The spectrum of endometrial pathology induced by progesterone receptor modulators

Predicting Progestin Therapy Response With PTEN, PAX2, and β-Catenin in Patients With Endometrioid Precancer

This study investigates the predictive value of biomarkers PTEN, PAX2, and β-catenin for therapeutic outcomes in patients with atypical endometrial hyperplasia or endometrioid intraepithelial neoplasia undergoing progestin therapy. In a retrospective study of 128 patients, we analyzed a total of 351 endometrial biopsy samples and categorized outcomes into responders (absence of residual disease) and nonresponders (presence of residual disease). We found aberrant biomarker expression in pretreatment cases: 48% for PTEN, 65% for PAX2, and 36% for β-catenin. Approximately 77.3% of patients responded to progestin treatment, with nonresponders showing significantly higher initial PTEN loss (75.86% vs 39.79%, P < 0.001). Nonresponders also demonstrated significant PTEN loss (53.33% vs 20.55%, P < 0.001), PAX2 loss (57.33% vs 41.22%, P < 0.05), and β-catenin nuclear staining (53.45% vs 27.91%, P < 0.01) in follow-up samples. In addition, nonresponders exhibited lower recovery of intact PTEN and PAX2, along with higher β-catenin aberrancy in cases initially showing normal β-catenin levels. We conclude that persistent aberrant PTEN and PAX2 expression, coupled with emerging aberrant β-catenin in follow-ups, indicates a greater likelihood of treatment failure. Conversely, the absence of these aberrations suggests successful progestin therapy. Our findings highlight the utility of this 3-marker panel in assessing residual disease status and predicting progestin treatment outcomes, thus offering critical insights for patient management.

Clinical Efficacy, Pharmacokinetics, and Safety of the Available Medical Options in the Treatment of Endometriosis-Related Pelvic Pain: A Scoping Review

BACKGROUND

In this scoping review, we sought to identify published studies evaluating the drugs currently used in the treatment of endometriosis-related pelvic pain, with reflection on their chemical properties, pharmacokinetics, safety profile, and clinical efficacy.

METHODS

A literature search was conducted with the use of the PubMed and EMBASE electronic databases, focusing on identifying articles published in English between January 1990 and 2023.

RESULTS

Based on the included studies, current therapy options for the treatment of endometriosis-related pain identified and reviewed in this article were: (1) non-steroidal anti-inflammatory drugs; (2) combined oral contraceptive (COCs); (3) progestins; (4) gonadotropin-releasing hormone agonists and antagonists; (5) aromatase inhibitors (AIs); (6) selective estrogen and progesterone receptor modulators; and (7) levonorgestrel-intrauterine device.

CONCLUSIONS

Based on the published evidence, clinicians should consider NSAIDs, COCs, and progestins as the first-line medical therapies. Compared with second-line options, such as GnRH agonists/antagonists or AIs, the abovementioned first-line options are well tolerated, efficacious, and exhibit lower overall price. Future research priorities should be to identify novel target therapies and to evaluate the effects of available drugs through different routes of administration.

Distinct clinicopathological features of ovarian endometriosis after long-term exposure to mifepristone

Objective

Mifepristone has been used to treat endometriosis, but it can cause a constellation of endometrial alterations. Our study investigated the effects of long-term mifepristone on ovarian endometriosis.

Methods

We retrospectively analyzed the clinicopathological changes of ovarian endometriosis in 11 Chinese patients after long-term low-dose mifepristone therapy and compared these alterations with those observed in eutopic endometrium and adenomyosis side-by-side. Immunohistochemistry was applied to investigate estrogen receptor (ER), progesterone receptor (PR), and Ki67 expression in eutopic and ectopic endometrium.

Results

Nearly all patients had a pelvic mass and elevated serum CA125 levels. The ovarian lesions were grossly solid, cystic-solid, or cystic. They had a grayish–reddish appearance and a fleshy, honeycomb-like cut surface. The ovarian lesions shared morphological features with the uterine endometrium, and they were characterized by dilated, crowding endometrial glands with non-physiological changes. Immunostaining revealed consistent staining for ER and PR and a low Ki67 index in both eutopic and ectopic endometrium.

Conclusions

Our findings suggest that ovarian endometriosis can mimic an endometrioid borderline tumor after long-term mifepristone administration. Careful histological assessment and related clinical information are critical for the correct interpretation of these rare entities.

Ultrasonographic appearance of the endometrium after saline infusion in women presenting with PRM-associated endometrial changes, due to the use of ulipristal acetate

Ulipristal acetate (UPA), used for the treatment in women with symptomatic fibroids, is associated with endometrial changes visualised on ultrasound as thickening up to more than 16 mm in approximately 10% of the patients. Is saline infusion sonography (SIS) a good alternative for more invasive techniques, to evaluate the presence of intrauterine pathology? Ten patients, presenting with UPA associated endometrial changes at their follow up ultra-sonographic evaluation, were included. Our study demonstrated that SIS is feasible and painless in patients presenting with UPA associated endometrial changes. The thickened endometrium appears to divide at the midline, making it possible to study both layers separately and exclude any suspected intrauterine pathology. Our findings suggest that SIS may be a first choice, non-invasive, painless technique to provide a proper visualisation to rule out intrauterine pathology when UPA associated endometrial changes are diagnosed after fibroid treatment. This is especially of clinical interest in front of assisted reproductive technology treatment. Invasive techniques can be withheld for patients in whom SIS examination is not contributive.Impact StatementWhat is already known on this subject? Reversible endometrial changes after ulipristal acetate (UPA) treatment in patients with symptomatic fibroids have been described. In patients who receive UPA, especially if planned to undergo ART, assessment of potential endometrial pathology is important as such interfere with proper implantation after ART. Consequently, clinicians may consider ruling out intrauterine pathology by invasive examinations such as biopsy or hysteroscopy after visualisation of the thickened endometrium.What do the results of this study add? Saline infusion sonography (SIS) was feasible and painless in patients presenting with UPA associated endometrial changes.What are the implications of these findings for clinical practice and/or further research? SIS may be a first choice, non-invasive, painless technique to provide a proper visualisation to rule out intrauterine pathology when UPA associated endometrial changes are diagnosed after fibroid treatment. This is especially of clinical interest in front of assisted reproductive technology treatment. Invasive techniques can be withheld for patients in whom SIS examination is not contributive in excluding intrauterine pathology.

Selective progesterone receptor modulators and reproductive health

PURPOSE OF REVIEW

This review is intended to provide perspective on the history of selective progesterone receptor modulators (SPRMs) and progesterone antagonists, their current availability, therapeutic promise and safety concerns.

RECENT FINDINGS

Despite keen interest in synthesis of these compounds, only a handful have had clinical test results allowing for commercialization. Mifepristone is well tolerated and effective for single dose first trimester at-home pregnancy termination and is available in much of the world. Ulipristal acetate, at single doses, is well tolerated and effective for emergency contraception, with less availability. Chronic use of these agents has been associated with abnormal liver enzymes, and rarely, with hepatic failure; causality is not understood.

SUMMARY

SPRMs and progesterone antagonists have great therapeutic promise for use in other reproductive disorders, including breast cancer, endometriosis, adenomyosis, estrogen-free contraception and cervical ripening but require additional study. Alternative formulations, whether local (topical breast or intrauterine) or extended-release may reduce the incidence of liver function abnormalities and should be explored.

Meta-Study of the Clinical Effect of Conservative Treatment in Uterine Fibroids

Heavy menstrual bleeding (HMB), distress in the pelvis, infertile, and stressed feelings are all indications of fibroids in the uterus, the most prevalent type of benign uterine tumor. Nearly one-third of women with fibroid in the uterus seek medical help. The goal of this analysis is for a better understanding of the mechanisms that relate fibroids to these symptoms and to assess several treatment options, including the application of the gonadotropin-releasing hormone (GnRH) antagonist. We compiled the commonest as well as appropriate studies on the most common symptom of fibroids, as well as medicinal and surgical treatment options. Those who said they used GnRH antagonists orally were probed further. The underlying mechanisms myoma-caused menorrhagia as well as sterility were examined since those have been critical to understand the detailed mechanism as well as the targeted treatment modality. New treatments are determined by the amount, dimension cum localization of fibroids, and the women's age and also her choice on future childbirth. Myomas have considerable economic consequences with respect to direct expenditure, wage losses, as well as difficulties. In this context, medical, surgical, and nonsurgical techniques were examined. The novelty applied in this research article is the implementation of the GnRH antagonist-based methodology for the removal of fibroids in the uterine layer. The methodology is superior to the existing techniques for the treatment of fibroids in the uterine membrane. Novel medical techniques including GnRH antagonists were investigated and proved to be a viable new option. Alternatives to surgical-surgical modalities are desperately needed, specifically for those who are looking forward for future childbirth. GnRH antagonists have been shown to effectively alleviate the symptoms of fibroids and welcome new techniques for myoma treatment.

