Uterine Fibroids: Burden and Unmet Medical Need

A phenome-wide association study of uterine fibroids reveals a marked burden of comorbidities

BACKGROUND

The burden of comorbidities in those with uterine fibroids compared to those without fibroids is understudied. We performed a phenome-wide association study to systematically assess the association between fibroids and other conditions.

METHODS

Vanderbilt University Medical Center's Synthetic Derivative and Geisinger Health System Database, two electronic health record databases, were used for discovery and validation. Non-Hispanic Black and White females were included. Fibroid cases were identified through a previously validated algorithm. Race-stratified and multi-population phenome-wide association analyses, adjusting for age and body mass index, were performed before statistically significant, validated results were meta-analyzed.

RESULTS

There were 52,295 and 26,918 (9022 and 10,232 fibroid cases) females included in discovery and validation analyses. In multi-population meta-analysis, 389 conditions were associated with fibroid risk, with evidence of enrichment of circulatory, dermatologic, genitourinary, musculoskeletal, and sense organ conditions. The strongest associations within and across racial groups included conditions previously associated with fibroids. Numerous novel diagnoses, including cancers in female genital organs, were tied to fibroid status.

CONCLUSIONS

Overall, individuals with fibroids have a marked increase in comorbidities compared to those without fibroids. This approach to evaluate the health context of fibroids highlights the potential to understand fibroid etiology through studying the common biology of comorbid diagnoses and through disease networks.

Magnetic resonance guided high intensity focused ultrasound (MR-HIFU) effectively reduces fibroid-related symptoms and improves quality of life-A prospective single-centre 12-month follow-up study

INTRODUCTION

Uterine fibroids are the most common benign tumors among women, and it is estimated that approximately 70% of women have one or multiple fibroids by the age of menopause. About 30% of these women suffer from symptoms related to the fibroids. Magnetic resonance-guided high-intensity focused ultrasound (MR-HIFU) is a novel, non-invasive treatment method for symptomatic uterine fibroids.

MATERIAL AND METHODS

In this prospective, single-centre follow-up study, 175 women with symptomatic uterine fibroids were treated with MR-HIFU. The effect of MR-HIFU on fibroid symptoms and quality of life was evaluated using a uterine fibroid-specific quality of life questionnaire (UFS-QoL). The main outcome measure was the symptom severity score and quality of life (QoL) before the MR-HIFU and 3 and 12 months after the treatment. This study was registered at clinicaltrials.gov (NCT03937401).

RESULTS

The median symptom severity score decreased from 56 (IQR 44-69) at baseline to 28 (IQR 16-44) at 3 months (p < 0.01) and 25 (IQR 16-38) at 12 months (p < 0.01) after treatment. The QoL score increased from a median of 48 (IQR 33-66) at baseline to 73 (IQR 59-93) at 3 months (p < 0.01) and 78 (IQR 66-90) at 12 months after treatment (p < 0.01). The reintervention rate during the 12-month follow-up was 2%.

CONCLUSIONS

MR-HIFU significantly reduces the severity of fibroid-related symptoms in selected patients as early as 3 months after MR-HIFU. The effect persists at 12 months. There is also a significant improvement in the quality of life 3 months after treatment, which further increases at 12 months.

Perioperative enhanced recovery after surgery (ERAS) for non-malignant gynaecological conditions

OBJECTIVES

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the effects of perioperative ERAS protocols compared to traditional perioperative care for women undergoing surgery due to non-malignant gynaecological conditions and to review the availability and key findings of health economic evaluations of ERAS, summarising their principal conclusions.

Preoperative medical therapy before surgery for uterine fibroids

BACKGROUND

Uterine fibroids occur in up to 40% of women over 35 years of age. Up to 50% of uterine fibroids cause symptoms that warrant treatment: anaemia caused by heavy menstrual bleeding, pelvic pain, dysmenorrhoea, infertility and poor quality of life. Surgery is the first choice of treatment, but medical therapies have been used prior to surgery to improve outcomes. Gonadotropin-hormone-releasing analogues (GnRHa) induce a low-oestrogen state that shrinks fibroids, but they have unacceptable side effects if used long-term. Other potential hormonal treatments include progestins and selective progesterone-receptor modulators (SPRMs). This updates a Cochrane review published in 2017.

OBJECTIVES

To assess the benefits and risks of medical treatments prior to surgery for uterine fibroids.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility Group Specialized Register, CENTRAL, MEDLINE, Embase, PsycINFO and CINAHL on 8 August 2024. We also searched trials registers (ClinicalTrials.gov; WHO ICTRP), theses and dissertations, and grey literature, as well as handsearching reference lists of retrieved articles and contacting pharmaceutical companies.

