recurrence and Quality of Life Between Myoma Embolization and Myomectomy

INTRODUCTION

Uterine myomas represent the most frequently diagnosed tumors among women of childbearing age. Symptoms often include profuse menstrual bleeding, diminished quality of life, and in some cases, infertility. The size and position of the fibroids typically influence the condition's manifestations. Moreover, symptomatology often varies depending on the fibroids' location. This investigation aimed to discern if there exists a significant correlation between life quality, reoccurrence rate, quality of life, and recurrence levels among patients who have undergone myomectomy and uterine fibroid embolization, respectively.

METHODOLOGY

A retrospective cross-sectional study was conducted to compare the rates of recurrence and impacts on life quality between uterine fibroid embolization and myomectomy in women diagnosed with uterine myomas. Data were collected from 152 women who sought treatment at the Obstetrics and Gynecology clinic and also the Interventional Radiology clinic between January 2009 and January 2021. Thirteen participants were excluded due to the inability to maintain contact. The trial encompassed 76 patients who underwent myomectomy and 63 who had uterine fibroid embolization. In both groups, the life quality of 50 patients, five years postsurgery, was assessed using the UFS-QOL measure. Eligible participants were females between 20 and 40 years, with symptomatic Type 3-5 fibroids as per the FIGO classification, and with no comorbidities. Individuals under 20 or over 40 years, or those with fibroids classified as FIGO types 1,2,6,7,8, were not included. Other exclusion criteria included pregnancy status, abnormal endometrial biopsy results, abnormal smear tests, polyps, cancer, adenomyosis and coagulation disorders.

RESULTS

The recurrence of fibroids was identified through symptomatology and diagnostic radiological methods. The recurrence rate was found to be 31.6% (n=24) for myomectomy patients and 14.3% (n=9) for those who underwent uterine fibroid embolization, with no statistically significant difference between the two groups (p > 0.05). The group subjected to myomectomy exhibited fewer symptoms, lower anxiety, and better physical mood scores. The myomectomy group displayed higher average anxiety scores (p<0.01). There were no significant disparities in control, consciousness, sexual function, or overall scores between the two groups. Symptoms and anxiety saw a marked reduction in the first postoperative year compared to the preoperative period (p<0.01). Compared to presurgery, energy, mood, awareness, and sexual function exhibited significant improvements in the first and fifth postoperative years (p<0.01).

CONCLUSIONS

Our findings suggest a nonsignificant recurrence rate in the myomectomy group compared to the uterine artery embolization group. Notably, the decrease in symptom occurrence and anxiety following myomectomy was significantly favorable in terms of quality of life. While embolization was offered as a therapeutic option, myomectomy yielded more favorable results concerning quality of life.

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.

Ultrasound-Guided Diagnosis of Multiple Uterine Fibroids in a Patient With Polycystic Ovaries and Treatment With Relugolix, Estradiol, and Norethisterone Acetate

Uterine fibroids and ovarian cysts are common gynecological conditions that, while benign, when present simultaneously with bacterial vaginosis, can present a more complicated course of management. Symptoms of uterine fibroids include menorrhagia and dysmenorrhea, while ovarian cysts may present with pelvic pain and an adnexal mass. Each condition is typically managed separately; however, they can coexist in some patients, leading to a more complex presentation. This case report presents a 35-year-old African American female patient with the simultaneous occurrence of uterine fibroids and ovarian cysts, complicated by recurrent vaginitis, along with the treatment approach. The treatment choice, relugolix, estradiol, and norethisterone (norethindrone) acetate, is the first once-daily U.S. Food and Drug Administration (FDA) combination hormonal medication approved for menorrhagia due to fibroids. This case is unique in that although the diagnoses are common, their coexistence makes for a more complex presentation, and the course of management presents a newly approved fixed-dose combination hormonal medication. This report discusses the incidence, pathophysiology, diagnosis, and management of uterine fibroids and ovarian cysts. Factors that may contribute to the concurrence of these conditions, such as genetic, hormonal, and environmental risks, are also explored. Diagnostic modalities and ultrasound techniques are reviewed, and treatment options, such as surgery and medical management, are discussed. The importance of a patient-centered approach in the treatment of multi-symptom gynecological disorders and the need to consider conservative management are emphasized.

Cysteine-Rich Intestinal Protein 1 is a Novel Surface Marker for Myometrial Stem/Progenitor Cells

Myometrial stem/progenitor cells (MyoSPCs) have been proposed as the cells of origin for uterine fibroids, which are benign tumors that develop in the myometrium of most reproductive age women, but the identity of the MyoSPC has not been well established. We previously identified SUSD2 as a possible MyoSPC marker, but the relatively poor enrichment in stem cell characteristics of SUSD2+ over SUSD2- cells compelled us to find better discerning markers for more rigorous downstream analyses. We combined bulk RNA-seq of SUSD2+/- cells with single cell RNA-seq to identify markers capable of further enriching for MyoSPCs. We observed seven distinct cell clusters within the myometrium, with the vascular myocyte cluster most highly enriched for MyoSPC characteristics and markers, including SUSD2. CRIP1 expression was found highly upregulated in both techniques and was used as a marker to sort CRIP1+/PECAM1- cells that were both enriched for colony forming potential and able to differentiate into mesenchymal lineages, suggesting that CRIP1+/PECAM1- cells could be used to better study the etiology of uterine fibroids.

Comparison of polyvinyl alcohol particles and tris-acryl gelatin microspheres embolic agents used in uterine artery embolization: A systematic review and meta-analysis

Objective

To identify the preferred agent by comparing the therapeutic efficacy, degree of infarction, and side effects of polyvinyl alcohol particles (PVA) and tris-acryl gelatin embolization (TAGM) agents in uterine artery embolization.

Materials and Methods

We included available articles comparing PVA with TAGM embolization agents in the management of fibroids. The primary outcomes included the decrease in uterine volume (%), decrease in dominant tumor volume (%), fibroid infarction rate, complete infarction fibroid, complications, pain score after 24 h, procedure time (minutes), duration of hospital stay, fluoroscopy time (minutes), and the change in symptom severity score.

Results

Eight articles that met our inclusion criteria were included in this study. Our analysis yielded an overall superiority of PVA compared to TAGM regarding complete fibroid infarction rate at the first 24 h. However, TAGM was better than PVA concerning <90% infarction rate outcome. While both embolization techniques showed similar effects regarding the change in symptom severity score, the percentage of decrease in uterine volume, percentage of decrease of dominant tumor volume, 90-99% infarction rate, complete infarction rate when assessed after the first 24 h, pain score after the first 24 h, procedure time, fluoroscopy time, minor, and major complications.