International Harmonization of Nomenclature and Diagnostic Criteria (INHAND): Non-proliferative and Proliferative Lesions of the Non-human Primate (M. fascicularis)

The INHAND (International Harmonization of Nomenclature and Diagnostic Criteria for Lesions Project (www.toxpath.org/inhand.asp) is a joint initiative of the Societies of Toxicologic Pathology from Europe (ESTP), Great Britain (BSTP), Japan (JSTP) and North America (STP) to develop an internationally accepted nomenclature for proliferative and nonproliferative lesions in laboratory animals. The purpose of this publication is to provide a standardized nomenclature for classifying microscopic lesions observed in most tissues and organs from the nonhuman primate used in nonclinical safety studies. Some of the lesions are illustrated by color photomicrographs. The standardized nomenclature presented in this document is also available electronically on the internet (http://www.goreni.org/). Sources of material included histopathology databases from government, academia, and industrial laboratories throughout the world. Content includes spontaneous lesions as well as lesions induced by exposure to test materials. Relevant infectious and parasitic lesions are included as well. A widely accepted and utilized international harmonization of nomenclature for lesions in laboratory animals will provide a common language among regulatory and scientific research organizations in different countries and increase and enrich international exchanges of information among toxicologists and pathologists.

Navigating through perplex morphologic changes after exogenous hormone usage

Clinical application of exogenous hormone as a method of contraception and/or treatment of various gynecologic disorders is exceedingly common. Unfortunately, the concurrent use of these agents also complicates the interpretation of pathology specimens. Various studies have shown that morphologic changes induced by hormonal therapies are present in both non-neoplastic and neoplastic tissues within the women's reproductive tract. It is important to understand the exogenous hormone induced morphologic changes, as it helps the pathologists make the accurate diagnosis, and in turn, guide clinicians to make optimal clinical decisions. In this review, we summarize the morphologic changes in both neoplastic and non-neoplastic endometrial, cervical, and myometrial surgical specimens after hormonal therapies, particularly after progestin treatment. In the endometrium, particularly in the scenario of progestin-treated atypical endometrial hyperplasia/endometrioid intraepithelial neoplasia (AEH/EIN), there is notoriously poor interobserver agreement and difficulty in assessing for the residual disease. We summarize current literature and propose our recommended approach in assessing these challenging endometrial biopsies, including a diagnostic algorism, the use of PAX-2, PTEN, beta-catenin immunohistochemistry panel, as well as consistency in diagnostic wording of the report. In the cervix, progestin makes dysplastic lesions appear metaplastic, thus high-grade squamous dysplastic lesions may be easily missed. Within the myometrium, lesions such as adenomyosis may show various degree of decidualization, while smooth muscle neoplasms may show apoplectic changes, and stromal lesions including endometrial stromal sarcoma may show more eosinophilic cytoplasm. All such changes may pose more or less diagnostic challenges in our daily practice. However, most are readily recognizable when we understand particular hormone related scenarios.

Ulipristal Acetate Modifies miRNA Expression in Both Superficial and Basal Layers of the Human Endometrium

(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.

Glucose and fatty acid metabolism involved in the protective effect of metformin against ulipristal-induced endometrial changes in rats

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.

The selective progesterone receptor modulator, telapristone acetate, is a mixed antagonist/agonist in the human and mouse endometrium and inhibits pregnancy in mice

OBJECTIVE

To investigate the effect of the selective progesterone receptor modulator, telapristone acetate (CDB-4124), on endometrial biology and reproductive outcomes. Ovariectomized and hormone-treated CD1 female mice, CD1 female mice with xenotransplants of reconstructed human endometrial tissue, mated wildtype female mice, and cultured human endometrial stromal cells (hESCs) were treated with CDB-4124, followed by the assessment of endometrial cell deoxyribonucleic acid (DNA) proliferation, stromal decidual response, and embryo implantation.

DESIGN

Experimental study.

SETTING

Academic research laboratory.

PATIENTS

Healthy volunteer women from the community were recruited for endometrial biopsies.

ANIMALS

CD1 out-bred mice (Charles River Laboratories) and nude mice, NU/J (Jackson Laboratories, Bar Harbor, ME).

INTERVENTION

Treatment of mice and hESCs with CDB-4124.

MAIN OUTCOME MEASURE

The effect of CDB-4124 on endometrial cell morphology and DNA synthesis, decidual response, and mouse embryo implantation.

RESULTS

CDB-4124 inhibited estradiol-induced epithelial DNA synthesis in the mouse uterus and xenotransplanted human endometrium. This antiproliferative effect was less than that of progesterone (P4) and was observed when CDB-4124 was administered alone or concomitantly with P4. In the uterine epithelium, CDB-4124 acted as a P4 agonist and partial antagonist. In contrast, CDB-4124 acted as a complete P4 antagonist in the uterine stroma, where it blocked P4's action to induce a decidual response in the pseudopregnant mouse uterus and wildtype mouse uterus after copulation. In mated female mice, CDB-4124 impaired embryo implantation. Similarly, CDB-4124 inhibited the morphological and biochemical transformations of hESCs to decidual cells in vitro.

CONCLUSION

CDB-4124 exerts mixed P4 antagonistic/agonistic effects in the human and mouse endometrium, which result in failed embryo implantation because of the absence of stromal decidualization.

Histomorphometric analysis of goat uterine tissue on in vitro exposure with ovarian hormones and mifepristone

Uterus, the largest reproductive tract organ in female mammals, is the site of implantation of fertilised egg and foetus development. Uterus is a dynamic reproductive organ; its morphology alters with reproductive phase and steroidal cues. The aim of the present study was to assess the effects of progesterone (P4), estrogen (E2) and antiprogestogen i.e., mifepristone on goat’s uterine histoarchitecture in in vitro short term culture. Uterine tissue slices were cultured in the presence of E2, P4 and mifepristone at the dose of 10–9 M, 10–7 M and 10–6 M respectively for 24 hours. Uter-ine morphology of E2- and P4-treated groups did not reveal marked changes from that of control group. Mifepristone treatment caused conspicuous changes in uterine histoarchitecture, led to congested endometrium, regressed uterine glands and constricted blood vessels. The changes ob-served in morphometry after E2 and P4 exposure included increased uterine gland diameter (47.00 and 45.95 µm respectively) and glandular epithelial cell height (18.37 and 17.43 µm respectively) while the mifepristone treatment resulted in significant reduction of gland diameter (34.95 µm) as well as epithelium height (14.25 µm) as compared to those in control group (39.9 and 15.56 µm respectively). These morphometrical changes revealed prominent regressive changes in anti-progestin treated group while E2 and P4 showed prolific effects in in vitro culture. Thus it is envis-aged that E2 and P4 induced characteristic progressive changes in the histologic structure especially in endometrial glands of the goat uterus while anti-steroidogenic formulation i.e. mifepristone severely reduced the normal histoarchitecture of the uterus which is a prerequisite for implanta-tion.

Vilaprisan, a New Selective Progesterone Receptor Modulator in Uterine Fibroid Pharmacotherapy-Will it Really be a Breakthrough?

BACKGROUND

Vilaprisan (VPR) is a new orally available selective progesterone receptor modulator (SPRM), with anti-proliferative activity against uterine fibroids (UFs). It definitively causes suppression of ovulation and inhibition of proliferation of endometrial, myometrial and UF cells.

PURPOSE

This review aims to summarize current knowledge on VPR from all studies, including clinical trials, conducted to date and to contextualize the potential role of VPR in future medical regimens for the treatment of UFs.

METHODS

We performed a literature search in PubMed US National Library of Medicine and Google Scholar databases. Both databases were extensively searched for all original and review articles/book chapters as well as congress abstracts published in English until July 2019. The use of VPR for UF therapy was identified by using the keywords: "uterine fibroids" and "vilaprisan".

RESULTS

In phase I and II clinical trials, VPR was shown to be effective in ameliorating UF-related clinical symptoms, especially abnormal or excessive uterine bleeding and in shrinking UFs. The tolerability of VPR is roughly similar to that of ulipristal acetate (UPA) and it tends to be more favorable than that of GnRH-agonists.

