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Singh S, Kumar P, Rathore SS, Singh Y, Garg N. Contemporary approaches in the management of uterine leiomyomas. Eur J Obstet Gynecol Reprod Biol 2023; 287:195-210. [PMID: 37385088 DOI: 10.1016/j.ejogrb.2023.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 04/24/2023] [Accepted: 06/20/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND Leiomyomas (fibroids), the most common benign solid tumours in females, originate from the myometrium and are associated with poor quality of life for patients. The current management of uterine leiomyomas mainly includes surgical interventions such as hysterectomy and myomectomy, either by laparoscopy or laparotomy, which have several complications and are not ideal for preserving fertility. Therefore, there is a need to develop or repurpose medical treatments that do not require surgical intervention. OBJECTIVE Many drugs are used to treat the symptoms associated with uterine fibroids. The main objective of this systematic review is to give an up-to-date account of potential pharmacological agents (non-surgical methods) for the management of uterine leiomyomas. SEARCH STRATEGY PubMed was searched for scientific and clinical literature using the keyword 'uterine fibroids' along with the drug names described in each section. For example, 'uterine fibroids' and 'ulipristal acetate' were the keywords used to search for literature on ulipristal acetate (UPA). RESULTS Various preclinical and clinical studies have shown that some drugs and herbal formulations exhibit activity in the management of uterine leiomyomas. Recent studies found that drugs such as UPA, elagolix, EC313, asoprisnol, nutritional supplements and herbal preparations were helpful in treating the symptoms associated with uterine leiomyomas. CONCLUSION Many drugs show efficacy in patients with symptomatic uterine fibroids. UPA is one of the most studied and prescribed medicines for uterine fibroids; however, its usage has been restricted due to a few recent incidences of hepatic toxicity. Herbal drugs and natural supplements have also shown promising effects on uterine fibroids. The synergistic effects of nutritional and herbal supplements have been reported in certain cases, and should be studied in detail. Further research is warranted to identify the mode of action of the drugs, and to determine the precise conditions that would explain the causes of toxicity in some patients.
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Affiliation(s)
- Shikha Singh
- Department of Prasuti Tantra, Faculty of Ayurveda, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Praveen Kumar
- Department of Medicinal Chemistry, Faculty of Ayurveda, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Saurabh Singh Rathore
- Department of Biotechnology, Mahatma Gandhi Central University, Raghunathpur, Motihari, East Champaran, Bihar, India
| | - Yashasvi Singh
- Department of Urology, CSSB, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Neha Garg
- Department of Medicinal Chemistry, Faculty of Ayurveda, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India.
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Don EE, Middelkoop MA, Hehenkamp WJK, Mijatovic V, Griffioen AW, Huirne JAF. Endometrial Angiogenesis of Abnormal Uterine Bleeding and Infertility in Patients with Uterine Fibroids-A Systematic Review. Int J Mol Sci 2023; 24:ijms24087011. [PMID: 37108180 PMCID: PMC10138959 DOI: 10.3390/ijms24087011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 04/03/2023] [Accepted: 04/06/2023] [Indexed: 04/29/2023] Open
Abstract
Uterine fibroids are the most common benign tumors in women, with abnormal uterine bleeding (AUB) as the main reported symptom. Additionally, an association between fibroids and infertility has been established, especially if the fibroid protrudes in the uterine cavity. Hormonal therapy is associated with side-effects and as well as hysterectomy, which is incompatible with a desire to conceive. To improve treatment, it is essential to unravel the etiology of fibroid-related symptoms. We aim to evaluate endometrial angiogenesis in women with fibroids, with and without AUB, and the influence of pharmaceutical therapies in these patients. Furthermore, we explore the possible role of altered angiogenesis in patients with fibroids and infertility. We performed a systematic review according to PRISMA-guidelines (PROSPERO: CRD42020169061), and included 15 eligible studies. Endometrial expression of vascular endothelial growth factor (VEGF) and adrenomedullin was increased in patients with fibroids. This suggests aberrant angiogenesis, potentially involving disturbed vessel maturation, resulting in immature and fragile vessels. Treatment with gonadotropin-releasing hormone agonist, ulipristal acetate, and continuous oral contraception pills reduced several angiogenic parameters, including VEGF. If infertile and fertile patients with fibroids were compared, a significant decreased expression of the bone morphogenetic protein/Smad-protein pathway was found, possibly caused by the increased expression of transforming growth factor-beta. For future therapeutic development, these different angiogenic pathways could be of interest as possible targets to treat fibroid-related symptoms.