Conclusion

Both PVA and TAGM embolization agents are effective and safe modalities in treating patients with fibroids, with no significant variation of both agents in most outcomes.

H3K4me3 mediates uterine leiomyoma pathogenesis via neuronal processes, synapsis components, proliferation, and Wnt/β-catenin and TGF-β pathways

BACKGROUND

Uterine leiomyomas (UL) are the most common benign tumor in women of reproductive age. Their pathology remains unclear, which hampers the development of safe and effective treatments. Raising evidence suggests epigenetics as a main mechanism involved in tumor development. Histone modification is a key component in the epigenetic regulation of gene expression. Specifically, the histone mark H3K4me3, which promotes gene expression, is altered in many tumors. In this study, we aimed to identify if the histone modification H3K4me3 regulates the expression of genes involved in uterine leiomyoma pathogenesis.

METHODS

Prospective study integrating RNA-seq (n = 48) and H3K4me3 CHIP-seq (n = 19) data of uterine leiomyomas versus their adjacent myometrium. Differentially expressed genes (FDR < 0.01, log2FC > 1 or < - 1) were selected following DESeq2, edgeR, and limma analysis. Their differential methylation and functional enrichment (FDR < 0.05) were respectively analyzed with limma and ShinyGO.

RESULTS

CHIP-seq data showed a global suppression of H3K4me3 in uterine leiomyomas versus their adjacent myometrial tissue (p-value< 2.2e-16). Integrating CHIP-seq and RNA-seq data highlighted that transcription of 696/922 uterine leiomyoma-related differentially expressed genes (DEG) (FDR < 0.01, log2FC > 1 or < - 1) was epigenetically mediated by H3K4me3. Further, 50 genes were differentially trimethylated (FDR < 0.05), including 33 hypertrimethylated/upregulated, and 17 hypotrimethylated/downregulated genes. Functional enrichment analysis of the latter showed dysregulation of neuron-related processes and synapsis-related cellular components in uterine leiomyomas, and a literature review study of these DEG found additional implications with tumorigenesis (i.e. aberrant proliferation, invasion, and dysregulation of Wnt/β-catenin, and TGF-β pathways). Finally, SATB2, DCX, SHOX2, ST8SIA2, CAPN6, and NPTX2 proto-oncogenes were identified among the hypertrimethylated/upregulated DEG, while KRT19, ABCA8, and HOXB4 tumor suppressor genes were identified among hypotrimethylated/downregulated DEG.

CONCLUSIONS

H3K4me3 instabilities alter the expression of oncogenes and tumor suppressor genes, inducing aberrant proliferation, and dysregulated Wnt/β-catenin, and TGF-β pathways, that ultimately promote uterine leiomyoma progression. The reversal of these histone modifications may be a promising new therapeutic alternative for uterine leiomyoma patients.

Uterine fibroids - Causes, impact, treatment, and lens to the African perspective

Leiomyomas, or uterine fibroids as they are commonly known, are mostly seen in women of reproductive age. However, they can go undetected in most women, and approximately 25% of women show clinical symptoms. Although fibroids are a global burden impacting 80% of premenopausal women, they are more prevalent among Black women than among women of other races. Based on clinical diagnosis, the estimated cumulative incidence of fibroids in women ≤50 years old is significantly higher for black (>80%) versus white women (∼70%). The cause of leiomyomas is not clearly known, but studies have shown evidence of factors that drive the development or exacerbation of the disease. Evidence has linked risk factors such as lifestyle, age, environment, family history of uterine fibroids, and vitamin D deficiencies to an increased risk of uterine fibroids, which impact women of African descent at higher rates. Treatments may be invasive, such as hysterectomy and myomectomy, or non-invasive, such as hormonal or non-hormonal therapies. These treatments are costly and tend to burden women who have the disease. Sub-Saharan Africa is known to have the largest population of black women, yet the majority of uterine fibroid studies do not include populations from the continent. Furthermore, the prevalence of the disease on the continent is not well determined. To effectively treat the disease, its drivers need to be understood, especially with regard to racial preferences. This paper aims to review the existing literature and build a case for conducting future research on African women.

Comparison of hysterectomy and uterine artery embolization in the treatment of symptomatic uterine fibroids: A protocol for systematic review and meta-analysis

BACKGROUND

Uterine fibroids are common benign tumors in premenopausal women. Surgery is the preferred treatment for symptomatic uterine fibroids. An alternative of hysterectomy to manage symptomatic uterine fibroids is selective uterine artery embolization. We performed a protocol for systematic review and meta-analysis to assess the effectiveness of uterine artery embolization for treating symptomatic uterine fibroids compared with hysterectomy.

METHODS

The current systematic review and meta-analysis will be reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol. This review protocol has been registered in the International Prospective Register of systematic reviews. Its registration number is CRD42022371866. Only randomized controlled trials (RCTs) are included in our study.Two independent reviewers will search for databases including PubMed, Embase, Cochrane Library website, ClinicalTrials.gov databases, Chinese National Knowledge Infrastructure Database, Wanfang database, and VIP database. The risk of bias in each included study will be assessed utilizing the Cochrane Collaboration's risk of bias tool. The RevMan 5.3 software (Cochrane Collaboration, Oxford, UK) will be used to conduct the meta-analyses.

RESULTS

The results of this systematic review will be published in a peer-reviewed journal.

CONCLUSION

This systematic review will provide high quality evidence to judge whether uterine artery embolization is an effective surgical method for patients with symptomatic uterine fibroids.

Рrediction of infertility in patients with uterine leiomyoma

Infertility is an important socio-economic problem due to the fact that planned childbearing occurs much later than three decades ago. In recent years, more attention has been paid to the role of uterine leiomyoma in the development of infertility. Uterine leiomyoma is a benign monoclonal, well-demarcated encapsulated tumor originating from the smooth muscle cells of the cervix or body of the uterus. Uterine leiomyoma is the most common uterine tumor in the reproductive age group, affecting 20-50 % of women. With conceptual changes in marriage and childbearing, the number of women over 35 with leiomyoma who want to have children has also increased significantly. The need to treat submucosal fibroids is widely recognized, but fibroids of other locations and sizes remain a clinical mystery. The purpose of the literature review was to determine the role of uterine fibroids in predicting infertility. It has been established that the incidence of uterine leiomyoma in women of reproductive age is on average about 40 %, infertility associated with this pathology occurs in 5-10 % of women. In 10 % of cases of infertility, uterine leiomyoma is the only established cause of infertility. Uterine leiomyoma is common among women of reproductive age, and as women continue to delay childbearing, an increasing number of patients will require fertility-preserving treatment options. Leiomyoma affects not only fertility but also obstetric outcomes. Women with intramural fibroids without cavity deformity have a 21 % reduction in live birth rates after in vitro fertilization compared with controls without fibroids. Despite advances in fundamental understanding of the biology of leiomyomas, the role of different fibroid variants remains a matter of discussion. The question of the negative impact of submucosal nodes on infertility today is not in doubt, and the effect of subserous and intramural nodes requires further study.

