Long-term health-related quality of life and symptom severity following hysterectomy, myomectomy, or uterine artery embolization for the treatment of symptomatic uterine fibroids

Machine learning models for prediction of NPVR ≥80% with HIFU ablation for uterine fibroids

BACKGROUND

Currently high-intensity focused ultrasound (HIFU) is widely used to treat uterine fibroids (UFs). The aim of this study is to develop a machine learning model that can accurately predict the efficacy of HIFU ablation for UFs, assisting the preoperative selection of suitable patients with UFs.

METHODS

This study collected data from 1,000 patients with UFs who underwent ultrasound-guided high-intensity focused ultrasound. The least absolute shrinkage and selection operator (LASSO) regression was used for multidimensional feature screening. Five machine learning algorithms such as logistic regression, random forest, extreme gradient boosting (XGBoost), artificial neural network, and gradient boosting decision tree were utilized to predict ablation efficacy. The efficacy was quantified by the non-perfused volume ratio (NPVR), which was classified into two categories: NPVR <80% and NPVR ≥80%.

RESULTS

The XGBoost model proved to be the most effective, showing the highest AUC of 0.692 (95% CI: 0.622-0.762) in the testing data set. The four key predictors were T2 weighted image, the distance from ventral side of UFs to skin, platelet count, and contrast-enhanced T1 weighted image.

CONCLUSIONS

The machine learning prediction model in this study showed significant potential for accurately predicting the preoperative efficacy of HIFU ablation for UFs. These insights were important for clinicians in the preoperative assessment and selection of patients, which could enhance the precision of treatment planning.

Womb for debate: the complexities of early-age hysterectomies

PURPOSE OF REVIEW

Hysterectomy remains one of the most performed gynecologic procedures, yet its application in young and nulliparous individuals raises complex ethical, medical, and psychosocial considerations. As early detection of gynecologic conditions improves, requests for hysterectomy at younger ages may increase. This review examines the current literature on the morbidity, quality of life, psychological impact, and social implications of hysterectomy in younger patients.

RECENT FINDINGS

Research indicates both benefits and risks associated with early-age hysterectomy. While it provides significant symptom relief for conditions such as chronic pelvic pain, endometriosis, and fibroids, studies also suggest an increased risk of cardiovascular disease, metabolic disorders, and psychological distress. Younger patients may experience residual symptoms and identity disruption, particularly in relation to fertility loss. While regret appears to be low in the short term, long-term data on patient satisfaction remain limited. In addition, hysterectomy plays a critical role in gender-affirming care, highlighting the need for individualized counseling.

SUMMARY

Gynecology providers must engage in shared decision-making, providing evidence-based counseling on the benefits, risks, and alternatives to hysterectomy. Future research should focus on long-term outcomes, particularly in younger and nulliparous patients, to guide best practices and optimize patient-centered care.

Short-term outcomes of minimally invasive total vs supracervical hysterectomy for uterine fibroids: a National Surgical Quality Improvement Program study

BACKGROUND

Uterine fibroids are the most common indication for benign hysterectomy in the United States, but data regarding the association between hysterectomy type and outcomes for this indication are lacking.

OBJECTIVE

This study aimed to describe the rate and odds of short-term (30 days) postoperative complications between patients who underwent minimally invasive total laparoscopic hysterectomy and those who underwent laparoscopic supracervical hysterectomy for uterine fibroids.

STUDY DESIGN

This was a cohort study of prospectively collected data from the American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2020. The characteristics of women who underwent total laparoscopic hysterectomy and those who underwent laparoscopic supracervical hysterectomy for uterine fibroids were identified. In addition, the risk factors associated with the occurrence of 30-day postoperative complications, defined according to the Clavien-Dindo classification, were identified. Multivariate regression analysis, including age, body mass index, race, comorbidities, American Society of Anesthesiologists classification, uterine weight, and concomitant procedures, was performed to identify the adjusted odds of postoperative complications. The co-primary outcomes were (1) the risk of a composite of any postoperative complications and (2) the risk of major postoperative complications according to surgical type.