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Affiliation(s)
- Emma E Don
- Department of Obstetrics and Gynecology, Amsterdam UMC, Location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
- Amsterdam Reproduction and Development, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Mei-An Middelkoop
- Department of Obstetrics and Gynecology, Amsterdam UMC, Location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
- Amsterdam Reproduction and Development, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Wouter J K Hehenkamp
- Department of Obstetrics and Gynecology, Amsterdam UMC, Location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
- Amsterdam Reproduction and Development, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Velja Mijatovic
- Department of Obstetrics and Gynecology, Amsterdam UMC, Location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
- Amsterdam Reproduction and Development, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Arjan W Griffioen
- Angiogenesis Laboratory, Department of Medical Oncology, Amsterdam UMC, Cancer Center Amsterdam, 1081 HV Amsterdam, The Netherlands
| | - Judith A F Huirne
- Department of Obstetrics and Gynecology, Amsterdam UMC, Location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
- Amsterdam Reproduction and Development, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
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Kolanska K, Sbeih M, Canlorbe G, Mekinian A, Varinot J, Capmas P, Koskas M, Aractingi S, Daraï E, Chabbert-Buffet N. Ulipristal Acetate Modifies miRNA Expression in Both Superficial and Basal Layers of the Human Endometrium. J Clin Med 2021; 10:jcm10194442. [PMID: 34640460 PMCID: PMC8509688 DOI: 10.3390/jcm10194442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 09/23/2021] [Accepted: 09/24/2021] [Indexed: 12/05/2022] Open
Abstract
(1) Background: Ulipristal acetate (UPA) is a selective progesterone receptor modulator (SPRM) widely used for emergency contraception and mid- to long-term leiomyoma treatment. The aim of this study was to identify modifications of miRNA expression in superficial and basal layers of the human endometrium at the end of the UPA treatment for at least 3 months. (2) Methods: Microarray miRNA analysis of formalin-fixed, paraffin-embedded hysterectomy tissue samples was conducted, followed by an Ingenuity Pathway Analysis. Samples were divided into three groups: women having had 3 months of UPA treatment (n = 7); and two control groups of UPA-naïve women in the proliferative (n = 8) or secretory (n = 6) phase. (3) Results: The UPA modified the expression of 59 miRNAs involved in the processes of cell cycle, carcinogenesis, and inflammation. Their expression profiles were different in the basal and superficial layers. Most of the processes influenced by the UPA in the basal layer were connected to the cell cycle and immune regulation. (4) Conclusion: Specific changes were observed in both layers of the endometrium in the UPA group. However, the miRNA expression in the basal layer was not consistent with that in the superficial layer. Other large studies analysing the long-term impact of SPRM on endometrial miRNA expression are necessary.
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Affiliation(s)
- Kamila Kolanska
- INSERM UMRS 938, Sorbonne Université, Site Saint-Antoine, 27 rue Chaligny, CEDEX 12, 75571 Paris, France; (M.S.); (G.C.); (M.K.); (S.A.); (E.D.); (N.C.-B.)
- Service de Gynécologie Sestertius et Médecine de la Reproduction, AP-HP Sorbonne Université Site Tenon, 4 rue de la Chine, 75020 Paris, France
- Correspondence:
| | - Maria Sbeih
- INSERM UMRS 938, Sorbonne Université, Site Saint-Antoine, 27 rue Chaligny, CEDEX 12, 75571 Paris, France; (M.S.); (G.C.); (M.K.); (S.A.); (E.D.); (N.C.-B.)
| | - Geoffroy Canlorbe
- INSERM UMRS 938, Sorbonne Université, Site Saint-Antoine, 27 rue Chaligny, CEDEX 12, 75571 Paris, France; (M.S.); (G.C.); (M.K.); (S.A.); (E.D.); (N.C.-B.)