SELECTION CRITERIA

We included randomised controlled trials of premenopausal women receiving medical therapy before myomectomy, hysterectomy or hysteroscopic resection for uterine fibroids versus placebo, no pretreatment or another medical therapy.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. We assessed the certainty of the evidence using GRADE.

MAIN RESULTS

We included 41 RCTs, which involved 3982 women. Thirty-six studies evaluated GnRHa: the comparators were no pretreatment (19 studies), placebo (9 studies), or other medical pretreatments (progestin, SPRMs, selective oestrogen receptor modulators (SERMs), dopamine agonists, oestrogen receptor antagonists) (8 studies). Five studies evaluated SPRMs versus placebo. Most results provided low-certainty evidence due to poor reporting of randomisation procedures, lack of blinding, imprecision and inconsistency. Some outcomes were not measured or did not have usable data. The use of ulipristal acetate (an SPRM) is suspended at this time (March 2025) because of an association with cases of liver failure. GnRHa versus placebo or no pretreatment before surgery for uterine fibroids GnRHa pretreatment may reduce uterine volume (mean difference (MD) -175.34 mL, 95% confidence interval (CI) -219.04 to -131.65; 13 studies, 858 participants; I² = 67%; low-certainty evidence) and fibroid volume (MD range 5.7 mL to 155.4 mL; 5 studies to heterogeneous to pool, 427 participants; low-certainty evidence), and probably increases preoperative haemoglobin (MD 0.88 g/dL, 95% CI 0.68 to 1.08; 10 studies, 834 participants; I² = 0%; moderate-certainty evidence). However, there is probably a greater likelihood of adverse events with GnRHa (odds ratio (OR) 2.78, 95% CI 1.77 to 4.36; 5 studies, 755 participants; I² = 28%; moderate-certainty evidence). No usable data were available for preoperative bleeding. Hysterectomy Duration of hysterectomy may be reduced amongst women who receive GnRHa treatment (-10.11 minutes, 95% CI -16.96 to -3.25; 6 studies, 617 participants; I² = 57%; low-certainty evidence). Results are uncertain for intraoperative blood loss (4 heterogeneous studies, 258 participants; MD range 25 mL to 148 mL, in favour of GnRHa; very low-certainty evidence). There are probably fewer blood transfusions with GnRHa (OR 0.54, 95% CI 0.29 to 1.01; 6 studies, 601 participants; I² = 0%; moderate-certainty evidence) and less postoperative morbidity (OR 0.54, 95% CI 0.32 to 0.91; 7 studies, 772 participants; I² = 28%; moderate-certainty evidence). Myomectomy There is uncertainty about the effects of GnRHa pretreatment on surgery duration (7 heterogeneous studies, 443 participants) (very low-certainty evidence) and intraoperative blood loss during myomectomy (11 studies too heterogenous to pool, 549 participants; very low-certainty evidence). GnRHa may make little to no difference to blood transfusions (OR 0.85, 95% CI 0.26 to 2.75; 4 studies, 121 participants; I² = 0%; low-certainty evidence) or postoperative morbidity (OR 1.07, 95% CI 0.43 to 2.64; I² = 0%; 5 studies, 190 participants; low-certainty evidence). Hysteroscopic resection GnRHa treatment before hysteroscopic resection of uterine myomas may result in little to no difference in surgery duration (2 studies,123 participants; low-certainty evidence). One study reported no cases of postoperative morbidity in either group (84 participants; low-certainty evidence). GnRHa versus other medical therapies before surgery - preoperative outcomes GnRHa may be associated with a greater reduction in uterine volume than other medical therapies (-47% compared to -20% and -22% with 5 mg and 10 mg ulipristal acetate, respectively; low-certainty evidence). There may be little to no difference in bleeding reduction (ulipristal acetate 5 mg: OR 0.71, 95% CI 0.30 to 1.68; 1 study, 199 participants; low-certainty evidence), and there is probably little to no difference in preoperative haemoglobin (MD -0.02, 95% CI -0.41 to 0.37; 242 participants; moderate-certainty evidence). We are uncertain whether there is any difference in fibroid volume between GnRHa and cabergoline (MD 12.71 mL, 95% CI -5.92 to 31.34; 2 studies, 110 participants; I² = 0%; low-certainty evidence). Adverse events such as hot flushes may be more likely with GnRHa (OR 2.83, 95% CI 1.68 to 4.77; 6 studies, 507 participants; I² = 59%; low-certainty evidence). SPRMs versus placebo before surgery - preoperative outcomes SPRMs (mifepristone, CDB-2914, ulipristal acetate and asoprisnil) before surgery probably reduce uterine volume (2 heterogenous studies, 275 participants; moderate-certainty evidence) and may reduce fibroid volume (5 heterogeneous studies, 451 participants; low-certainty evidence). SPRMs probably increase preoperative haemoglobin (MD 0.93 g/dL, 95% CI 0.52 to 1.34; 2 studies, 173 participants; I² = 0%; moderate-certainty evidence), and they may reduce bleeding before surgery (ulipristal acetate 5 mg: OR 41.41, 95% CI 15.26 to 112.38; 1 study, 143 participants; asoprisnil: MD -166.9 mL; 95% CI -277.60 to -56.20; 1 study, 22 participants; low-certainty evidence). Results were very imprecise for adverse events (low-certainty evidence).