CONCLUSION

Presently, all trials examining the utility of VPR for the treatment of UF are halted; likely, due to the recently reported cases of hepato-toxicity with UPA, in addition to non reassuring toxicology results from preclinical long-term testing on rodents, carried out in parallel with late stage testing on humans. An accurate summary of robust data related to the safety of VPR is urgently needed to draw definitive conclusions on the future clinical development of this drug for UF therapy.

Menstruation: science and society

Women's health concerns are generally underrepresented in basic and translational research, but reproductive health in particular has been hampered by a lack of understanding of basic uterine and menstrual physiology. Menstrual health is an integral part of overall health because between menarche and menopause, most women menstruate. Yet for tens of millions of women around the world, menstruation regularly and often catastrophically disrupts their physical, mental, and social well-being. Enhancing our understanding of the underlying phenomena involved in menstruation, abnormal uterine bleeding, and other menstruation-related disorders will move us closer to the goal of personalized care. Furthermore, a deeper mechanistic understanding of menstruation-a fast, scarless healing process in healthy individuals-will likely yield insights into a myriad of other diseases involving regulation of vascular function locally and systemically. We also recognize that many women now delay pregnancy and that there is an increasing desire for fertility and uterine preservation. In September 2018, the Gynecologic Health and Disease Branch of the Eunice Kennedy Shriver National Institute of Child Health and Human Development convened a 2-day meeting, "Menstruation: Science and Society" with an aim to "identify gaps and opportunities in menstruation science and to raise awareness of the need for more research in this field." Experts in fields ranging from the evolutionary role of menstruation to basic endometrial biology (including omic analysis of the endometrium, stem cells and tissue engineering of the endometrium, endometrial microbiome, and abnormal uterine bleeding and fibroids) and translational medicine (imaging and sampling modalities, patient-focused analysis of menstrual disorders including abnormal uterine bleeding, smart technologies or applications and mobile health platforms) to societal challenges in health literacy and dissemination frameworks across different economic and cultural landscapes shared current state-of-the-art and future vision, incorporating the patient voice at the launch of the meeting. Here, we provide an enhanced meeting report with extensive up-to-date (as of submission) context, capturing the spectrum from how the basic processes of menstruation commence in response to progesterone withdrawal, through the role of tissue-resident and circulating stem and progenitor cells in monthly regeneration-and current gaps in knowledge on how dysregulation leads to abnormal uterine bleeding and other menstruation-related disorders such as adenomyosis, endometriosis, and fibroids-to the clinical challenges in diagnostics, treatment, and patient and societal education. We conclude with an overview of how the global agenda concerning menstruation, and specifically menstrual health and hygiene, are gaining momentum, ranging from increasing investment in addressing menstruation-related barriers facing girls in schools in low- to middle-income countries to the more recent "menstrual equity" and "period poverty" movements spreading across high-income countries.

Clinical management of patients with Cushing syndrome treated with mifepristone: consensus recommendations

BACKGROUND

While surgery is the first-line treatment for patients with endogenous hypercortisolism (Cushing syndrome [CS]), mifepristone has been shown to be a beneficial medical treatment option, as demonstrated in the SEISMIC (Study of the Efficacy and Safety of Mifepristone in the Treatment of Endogenous Cushing Syndrome) trial. Mifepristone is a competitive glucocorticoid receptor antagonist and progesterone receptor antagonist that is associated with several treatment effects and adverse events that clinicians need to be aware of when considering its use. The objective of this review was to provide updated clinical management recommendations for patients with CS treated with mifepristone.

METHODS

A panel of endocrinologists from the US with extensive experience in treating patients with CS, including with mifepristone, convened as part of a clinical advisory board to develop a consensus on the practical, real-world clinical management of patients on mifepristone.

RESULTS

Comprehensive considerations and recommendations are provided for managing mifepristone-associated effects, including symptoms of cortisol withdrawal, hypokalemia, and change in thyroid function; effects related to its antiprogesterone activity; and rash. Additional management strategies to address concomitant medications and special clinical situations, such as surgery and use in specific populations, are also provided.

CONCLUSION

Safe and effective use of mifepristone requires clinical judgment and close patient monitoring to ensure optimal clinical outcomes. These consensus recommendations provide useful, practical guidance to clinicians using mifepristone.

A multi-centre, randomized, non-inferiority trial to compare ulipristal with standard surgical treatment in women with symptomatic uterine fibroids: Protocol of the MYOMEX-2 trial

OBJECTIVES

Fibroids are the most common benign tumours found in the uterus and can cause various symptoms. In 20-50 % of the women, an intervention is required. When conservative options fail, invasive options such as hysterectomy, uterine artery embolization or myomectomy are eligible options. Ulipristal acetate (UPA) was launched as the sole available long term pharmaceutical treatment, with the potential to avoid surgery. It is suggested that UPA improves quality of life, reduces symptoms and fibroid volumes. However, UPA is an expensive medicine, is possibly associated with liver injury and has never been directly compared to surgical treatment. The aim of this trial is to compare UPA to surgical treatment on both effectiveness and cost-effectiveness. Primary outcome is the reduction in symptom severity scores (part of the Uterine Fibroid Symptom and Quality of Life questionnaire) at 24 months of follow-up compared to baseline. Secondary outcomes include quality of life, societal costs, societal participation, liver function variation, patient satisfaction and preference. Outcomes will be analysed according to intention-to-treat principle.

STUDY DESIGN

The MYOMEX-2 trial is an open-label, multicentre, non-inferiority randomized controlled trial. Patients are pre-menopausal women with symptomatic fibroids eligible for surgical treatment (hysterectomy, myomectomy or UAE). Fibroid symptoms may comprise (but are not limited to) heavy menstrual bleeding, bulk symptoms or pain. Patients are randomised 2:1 in a parallel group design between two treatment arms: 119 patients in the UPA group and 60 patients in the surgery group. Follow up comprises of online questionnaires, outpatient visits and phone appointments on several follow up moments, up to 24 months after surgery or start UPA.

REGISTRATION DETAILS

MYOMEX-2 trial; protocol version 4, date 22-02-2019; NTR6860; NL62638.029.18. All items from the World Health Organization Trial Registration Data Set are provided in the online supplementary file (Appendix-B).

Hysteroscopic and ultrasonographic evaluation of ulipristal acetate treatment for symptomatic myomas in premenopausal women: a prospective study

OBJECTIVE

This study aimed to analyze the effects of a six-month therapy with ulipristal acetate (UPA) on myoma size and endometrial thickness in premenopausal women.

MATERIAL AND METHODS

Seventy-four women undergoing conservative therapy with UPA were enrolled for this study. All women underwent transvaginal ultrasound evaluation to assess the endometrial thickness, and the number and size of myomas at the beginning and after six months. Hysteroscopy and biopsy were performed after six months, if necessary.

RESULTS

After six months of treatment, sonographic examination showed a statistically significant (p < .05) reduction of the size of the largest myoma (56.3 ± 5.1 vs. 31.7 ± 10.1 mm) and a statistically significant (p < .05) increase in endometrial thickness (5.9 ± 2.1 vs. 9.7 ± 3.4 mm). Twenty-two patients with endometrial thickness >10 mm or nonhomogeneous pattern and ten patients with metrorrhagia underwent hysteroscopy: the most frequent finding was the combination of endometrial hypotrophy, floating surface, and chicken-wire vascular pattern aspect (14 cases, 43.7%). Histologic findings showed no case of complex hyperplasia.

CONCLUSION

UPA is a safe, effective and assured method to decrease symptoms, reduce the need for surgery in premenopausal women suitable for the treatment.

Selective Progesterone Receptor Modulators-Mechanisms and Therapeutic Utility

Selective progesterone receptor modulators (SPRMs) are a new class of compounds developed to target the progesterone receptor (PR) with a mix of agonist and antagonist properties. These compounds have been introduced for the treatment of several gynecological conditions based on the critical role of progesterone in reproduction and reproductive tissues. In patients with uterine fibroids, mifepristone and ulipristal acetate have consistently demonstrated efficacy, and vilaprisan is currently under investigation, while studies of asoprisnil and telapristone were halted for safety concerns. Mifepristone demonstrated utility for the management of endometriosis, while data are limited regarding the efficacy of asoprisnil, ulipristal acetate, telapristone, and vilaprisan for this condition. Currently, none of the SPRMs have shown therapeutic success in treating endometrial cancer. Multiple SPRMs have been assessed for efficacy in treating PR-positive recurrent breast cancer, with in vivo studies suggesting a benefit of mifepristone, and multiple in vitro models suggesting the efficacy of ulipristal acetate and telapristone. Mifepristone, ulipristal acetate, vilaprisan, and asoprisnil effectively treated heavy menstrual bleeding (HBM) in patients with uterine fibroids, but limited data exist regarding the efficacy of SPRMs for HMB outside this context. A notable class effect of SPRMs are benign, PR modulator-associated endometrial changes (PAECs) due to the actions of the compounds on the endometrium. Both mifepristone and ulipristal acetate are effective for emergency contraception, and mifepristone was approved by the US Food and Drug Administration (FDA) in 2012 for the treatment of Cushing's syndrome due to its additional antiglucocorticoid effect. Based on current evidence, SPRMs show considerable promise for treatment of several gynecologic conditions.