RESULTS

Overall, 44,413 patients underwent minimally invasive total laparoscopic hysterectomy, and 6383 patients underwent laparoscopic supracervical hysterectomy. The operative time was shorter in the total laparoscopic hysterectomy group than in the laparoscopic supracervical hysterectomy group (143.0 vs 150.6 minutes, respectively; P < .001). In addition, the proportion of uterine weight of >250 g was lower in the total laparoscopic hysterectomy group than in the laparoscopic supracervical hysterectomy group (39.4% vs 45.1%, respectively; P < .001). The rates of any and major complications were higher in the total laparoscopic hysterectomy group than in the laparoscopic supracervical hysterectomy group (any complications: 6.6% vs 5.3%, respectively; P < .001; major complications: 2.7% vs 1.6%, respectively; P < .001), whereas the rates of minor complications were comparable in both groups (4.4% vs 4.1%, respectively; P = .309). In multivariate regression analysis, laparoscopic supracervical hysterectomy was independently associated with a lower risk of any (adjusted odds ratio, 0.79; 95% confidence interval, 0.70-0.88) and major (adjusted odds ratio, 0.55; 95% confidence interval, 0.44-0.69) complications than total laparoscopic hysterectomy.

CONCLUSION

Laparoscopic supracervical hysterectomy was associated with a lower risk of short-term postoperative complications in patients with uterine fibroids than total laparoscopic hysterectomy. Our findings can aid in shared decision-making before minimally invasive hysterectomy for uterine fibroids.

Quality of Life Assessment After Uterine Artery Embolization in Patients with Fibroids Treated in an Ambulatory Setting

Background: Despite the growing acceptance of uterine artery embolization (UAE) to treat women with fibroid disease, its wider use remains limited because it is not considered to be a definitive therapy, as opposed to surgical treatments such as myomectomy or hysterectomy. Given the evolution of health care towards outpatient medicine, it is critical to determine the impact of UAE on the quality of life (QoL) of women with fibroid disease treated in an outpatient setting. Objectives: The purpose of this study was to assess the QoL of patients with fibroids treated with UAE in an office-based lab setting. Study Design: This prospective single-arm study was approved by the western IRB (wIRB) and included 1285 consecutive patients-the largest study on UAE to date-enrolled from September 2021 to December 2023 who were seen for a baseline evaluation in a clinic and then, subsequently, between 2 and 8 months post-UAE for follow-up clinical and imaging evaluation. Patient QoL was assessed using the validated QoL questionnaire: the Uterine Fibroid Symptom and Health-Related Quality of Life questionnaire. Results: The results from all 1285 patients were analyzed. The median and mean follow-up periods were 182 and 180 days, respectively (interquartile range of 19 days). UAE led to reduced bleeding in 96% of patients, pelvic pain and bulk-related symptoms in 94%, fatigue in 94%, and urination frequency in 92%. On the other hand, improvements were seen in the level of activity in 82%, energy and mood in 85%, and sexual function in 71% of the patients, whereas the general QoL index significantly increased in 86% of the patients (p < 0.001). More than one third of our patients (39%) had Medicaid insurance, reflecting the relatively low socioeconomic status of our patient population. Conclusions: In this largest clinical trial on UAE to date, we found that performing UAE in an outpatient setting significantly improved patients' clinical symptoms such as bleeding and bulk symptoms and, most importantly, their overall QoL.

Lichong decoction improves inflammatory microenvironment and alleviates fibrosis in uterine leiomyoma via targeting CXCL8

ETHNOPHARMACOLOGICAL RELEVANCE

Lichong decoction (LD) is extensively employed in the treatment of uterine leiomyoma (ULM), demonstrating remarkable clinical effectiveness with an absence of notable adverse reactions. Its composition aligns with the traditional Chinese medicine (TCM) etiology of ULM, making it a highly suitable therapy. Nonetheless, the precise mechanisms underlying its therapeutic actions remain to be fully elucidated.

AIM OF THE STUDY

The objective of this study was to clarify the therapeutic mechanism of LD improving ULM.

MATERIALS AND METHODS

The effects of LD on ULM cell viability, proliferation, and apoptosis were assessed using CCK-8, crystal violet staining, EdU incorporation, TUNEL, and Annexin V-FITC/PI assays. Gene microarray was used to profile differential gene expression after LD treatment. A rat ULM model was created to evaluate LD's anti-tumor efficacy, measuring body weight, uterine weight index, and sex hormone levels. Histopathological changes were analyzed with hematoxylin and eosin staining, Masson's trichrome staining, and transmission electron microscopy. Protein and RNA expression changes were analyzed via immunohistochemistry, western blotting, and qPCR. UHPLC-QE-MS enabled a detailed non-targeted LD analysis. Key components were identified through their correlation with serum sex hormones and inflammatory cytokines, and then examined by molecular docking studies.