AUTHORS' CONCLUSIONS

Pretreatment with gonadotropin-hormone-releasing analogues may reduce uterine and fibroid volume and probably increases preoperative haemoglobin levels, but probably also increases the number of adverse events. Blood transfusions and operation time during hysterectomy may be reduced, with fewer women experiencing postoperative morbidity. SPRMs, such as ulipristal acetate, seem to offer similar advantages: they probably reduce uterine volume and increase haemoglobin level before surgery, and may reduce fibroid volume and fibroid-related bleeding. However, replication of these studies is advised as the certainty of the evidence is moderate to low.

Patterns and Outcomes in the Management of Uterine Fibroids: A Hospital-Based Retrospective Study

BACKGROUND

Uterine fibroids are common benign tumors that can cause significant symptoms such as heavy bleeding, pelvic pain, and reproductive issues.

OBJECTIVE

The aim of this study was to evaluate the clinical patterns, treatment modalities, and patient outcomes associated with uterine fibroids.

METHODS

This retrospective study was conducted at DHQ Hospital Okara, Okara, Pakistan, from June 2024 to December 2024. Data were collected from the medical records of 355 patients diagnosed with symptomatic uterine fibroids. Women who had confirmed uterine fibroids diagnosed through ultrasound were included in the study. Women who received treatment for uterine fibroids and patients with incomplete medical records were excluded from the study. Data were collected from medical records. The demographic information included age, marital status, parity, and reproductive history.

RESULTS

The majority of patients were aged between 35 and 50 years (69.9%), with a mean age of 41.2 ± 7.83 years. Most patients were premenopausal (231, 65%) and multiparous (266, 74.9%). The most common symptoms were menorrhagia (248, 69.9%) and pelvic pain (195, 54.9%). The most frequent treatment modality was hormonal therapy (142, 40%), followed by surgical management (89, 25.1%) and minimally invasive procedures (53, 14.9%). Symptom improvement was highest in the minimally invasive group (92, 80%), while surgical treatments showed high patient satisfaction (64, 90%).

CONCLUSIONS

It is concluded that the treatment of uterine fibroids is largely influenced by factors such as age, fibroid size, and the severity of symptoms.

Activation of FGFR genes by genetic and epigenetic alterations in uterine leiomyomas

BACKGROUND

Fibroblast growth factor 1-4 (FGFR1-4) are well-known oncogenic drivers in many cancer types. Here, we studied the role of FGFRs in uterine leiomyoma (UL) that is a benign neoplasm arising from the myometrium and the most common tumour in women. Although ULs can be classified to molecular subtypes based on genetic drivers, potential secondary drivers are not well characterised.

METHODS

We performed mutation analysis of RNA-sequencing data of ULs, followed by screening of FGFR alterations in our Finnish (n = 2677) and Swedish (n = 372) UL collections, utilising Sanger-, next-generation and Nanopore sequencing and SNP array data. The role of FGFR genes in UL predisposition was examined by GWAS.

RESULTS

We identified FGFR activation in a subset of ULs on both genetic and epigenetic levels. In addition to single-nucleotide mutations in FGFR1/2, we detected an FGFR2-ERC1 fusion gene, FGFR1 gains and hypomethylation of regulatory regions of FGFR2/3. FGFR alterations were enriched in molecularly similar HMGA2, HMGA1 and PLAG1 UL subtypes. We also unveil a UL predisposing variant upstream of FGFR4 associated with increased expression in both normal myometrium and ULs.

CONCLUSIONS

Our results establish the role of FGFR signalling in the genesis of UL.

Association between blood heavy metals exposure with uterine fibroids among American women: a cross-sectional analysis from NHANES data

BACKGROUND

Excessive exposure to heavy metals has been linked to various health problems, including organ damage, neurological disorders, and reproductive and developmental abnormalities. However, the relationship between heavy metals exposure and uterine fibroids remains uncertain. To explore this association, we conducted a cross-sectional study among American women.

METHODS

We utilized data from three cycles of the National Health and Nutrition Examination Survey (NHANES, 1999-2006) to evaluate the association between uterine fibroids and blood heavy metal levels, including lead (Pb), cadmium (Cd), and mercury (Hg). Weighted logistic regression, restricted cubic spline (RCS), Bayesian kernel machine regression (BKMR), and subgroup analyse were used to examine the potential relationships between blood heavy metals and uterine fibroids.