The effects of vilaprisan on the pharmacodynamics and pharmacokinetics of a combined oral contraceptive-A randomized controlled trial

AIMS

The primary objective was to explore whether the suppression of ovarian activity induced by a combined oral contraceptive (COC) is influenced by the simultaneous intake of the selective progesterone receptor modulator (SPRM) vilaprisan (VPR).

METHODS

In this exploratory randomized, double-blind, parallel-group study, 71 healthy premenopausal women were randomized (1:1) to receive either 2 mg/d VPR or placebo for 3 months. Concomitantly, a COC (0.15 mg levonorgestrel, 0.03 mg ethinyloestradiol) was administered in a cyclic regimen. Ovarian activity (Hoogland score based on follicle size and hormone concentrations), cervical function (Insler score), bleeding pattern and endometrial thickness/histology were assessed before treatment, in treatment cycle 3 and during follow-up.

RESULTS

The known COC-driven suppression of ovarian activity was mildly affected by VPR. COC+VPR group: 22, 0 and 6% of the subjects had Hoogland scores of 4 (active follicle-like structures), 5 or 6 (ovulation). COC+placebo group: 14% of the subjects had a score of 4 and none a score of 5 or 6 (Bayesian analysis for Hoogland score = 4, median difference in response rate: 7.5%; 90% credible interval [-8.5; 23.5%]). COC effects on cervical function were moderately affected (mucus more sperm permeable under COC+VPR). COC withdrawal bleeding, in contrast, was absent in 81% of the subjects receiving COC+VPR vs 0% receiving COC+placebo.

CONCLUSION

The SPRM VPR interfered with the pharmacodynamic effects of the COC. Therefore, full contraceptive effectiveness cannot be assumed without final judgement by a Pearl index study. Women on SPRMs should be advised to use nonhormonal contraception methods.

Safety and efficacy of the selective progesterone receptor modulator asoprisnil for heavy menstrual bleeding with uterine fibroids: pooled analysis of two 12-month, placebo-controlled, randomized trials

STUDY QUESTION

Can asoprisnil, a selective progesterone receptor modulator, provide clinically meaningful improvements in heavy menstrual bleeding (HMB) associated with uterine fibroids with an acceptable safety profile?

SUMMARY ANSWER

Uninterrupted treatment with asoprisnil for 12 months effectively controlled HMB and reduced fibroid and uterine volume with few adverse events.

WHAT IS KNOWN ALREADY

In a 3-month study, asoprisnil (5, 10 and 25 mg) suppressed uterine bleeding, reduced fibroid and uterine volume, and improved hematological parameters in a dose-dependent manner.

STUDY DESIGN, SIZE, DURATION

In two Phase 3, double-blind, randomized, placebo-controlled, multicentre studies, women received oral asoprisnil 10 mg, asoprisnil 25 mg or placebo (2:2:1) once daily for up to 12 months.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Premenopausal women ≥18 years of age in North America with HMB associated with uterine fibroids were included (N = 907). The primary efficacy endpoint was the percentage of women who met all three predefined criteria at 12 months or the final month for patients who prematurely discontinued: (1) ≥50% reduction in monthly blood loss (MBL) by menstrual pictogram, (2) hemoglobin concentration ≥11 g/dL or an increase of ≥1 g/dL, and (3) no interventional therapy for uterine fibroids. Secondary efficacy endpoints included changes in other menstrual bleeding parameters, volume of the largest fibroids, uterine volume and health-related quality of life (HRQL).

MAIN RESULTS AND THE ROLE OF CHANCE

In all, 90% and 93% of women in the asoprisnil 10-mg and 25-mg groups, respectively, and 35% of women in the placebo group met the primary endpoint (P < 0.001). Similar results were observed at month 6 (P < 0.001). The percentage of women who achieved amenorrhea in any specified month ranged from 66-78% in the asoprisnil 10-mg group and 83-93% in the asoprisnil 25-mg group, significantly higher than with placebo (3-12%, P < 0.001). Hemoglobin increased rapidly (by month 2) with asoprisnil treatment and was significantly higher versus placebo throughout treatment. The primary fibroid and uterine volumes were significantly reduced from baseline through month 12 with asoprisnil 10 mg (median changes up to -48% and -28%, respectively) and 25 mg (median changes up to -63% and -39%, respectively) versus placebo (median changes up to +16% and +13%, respectively; all P < 0.001). Dose-dependent, significant improvements in HRQL (Uterine Fibroid Symptom and Quality of Life instrument) were observed with asoprisnil treatment. Asoprisnil was generally well tolerated. Endometrial biopsies indicated dose- and time-dependent decreases in proliferative patterns and increases in quiescent or minimally stimulated endometrium at month 12 of treatment. Although not statistically significantly different at month 6, mean endometrial thickness at month 12 increased by ~2 mm in both asoprisnil groups compared with placebo (P < 0.01). This effect was associated with cystic changes in the endometrium on MRI and ultrasonography, which led to invasive diagnostic and therapeutic procedures in some asoprisnil-treated women.

LIMITATIONS, REASONS FOR CAUTION

Most study participants were black; few Asian and Hispanic women participated. The study duration may have been insufficient to fully characterize the endometrial effects.

WIDER IMPLICATIONS OF THE FINDINGS

Daily uninterrupted treatment with asoprisnil was highly effective in controlling menstrual bleeding, improving anemia, reducing fibroid and uterine volume, and increasing HRQL in women with HMB associated with uterine fibroids. However, this treatment led to an increase in endometrial thickness and invasive diagnostic and therapeutic procedures, with potential unknown consequences.

STUDY FUNDING/COMPETING INTEREST(S)

This trial was funded by AbbVie Inc. (prior sponsors: TAP Pharmaceutical Products Inc., Abbott Laboratories). E.A. Stewart was a site investigator in the Phase 2 study of asoprisnil and consulted for TAP during the design and conduct of these studies while at Harvard Medical School and Brigham and Women's Hospital. She received support from National Institutes of Health grants HD063312, HS023418 and HD074711 and research funding, paid to Mayo Clinic for patient care costs related to an NIH-funded trial from InSightec Ltd. She consulted for AbbVie, Allergan, Bayer HealthCare AG, Gynesonics, and Welltwigs. She received royalties from UpToDate and the Med Learning Group. M.P. Diamond received research funding for the conduct of the studies paid to the institution and consulted for AbbVie. He is a stockholder and board and director member of Advanced Reproductive Care. He has also received funding for study conduct paid to the institution from Bayer and ObsEva. A.R.W. Williams consulted for TAP and Repros Therapeutics Inc. He has current consultancies with PregLem SA, Gedeon Richter, HRA Pharma and Bayer. B.R. Carr consulted for and received research funding from AbbVie. E.R. Myers consulted for AbbVie, Allergan and Bayer. R.A. Feldman received compensation for serving as a principal investigator and participating in the conduct of the trial. W. Elger was co-inventor of several patents related to asoprisnil. C. Mattia-Goldberg is a former employee of AbbVie and may own AbbVie stock or stock options. B.M. Schwefel and K. Chwalisz are employees of AbbVie and may own AbbVie stock or stock options.

TRIAL REGISTRATION NUMBER

NCT00152269, NCT00160381 (clinicaltrials.gov).

TRIAL REGISTRATION DATE

7 September 2005; 8 September 2005.

DATE OF FIRST PATIENT’S ENROLMENT

12 September 2002; 6 September 2002.

Physiology of the Endometrium and Regulation of Menstruation

The physiological functions of the uterine endometrium (uterine lining) are preparation for implantation, maintenance of pregnancy if implantation occurs, and menstruation in the absence of pregnancy. The endometrium thus plays a pivotal role in reproduction and continuation of our species. Menstruation is a steroid-regulated event, and there are alternatives for a progesterone-primed endometrium, i.e., pregnancy or menstruation. Progesterone withdrawal is the trigger for menstruation. The menstruating endometrium is a physiological example of an injured or “wounded” surface that is required to rapidly repair each month. The physiological events of menstruation and endometrial repair provide an accessible in vivo human model of inflammation and tissue repair. Progress in our understanding of endometrial pathophysiology has been facilitated by modern cellular and molecular discovery tools, along with animal models of simulated menses. Abnormal uterine bleeding (AUB), including heavy menstrual bleeding (HMB), imposes a massive burden on society, affecting one in four women of reproductive age. Understanding structural and nonstructural causes underpinning AUB is essential to optimize and provide precision in patient management. This is facilitated by careful classification of causes of bleeding. We highlight the crucial need for understanding mechanisms underpinning menstruation and its aberrations. The endometrium is a prime target tissue for selective progesterone receptor modulators (SPRMs). This class of compounds has therapeutic potential for the clinical unmet need of HMB. SPRMs reduce menstrual bleeding by mechanisms still largely unknown. Human menstruation remains a taboo topic, and many questions concerning endometrial physiology that pertain to menstrual bleeding are yet to be answered.