RESULTS

Experiments showed that LD reduced ULM cell viability and induced apoptosis. Gene expression profiling identified 313 differentially expressed genes. Enrichment analysis combined with experimental validation demonstrated that LD can reduce ULM fibrosis and inflammation by inhibiting the CXCL8/PI3K/AKT pathway. The analysis identified 494 primary compounds and 87 serum components in LD. Key compounds such as formononetin, palmatine, curcumenol, and hecogenin, which exhibit high affinity for CXCL8, may contribute to the anti-inflammatory and anti-tumor properties of LD.

CONCLUSION

This study demonstrates that LD effectively inhibits ULM proliferation and fibrosis by improving the inflammatory microenvironment, primarily through the inhibition of CXCL8. These findings highlight the therapeutic potential of LD for ULM and provide new insights into its mechanisms.

Postoperative symptom changes following uterine artery embolization for uterine fibroid based on FIGO classification

BACKGROUND

Classifying uterine fibroid using the International Federation of Gynecology and Obstetrics (FIGO) classification system assists treatment decision-making and planning. This study aimed to study whether different fibroid locations influence clinical outcomes following uterine artery embolization (UAE).

METHODS

This is a retrospective cohort study of patients who underwent UAE for symptomatic uterine fibroid between December 2016 and January 2023 at our hospital. Changes in mean fibroid volume were compared based on MR images. Menstrual pain, excessive flow symptoms, and treatment satisfaction before UAE and 6 months after UAE were compared.

RESULTS

A total of 149 premenopausal patients (mean age 45.7 ± 2.7 years) were included for analysis (FIGO 2/3, n = 57; FIGO 4-7, n = 92). Baseline menstrual pain, fibroid, and uterine volume before UAE were comparable between the two FIGO groups (p > 0.05). The menstrual flow index was higher for the FIGO 2/3 group (mean ± SD [min-max]: 9.4 ± 1.4 [4-10] vs 8.0 ± 2.3 [0-10], p < 0.001). Six months after UAE, the improvements in menstrual flow index (mean ± SD]: -3.7 ± 2.6 vs -2.6 ± 2.2, p = 0.035), fibroid volume (mean ± SD: -54.7 ± 21.7% vs -39.8 ± 16.2%, p < 0.001), and uterine volume (mean ± SD: -38.2 ± 16.3% vs -31.1 ± 11.6%, p = 0.008) in the FIGO 2/3 group were significantly higher than the FIGO 4-7 group. Both groups had comparable improvements in menstrual pain index (-2.1 ± 2.6 vs -1.8 ± 2.5, p = 0.008) and 88% of the patients were satisfied or very satisfied overall.

CONCLUSION

UAE treatment satisfaction was high for patients with fibroids at different FIGO stages. UAE treatment outcomes were better for patients with fibroids affecting the endometrium (FIGO 2/3).

LEVEL OF EVIDENCE

3B, Retrospective observational study.

Quality of life after myomectomy according to the surgical approach and MED12 mutation status

OBJECTIVE

Molecular status of uterine leiomyomas has been shown to affect both tumor characteristics and treatment response. Mutations in mediator complex subunit 12 (MED12), the most prevalent alterations in leiomyomas, are associated with tumor size and number of leiomyomas. Myomectomy can be performed by laparoscopy or by open abdominal surgery, depending on the size and number of leiomyomas removed. The aim of this study was to examine the association between MED12 mutation status and surgical approach of myomectomy. We also evaluated myomectomy patients' quality of life after laparoscopic or abdominal surgery and according to the MED12 mutation status.

STUDY DESIGN

The prospective cohort study included 104 women who underwent laparoscopic or abdominal myomectomy at the Helsinki University Hospital during 2015-2019. Patients filled in the validated Uterine Fibroid Symptom and Quality of Life (UFS-QOL) questionnaire before the operation and 6 and 12 months after the operation. Medical records were reviewed to collect clinical data. Leiomyoma tissue samples were collected and screened for MED12 mutations.

RESULTS

Patients undergoing abdominal myomectomy had larger and more numerous leiomyomas compared to patients with laparoscopic myomectomy (10 cm vs 7.4 cm, p < 0.001 and 3 vs 1 leiomyomas, p < 0.001, respectively). A mean change of over 20 points was seen in UFS-QOL scores at 6 months after both laparoscopic and abdominal myomectomy (p < 0.001). MED12 mutations were detected in 178/242 (74 %) of leiomyomas. Of the patients, 45/97 (46 %) had only MED12 positive leiomyomas, while 39/97 (40 %) had only MED12 wild type leiomyomas. The number of leiomyomas removed was higher among patients with MED12 positive leiomyomas than in patients with MED12 wild type tumors (p < 0.001). Laparoscopic approach was equally common in both groups (62 % and 64 %), and there was no statistically significant difference in the UFS-QOL scores.