RESULTS

Of the 4502 American women studied, 542 (12.04%) had uterine fibroids. Elevated levels of all heavy metals were significantly more common in women with uterine fibroids (P < 0.001). Blood Hg levels were notably associated with uterine fibroid prevalence in the adjusted model (OR = 1.41, 95% CI: 1.06-1.89, p = 0.03). Similar patterns were partly observed for blood Pb and Cd. Age and marital status were significant interaction factors concerning Hg exposure (P for interaction < 0.05). A dose-response relationship with an inflection point at 7µmol/L was identified for Hg, and BKMR models indicated a positive association between mixed heavy metal exposure and uterine fibroid risk.

CONCLUSIONS

Exposure to blood heavy metals, particularly Hg, is significantly associated with an elevated risk of uterine fibroids. Further prospective studies are necessary to confirm these findings.

A systematic review and meta-analysis comparing the use of elagolix therapy alone or in combination with add-back therapy to treat women with uterine fibroid associated heavy menstrual bleeding

Background

Elagolix is an oral small molecule second-generation nonpeptide gonadotropin-releasing hormone (GnRH) antagonist drug that can quickly and reversibly inhibit female gonadotropins and ovarian sex hormones. Previous randomized controlled trials (RCTs) have evaluated the efficacy and safety of elagolix alone or in combination with add-back therapy to treat women with heavy menstrual bleeding (HMB) caused by uterine fibroids. Hence, this study sought to evaluate the safety and efficacy of elagolix alone or in combination with add-back therapy for the treatment of uterine fibroids with HMB.

Methods

The Cochrane Library, PubMed, Embase and ClinicalTrials.gov databases were searched for randomized controlled studies on the application of elagolix alone or with add-back therapy in patients with uterine fibroids and HMB from databases establishment to June 15, 2021. The outcomes reference menstrual blood loss (MBL), amenorrhea, uterine fibroid symptom quality of life (UFS-QoL), hemoglobin level, bone mineral density loss, and adverse events (AEs). The primary endpoint is MBL. Fixed/random effects models were used to calculate the risk ratio (RR)/mean difference (MD) and 95% confidence interval (CI) for each outcome.

Results

Two studies with four trials involving 1,217 patients were included in this meta-analysis. Compared with the placebo, when elagolix was used alone or given with additional therapy, the number of participants who satisfied the MBL was greater (MBL <80 mL and MBL was reduced by more than 50% in the last month), improved hemoglobin levels (increased by more than 2 g/dL from baseline to the final treatment month) criteria as well as triggered amenorrhea. Elagolix alone or in combination with add-back therapy improved the quality of life of patients. Compared with the elagolix treatment alone or with add-back therapy, the placebo was superior in terms of less bone mineral density change and a lower incidence of AEs.

Conclusions

This study indicated that elagolix alone or in use with add-back therapy can be considered as a satisfactory treatment plan for the majority of patients who are diagnosed with uterine fibroids and HMB; however, the specific treatment plan should also consider patients' physical condition and any adverse reactions to the drug, based on existing research.

Uterine fibroids show evidence of shared genetic architecture with blood pressure traits

Uterine leiomyomata (fibroids, UFs) are common, benign tumors in females, having an estimated prevalence of up to 80%. They are fibrous masses growing within the myometrium leading to chronic symptoms like dysmenorrhea, abnormal uterine bleeding, anemia, severe pelvic pain, and infertility. Hypertension (HTN) is a common risk factor for UFs, though less prevalent in premenopausal individuals. While observational studies have indicated strong associations between UFs and HTN, the biological mechanisms linking the two conditions remain unclear. Understanding the relationship between HTN and UFs is crucial because UFs and HTN lead to substantial comorbidities adversely impacting female health. Identifying the common underlying biological mechanisms can improve treatment strategies for both conditions. To clarify the genetic and causal relationships between UFs and BP, we conducted a bidirectional, two-sample Mendelian randomization (MR) analysis and evaluated the genetic correlations across BP traits and UFs. We used data from a multi-ancestry genome-wide association study (GWAS) meta-analysis of UFs (44,205 cases and 356,552 controls), and data from a cross-ancestry GWAS meta-analysis of BP phenotypes (diastolic BP [DBP], systolic BP [SBP], and pulse pressure [PP], N=447,758). We evaluated genetic correlation of BP phenotypes and UFs with linkage disequilibrium score regression (LDSC). LDSC results indicated a positive genetic correlation between DBP and UFs (Rg=0.132, p<5.0x10-5), and SBP and UFs (Rg=0.063, p<2.5x10-2). MR using UFs as the exposure and BP traits as outcomes indicated a relationship where UFs increases DBP (odds ratio [OR]=1.20, p<2.7x10-3). Having BP traits as exposures and UFs as the outcome showed that DBP and SBP increase risk for UFs (OR =1.04, p<2.2x10-3; OR=1.00, p<4.0x10-2; respectively). Our results provide evidence of shared genetic architecture and pleiotropy between HTN and UFs, suggesting common biological pathways driving their etiologies. Based on these findings, DBP appears to be a stronger risk factor for UFs compared to SBP and PP.