Letrozole as premedication of high intensity focused ultrasound treatment of uterine fibroids: A retrospective observation study

Background

No reports on Letrozole as a pretreatment before ablation of uterine fibroid with high intensity focused ultrasound (HIFU), so a retrospective observation study was performed to evaluate the response of different pre-HIFU medication.

Methods

We collected patients with single uterine fibroid receiving HIFU ablation from January 2018 to April 2021. All enrolled patients were classified into three group: group A (no pre-HIFU medication use), group B (Pre-HIFU letrozole use), group C (pre-HIFU gonadotrophin releasing hormone analog, GnRHa). Further associated clinical data and treatment response after HIFU treatment were reviewed and evaluated.

Results

A total of 39 patients including 21, 7, and 11 in group A, B, and C were collected respectively. After pre-HIFU medication, no difference of fibroid volume was found (A: 251.4, B: 360.6, C: 409.4 cm³, p = 0.250), and GnRHa group had significantly larger volume reduction than Letrozole users (38.6% vs. 16.4%, p = 0.007). The incidence of hypoestrogenic symptoms was higher in GnRHa group than in letrozole users (27.3% vs. 0, p = 0.170). GnRHa group had more sonication time (p = 0.001), treatment duration (p = 0.002), and ablated energy (p = 0.001) than group A and B. The treatment efficiency was higher in letrozole group than that in other 2 groups (4.52 vs. 2.39 vs. 2.34 cm³/min, p = 0.050). For patients with fibroid over 10 cm in diameter, letrozole group had even better energy efficiency (p = 0.067), treatment speed (p = 0.007), treatment efficiency (p = 0.001), NPV per energy (p = 0.005), and NPV per sonication (p = 0.004) than other 2 groups.

Conclusion

Letrozole as a pretreatment medication before HIFU treatment might increase the energy efficiency and treatment efficiency of its ablation of uterine leiomyoma, especially for fibroid over 10 cm. Future study of larger patient number is needed to confirm our results.

Efficacy and Safety of Oral GnRh Antagonists in Patients With Uterine Fibroids: A Systematic Review

OBJECTIVE

This review aimed to assess the efficacy and safety of GnRH antagonists in patients with symptomatic uterine fibroids.

DATA SOURCES

A literature search was performed on PubMed, Web of Science, Embase, Cochrane, and ClinicalTrials.gov using the MeSH and Emtree terms "leiomyoma" and "gonadotropin-releasing hormone."

STUDY SELECTION

All clinical trials that provided efficacy and safety data in clinical terms (i.e., reduction in menstrual bleeding and discomfort, changes in the size of leiomyoma and uterine volume, etc.) were included. We excluded all preclinical studies, case reports, meta-analyses, review articles, and clinical studies irrelevant to the study question.

DATA EXTRACTION AND SYNTHESIS

Two authors extracted data from 9 clinical studies. The extracted data included the study's characteristics, participants' baseline characteristics, treatment drugs, efficacy measures, and toxicity.

CONCLUSION

Among oral GnRH antagonists, relugolix, elagolix, and linzagolix were safe in patients with uterine fibroids. These drugs, alone and in combination with E2/NETA (estradiol/norethindrone acetate), showed significantly better efficacy than placebo in improving bleeding, discomfort, uterine/leiomyoma sizes, and quality of life in premenopausal patients with symptomatic uterine fibroids. However, more randomized, double-blind, multicentre clinical trials are needed to confirm these results and to see long-term benefits.

Magnetic resonance imaging parameter-based machine learning for prognosis prediction of high-intensity focused ultrasound ablation of uterine fibroids

Objectives: To develop and apply magnetic resonance imaging (MRI) parameter-based machine learning (ML) models to predict non-perfused volume (NPV) reduction and residual regrowth of uterine fibroids after high-intensity focused ultrasound (HIFU) ablation.Methods: MRI data of 573 uterine fibroids in 410 women who underwent HIFU ablation from the Chongqing Haifu Hospital (training set, N = 405) and the First Affiliated Hospital of Chongqing Medical University (testing set, N = 168) were retrospectively analyzed. Fourteen MRI parameters were screened for important predictors using the Boruta algorithm. Multiple ML models were constructed to predict NPV reduction and residual fibroid regrowth in a median of 203.0 (interquartile range: 122.5-367.5) days. Furthermore, optimal models were used to plot prognostic prediction curves.Results: Fourteen features, including postoperative NPV, indicated predictive ability for NPV reduction. Based on the 10-fold cross-validation, the best average performance of multilayer perceptron achieved with R² was 0.907. In the testing set, the best model was linear regression (R² =0.851). Ten features, including the maximum thickness of residual fibroids, revealed predictive power for residual fibroid regrowth. Random forest model achieved the best performance with an average area under the curve (AUC) of 0.904 (95% confidence interval (CI), 0.869-0.939), which was maintained in the testing set with an AUC of 0.891 (95% CI, 0.850-0.929).Conclusions: ML models based on MRI parameters can be used for prognostic prediction of uterine fibroids after HIFU ablation. They can potentially serve as a new method for learning more about ablated fibroids.

Analysis of Pregnancy Outcomes after Laparoscopic Myomectomy: A Retrospective Cohort Study

Objective. This study aimed to investigate the factors related to pregnancy outcomes after laparoscopic myomectomy. Methods. A retrospective review was conducted on 156 patients aged 18 to 45 years who underwent laparoscopic myomectomy in Ningbo Women and Children’s Hospital from January 2010 to December 2016. Follow-up medical records and information were collected on demographic variables, clinical variables, and postoperative pregnancy rate. The logistic regression model was used to assess the association between related factors and postoperative pregnancy rate or pregnancy outcome. The outcome indicators included $\text{abortion}=0$ , $\text{premature}\text{birth}=1$ , and $\text{full}\text{term}=2$ . The chi-squared test or Fisher’s exact test was used to compare the differences in pregnancy outcomes, postpartum hemorrhage, and placenta adhesion between the cohorts. Results. The size of fibroids correlated with the postoperative pregnancy rate. The larger the fibroids, the lower the postoperative pregnancy rate, and the difference was statistically significant. The number of fibroids and placental adhesions was positively associated with postoperative pregnancy; the higher the number of fibroids, the higher the incidence of placental adhesions. However, the postoperative interval of pregnancy, fibroid size, and number and type of fibroids are not correlated with the pregnancy outcomes of postoperative patients. Conclusions. The size of myoma may influence the pregnancy rate of patients after laparoscopic myomectomy. The number of fibroids can affect the incidence of placental adhesions during postoperative pregnancy.