Effects of the levonorgestrel intrauterine system on the endometrium after long-term exposure to mifepristone: Secondary outcomes of a randomized controlled trial

OBJECTIVE

Long-term treatment with progesterone receptor modulators (PRM) is associated with a distinct histological entity termed progesterone receptor modulator associated endometrial changes (PAEC). While accumulating evidence implies that these changes are benign and reversible after cessation of treatment, there are currently no data underpinning their development. Consequently, as a precaution, endometrial shedding is recommended after long-term PRM intake. Avoiding endometrial shedding after treatment with a PRM and prior to the start of a progestin treatment would be beneficial for women in reproductive age to avoid pregnancy and bleeding. However, the endometrial morphology with such a treatment regimen is unknown. The aim of this study was to delineate the endometrial morphology following continuous long-term treatment with the PRM mifepristone and subsequent placement of a levonorgestrel intrauterine system (LNG-IUS) without prior shedding of the endometrium.

STUDY DESIGN

This study reports the secondary outcome from a double-blinded randomized controlled trial conducted at Karolinska University Hospital, Sweden, November 2009 to January 2015. Healthy women aged 18-43 years with regular menstrual cycles were included. Eligible women were randomized to receive either 50 mg of mifepristone (n = 29) or a comparator (n = 29), every other day for two months followed by insertion of an LNG-IUS 52 mg. Endometrial biopsies were obtained at baseline and three months after placement of the device. The samples were histologically assessed. The main outcome measure of this sub-study was the endometrial morphology including presence of PAEC three months after LNG-IUS insertion.

RESULTS

Nine and eight paired biopsies from the mifepristone and comparator group, respectively, were included in the histological analysis. There were no differences in baseline characteristics between the groups and all baseline endometrial biopsies were physiological. Three months after LNG-IUS placement the endometrial morphology was still benign without PAEC in all samples treated with either mifepristone or comparator. A progestin effect on the endometrium was seen in all samples.

CONCLUSIONS

Placement of an LNG-IUS immediately following two months' treatment with the PRM mifepristone, without any prior shedding of the endometrium, may represent a feasible approach in terms of endometrial safety. However, larger studies are needed to confirm our results.

Hormone therapy for intramural myoma-related infertility from ulipristal acetate to GnRH antagonist: a review

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.

Gonadotropin-releasing hormone antagonist (linzagolix): a new therapy for uterine adenomyosis

OBJECTIVE

To compare the efficacy of a selective progesterone receptor modulator, ulipristal acetate, and a gonadotropin-releasing hormone antagonist, linzagolix, in a case of severe uterine adenomyosis.

DESIGN

Case report.

SETTING

Private clinic and infertility research unit.

PATIENT

One patient born in 1981 who presented because of heavy menstrual bleeding, pelvic pain, and dysmenorrhea due to diffuse and disseminated uterine adenomyosis confirmed by magnetic resonance imaging (MRI).

INTERVENTION

The patient received a first treatment of 5 mg UPA daily for one course of 3 months. This therapy was discontinued because MRI revealed a worsened aspect. One year later, a once-daily dose of 200 mg linzagolix administered orally was initiated for 3 months, followed by another 3-month course of 100 mg once daily.

MAIN OUTCOME MEASURES

Clinical symptoms and MRI aspect.

RESULTS

During treatment with UPA, the symptoms (pelvic pain, dysmenorrhea, bulk symptoms) worsened and MRI revealed aggravation of the adenomyotic lesions. During the 12-week course of once-daily 200 mg linzagolix, the patient remained in amenorrhea and noted a very significant improvement in symptoms. On MRI, the uterine volume had fallen from 875 cm³ to 290 cm³, and the adenomyotic lesions had significantly regressed. During the 100-mg linzagolix course (weeks 13-24), the patient reported continued alleviation of her symptoms.

CONCLUSION

To our knowledge, this is the first reported use of linzagolix, a new oral gonadotropin-releasing hormone antagonist that significantly reduced lesion size and improved quality of life in a patient with severe adenomyosis, who was previously nonresponsive to treatment with a selective progesterone receptor modulator, ulipristal acetate.

Endometrial Calcifications

Benign endometrial calcifications with or without bone fragments are uncommon clinicopathologic findings. They can be detected during pelvic ultrasonography or as incidental pathologic findings. They have been found to be associated with infertility and menstrual anomalies in young adult patients and in symptomatic postmenopausal women with endometrial atrophy and endometrial polyps. Its exact etiology is unknown, its pathogenesis is controversial, and its clinical importance is not fully validated. We performed a retrospective review study over 7 years and found 11 (0.4%) cases of benign endometrial calcifications. The mean patient age was 45.2 years (range = 20-66 years). All of the women complained of menstrual abnormalities and 4 complained of infertility. Six had a previous procedure of abortion, 2 had oral contraceptive pills, and 4 a course of progesterone therapy. Their size and morphology varied from heterogeneous microcalcifications of variable appearances, shattered glassy chunks to detached bones. Four cases were associated with endometrial polyps, 1 with a placental site nodule, 1 with chronic endometritis, and 1 with endometrial hyperplasia. Most showed secretory endometrial tissue and ciliated cell metaplasia. Two cases showed atrophic endometrium. Etiology and pathogenesis are multifactorial and miscellaneous. Progesterone may play a role. Heterogeneous histomorphologic patterns may carry potential pitfalls. Pathologic recognition is clinically important to reassure clinicians in symptomatic postmenopausal women, alert gynecologists to a treatable albeit rare cause of infertility in younger women, and assist in patients' counselling. We also included cases of calcifications associated with endometrial malignancies to compare and contrast malignant endometrial calcifications with benign endometrial calcifications.

Role of Hormones in Common Benign Uterine Lesions: Endometrial Polyps, Leiomyomas, and Adenomyosis

Leiomyoma, adenomyosis, and endometrial polyps are benign uterine disorders which seem to develop in the context of hormonal imbalances, due to steroid hormones, estrogen and progesterone, in association with various factors ranging from genetic factors to modifiable lifestyle factors. A growing body of evidence suggests that those hormones and their receptors are key modulators in the genesis and the growth of those pathologic entities. Further studies are required to understand their involvement in the pathogenesis of those lesions and their link to other factors such as extracellular matrix components, growth factors, chemokines, cytokines, and tissue repair mechanisms.

Ulipristal acetate for Japanese women with symptomatic uterine fibroids: A double-blind, randomized, phase II dose-finding study

PURPOSE

A multicenter, randomized, double-blind, placebo-controlled trial was conducted to evaluate the efficacy, safety, and appropriate dose of ulipristal acetate (UPA) in Japanese women with symptomatic uterine fibroids (UFs).

METHODS

A total of 121 premenopausal women with UFs were enrolled to receive either placebo, UPA-2.5 mg, UPA-5 mg, UPA-10 mg, or leuprorelin acetate (LEU), a reference drug, for 12 weeks. The primary end point was the rate of patients having achieved amenorrhea for 35 days at Week 12.

RESULTS

The rates for amenorrhea were 4.5%, 60.0%, 72.7%, 88.0%, and 76.2% in the placebo, UPA-2.5 mg, UPA-5 mg, UPA-10 mg, and LEU groups, respectively. The median times to amenorrhea were 20.0, 5.0, 5.0, and 23.0 days for treatment with UPA-2.5 mg, UPA-5 mg, UPA-10 mg, and LEU, respectively. A significant dose-response of UPA for the rate of amenorrhea was observed. The overall incidence rates of adverse events were 45.8% in the placebo group, 56.5%-80.0% in the UPA groups, and 100.0% in the LEU group. There were no notable safety issues with UPA.

CONCLUSIONS

Ulipristal acetate was effective and well tolerated in Japanese women with UFs. The recommended dose of UPA is considered to be 10 mg.