Reproductive outcomes of high-intensity focused ultrasound ablation and myomectomy for uterine fibroids: a systematic review and meta-analysis

RESEARCH QUESTION

Does high-intensity focused ultrasound (HIFU) ablation have comparable reproductive outcomes to myomectomy for patients with uterine fibroids?

DESIGN

A systematic review and a meta-analysis of data extracted from published studies up to March 2024.

RESULTS

Through a more structured analysis, HIFU treatment yielded a pooled pregnancy rate of 23.3% (95% CI 11.5 to 37.6%) and a pooled live birth rate (LBR) of 17.3% (95% CI 7.8 to 29.3%), significantly lower than those after myomectomy, which had a pooled pregnancy rate of 56.9% (95% CI 45.6 to 67.9%) and a pooled LBR of 44.1% (95% CI 34.9 to 53.4%) (P = 0.0001 and P = 0.0003, respectively). After controlling for patient age, ultrasound-guided HIFU studies reported significantly lower pregnancy rate and LBR compared with myomectomy. Moreover, studies enrolling younger patients and explicitly recruiting those desiring to conceive reported better reproductive outcomes.

CONCLUSIONS

Patients with uterine fibroids undergoing HIFU treatment and desiring to preserve their uteri resulted in poorer reproductive outcomes compared with myomectomy. Although uterine fibroids are now the number one disease that receives HIFU treatment worldwide, the overall quality in design and execution of HIFU studies on reproductive outcomes for women with uterine fibroids leaves much room for improvement. Above all, comparative trials against the standard of care are badly needed.

Homeopathic Management of Bulky Uterus with Uterine Fibroid in a 40-year-old Patient: An Evidence-Based Case Report

BACKGROUND

 Uterine fibroids are benign gynecological tumours that arise in the uterine smooth muscle tissue and are characterized by the production of excessive quantities of extracellular matrix. Various therapeutic options, from medical management to surgical intervention, exist for uterine fibroids, for which homeopathy has emerged as a promising therapeutic option in patient-centered care.

CASE HISTORY

 A 40-year-old woman presented with complaints of heavy menstrual bleeding, with pain in the pelvic region and back. She was diagnosed as a case of bulky uterus with uterine fibroid. The patient opted for homeopathic management and was prescribed Thuja occidentalis based on individualization, miasmatic analysis and repertorial totality.

RESULTS

 After treatment, there was regression in size of the fibroid within 5 months, with complete resolution and restoration of the uterus to normal size within 9 months. Changes were validated through ultrasonography, which added objective evidence to the positive outcome. The Modified Naranjo Criteria for Homeopathy (MONARCH) inventory total score was +9, which indicated causal attribution of clinical outcome to the homeopathic intervention.

CONCLUSION

 This case study has illustrated the clinical benefits of homeopathy in the management of a patient with uterine fibroids, reaffirming the need for further research to explore its value as a therapeutic option for individuals seeking alternative or complementary approaches for appropriate medical conditions.

Modifiable prognostic factors in uterine fibroid development: a systematic review of literature

BACKGROUND

Many risk factors in uterine fibroid development have been identified, but women and their physicians are less aware of the influence of lifestyle on uterine fibroid development. The objective of this systematic review is to investigate and summarize modifiable prognostic factors associated with uterine fibroid development.

METHODS

Pubmed and Embase were searched for relevant articles according to PRISMA guidelines. References from included articles were screened and when relevant also included. Human in vivo studies on modifiable factors in fibroid development were included. Studies on non-modifiable factors and treatment, in vitro studies and animal studies were excluded. 607 articles were screened and 33 articles were included. Two independent investigators collected data from the report.

RESULTS

The strongest risk factor for fibroid development was a high BMI, while the strongest protective factors were a high fruit and vegetable intake and high vitamin D intake.

CONCLUSION

More high-quality studies are necessary to better understand the impact of the abovementioned factors as well as the role they play in the growth of already existing fibroids.

Global and regional trends in the incidence and prevalence of uterine fibroids and attributable risk factors at the national level from 2010 to 2019: A worldwide database study

BACKGROUND

Uterine fibroids (UFs), the most common tumors in women worldwide, may reduce quality of life and daily activities and even lead to adverse fertility and general health events in patients, causing significant societal health and financial burdens. The objective of this study was to evaluate the global burden through epidemiological trends and examine the potential risk factors for UFs at the national level.