CONCLUSION

Both laparoscopic and abdominal myomectomy significantly improved the quality of life. While MED12 mutations were related with multiple leiomyomas and therefore potentially generated a greater leiomyoma burden, they were not associated with the surgical approach. Pre- and postoperative quality of life was comparable between patients regardless of MED12 status.

Abnormal Uterine Bleeding With Leiomyomas: A Case Report of Its Natural Course and Therapeutic Management

Uterine fibroids (UFs), or leiomyomas, are common benign tumors affecting a significant proportion of women by the age of 50 years. While typically non-cancerous, UFs can severely impact the quality of life (QoL) through symptoms such as heavy menstrual bleeding (HMB) and pelvic pain. We report a case of a 45-year-old Hispanic female with a history of hypertension, diabetes, nephrolithiasis, and a solitary kidney, who presented with symptomatic UFs and an ovarian cyst. Despite initial pharmacological treatment with Ortho Micronor and Myfembree, the patient experienced persistent symptoms, prompting surgical intervention. A supracervical hysterectomy, bilateral salpingectomy, lysis of adhesions, and left ovarian cystectomy were performed, resulting in symptom relief and benign postoperative findings. This case report highlights the need for personalized treatment plans and comprehensive patient counseling to manage complex gynecological conditions effectively.

The role of VEGF and TGF-β blood levels for fibroid shrinkage, menorrhagia score, and quality of life improvement after uterine artery embolization for uterine fibroids: a study protocol

Uterine leiomyoma is a common condition affecting women that occurs in more than 70% of females. Women with leiomyomas overall have lower quality of life and deficiency in many specific spheres of life including work-related productivity, sexuality, relationships, social-emotional health, and physical well-being that might be present even in pre-and extended throughout early postmenopausal life. Choices for symptomatic fibroid management include medical, interventional radiology procedures, surgical, and expectant management. The uterine artery embolization (UAE) procedure has gained justified popularity for myoma management. Growth factors, vascular endothelial growth factor (VEGF) and tumor growth factor β (TGF-β), hold an important role in leiomyoma progression. However, blood levels of VEGF and TGF-β in patients before and after UAE are not fully investigated and the possible relationship with myoma shrinkage has not been evaluated. Therefore, this study aims to assess menorrhagia score and quality of life improvement after UAE for uterine fibroids and compare blood levels of VEGF and TGF-β in patients with uterine leiomyoma before and after UAE. This cross-sectional study will be performed at the University Medical Center, Astana, Kazakhstan. Women undergoing the UAE procedure for uterine leiomyoma will be involved in the study following the precisely defined inclusion/exclusion criteria. Uterine leiomyoma nodules' structural changes after UAE will be assessed along with the blood levels of growth factors (VEGF and TGF-β), menorrhagia score, and quality of life. An important outcome of this project will be an investigation of the blood levels of growth factors (VEGF and TGF-β) before and after the procedure and their association with leiomyoma shrinkage in correlation with the menorrhagia score and quality of life alterations among patients undergoing UAE.

The modern management of uterine fibroids-related abnormal uterine bleeding

Uterine fibroids (UFs) are the most common female benign pelvic tumors, affecting >60% of patients aged 30-44 years. Uterine fibroids are asymptomatic in a large percentage of cases and may be identified incidentally using a transvaginal ultrasound or a magnetic resonance imaging scan. However, in approximately 30% of cases, UFs affect the quality of life and women's health, with abnormal uterine bleeding and heavy menstrual bleeding being the most common complaints, along with iron deficiency (ID) and ID anemia. Medical treatments used for UFs-related abnormal uterine bleeding include symptomatic agents, such as nonsteroidal antiinflammatory drugs and tranexamic acid, and hormonal therapies, including combined oral contraceptives, gonadotropin-releasing hormone agonists or antagonists, levonorgestrel intrauterine systems, selective progesterone receptor modulators, and aromatase inhibitors. Nevertheless, few drugs are approved specifically for UF treatment, and most of them manage the symptoms. Surgical options include fertility-sparing treatments, such as myomectomy, or nonconservative options, such as hysterectomy, especially in perimenopausal women who are not responding to any treatment. Radiologic interventions are also available: uterine artery embolization, high-intensity focused ultrasound or magnetic resonance-guided focused ultrasound, and radiofrequency ablation. Furthermore, the management of ID and ID anemia, as a consequence of acute and chronic bleeding, should be taken into account with the use of iron replacement therapy both during medical treatment and before and after a surgical procedure. In the case of symptomatic UFs, the location, size, multiple UFs, or coexistent adenomyosis should guide the choice with a shared decision-making process, considering long- and short-term treatment goals expected by the patient, including pregnancy desire or wish to preserve the uterus independently of reproductive goals.