Integrative analysis of the DNA methylome and transcriptome in uterine leiomyoma shows altered regulation of genes involved in metabolism, proliferation, extracellular matrix and vesicles

Uterine leiomyomas are the most common benign tumors in women of reproductive age. Despite the high prevalence, tumor pathology remains unclear, which hampers development of safe and effective treatments. Epigenetic mechanisms appear to be involved in uterine leiomyoma development, particularly via DNA methylation that regulates gene expression. We aimed to determine the relationship between DNA methylation and gene expression in uterine leiomyoma compared to adjacent myometrium to identify molecular mechanisms involved in uterine leiomyoma formation that are under epigenetic control. Our results showed a different DNA methylation profile between uterine leiomyoma and myometrium, leading to hypermethylation of uterine leiomyoma, and a different global transcriptome profile. Integration of DNA methylation and whole-transcriptome RNA-sequencing data identified 93 genes regulated by methylation, with 22 hypomethylated/upregulated and 71 hypermethylated/downregulated. Functional enrichment analysis showed dysregulated biological processes and molecular functions involved in metabolism and cell physiology, response to extracellular signals, invasion, and proliferation, as well as pathways related to uterine biology and cancer. Cellular components such as cell membranes, vesicles, extracellular matrix, and cell junctions were dysregulated in uterine leiomyoma. In addition, we found hypomethylation/upregulation of oncogenes (PRL, ATP8B4, CEMIP, ZPMS2-AS1, RIMS2, TFAP2C) and hypermethylation/downregulation of tumor suppressor genes (EFEMP1, FBLN2, ARHGAP10, HTATIP2), which are related to proliferation, invasion, altered metabolism, deposition of extracellular matrix, and Wnt/β-catenin pathway dysregulation. This confirms that key processes of uterine leiomyoma development are under DNA methylation control. Finally, inhibition of DNA methyltransferases by 5-aza-2'-deoxycitidine increased expression of hypermethylated/downregulated genes in uterine leiomyoma cells in vitro. In conclusion, gene regulation by DNA methylation is implicated in uterine leiomyoma pathogenesis, and reversion of this methylation could offer a therapeutic option for uterine leiomyoma. This article is protected by copyright. All rights reserved.

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.

Rare Case of Osseus Metaplasia in a Detached Remnant Leiomyoma Following Hysteroscopic Myomectomy

Uterine leiomyoma is the most common benign tumor of the uterus, affecting reproductive-age women. Although women with uterine fibroids are commonly asymptomatic, in symptomatic patients, hysteroscopic myomectomy is considered the first-line surgical treatment for intracavitary fibroids in women who wish to maintain fertility. 

Osseous metaplasia in uterine fibroids is the transformation of fibroids cells into pure mature or immature bone. It is rare, and few case reports present with osseous metaplasia in uterine fibroids. This is the first report in the literature of osseous metaplasia in a remnant fibroid after hysteroscopic myomectomy. Every effort should be attempted to ensure complete retrieval of the detached fibroid remnant after hysteroscopic resection, as this might decrease the risk for subsequent surgeries.

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.

Comparison of two invasive non-surgical treatment options for uterine myomas: uterine artery embolization and magnetic resonance guided high intensity focused ultrasound-systematic review

BACKGROUND

Uterine Artery Embolization (UAE) and Magnetic Resonance guided High Intensity Focused Ultrasound (MRgHIFU) are two noninvasive treatments for uterine leiomyoma.

METHODS

This systematic review, following PRISMA guidelines, analyzed the effectiveness of two treatments by comparing percent fibroid volume shrinkage immediately after the procedure and after 3, 6, 12 and 24 months of follow-up and also assessed and compared common complications following treatment. The search utilized Science Direct, PubMed, MEDLINE, Google Scholar and BioMed Central databases, selecting manuscripts published during the period 2000 and 2020. Studies with premenopausal patients with previous treatments for uterine leiomyoma and/or with other pelvic diseases were excluded.

RESULTS

Twenty-nine papers satisfied inclusion and exclusion criteria. Results were pooled and stratified by treatment and follow-up time. Weighted fibroid volume percent shrinkage after UAE was statistically significantly greater than MRgHIFU at 6, 12, and 24 months follow-up times. However, UAE had statistically significantly more complications, such as pain, nausea and vomiting. However, this study cannot conclude that UAE is more effective than MRgHIFU due to confounding factors.

Anxiety, Depression, and Quality of Life After Procedural Intervention for Uterine Fibroids

Background: Quality of life (QOL) and psychological health has been reported to be decreased among women with gynecological conditions such as uterine fibroids (UFs). Materials and Methods: Women enrolled in the Comparing Options for Management: PAtient-centered REsults for Uterine Fibroids (COMPARE-UF) registry, receiving procedural therapy for symptomatic UFs, were eligible for this analysis if they completed a series of health-related QOL surveys administered at three time points (baseline, 6-12 weeks postprocedure, and 1 year postprocedure; n = 1486). Ethical approval for this study was obtained at each recruiting site and the coordinating center (NCT02260752, clinicaltrials.gov). Results: More than 26% (n = 393) of women reported moderate anxiety/depression on the baseline anxiety/depression domain of the Euro-QOL 5-dimension instrument. At both the 6-12 weeks and 1-year postprocedural follow-up, there was significant improvement in the UF QOL symptom severity score (p < 0.001, p < 0.001), the total UF symptom QOL score (p < 0.001, p < 0.001), and the Euro-QOL 5-dimension visual analog scale (p < 0.001, p = 0.004) compared with the preprocedural baseline scores. The reporting of anxiety/depression decreased by 66.4% among women who were at baseline, whereas 5.6% of women previously reporting no anxiety/depression reported anxiety/depression at the 1-year follow-up. Conclusion: UF symptoms were more severe among women reporting anxiety/depression at baseline. At the 1-year follow-up, health-related QOL scores improved among all women and the prevalence of anxiety/depression decreased in most, but not all women, whereas severity of anxiety/depression worsened in a small percentage of women (5.6%). Overall, these results suggest that UF treatment improves symptoms of anxiety/depression associated with symptomatic UFs.