METHODS

Data on the incidence, prevalence, disability-adjusted life years (DALYs), age-standardized incidence rates (ASIRs), age-standardized prevalence rates (ASPRs), and age-standardized DALY rates for UFs were collected, and the associations with the Human Development Index (HDI) and fertility were evaluated. The age trends in the average annual percent change (AAPC) of the incidence and prevalence rates of UFs were evaluated by joinpoint regression analysis. The associations between lifestyle, metabolic, and socioeconomic factors and the ASIRs of UFs were examined using multivariable linear regression analysis.

RESULTS

The worldwide incidence and prevalence of UFs have been increasing in the past decade, with AAPCs of 0.27% in the incidence rate and 0.078% in the prevalence rate. During 2010-2019, significant increasing trends in UF ASIR were observed in 52 of 88 countries. The age-specific incidence and prevalence of UFs in most age groups showed increasing trends except for 45-54-year-old women which showed no significant trend. Ecological analysis demonstrated no relationship between the incidence of UFs and the HDI but an inverse association with fertility. The incidence of UFs was positively correlated with alcohol intake, hypertension, overweight, and obesity and negatively correlated with smoking.

CONCLUSION

With the increasing incidence and prevalence worldwide, effective targeted prevention and control of relevant risk factors at the national level should be encouraged to reduce the disease burden of UFs.

First identification of microplastics in human uterine fibroids and myometrium

Microplastics (MPs) pollution has received widespread attention in recent years as the use of plastics continues to increase. However, currently no studies have reported the finding of MPs in human uterine fibroids (UFs) and myometrium tissues. In this study, UFs tissues (n = 48) and myometrium tissues (n = 40) from 48 patients and myometrium tissues (n = 8) from healthy population were collected. Following digestion of the samples by 10% KOH and 30% H2O2, MPs were analyzed qualitatively and quantitatively using Raman spectroscopy. The 16 UFs and myometrium tissue samples contained an average of 1.5 ± 1.17 MP particles per gram of tissue. Notably, the abundance of MPs in the UFs tissues (2.13 ± 1.17 particles per gram) was higher than in the myometrium tissues (0.88 ± 0.78 particles per gram). In the same cohort of individuals with UFs, the quantities of MPs detected in the affected UFs tissue (2.63 ± 1.77 particles per gram) exceeded those detected in healthy tissue (1.08 ± 0.93 particles per gram), particularly in elderly patients. A correlation was observed between elevated MP levels and frequent consumption of takeout meals and bottled water among patients, indicating that MP ingestion through food sources might have contributed to the increased abundance and variety of MPs within UFs. Furthermore, UFs increased in size with higher concentrations of MPs, which may have been related to elevated levels of MPs-induced hormones. This study provides new insights into the assessment of the relationship between exposure to MPs and human disease risk.

Mifepristone's Efficacy for Symptomatic Relief and Size Reduction in Uterine Fibroids: A 2023 Prospective Observational Study at Rabia Balkhi Hospital, Afghanistan

Background Uterine fibroids (leiomyomas) are common benign tumors, affecting 70-80% of women by age 50, and can cause symptoms such as heavy bleeding, pelvic pain, and pressure, significantly impacting the quality of life. In severe cases, fibroids may lead to infertility or miscarriage, making their management a key healthcare challenge. Traditional treatments, including hysterectomy, may not be suitable for women wishing to preserve fertility or avoid surgery. Mifepristone, an antiprogestogen, has shown promise as a non-invasive alternative by blocking progesterone, which promotes fibroid growth. It has been proven to reduce fibroid size and alleviate symptoms, offering a valuable option for women seeking alternatives to invasive procedures. Objective This study aimed to evaluate the efficacy of mifepristone in providing symptomatic relief and reducing fibroid size in patients with uterine fibroids at Rabia Balkhi Hospital, Kabul, Afghanistan, in 2023. Methodology A descriptive, prospective study was conducted from January to June 2023, enrolling 20 women with symptomatic uterine fibroids. The inclusion criteria were women aged 30-55 years with clinically diagnosed fibroids causing symptoms such as heavy bleeding or pelvic pain. Exclusion criteria included pregnancy, active infections, or other uterine pathologies. Patients were treated with 25 mg of mifepristone daily for three months. Follow-up assessments were conducted at one, two, and three months to monitor clinical outcomes, including changes in bleeding, fibroid size (measured by ultrasound), and hemoglobin levels. Results Twenty patients (6.25%) with symptomatic fibroids were treated with mifepristone. The majority of cases were in patients aged 46-55 years (50%). Treatment led to a reduction in bleeding in 78% of patients, a decrease in fibroid size in 42.6%, and a reduction in menorrhagia in 44%, evidenced by fewer daily sanitary products used. Hemoglobin levels improved in 33.5% of patients, with an average post-treatment level of 11.8 ± 1.4 g/dL. Statistical significance was set at p < 0.05, supporting mifepristone's efficacy in managing symptomatic fibroids and enhancing patient quality of life. Conclusion Our study concludes that mifepristone at 25 mg is an effective and accessible treatment for fibroids, the same as other published evidence. It offers a practical and economical alternative to surgery, reducing bleeding, inhibiting fibroid growth, and decreasing fibroid size. These findings have significant public health implications, reassuring patients and healthcare providers about the accessibility of effective fibroid treatment.