Transvaginal natural orifice transluminal endoscopic surgery for myomectomy: A more suitable surgical approach for enhanced recovery after surgery

OBJECTIVE

Vaginal natural orifice transluminal endoscopic surgery (vNOTES) is widely recognized for its potential benefits, including reducing post-surgical pain and leaving no discernible scarring. However, the anatomical specificity of the vNOTES approach may elevate the risk of nearby organ damage, such as the rectum and bladder. Thus, this study aims to demonstrate the safety and relative merits of vNOTES over transumbilical laparoendoscopic single-site surgery (LESS).

METHODS

The Longitudinal Vaginal Natural Orifice Transluminal Endoscopic Surgery Study (LovNOTESS), which was conducted in Chengdu, China. A total of 110 patients who underwent myomectomy in vNOTES or LESS from January 2021 to December 2022. This study prospectively collected and compared perioperative and follow-up data of the two groups.

RESULTS

In the vNOTES group, patients had shorter postoperative anal exhaust time, lower pain medications use rate, shorter hospital stay but higher intraoperative conversion rate, and higher postoperative fever rate. vNOTES decreased the anal exhaust time by approximately 8.7 h (95 %CI: -16.182, -1.262, p = 0.007). Moreover, vNOTES reduces pain medication use risk by 73.1 % (OR: 0.269, 95 %CI: 0.172, 0.318, p = 0.016).

CONCLUSION

Relative to LESS, vNOTES can make patients mitigate postoperative discomfort, accelerate the recovery of gastrointestinal function, curtail hospitalization duration, and enable a more rapid return to daily activities in myomectomy. However, vNOTES has a higher risk of surgical conversion and adjacent organ injury. Therefore, larger scale prospective studies are needed to prove its security and promote the widespread application of vNOTES in myomectomy.

The Effect of a Myomectomy on Myoma-related Symptoms and Quality of Life: A Retrospective Cohort Study

STUDY OBJECTIVE

Although it is assumed that myomectomy improves uterine myoma-related symptoms such as pelvic pain and heavy menstrual bleeding (HMB), validated measures are rarely reported. This study aimed to verify the effect of myomectomy on myoma-related symptoms.

DESIGN

A retrospective cohort study.

SETTING

A university-affiliated hospital.

PATIENTS

Our study included 241 patients with a myoma diagnosis and received a myomectomy between 2004 and 2018. Data were collected from the patient medical file and patients responded in 1 questionnaire.

INTERVENTIONS

Transcervical resection of myoma (TCRM) and laparoscopic or abdominal myomectomy (LAM).

MEASUREMENTS AND MAIN RESULTS

One year after TCRM, a significant number of women experienced symptom improvement for pelvic pain (79% [19/24, p = .01]) and HMB (89% [46/52, p <.001]). For other myoma-related symptoms, abdominal pressure (43%, 10/23), sexual complaints (67%, 2/3), infertility (56%, 10/18), and other complaints (83%, 5/6), improvements were not statistically significant. One year after LAM, a significant number of women experienced symptom improvement for pelvic pain (80%, 74/93), HMB (83%, 94/113), abdominal pressure (85%, 79/93), sexual complaints (77%, 36/47), and other complaints (91%, 40/44). One year after myomectomy, 47% (30/64) (TCRM) and 44% of women (78/177) (LAM) described no myoma-related symptoms. Most women (82% [172/217]) were satisfied with the postoperative result after 1 year and 53% (114/217) would have liked to receive the myomectomy earlier in life. Average quality of life (measured on a 10-point Likert scale) increased from 6.3 at baseline to 8.0 at 1 year after TCRM and from 6.2 to 8.0 1 year after LAM, resulting in a difference of 1.7 points (p <.001; 95% confidence interval, 1.1-2.3) and 1.9 points (p <.001; 95% confidence interval, 1.4-2.3), respectively.

CONCLUSION

One year after myomectomy, most women have benefited from myomectomy, concluded by a significant number of women who experienced myoma-related symptom improvement, positive patient satisfaction, and a significant improvement in reported quality of life. Validation of results after conventional treatment such as myomectomy is essential in counseling patients for surgical treatment in today's evidence based practice. In addition, it is necessary to make an adequate comparison with new treatment options for myomas. To provide this, further research should preferably be conducted prospectively or by randomization.