Epigenomic and enhancer dysregulation in uterine leiomyomas

BACKGROUND

Uterine leiomyomas, also known as uterine fibroids or myomas, are the most common benign gynecological tumors and are found in women of reproductive and postmenopausal age. There is an exceptionally high prevalence of this tumor in women by the age of 50 years. Black women are particularly affected, with an increased incidence, earlier age of onset, larger and faster growing fibroids and greater severity of symptoms as compared to White women. Although advances in identifying genetic and environmental factors to delineate these fibroids have already been made, only recently has the role of epigenomics in the pathogenesis of this disease been considered.

OBJECTIVE AND RATIONALE

Over recent years, studies have identified multiple epigenomic aberrations that may contribute to leiomyoma development and growth. This review will focus on the most recent discoveries in three categories of epigenomic changes found in uterine fibroids, namely aberrant DNA methylation, histone tail modifications and histone variant exchange, and their translation into altered target gene architecture and transcriptional outcome. The findings demonstrating how the altered 3D shape of the enhancer can regulate gene expression from millions of base pairs away will be discussed. Additionally, translational implications of these discoveries and potential roadblocks in leiomyoma treatment will be addressed.

SEARCH METHODS

A comprehensive PubMed search was performed to identify published articles containing keywords relevant to the focus of the review, such as: uterine leiomyoma, uterine fibroids, epigenetic alterations, epigenomics, stem cells, chromatin modifications, extracellular matrix [ECM] organization, DNA methylation, enhancer, histone post-translational modifications and dysregulated gene expression. Articles until September 2021 were explored and evaluated to identify relevant updates in the field. Most of the articles focused on in the discussion were published between 2015 and 2021, although some key discoveries made before 2015 were included for background information and foundational purposes. We apologize to the authors whose work was not included because of space restrictions or inadvertent omission.

OUTCOMES

Chemical alterations to the DNA structure and of nucleosomal histones, without changing the underlying DNA sequence, have now been implicated in the phenotypic manifestation of uterine leiomyomas. Genome-wide DNA methylation analysis has revealed subsets of either suppressed or overexpressed genes accompanied by aberrant promoter methylation. Furthermore, differential promoter access resulting from altered 3D chromatin structure and histone modifications plays a role in regulating transcription of key genes thought to be involved in leiomyoma etiology. The dysregulated genes function in tumor suppression, apoptosis, angiogenesis, ECM formation, a variety of cancer-related signaling pathways and stem cell differentiation. Aberrant DNA methylation or histone modification is also observed in altering enhancer architecture, which leads to changes in enhancer-promoter contact strength, producing novel explanations for the overexpression of high mobility group AT-hook 2 and gene dysregulation found in mediator complex subunit 12 mutant fibroids. While many molecular mechanisms and epigenomic features have been investigated, the basis for the racial disparity observed among those in the Black population remains unclear.

WIDER IMPLICATIONS

A comprehensive understanding of the exact pathogenesis of uterine leiomyoma is lacking and requires attention as it can provide clues for prevention and viable non-surgical treatment. These findings will widen our knowledge of the role epigenomics plays in the mechanisms related to uterine leiomyoma development and highlight novel approaches for the prevention and identification of epigenome targets for long-term non-invasive treatment options of this significantly common disease.

The Potential of Transforming Growth Factor-beta Inhibitor and Vascular Endothelial Growth Factor Inhibitor as Therapeutic Agents for Uterine Leiomyoma

Background: Uterine leiomyoma is the most common benign tumor in women of reproductive age, and it can cause infertility. The growth of uterine leiomyoma is mediated by various steroids and growth factors. The purpose of this study was to evaluate the expression of various growth factors in uterine leiomyoma. Additionally, comparing the effects of existing medication and specific growth factor inhibitors on leiomyoma and the normal myometrium, we aimed to see the potential of transforming growth factor-beta (TGF-β) inhibitors and vascular endothelial growth factor (VEGF) inhibitors as therapeutic drugs for uterine leiomyoma. Methods: This in vitro study included uterine leiomyoma samples from 12 patients who underwent hysterectomy by laparoscopy or laparotomy at Seoul St. Mary's Hospital between May 2016 and March 2018. Normal myometrium and uterine leiomyoma tissue were obtained from each patient and the expression of growth factors was compared using immunohistochemical staining. After the primary culture of normal myometrial and leiomyoma cells, cell viability was evaluated following treatment with 100 nM ulipristal acetate (UPA) and mifepristone for 48 h. Western blot analysis was performed to determine the protein expression of each growth factor. Cell viability was determined following treatment with a 10-µM TGF-β inhibitor (LY364947) and a 5-µM VEGF inhibitor (axitinib) for 24 h in cultured normal myometrium and leiomyoma cells. Results: Immunohistochemical staining revealed the significantly higher intensity of TGF-β and VEGF in the leiomyoma tissue than in the normal myometrium (P < 0.05). Mifepristone treatment decreased VEGF expression by 62% in the leiomyoma cells (P < 0.05). According to the cell counting kit-8 (CCK-8) assay, cell viability was decreased after UPA, mifepristone, TGF-β1 inhibitor, and VEGF inhibitor treatments in the normal myometrium and leiomyoma tissue. The effects of the TGF-β1 inhibitor significantly differed between normal myometrium and leiomyoma tissue, with a greater decrease in cell survival in the leiomyoma tissue (P < 0.05). Post-hoc analysis showed that the TGF-β1 and VEGF inhibitors had a greater inhibitory effect on leiomyoma tissue compared with that of UPA. Conclusion: TGF-β and VEGF inhibitors significantly decreased the viability of uterine leiomyoma cells, showing stronger effects than the conventional drug, UPA. TGF-β1 inhibitors affect both leiomyoma tissue and the normal uterus; thus, targeted local treatment rather than systemic treatment should be considered.

A Comparison of Shear Wave Elastography between Normal Myometrium, Uterine Fibroids, and Adenomyosis: A Cross-Sectional Study

Background

The differential diagnosis between uterine fibroid and adenomyosis is sometimes difficult; a precise diagnosis is required in women with infertility because of the different choice of treatments. Ultrasound elastography (UE) is a novel technique to evaluate the elasticity or the stiffness of the tissue of interest. The present study aims to compare UE shear wave velocity (SWV) among normal uterine myometrium, uterine fibroid, and adenomyosis, and assess the accuracy of shear wave elastography in the diagnosis of adenomyosis.