Large subserous uterine leiomyoma presenting as intraabdominal tumor: A case report

Uterine leiomyomas are common benign gynecological tumors due to the overgrowth of uterine smooth muscle. Pedunculated uterine leiomyoma occurs when the mass is in continuity with the uterus with a stalk and may grow either within the uterine cavity or outside of the uterus and may mimic ovarian neoplasms or intraabdominal tumors. Presented is a 28-year-old woman with a progressive abdominal swelling in the past 9 months seen at the surgical outpatient of our facility. Preoperative CT suggested a diagnosis of an intrabdominal cystic. She had laparotomy and was offered myomectomies on account of a large subserous uterine mass arising from the right side of the uterine fundus, small subserous fundal mass, intramural mass in the left side of the fundus and a cervical mass. Histology confirmed multiple uterine leiomyomas with extensive cystic degenerative changes of the large subserous uterine myoma and adenomyosis of the left fundal mass. Detecting the continuity of an abdominal mass even with extensive degenerative changes mimicking a cyst in continuity with the uterus by a pedicle sign on imaging in the absence of ascites should arouse the diagnosis of pedunculated subserosal leiomyoma. This should be further heightened when it is found in association with cervical myoma. Subserous uterine leiomyoma should be considered in a patient of childbearing age with a grossly distended abdomen without obvious evidence of pregnancy or malignancy. Large subserous uterine leiomyoma in an intraabdominal location may present with diagnostic and surgical challenges that require interdisciplinary cooperation.

Giant "Hydra Headed" Uterine Fibroid in a Nullipara: A Case Report

Background

Uterine fibroids, or Leiomyoma is a type of Smooth Muscle Tumors of the uterus (SMTs) and are common in the black race. Giant uterine fibroids, on the other hand, are uncommon and may occur during patient dissimulation. Dissimulation may occur because of a dread of surgery and hospitals visits, fear of surgical death, chronic intake of herbal concussion, and a religio-traditional strong belief system on instant healing following prayers, among others. Myths like belief of defecating the uterine fibroids, some herbs that can melt them away, and the belief that such illness may follow ancestral curses can fuel dissimulation. The surgical approach can be a source of challenge, careful case selection considering the size and number of tumors can be helpful.

Case report

We present a 35-year-old nulligravida who presented to the clinic with a 14-year history of progressive abdominal swelling. Examination revealed a firm mass with a symphysio-fundal height of 55 cm. She subsequently had an open abdominal myomectomy with all the myoma nodules weighing 12.9 kg in total! Histology confirmed uterine fibroid.

Conclusion

It is possible to offer open myomectomy in patients with giant uterine fibroid following careful patient selection with a consent for possible hysterectomy. Dissimulation can be minimized with repetitive counseling of patients. The choice of surgery depends on the size and number of uterine fibroids, but surgical approach does not necessarily influence fecundity.

Robotic-assisted laparoscopic versus abdominal and laparoscopic myomectomy: A systematic review and meta-analysis

BACKGROUND

Myomectomy is the preferred treatment for women with uterine fibroids and fertility requirements. There are three modalities are used in clinical practice for myomectomy: abdominal myomectomy (AM), laparoscopic myomectomy (LM), and robot-assisted laparoscopic myomectomy (RLM).

OBJECTIVES

To compare the perioperative and postoperative outcomes of RLM, AM, and LM.

SEARCH STRATEGY

We searched PubMed, Web of Science, Embase, and Clinical Trials for relevant literature published between January 2000 and January 2023.

SELECTION CRITERIA

We included all studies reporting peri- and postoperative outcomes of myomectomy in patients with uterine myomas. Surgical treatments were classified as RLM, LM, or AM.

DATA COLLECTION AND ANALYSIS

Two or more authors selected studies independently, assessed risk of bias, and extracted data. We derived mean difference (MD) or odds ratio (OR) with 95% confidence intervals (CIs) for each outcome, subgrouping trials by the patient characteristics and myoma characteristics. We used the I2 statistic to quantify heterogeneity and the random-effects model for meta-analysis when appropriate. We used the funnel plot to assess the publication bias.