Hormone Therapy Effects on the Uterus

The uterus and especially the endometrium are sensitive targets for steroid sex hormones, capable to modify structure and function with promptitude and versatility in order to secure reproductive functions. Hormone therapy is used to counteract deprivation, abnormal, and deleterious functions of "natural" hormones. It is widely prescribed, being used by millions of women all over the world. It seems that most women would use at least some hormone therapy at some point of their life, as contraceptives, ovarian stimulation, replacement therapy, or hormone antitumoral therapy. The diagnosis of uterine tissue, mostly of the frequently performed endometrial biopsies taken from women undergoing hormone therapy, is often confusing and difficult to interpret due to the complexity of histologic changes. Permanently changing hormonal pharmaceutical products, regimens, dosages, as well as new concepts of therapy are challenges for both users and medical prescribers. This chapter addresses the most commonly issues arising from the gynecological pathology interpretation of hormonal therapy effects on the uterus.

Benign polypoid adenomyomatous endometrium associated with hpt-JT syndrome: a case report

Hyperparathyroidism-jaw tumor (HPT-JT) is an autosomal dominant disorder responsible for benign and/or malignant tumors. Affected women often present life-threatening menorrhagia that leads to the identification of uterine tumors, and experience miscarriages and infertility. Overall though, fewer data concerning gynecological pathologies related to HPT-JT syndrome are available. We report the case of a 32-year-old woman with HPT-JT syndrome, referred for recurrent vaginal bleeding, with a history of repeated endometrial polyps and infertility. We also review the literature that explores medical options for these women.

A 12-month extension study to evaluate the safety and efficacy of asoprisnil in women with heavy menstrual bleeding and uterine fibroids

STUDY QUESTION

What is the safety and efficacy profile during long-term (12–24 months) uninterrupted treatment with the selective progesterone receptor modulator asoprisnil, 10 and 25 mg in women with heavy menstrual bleeding (HMB) associated with uterine fibroids?

SUMMARY ANSWER

Uninterrupted treatment with asoprisnil should be avoided due to endometrial safety concerns and unknown potential long-term consequences.

WHAT IS KNOWN ALREADY

Asoprisnil was well tolerated in shorter-term studies and effectively suppressed HMB and reduced fibroid volume.

STUDY DESIGN, SIZE, DURATION

Women with uterine fibroids who had previously received placebo (n = 87) or asoprisnil 10 mg (n = 221) or 25 mg (n = 215) for 12 months in two double-blind studies entered this randomized uncontrolled extension study and received up to 12 additional months of treatment followed by 6 months of post-treatment follow-up. Women who previously received placebo were re-randomized to either asoprisnil 10 or 25 mg for the extension study. This report focuses on the 436 women who received asoprisnil in the double-blind studies and this extension study. Results for women who previously received placebo in the double-blind studies are not described.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women ≥18 years of age who completed a 12-month, double-blind, placebo-controlled study, had estradiol levels indicating that they were not menopausal and had no endometrial hyperplasia or other significant endometrial pathology were eligible. The safety endpoints were focused on endometrial assessments. The composite primary efficacy endpoint was the proportion of women who demonstrated a response to treatment by meeting all three of the following criteria at the final month for participants who prematurely discontinued or at month 12 for those who completed the study: a reduction from initial baseline to final visit of ≥50% in the menstrual pictogram score, hemoglobin concentration ≥11 g/dl or an increase of ≥1 g/dl from initial baseline at the final visit, and no surgical or invasive intervention for uterine fibroids. Other efficacy endpoints included rates for amenorrhea and suppression of bleeding, changes in fibroid and uterine volume and changes in hematologic parameters. No statistical tests were planned or performed for this uncontrolled study.

MAIN RESULTS AND ROLE OF CHANCE

Imaging studies revealed a progressive increase in endometrial thickness and cystic changes that frequently prompted invasive diagnostic procedures. Endometrial biopsy results were consistent with antiproliferative effects of asoprisnil. Two cases of endometrial cancer were diagnosed. At the final month of this extension study (total duration of uninterrupted treatment up to 24 months), the primary efficacy endpoint was achieved in 86 and 92% of women in the asoprisnil 10- and 25-mg groups, respectively. During each month of treatment, amenorrhea was observed in the majority of women (up to 77 and 94% at 10 and 25 mg, respectively). There was a progressive, dose-dependent decrease in the volume of the primary fibroid with asoprisnil 10 and 25 mg (−55.7 and −75.2% median decrease, respectively, from baseline [i.e. the beginning of the placebo-controlled study] to month 12 [cumulative months 12–24] of this extension study). These effects were associated with improvements in quality of life measures.

LIMITATIONS, REASONS FOR CAUTION

This study was uncontrolled, which limits the interpretation of safety and efficacy findings. The study also had multiple protocol amendments with the addition of diagnostic procedures and, because no active comparator was included, the potential place of asoprisnil in comparison to therapies such as GnRH agonists and surgery cannot be determined.

WIDER IMPLICATIONS OF THE FINDINGS

Long-term, uninterrupted treatment with asoprisnil leads to prominent cystic endometrial changes that are consistent with the ‘late progesterone receptor modulator’ effects, which prompted invasive diagnostic procedures, although treatment efficacy is maintained. Although endometrial cancers were uncommon during both treatment and follow-up, these findings raise concerns regarding endometrial safety during uninterrupted long-term treatment with asoprisnil. This study shows that uninterrupted treatment with asoprisnil should be avoided due to safety concerns and unknown potential long-term consequences.

STUDY FUNDING/COMPETING INTEREST(S)

AbbVie Inc. (prior sponsor, TAP Pharmaceutical Products Inc.) sponsored the study and contributed to the design and conduct of the study, data management, data analysis, interpretation of the data and the preparation and approval of the manuscript. Financial support for medical writing and editorial assistance was provided by AbbVie Inc. M. P. Diamond received research funding for the conduct of the study paid to the institution and is a consultant to AbbVie. He is a stockholder and board and director member of Advanced Reproductive Care. He has also received funding for study conduct paid to the institution for Bayer and ObsEva. E. A. Stewart participated as a site investigator in the phase 2 study of asoprisnil and served as a consultant to TAP Pharmaceuticals during the time of design and conduct of the studies while on the faculty of Harvard Medical School and Brigham and Women’s Hospital, Boston, MA. In the last 3 years, she has received support from National Institutes of Health grants HD063312, HS023418 and HD074711. She has served as a consultant for AbbVie Inc., Allergan, Bayer HealthCare AG and Myovant for consulting related to uterine leiomyoma and to Welltwigs for consulting related to infertility. She has received royalties from UpToDate and the Med Learning Group. A.R.W. Williams has acted as a consultant for TAP Pharmaceutical Products Inc. and Repros Therapeutics Inc. He has current consultancies with PregLem SA, Gedeon Richter, HRA Pharma and Bayer. B.R. Carr has served as consultant and received research funding from AbbVie Inc. and Synteract (Medicines360). E.R. Myers has served as consultant for AbbVie Inc., Allergan and Bayer. R.A. Feldman received compensation for serving as a principal investigator and participating in the conduct of the trial. W. Elger was a co-inventor of several patents related to asoprisnil.

C. Mattia-Goldberg is a former employee of AbbVie Inc. and owns AbbVie stock or stock options. B.M. Schwefel and K. Chwalisz are employees of AbbVie Inc. and own AbbVie stock or stock options.

TRIAL REGISTRATION NUMBER

NCT00156195 at clinicaltrials.gov.

NAMS 2018 Utian Translational Science Symposium, October 2018, San Diego, California New therapies for leiomyomas: when surgery may not be the best option

The North American Menopause Society (NAMS) held the 2018 Utian Translational Science Symposium on October 2, 2018, in San Diego, California, to discuss new therapeutic approaches to uterine leiomyomas when surgery is not the optimal choice.Uterine leiomyomas arise from a single clonal cell and are the most common gynecologic disorder affecting reproductive and perimenopausal women worldwide. The prevalence of this disorder is approximately 40% to 70% in white women and 60% to 80% in black women. Recent research suggests that both estrogen and progesterone modulate the growth of leiomyomas, with progesterone being a major stimulator of leiomyoma growth.Women with symptomatic uterine leiomyomas experience heavy uterine bleeding, bulk symptoms, miscarriages, and pregnancy complications. Surgical therapies such as myomectomy or hysterectomy are highly effective; however, medical therapy with progestin-predominant contraceptives or gonadotropin-releasing hormone (GnRH) agonists are in many ways inadequate to address the unmet need for better, noninvasive, and cost-effective treatments.Recent advances in medical treatment, such as selective progesterone receptor modulators, new oral GnRH analogs, and clinical trials that provide new therapeutic approaches, were presented by speakers at the symposium. Research on why there is a prevalence of leiomyomas in black women, the racial and genetic effects on leiomyoma growth, and potential molecular mechanisms also were discussed.