Materials and Methods

This cross-sectional study recruited 25 subjects for each group (control, adenomyosis, and fibroid) from April 2019 to April 2020. Transvaginal UE using an Aplio 500 (Toshiba Medical Systems, Japan) with ultrasound mapping for point of tissue biopsy was performed for all subjects. The diagnosis was confirmed by histology. Masson’s trichrome staining for collagen was performed and quantified

Results

The mean ± standard deviation (SD) for SWV was 3.44 ± 0.95 m/seconds (control group), 4.63 ± 1.45 m/seconds (adenomyosis group), and 4.53 ± 1.07 m/seconds (fibroid group). The mean SWV differed when comparing normal myometrium and adenomyosis after adjustments for age and endometrial pathology (P=0.019). The cut-off point of SWV at 3.465 m/seconds could differentiate adenomyosis from the normal uterus with an 80% sensitivity, 80% specificity, and an area under the curve (AUC) of 0.80 (95% confidence interval [CI]: 0.68-0.93) (P<0.001). No significant difference in SWV between the adenomyosis and fibroid groups was detected.

Conclusion

Shear wave elastography could be an alternative tool to distinguish between normal myometrium and adenomyosis; however, it could not differentiate adenomyosis from uterine fibroid or uterine fibroid from normal myometrium.

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.

The role of anti-proliferative effects of atorvastatin on uterine fibroids: findings from a clinical study

AIM

Uterine myomas/fibroids are one of the most common benign tumors of the reproductive system in women. Given pleiotropic effects of statins, the aim of this study is to evaluate the therapeutic effects of atorvastatin on uterine fibroids in women of reproductive age.

MATERIALS AND METHODS

This randomized clinical study included 90 women aged 35-45 years with uterine fibroids. The patients were randomly allocated into the intervention group (received one tablet, 20 mg of atorvastatin every day for three months) and placebo. Ultrasound was performed every month, and the change in the size of fibroids was recorded for each patient. At the end of the study, the data obtained were analyzed using SPSSv22 and a p value < .05 was considered statistically significant.

RESULTS

The mean age in the placebo and intervention group was 39.63 ± 36.3 and 40.35 ± 3.32 years, respectively. The number and location of the tumor was comparable for the two groups. We observed a statically significant reduction in fibroid size from the treatment initiation until completion of three months, (41.06 ± 6.68 mm³ vs 35.16 ± 6.67 mm³) p = .0001. However, the decrease in fibroid size from 1st month to the 3rd month was not statistically significant, p = .189 (36.71 ± 5.54 mm³ vs 35.16 ± 6.67 mm³).

CONCLUSION

This study shows that treatment with atorvastatin might positively reduce the size of fibroids. The decrease was only statistically significant during the first month. Further studies with a detailed analysis of the intervention's clinical impact are required to consider statins as a therapeutic tool.

Uterine Fibroids in Black Women: A Race-Stratified Subgroup Analysis of Treatment Outcomes After Laparoscopic Radiofrequency Ablation

Background: The disease and treatment burden of uterine fibroids (UF) in Black women is substantially greater compared with other racial groups, with higher rates of complications and poorer outcomes with both hysterectomy and myomectomy. The inequities in the access Black women have to minimally invasive routes of surgery contribute to their burden of illness. Laparoscopic radiofrequency ablation (LAP-RFA) is a minimally invasive, safe, and effective uterine-sparing treatment option. Methods: This subgroup analysis of the LAP-RFA Pivotal Trial stratified outcomes by race comparing White women (n = 28, 21%) versus Black women (n = 46, 34%). Results: At baseline, Black women had more fibroids on average (7.3 vs. 3.7; P ≤ 0.001), a greater symptom severity score (SSS) (P ≤ 0.001), and a lower health-related quality of life (HRQoL) score (P = 0.005) than White women. At 36 months post-treatment with LAP-RFA, the statistical differences that existed with baseline SSS and HRQoL score were eliminated between Black and White women. Menstrual blood loss (140.1 mL vs. 127.02 mL; P = 0.44) and mean fibroid volume reduction (47.5 cm³ vs. 36.0 cm³; P = 0.17) were similar between Black and White women at 12 months. Although not statistically significant, the intraoperative total blood loss and uterine blood loss was lower in Black women than White women, despite greater operative time (160 minutes vs. 137 minutes; P = 0.09). Conclusions: These results are promising in providing an alternative uterine-sparing option for Black women and may help to provide a minimally invasive option that can address some of the racial inequities in care for Black women with UF.

Safety and efficacy of elagolix (with and without add-back therapy) for the treatment of heavy menstrual bleeding associated with uterine leiomyomas: a systematic review and meta-analysis

Background

Heavy menstrual bleeding (HMB) is a common clinical finding in patients with uterine leiomyomas that can negatively impact their quality of life. Recently, a novel oral GnRH-antagonist (elagolix) has emerged as a possible therapeutic agent for this ailment. Herein data was pooled from clinical trials assessing the safety and efficacy of elagolix with and without add-back therapy.

Main text

PubMed and Cochrane library were systematically searched for RCTs that measured the efficacy and safety of elagolix for the treatment of uterine fibroid-associated HMB. All safety and efficacy endpoints were compared between elagolix-alone, elagolix w/add-back therapy, and placebo. The primary efficacy endpoint was defined as the number of women who achieved menstrual blood loss (MBL) < 80 ml and a reduction in MBL from baseline of > 50% at the end of treatment. Secondary outcomes assessed included change in hemoglobin levels, incidence suppression of bleeding and amenorrhea, and the incidence of adverse events. The random effects model was used to pool data, and heterogeneity was assessed using I2.

Our search identified 4 clinical trials meeting our PICO criteria, with a total of 916 patients. Analysis of the primary outcome revealed that elagolix-alone was the most effective treatment compared to both placebo (LOR = 3.47, CI = 3.03–3.91, p = 0.000, I2 = 0.0%) and add-back therapy (LOR = 0.64, CI = 0.12–1.16, p = 0.016, I2 = 43.1%). Furthermore, both elagolix groups (irrespective of add-back therapy) observed a significant improvement in post-treatment hemoglobin levels as compared to the placebo group (elagolix-alone vs PBO: LOR = 1.44, CI = 0.66–2.22, I2 = 66.0%, p = 0.000; elagolix-w/add-back therapy vs PBO: LOR = 1.22, CI = 0.78–1.66, I2 = 0.0%, p = 0.000). Concerning safety, while elagolix without add-back therapy had the highest overall incidence of adverse effects (elagolix-alone vs placebo LOR = 0.84, CI = 0.48–1.20, I2 = 7.8%, p = 0.000; elagolix-alone vs elagolix-w/add-back LOR = 0.68, CI = 0.09–1.26, p = 0.024, I2 = 64.6%), the incidence of serious (life threatening) adverse events between all 3 treatment groups was not statistically different. The inclusion of add-back therapy with elagolix made the treatment noticeably safer (elagolix-w/add-back vs placebo: LOR = 0.19, CI = − 0.10 to 0.48, I2 = 0.0%, p = 0.194) without seriously compromising its efficacy.