- Department of Gynecological and Breast Surgery and Oncology, Pitié-Salpêtrière University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), 75013 Paris, France
| | - Arsène Mekinian
- Service de Médecine Interne, AP-HP Sorbonne Université Site St Antoine, 184 rue du Faubourg Saint Antoine, 75012 Paris, France;
| | - Justine Varinot
- Service d’Anatomopathologie, AP HP Sorbonne Université Site Tenon, 4 rue de la Chine, 75020 Paris, France;
| | - Perrine Capmas
- Department of Gynecology and Obstetrics, University Paris Saclay, 78 rue du Général Leclerc, 94270 Le Kremlin-Bicêtre, France;
- Inserm, Centre of Research in Epidemiology and Population Health (CESP), U1018, 94276 Le Kremlin-Bicêtre, France
| | - Martin Koskas
- INSERM UMRS 938, Sorbonne Université, Site Saint-Antoine, 27 rue Chaligny, CEDEX 12, 75571 Paris, France; (M.S.); (G.C.); (M.K.); (S.A.); (E.D.); (N.C.-B.)
- Department of Obstetrics and Gynecology, AP-HP Bichat University Hospital, 75018 Paris, France
- Institut de Recherche en Santé de la Femme, Equipe d’accueil 7285, Universite de Versailles Saint-Quentin-en-Yvelines, 78180 Montigny-le-Bretonneux, France
| | - Selim Aractingi
- INSERM UMRS 938, Sorbonne Université, Site Saint-Antoine, 27 rue Chaligny, CEDEX 12, 75571 Paris, France; (M.S.); (G.C.); (M.K.); (S.A.); (E.D.); (N.C.-B.)
| | - Emile Daraï
- INSERM UMRS 938, Sorbonne Université, Site Saint-Antoine, 27 rue Chaligny, CEDEX 12, 75571 Paris, France; (M.S.); (G.C.); (M.K.); (S.A.); (E.D.); (N.C.-B.)
- Service de Gynécologie Sestertius et Médecine de la Reproduction, AP-HP Sorbonne Université Site Tenon, 4 rue de la Chine, 75020 Paris, France
| | - Nathalie Chabbert-Buffet
- INSERM UMRS 938, Sorbonne Université, Site Saint-Antoine, 27 rue Chaligny, CEDEX 12, 75571 Paris, France; (M.S.); (G.C.); (M.K.); (S.A.); (E.D.); (N.C.-B.)
- Service de Gynécologie Sestertius et Médecine de la Reproduction, AP-HP Sorbonne Université Site Tenon, 4 rue de la Chine, 75020 Paris, France
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Jiménez Guerrero M, Fava M, Baccaro LF, Caille AM, Cuasnicú PS, Horcajadas JA, Cohen DJ, Bahamondes L, Cotán D, Munuce MJ. Effect of ulipristal acetate on gene expression profile in endometrial cells in culture and in vivo upon post-ovulatory administration in fertile women. EUR J CONTRACEP REPR 2021; 27:199-207. [PMID: 34486904 DOI: 10.1080/13625187.2021.1975270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE To analyse the effect of ulipristal acetate (UPA) as emergency contraception (EC) on the gene expression of human endometrial cell line (HEC-1A) and endometrium from fertile women treated with UPA after ovulation. MATERIALS AND METHODS HEC-1A cells were treated with UPA, and endometrial tissue from four healthy women was collected in cycles before, during and 2 months after post-ovulation pill intake. Ovulation and luteal phase were monitored, and endometrial biopsies were obtained at day LH + 7 in each cycle. In all cases, we analysed the expression profile of 192 genes associated to endometrial receptivity. RESULTS We observed a significant change in total transcriptomic activity of UPA-treated HEC-1A cells compared to controls. In vivo, we also observed a trend to down-regulation of genes in the UPA-treated cycle that was partially restored in the post-treatment cycle. Altogether, our results supported a partially reversible effect of UPA in gene expression associated with uterine receptivity. CONCLUSIONS When UPA was administered after ovulation, it seems to induce a down-regulation of the main genes involved in conditioning the endometrium for implantation. This effect is partially restored two months after pill intake. The action of UPA on the endometrium for users of EC should be further investigated.