[Precursor lesions of endometrial carcinoma]

The 2014 WHO classification distinguishes between endometrial hyperplasia without atypia (EH) and atypical endometrial hyperplasia/endometrioid intraepithelial neoplasia (AEH/EIN). AEH/EIN is characterized by crowded glands with cytologically atypical epithelium separated by little intervening stroma. Cellular atypia is characterized by nuclear enlargement and rounding, pleomorphism, loss of polarity, and presence of nucleoli. The diagnosis of atypia is facilitated by comparison with areas of adjacent normal and non-atypical glands, respectively. AEH/EIN is often associated with squamous but also secretory and mucinous metaplasia. Loss of PTEN and/or PAX2 immunoreactivity occurs in up to two thirds of AEH/EIN. In contrast, invasive low-grade endometrioid carcinoma shows confluent growth with loss of stroma and formation of labyrinth-like or cribriform structures. Differential diagnosis includes different forms of metaplasias, papillary proliferations, and hyperplastic polyps. Epithelial metaplasia may be present in various benign endometrial lesions as well as in endometrioid adenocarcinoma. AEH/EIN may also occur in endometrial polyps. Progestin therapy of AEH/EIN has low level of evidence but frequently leads to complete regression. Serous intraepithelial carcinoma (SEIC) is characterized by high-grade cellular atypia and polymorphism, detachment of cells, a mutant immunoreactive pattern for the P53 and an increased Ki67 labeling index. Although designated as precursor of serous carcinoma of the endometrium, biologically it is considered a non-invasive serous carcinoma since it may already be associated with massive extrauterine spread.

Canadian Consensus-based and Evidence-based Guidelines for Benign Endometrial Pathology Reporting in Biopsy Material

Standardized terminology has proven benefits in cancer reporting; in contrast, reporting of benign diagnoses in endometrial biopsy currently lacks such standardization. Unification and update on the lexicon can provide the structure and consistency needed for optimal patient care and quality assurance purposes. The Special Interest Group in Gynecologic Pathology of the Canadian Association of Pathologists-Association Canadienne des Pathologistes (CAP-ACP) embarked in an initiative to address the current need for consensus terminology in benign endometrial biopsy pathology reporting. Nine members of the Special Interest Group developed a guideline for structured diagnosis of benign endometrial pathology through critical appraisal of the available peer-reviewed literature and joint discussions. The first version of the document was circulated for feedback to a group of professionals in akin fields, the CAP-ACP Executive Committee and the CAP-ACP general membership. The final 1-page document included 17 diagnostic terms comprising the most common benign endometrial entities, as well as explanatory notes for pathologists. The proposed terminology was implemented in the practice of 5 pathologists from the group, who applied the guideline to all benign endometrial biopsies over a 2-wk period. A total of 212 benign endometrial biopsies were evaluated in this implementation step; the recommended terminology adequately covered the diagnosis in 203 cases (95.8%). A list of terminology for benign endometrial biopsy reporting, based on expert consensus and critical appraisal of the available literature, is presented. On the basis of our results of implementation at multiple centers, the proposed guideline can successfully cover the large majority of diagnostic scenarios. The document has the potential to positively impact patient care, promote quality assurance, and facilitate research initiatives aimed at improving histopathologic assessment of benign endometrium.

Uterine fibroid management: Today and tomorrow

Current treatments for fibroids are mainly surgical and expensive, so alternatives need to be found. It is, therefore, vital to develop and evaluate alternatives to surgical procedures, especially when fertility preservation is the goal. Selective progesterone receptor modulators (SPRMs) are synthetic compounds that have either an agonistic or antagonistic impact on target tissues determined by their binding to progesterone receptors. Their mixed activity depends on recruitment of cofactors that regulate transcription along so-called genomic pathways, as well as nongenomic interactions with other signaling pathways. There is no doubt that surgery remains indicated in some instances, but we must now establish whether use of SPRMs (notably ulipristal acetate) allows less invasive surgery or even complete avoidance of surgery. Long-term intermittent administration of ulipristal acetate will undoubtedly change our approach to the management of uterine fibroids according to the International Federation of Gynecology and Obstetrics classification, which provides a comprehensive basis for different treatment options. When considering less invasive techniques (uterus-sparing options like myomectomy), the choice is guided by the size, number and location of fibroids, as well as the personal experience of the gynecologist and available equipment. There is now a growing body of evidence pointing to the crucial role of progesterone pathways in the pathophysiology of uterine fibroids. SPRMs should, therefore, be considered an alternative to surgical therapy, or at least an adjunct to surgery, as illustrated in the algorithms. © 2019 Japan Society of Obstetrics and Gynecology.

Ulipristal Acetate for Treatment of Symptomatic Uterine Leiomyomas: A Randomized Controlled Trial

OBJECTIVE

To assess efficacy and tolerability of ulipristal acetate, a selective progesterone receptor modulator, for treatment of symptomatic uterine leiomyomas.

METHODS

This phase 3, double-blind, placebo-controlled study enrolled premenopausal women (aged 18-50 years) with abnormal uterine bleeding, one or more discrete leiomyomas, and uterine size 20 weeks of gestation or less. Patients were randomized 1:1:1 to 5 mg ulipristal, 10 mg ulipristal, or placebo once daily for 12 weeks followed by 12-week drug-free follow-up. Coprimary endpoints were rate of and time to amenorrhea, defined as no bleeding for the last 35 consecutive days of treatment. Secondary endpoints included rates of amenorrhea from day 11 and change from baseline to endpoint in the Revised Activities subscale of the Uterine Fibroid Symptom and Quality of Life questionnaire, which includes questions pertaining to physical and social activities. Safety assessments included adverse event monitoring and endometrial biopsies. A sample size of 150 was planned to compare separately each dose of ulipristal with placebo.

RESULTS

From March 2014 to March 2016, 157 patients were randomized. Demographics were similar across treatment groups. Amenorrhea was achieved by 25 of 53 (47.2% [97.5% CI 31.6-63.2]) and 28 of 48 (58.3% [97.5% CI 41.2-74.1]) patients treated with 5 mg and 10 mg ulipristal, respectively, compared with 1 of 56 (1.8% [97.5% CI 0.0-10.9]) placebo-treated patients (both P<.001). Time to amenorrhea was shorter for both ulipristal doses compared with placebo (P<.001), and both doses of ulipristal resulted in improved quality of life compared with placebo (P<.001). Common adverse events (5% or greater in either ulipristal group during treatment) were hypertension, elevated blood creatinine phosphokinase, and hot flushes. Serious adverse events occurred in four patients, but none was considered related to treatment. Endometrial biopsies were benign.

CONCLUSION

Ulipristal at 5 mg and 10 mg were well tolerated and superior to placebo in rate of and time to amenorrhea in women with symptomatic uterine leiomyomas.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov number, NCT02147197.

Ulipristal acetate therapy increases ultrasound features of adenomyosis: a good treatment given in an erroneous diagnosis of uterine fibroids

Ulipristal acetate (UPA) is used for medical treatment of uterine fibroids. The aim of this study was to describe the effects on painful symptoms and the sonographic uterine modifications in patients with adenomyosis erroneously treated with UPA. This is an observational study on six women affected by adenomyosis and treated with three months of UPA (5 mg/24h). The baseline ultrasonography (US) was not performed at out center nor was the diagnosis of fibroids. The patients came to our attention after the treatment with UPA, prescribed by an external physician. During our post-treatment scan we found aspects of adenomyosis, while no fibroids were detected. Symptoms, myometrial and endometrial ultrasound features were evaluated. All patients reported an increase in pelvic pain. At US evaluation intramyometrial cystic areas were found in all six cases (100%). All patients showed an enhancement of adenomyosis features.The intra-myometrial cysts appeared enlarged and the vascularization enhanced when compared to the images of the pretreatment scan. In patients with adenomyosis treated with UPA due to an erroneous diagnosis of uterine fibroids we observed a worsening of the US features of adenomyosis and of the painful symptoms.

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

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

Absence of predictable long-term molecular effect of ulipristal acetate (UPA) on the endometrium

RESEARCH QUESTION

What are the effects of ulipristal acetate (UPA) on the expression of endometrial proliferation and maturation markers?