Conclusion

High-quality evidence from 4 trials suggests that elagolix is an effective treatment for leiomyoma-associated HMB, with a marked improvement in all efficacy endpoints. Furthermore, the inclusion of add-back therapy in the treatment regimen should be considered as it mitigates the hypoestrogenic effects of elagolix.

The health concerns related to hysterectomy among Taiwanese women with uterine fibroids- a mixed-methods study

This study aimed to assess health concerns after hysterectomy from different perspectives among Taiwanese women with uterine fibroids. A mixed-methods was used in this study. In a cross-sectional study, 95 patients completed a structured questionnaire (Health Concern Questionnaire-HCQ). Face-to-face interviews with 5 patients were implemented for the qualitative component from OBS-GYN outpatient departments at two hospitals in Northern Taiwan. Participants who met the following criteria, 20 years of age or older, conscious alert without mental disturbances were recruited to this study. Descriptive statistics were calculated for social demographic variables and HCQ. A content analysis was used to analyze the qualitative data. The mean age was 46.28 of 95 patients. Findings of the present study showed that the most health concerns among patients with UFs after hysterectomy are hysterectomy-related complications, follow by impacts on daily life, body image and female identity, and intimacy and sexual relations. The findings of qualitative interviews supported the above findings. In addition, the information needs of post-operative self-care were identify in this qualitative interviews. The results of this research study could help healthcare professionals to address women's health concerns and provide adequate care for Taiwanese women with uterine fibroids after hysterectomy.

[Myoma, fortuitous discovery or metrorrhagia: Which is more revealing?]

Introduction

le myome est une pathologie fréquente dans notre contexte, découverte de façon fortuite ou par des métrorragies; notre objectif était de mesurer l´association entre la taille des myomes et leur circonstance de découverte, et entre le siège des myomes et la survenue de métrorragies.

Méthodes

nous avons mené une étude transversale de 6 ans de janvier 2012 à décembre 2018 incluant les femmes de 18 ans et plus reçues au Centre Hospitalier Universitaire (CHU) Bogodogo pour une échographie pelvienne ou abdomino pelvienne, chez qui au moins un myome utérin a été découvert. L'analyse a consisté en une régression logistique binaire pour la métrorragie et multinomiale pour les circonstances de découverte et la taille.

Résultats

nous avons analysé 1049 femmes, chez qui 2294 myomes ont été répertorié par échographie: soit 2 myomes par femme. L´âge moyen était de 37 ans. Les femmes dont le plus gros myome était supérieur à 50mm représentaient 29,7% (n=311). Il existait une forte association entre le siège interstitiel, sous-séreux ou sous-muqueux et la survenue de métrorragies (p<0,001). La taille inférieure à 50mm était significativement associée à une découverte fortuite (p=0,016), mais pas à une métrorragie révélatrice (p=0,084). Les femmes qui avaient des myomes sous-muqueux (OR=3,13; IC95%= [1,45-6,76]), interstitiel et sous-muqueux (OR=2,24; IC95%= [1,05-4,78] et interstitiel, sous-séreux et sous muqueux (OR=3,57; IC95%= [1,88-6,76]) avaient une côte de présenter une métrorragie plus élevée. Les myomes inférieurs à 50mm avaient un rapport de cote deux fois plus élevé de se révéler de façon fortuite (RRR=1,80; IC95%= [1,25-2,62]) ou par des métrorragies (RRR=1,75; IC95%= [1,04-2,95].

Conclusion

les associations de siège des myomes sont plus à risque de métrorragie.

Transcriptome Analyses of Myometrium from Fibroid Patients Reveals Phenotypic Differences Compared to Non-Diseased Myometrium

Uterine fibroid tissues are often compared to their matched myometrium in an effort to understand their pathophysiology, but it is not clear whether the myometria of uterine fibroid patients represent truly non-disease control tissues. We analyzed the transcriptomes of myometrial samples from non-fibroid patients (M) and compared them with fibroid (F) and matched myometrial (MF) samples to determine whether there is a phenotypic difference between fibroid and non-fibroid myometria. Multidimensional scaling plots revealed that M samples clustered separately from both MF and F samples. A total of 1169 differentially expressed genes (DEGs) (false discovery rate < 0.05) were observed in the MF comparison with M. Overrepresented Gene Ontology terms showed a high concordance of upregulated gene sets in MF compared to M, particularly extracellular matrix and structure organization. Gene set enrichment analyses showed that the leading-edge genes from the TGFβ signaling and inflammatory response gene sets were significantly enriched in MF. Overall comparison of the three tissues by three-dimensional principal component analyses showed that M, MF, and F samples clustered separately from each other and that a total of 732 DEGs from F vs. M were not found in the F vs. MF, which are likely understudied in the pathogenesis of uterine fibroids and could be key genes for future investigation. These results suggest that the transcriptome of fibroid-associated myometrium is different from that of non-diseased myometrium and that fibroid studies should consider using both matched myometrium and non-diseased myometrium as controls.

The Association Between Ferritin and Vitamin D Levels in Premenopausal Fibroid Uterus Cases With Anemia

Objective

The present study aimed to evaluate the association between serum ferritin and vitamin D levels in fibroid uterus cases presenting with anemia.

Methods

Sixty premenopausal women with uterine fibroids (30 associated with anemia and 30 without anemia) were enrolled as cases and control. All participants were evaluated on the basis of a questionnaire, which included queries related to obstetric, medical, and sociodemographic history. Peripheral blood smear, complete blood count (CBC), hemoglobin (Hb), and serum ferritin concentration were measured by a fully automated analyzer, and 25(OH) vitamin D level was measured by enzyme-linked immunosorbent assay (ELISA).

Results

There was a significant difference in ferritin levels between cases and control (p<0.001). The exposure to sunlight was moderate (one-hour exposure) in all subjects, eliminating the confounding effect of sunlight exposure influencing vitamin D levels. The median vitamin D level in cases was 5.0 ng/ml [interquartile range (IQR): 4.8], and that in control was 18.4 ng/ml (IQR: 7.9; p<0.001). A strong positive correlation of (r)=0.616 (p<0.001) was found between serum ferritin and vitamin D levels.