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Affiliation(s)
| | - Mariana Fava
- Department of Obstetrics and Gynecology, Faculty of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Luiz F Baccaro
- Department of Obstetrics and Gynecology, Faculty of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Adriana M Caille
- Laboratorio de Medicina Reproductiva, Facultad de Ciencias Bioquímicas y Farmacéuticas, Universidad Nacional de Rosario, Rosario, Argentina
| | - Patricia S Cuasnicú
- Instituto de Biología y Medicina Experimental (IBYME-CONICET), Buenos Aires, Argentina
| | | | - Débora J Cohen
- Instituto de Biología y Medicina Experimental (IBYME-CONICET), Buenos Aires, Argentina
| | - Luis Bahamondes
- Department of Obstetrics and Gynecology, Faculty of Medical Sciences, University of Campinas, Campinas, Brazil
| | | | - María José Munuce
- Laboratorio de Medicina Reproductiva, Facultad de Ciencias Bioquímicas y Farmacéuticas, Universidad Nacional de Rosario, Rosario, Argentina
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Glucose and fatty acid metabolism involved in the protective effect of metformin against ulipristal-induced endometrial changes in rats. Sci Rep 2021; 11:8863. [PMID: 33893356 PMCID: PMC8065147 DOI: 10.1038/s41598-021-88346-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 04/09/2021] [Indexed: 11/29/2022] Open
Abstract
Ulipristal acetate (UPA) is effective in the treatment of uterine fibroids. However, its clinical use is hampered by the development of pathologic progesterone receptor modulator-associated endometrial changes (PAECs). The current study was designed to test the hypothesis that UPA-induced PAECs are associated with deranged expression of some metabolic genes. In addition, metformin can mitigate UPA-induced PAECs through modulating the expression of these genes. In the present study, twenty-eight female non-pregnant, nulligravid Wistar rats were treated with UPA (0.1 mg/kg/day, intragastric) and/or metformin (50 mg/kg/day, intragastric) for 8 weeks. Our results demonstrated that co-treatment with metformin significantly reduced UPA-induced PAECs. In addition, co-treatment with metformin and UPA was associated with significant increase in the Bax and significant reduction in Bcl-2, PCNA, Cyclin-D1and ER-α as compared to treatment with UPA alone. Furthermore, treatment with UPA alone was associated with deranged expression of 3-phosphoglycerate dehydrogenase (3-PHGDH), glucose-6-phosphate dehydrogenase (G6PD), transketolase (TKT), fatty acid synthase (FAS) and CD36. Most importantly, co-treatment with metformin markedly reduced UPA-induced altered expression of these metabolic genes in endometrial tissues. In conclusion, UPA-induced PAECs are associated with altered expression of genes involved in cell proliferation, apoptosis, estrogen receptor, glucose metabolism and lipid metabolism. Co-treatment with metformin abrogated UPA-induced PAECs most likely through the modulation of the expression of these genes.
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Chodankar RR, Murray A, Nicol M, Whitaker LHR, Williams ARW, Critchley HOD. The endometrial response to modulation of ligand-progesterone receptor pathways is reversible. Fertil Steril 2021; 116:882-895. [PMID: 33865567 DOI: 10.1016/j.fertnstert.2021.02.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/29/2021] [Accepted: 02/05/2021] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To study the impact of the progesterone receptor modulator (PRM), ulipristal acetate (UPA), on endometrial morphology and function. DESIGN Cross-sectional. SETTING University Research Institute. PATIENT(S) Endometrial biopsies from 16 patients with heavy menstrual bleeding with a structurally normal uterus or in association with structural abnormalities identified on radiological imaging (fibroids, adenomyosis or a combination of fibroids and adenomyosis). INTERVENTION(S) Participants received UPA (5 mg once daily) for three 12-week courses, each separated by 4 weeks without treatment. MAIN OUTCOME MEASURE(S) Gene expression by real-time quantitative reverse transcription polymerase chain reaction, immunohistochemistry, and digital image analysis were analyzed to investigate the endometrial impact of modulation of progesterone receptor pathways upon expression of steroid receptors, steroid metabolizing enzymes, cell proliferation, and progesterone-regulated genes in the same patients at 3 time points: before, during, and after discontinuation of PRM treatment. RESULT(S) Ulipristal acetate treatment resulted in increased messenger ribonucleic acid (mRNA) levels of steroid receptors compared with pretreatment secretory endometrium; decreased mRNA levels of 17- and 11-beta-hydroxysteroid dehydrogenases compared with pretreatment proliferative endometrium and pretreatment secretory endometrium; reduced cell proliferation compared with pretreatment proliferative endometrium; and altered mRNA levels of progesterone-regulated genes. A strong consistency between immunohistochemistry-digital image analysis and real-time quantitative reverse transcription polymerase chain reaction results was evident. Alterations in the mRNA levels and endometrial morphology returned to a pretreatment phenotype after the cessation of PRM exposure. CONCLUSION(S) The endometrial impact of the modulation of progesterone receptor pathways with PRM (UPA) treatment is reversible. CLINICAL TRIAL REGISTRATION NUMBER Ulipristal acetate versus conventional management of heavy menstrual bleeding (UCON) trial (EudraCT 2014-003408-65; REC14/LO/1602).