DESIGN

A total of 45 endometrium-containing blocks of hysterectomy samples from non-menopausal women with a diagnosis of moderate to severe symptoms of uterine fibroids: 14 women operated on at the end of a 3-month course of UPA; four women who had discontinued UPA treatment 1-12 months before surgery; 27 control unexposed samples (14 in the proliferative and 13 in the secretory phase). Immunohistochemical staining of Ki67, vascular endothelial growth factor-receptor 2 (VEGFR2), oestradiol receptor, progesterone receptor, interleukin-15 (IL-15), indoleamin-2,3-dioxygenase (IDO) and C-C motif chemokine ligand-2 (CCL2) markers were analysed in both endometrial compartments and layers.

RESULTS

Under UPA, oestradiol receptor and progesterone receptor expression is similar to the proliferative phase in both layers, although with a decrease in cell proliferation. IL-15, IDO and CCL2 expressions are similar to the proliferative phase, suggesting a progesterone-antagonist effect of UPA. VEGFR2 staining suggests a trend to a mixed agonist-antagonist effect. No significant difference is observed in the post-UPA proliferative phase group compared with the control group in both layers of the endometrium.

CONCLUSION

The effect of 3-month UPA treatment is mostly progesterone receptor antagonist-like. After treatment is discontinued, there are no signs of any long-term effects of this molecule on endometrial proliferation and maturation. Therefore, UPA may be administered to women willing to conceive in the short term without consequences for further implantation.

Sonographic and hysteroscopic endometrial examination in women treated with ulipristal acetate: Exploratory findings at a tertiary referral center

OBJECTIVE

Ulipristal acetate (UPA) is a progesterone receptor modulator (PRM) agent that has shown benefits in women with symptomatic uterine fibroids. However, its effects on the endometrium are complex and not fully understood. We describe exploratory findings on macroscopic observation of the endometrium at transvaginal sonography (TVS) and hysteroscopy. The aim of the study is to characterize endometrial patterns commonly observed after UPA treatment.

STUDY DESIGN

We performed a prospective longitudinal study at a tertiary referral center with 100 women with symptomatic uterine fibroids who received a 12-week treatment with UPA (5 mg/day). Patients underwent TVS before and after the treatment, and also a hysteroscopy examination was performed. Main outcome was to compare sonographic and hysteroscopic findings to histology after UPA treatment.

RESULTS

Twenty one out of 100 (21%) women showed PAEC confirmed by histology after UPA treatment. Ultrasound findings were normal in most women after UPA treatment, but 18/100 (18%) showed an endometrial pattern suggestive of PRM effects (non-uniform, homogeneous endometrium with regular cystic areas). Endometrial thickness ≥16 mm was detected in 6/100 patients (6%), and all of them also presented sonographic PRM pattern. No patient presented malignancy according to histology in this subgroup, and 100% of them had PAEC pattern at histology. Among total patient population showing PAEC at histology, only 33% of these were identified by hysteroscopy, while 57% were identified by TVS with the PRM suggestive pattern. Of note, visibility of endometrium was improved at TVS after UPA.

CONCLUSION

Identification of increased endometrial thickness together with the categorized endometrial PRM pattern at TVS may be correlated to benign lesions and may not be a cause of concern. This study is exploratory and further research is necessary to support these conclusions. Nevertheless, TVS seems to be feasible to plan adequate follow-up protocols by avoiding unnecessary interventional procedures such as hysteroscopy.

Pericoital contraception

PURPOSE OF REVIEW

To evaluate the literature on repeat use of emergency contraception and pericoital approaches to contraception.

RECENT FINDINGS

Women are very interested in an oral, on-demand contraceptive option, were one available. Ulipristal acetate and a combination of levonorgestrel (LNG) and meloxicam (a cyclo-oxygenase-2 inhibitor) both appear to be more effective at disrupting ovulation than LNG alone. Recent advisories from the United Kingdom regarding daily dosing of ulipristal for fibroids emphasize the need for more safety data.

SUMMARY

Repeat pericoital dosing of 1.5-mg LNG is approximately as effective as other on-demand contraceptive methods and is overall very safe. The most common side effect is irregular bleeding. Repeat on-demand ulipristal acetate or meloxicam/other cyclo-oxygenase-2 inhibitors have potential as an on-demand option either alone or in combination but have not been evaluated for contraceptive efficacy in a large-scale study. Given the high unmet need for contraception, even among women with access to available options, there is a distinct need for options that address needs of women who are interested in an on-demand option. On-demand oral contraception has the potential to expand the convenience of contraceptive options and overall contraceptive use.

Failure of ulipristal acetate treatment as an indication for uterine malignancy: Two case reports

INTRODUCTION

To study the clinical, pathological and therapeutic implications of ulipristal acetate (UPA) treatment failure in patients affected by uterine smooth muscle tumors.

CASE PRESENTATION

Two patients affected by uterine leiomyosarcoma were preoperatively diagnosed as uterine leiomyomas and, thus, treated conservatively with UPA and morcellation. Both patients experienced a worsening of symptoms (persistent bleeding) after 3 month of treatment with UPA. Therefore a myomectomy with morcellation of tumor specimens was performed. Pathological examination of morcellated specimens revealed the unsuspected diagnosis of leiomyosarcoma based on the presence of severe nuclear atypia, tumor necrosis and increased mitotic activity. Unfortunately after 6 month of follow-up, 1 patient died for multiple peritoneal recurrences and lung metastases. The other patient is still alive after 3 month of follow-up and shows no local recurrences or metastases.

CONCLUSION

Our reported cases emphasize that the poor or absent response to UPA treatment in addition to the instrumental evidence of a single mass may be indicative of the presence of an unsuspected leiomyosarcoma clinically and radiologically misdiagnosed as leiomyoma. The awareness of this possibility would avoid a delay in the diagnosis as well as unuseful and potentially dangerous treatments such as morcellation.

Selective progesterone receptor modulators for fertility preservation in women with symptomatic uterine fibroids

Uterine fibroids (UFs, AKA leiomyoma) are the most important benign neoplastic threat to women's health, with costs up to hundreds of billions of health care dollars worldwide. Uterine fibroids caused morbidities exert a tremendous health toll, impacting the quality of life of women of all ethnicities, especially women of color. Clinical presentations include heavy vaginal bleeding, pelvic pain, bulk symptoms, subfertility, and obstetric complications. Current management strategies heavily lean toward surgical procedures; nonetheless, the choice of treatment is generally subject to patient's age and her desire to preserve future fertility. Women with UF who desire to maintain future fertility potential face a dilemma because of the limited treatment choices that are currently available to help them achieve that goal. Recently, ulipristal acetate the first of the promising family of oral selective progesterone receptor modulators has been approved for UF treatment in Europe, Canada, and several other countries and is under review for possible approval in the USA. In this review article, we discuss recent advances in the management options against UF with a bend toward oral effective long-term treatment alternatives who are particularly suited for those seeking to preserve their future fertility potential. We also explore the transformative concept of primary and secondary UF prevention using these new anti-UF agents. We envision a remarkable shift in the management of UF in future years from surgical/invasive treatment to orally administrated options; clearly, this potential shift will require additional intense clinical research.

Molecular characterization of PRM-associated endometrial changes, PAEC, following mifepristone treatment

OBJECTIVE

The progesterone receptor modulator (PRM) mifepristone holds the potential to be developed for regular contraception. However, long-term treatment can cause thickening of the endometrium and PRM-associated endometrial changes (PAEC). The objective of this study was to explore the molecular expression of endometrium displaying PAEC after mifepristone treatment in order to understand the future implications of PAEC and safety of long-term use.

STUDY DESIGN

Endometrial biopsies were obtained from premenopausal women following 3 months of continuous mifepristone treatment. The biopsies were evaluated regarding occurrence of PAEC and followed up by a comparative analysis of gene expression in PAEC endometrium (n=7) with endometrium not displaying PAEC (n=4). Methods used included microarray analysis, Ingenuity Pathway Analysis (IPA) and real-time polymerase chain reaction.

RESULTS

Three genes relevant within endometrial function were up-regulated with PAEC: THY1 (p=.02), ADAM12 (p=.04) and TN-C (p=.04). The proliferation marker MKi67 was not altered (p=.31). None of the differentially regulated genes were involved in the endometrial cancer-signaling pathway (based on IPA knowledge database).

CONCLUSION

The genes altered in endometrium displaying PAEC after 3 months of mifepristone exposure are mainly involved in the structural architecture of tissue.

IMPLICATIONS

PAEC features may be explained by the altered genes and their networks affecting tissue architecture although not involved in endometrial cancer signaling pathways, and thus, treatment with mifepristone at this dosage does not show any adverse effect at endometrial level.