Conclusion

Fibroid uterus cases with anemia are more prone to vitamin D deficiency as compared to cases without anemia. Vitamin D estimation in fibroid uterus cases presenting with anemia would be useful for better patient management.

Contrast-Enhanced Ultrasound for Monitoring Non-surgical Treatments of Uterine Fibroids: A Systematic Review

Non-surgical treatment options for uterine fibroids are uterine artery embolization (UAE), high-intensity focused ultrasound ablation (HIFUA), and percutaneous microwave ablation (PMWA). Magnetic resonance imaging (MRI) is the reference standard imaging method before and after these procedures. Contrast-enhanced ultrasound (CEUS) has been studied as an alternative to MRI for evaluating the fibroids' characteristics and responses to non-surgical treatments. PubMed, Ovid MEDLINE and Scopus databases were searched for literature published from January 2000 through June 7, 2020, that investigated the application of CEUS as an adjunct to monitor UAE, HIFUA or PMWA in human uterine fibroid treatments. Two independent reviewers analyzed 128 publications, out of which 17 were included. Based on this systematic review, CEUS provides detailed data about fibroid volume and vascularization prior, during and post UAE, and it helps determine the endpoint of the procedure. HIFUA with intra-procedural CEUS has faster volume shrinkage over a shorter time period with less needed energy and provides early detection of residual tissue after HIFUA. CEUS and contrast-enhanced MRI have sufficient agreement to be used interchangeably in the clinic to evaluate the therapeutic effect of PMWA and HIFUA on fibroids.

Uterine Fibroids and Progestogen Treatment: Lack of Evidence of Its Efficacy: A Review

BACKGROUND

The objective of this review is to determine the evidence or, conversely, the absence of evidence regarding the effectiveness of progestogens in treating premenopausal women with uterine fibroids. In particular, the goal is to address recurring questions as to whether they are effective or not for managing symptoms commonly attributed to fibroids.

METHODS

A review of the most relevant papers (n = 63) on the efficacy of progesterone and progestogens as medical therapy for uterine fibroids.

RESULTS

Having reviewed the most significant papers on the relationship between uterine fibroids and progesterone/progestogens, it is clear that there is biochemical, histological and clinical evidence that progesterone and progestogens play a critical role in the pathogenesis of myomas.

CONCLUSION

Since progesterone is already implicated in the pathogenesis of this entity, using progestogens to manage fibroids is like constantly adding fuel to the fire, rendering this treatment ineffective.

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.

Discovery and Characterization of BAY 1214784, an Orally Available Spiroindoline Derivative Acting as a Potent and Selective Antagonist of the Human Gonadotropin-Releasing Hormone Receptor as Proven in a First-In-Human Study in Postmenopausal Women

The growth of uterine fibroids is sex hormone-dependent and commonly associated with highly incapacitating symptoms. Most treatment options consist of the control of these hormonal effects, ultimately blocking proliferative estrogen signaling (i.e., oral contraceptives/antagonization of human gonadotropin-releasing hormone receptor [hGnRH-R] activity). Full hGnRH-R blockade, however, results in menopausal symptoms and affects bone mineralization, thus limiting treatment duration or demanding estrogen add-back approaches. To overcome such issues, we aimed to identify novel, small-molecule hGnRH-R antagonists. This led to the discovery of compound BAY 1214784, an orally available, potent, and selective hGnRH-R antagonist. Altering the geminal dimethylindoline core of the initial hit compound to a spiroindoline system significantly improved GnRH-R antagonist potencies across several species, mandatory for a successful compound optimization in vivo. In a first-in-human study in postmenopausal women, once daily treatment with BAY 1214784 effectively lowered plasma luteinizing hormone levels by up to 49%, at the same time being associated with low pharmacokinetic variability and good tolerability.

Contemporary treatment utilization among women diagnosed with symptomatic uterine fibroids in the United States

BACKGROUND

This study evaluated treatment patterns among women diagnosed with symptomatic uterine fibroids (UF) in the United States. Data were retrospectively extracted from the IBM Watson Health MarketScan® Commercial Claims and Encounters and Medicaid Multi-State databases.

METHODS

Women aged 18-64 years with ≥1 medical claim with a UF diagnosis (primary position, or secondary position plus ≥1 associated symptom) from January 2010 to June 2015 (Commercial) and January 2009 to December 2014 (Medicaid) were eligible; the first UF claim during these time periods was designated the index date. Data collected 12 months pre- and 12 and 60 months post-diagnosis included clinical/demographic characteristics, pharmacologic/surgical treatments, and surgical complications. Prevalence (2015) and cumulative incidence (Commercial, 2010-2015; Medicaid, 2009-2015) of symptomatic UF were estimated.

RESULTS

225,737 (Commercial) and 19,062 (Medicaid) women had a minimum of 12 months post-index continuous enrollment and were eligible for study. Symptomatic UF prevalence and cumulative incidence were: 0.57, 1.23% (Commercial) and 0.46, 0.64% (Medicaid). Initial treatments within 12 months post-diagnosis were surgical (Commercial, 36.7%; Medicaid, 28.7%), pharmacologic (31.7%; 53.0%), or none (31.6%; 18.3%). Pharmacologic treatments were most commonly non-steroidal anti-inflammatory drugs and oral contraceptives; hysterectomy was the most common surgical treatment. Of procedures of abdominal hysterectomy, abdominal myomectomy, uterine artery embolization, and ablation in the first 12 months post-index, 14.9% (Commercial) and 24.9% (Medicaid) resulted in a treatment-associated complication. Abdominal hysterectomy had the highest complication rates (Commercial, 18.5%; Medicaid, 31.0%).

CONCLUSIONS

Off-label use of pharmacologic therapies and hysterectomy for treatment of symptomatic UF suggests a need for indicated non-invasive treatments for symptomatic UF.

Beyond Birth Control: Noncontraceptive Benefits of Hormonal Methods and Their Key Role in the General Medical Care of Women

Contraceptives that contain estrogen and/or progestins are used by millions of women around the world to prevent pregnancy. Owing to their unique physiological mechanism of action, many of these medications can also be used to prevent cancer and treat multiple general medical conditions that are common in women. We performed a comprehensive literature search. This article will describe the specific mechanisms of action and summarize the available data documenting how hormonal contraceptives can prevent ovarian and uterine cancer and be used to treat women with a variety of gynecological and nongynecological conditions such as endometriosis, uterine fibroids, heavy menstrual bleeding, polycystic ovary syndrome, acne, and migraines. Contraceptive methods containing estrogen and progestin can be used for a wide variety of medical issues in women.