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Affiliation(s)
- Rohan R Chodankar
- Medical Research Council Centre for Reproductive Health, The University of Edinburgh, The Queen's Medical Research Institute, Edinburgh, United Kingdom
| | - Alison Murray
- Medical Research Council Centre for Reproductive Health, The University of Edinburgh, The Queen's Medical Research Institute, Edinburgh, United Kingdom
| | - Moira Nicol
- Medical Research Council Centre for Reproductive Health, The University of Edinburgh, The Queen's Medical Research Institute, Edinburgh, United Kingdom
| | - Lucy H R Whitaker
- Medical Research Council Centre for Reproductive Health, The University of Edinburgh, The Queen's Medical Research Institute, Edinburgh, United Kingdom
| | - Alistair R W Williams
- Medical Research Council Centre for Reproductive Health, The University of Edinburgh, The Queen's Medical Research Institute, Edinburgh, United Kingdom
| | - Hilary O D Critchley
- Medical Research Council Centre for Reproductive Health, The University of Edinburgh, The Queen's Medical Research Institute, Edinburgh, United Kingdom.
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Donnez J, Dolmans MM. Hormone therapy for intramural myoma-related infertility from ulipristal acetate to GnRH antagonist: a review. Reprod Biomed Online 2020; 41:431-442. [PMID: 32703756 DOI: 10.1016/j.rbmo.2020.05.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 05/15/2020] [Accepted: 05/29/2020] [Indexed: 12/30/2022]
Abstract
Uterine fibroids may cause infertility, depending on their size and location according to the International Federation of Gynecology and Obstetrics classification. In this review, infertility relating to intramural myomas is evaluated. The mechanisms linking uterine fibroids and infertility are numerous: uterine cavity distortion (fibroids types 0, 1, 2, 2-5); impaired endometrial and myometrial blood supply; increased uterine contractility; hormonal, paracrine and molecular changes; impaired endometrial receptivity in gene expression (decrease in homeobox 10 [HOXA-10] expression); and thicker capsule. The negative effect of intramural myoma is related to myoma size and proximity of the uterine cavity. Therefore, a medical approach could be proposed to reduce the size of the myoma and push it back deep into the myometrium. The relevant medical treatments, including selective progesterone receptor modulator and gonadotrophin releasing hormone antagonist are reviewed. Even if the mystery surrounding intramural myomas remains, the development of new algorithms for intramural myoma-related infertility, and evaluation of the place of medical treatment as a primary approach are urgently needed. An algorithm, taking into account the mechanisms linking uterine fibroids and infertility, is proposed.
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Affiliation(s)
- Jacques Donnez
- Catholic University of Louvain and Société de Recherche pour l'Infertilité (SRI) 143 Avenue Grandchamp, Brussels B-1150, Belgium.
| | - Marie-Madeleine Dolmans
- Gynecology Department, Cliniques Universitaires St-Luc, Avenue Hippocrate 10, 1200 Brussels, Belgium: Pôle de Gynécologie, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Avenue Mounier 52, bte B1.52.02, Brussels 1200, Belgium
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