MAIN RESULTS

A total of 32 studies with 6357 patients were included, of which 1982 women had undergone RLM. The operating time was significantly longer (MD = 43.58, 95% confidence interval [CI]: 25.22-61.93, P < 0.001), and the incidence of cesarean section after myomectomy was significantly lower (OR = 0.27, 95% CI: 0.10-0.78, P = 0.02) in RLM than in LM. Compared with AM, the operation time, blood loss, blood transfusion rate, complication rate, total cost, length of hospital stay, and pregnancy rate of patients with RLM were significantly different.

CONCLUSIONS

The safety and effectiveness of RLM are superior to those of AM but inferior to those of LM.

Advancing women's health: The imperative for public health screening of uterine fibroids for personalized care

Uterine fibroids represent the most prevalent genital tract tumours among women, with a disproportionately higher impact on ethnic minority groups, notably black women. These hormonally dependent monoclonal tumours, characterized by excessive extracellular matrix and influenced by genetic, epigenetic, and lifestyle factors, significantly affect women's quality of life and pose substantial economic burdens on healthcare systems. Recent advances in early detection and minimally invasive treatment options have shifted management paradigms towards personalized care, yet challenges in early diagnosis, education and access to treatment persist. This review synthesizes current knowledge on uterine fibroids, highlighting the impact of fibroids on women's health, risk factors, principles of screening, diagnostic tools, and treatment modalities. It emphasizes the importance of early screening and individualized management strategies in improving patient outcomes and reducing healthcare costs. The article also discusses the socio-economic and health disparities affecting the disease burden, underscoring the need for improved patient education, clinician training, and public health strategies to enhance fibroid management. This review proposes a pathway to not only ameliorate the quality of life for women with fibroids, but also to advance global women's health equity.

Pathogenesis of uterine fibroids: current understanding and future directions

Fibroids are benign uterine tumors characterized by the proliferation of uterine smooth muscle cells, embedded in an abundant extracellular matrix. Their prevalence is estimated to be >50% in women aged >45 years. Fibroids represent a considerable health burden. It is time to acquire a deeper mechanistic understanding of uterine fibroid-related etiology and pathogenesis, which may help pinpoint new strategies and an individualized approach. There is a need to gather prospective data and conduct studies to compare alternative approaches and assess long-term outcomes with respect to quality of life, recurrence of symptoms (bleeding and bulk symptoms), fertility, and even complications The goal of this review was to evaluate the widely accepted pathogenesis and identify risks factors and future directions for clinical and basic research into fibroids.

The Differential Diagnosis of Abdominal Mass: A Case of Uterine Leiomyoma

The most common benign neoplastic uterine tumors that grow monoclonally from the smooth muscle cells of the uterus are uterine fibroids or leiomyomas, which may occur as a single lesion or as multiple lesions with variation in size from microscopic to large macroscopic extent. The majority are diagnosed in the preclinical routine reliably, despite challenges due to the possibility of multiple differential diagnoses. Hence, this report highlights a case of a postmenopausal female of 53-year-old working as a staff nurse at the same hospital and who visited the outpatient department of obstetrics and gynecology with chief complaints of pain in the right side of the abdomen for four hours (presentation similar to that of appendicitis). Per abdomen examination resulted in a non-tender mass with flank fullness and firmness with a smooth surface and approachable lower border. It clinically appeared as a large uterine fibroid. The built of the patient was obese due to which neither the patient nor relatives were ever able to make out any evident symptoms. The diagnostic investigation involved a magnetic resonance imaging (MRI) that confirmed the diagnosis of two parity with both living, and two were aborted (P2L2A2) with uterine fibroid. The management of the fibroid consisted of exploratory laparotomy along with a hysterectomy and bilateral salpingo-oophorectomy. The intraoperative findings and frozen section report confirmed the presence of benign uterine leiomyoma. Therefore, the utilization of physical examinations and diagnostic tests may assist in preventing a delay in the detection and management of curable conditions such as fibroids, which can be treated without complications with surgery.

Multiparametric quantitative magnetic resonance imaging of uterine fibroids for prediction of growth rate-a pilot study

Background

Uterine fibroid (UF) growth rate and future morbidity cannot be predicted. This can lead to sub-optimal clinical management, with women being lost to follow-up and later presenting with severe disease that may require hospitalization, transfusions, and urgent surgical interventions. Multi-parametric quantitative magnetic resonance imaging (MRI) could provide a biomarker to predict growth rate facilitating better-informed disease management and better clinical outcomes. We assessed the ability of putative quantitative and qualitative MRI predictive factors to predict UF growth rate.

Methods

Twenty women with UFs were recruited and completed baseline and follow-up MRI exams, 1-2.5 years apart. The subjects filled out symptom severity and health-related quality of life questionnaires at each visit. A standard clinical pelvic MRI non-contrast exam was performed at each visit, followed by a contrast-enhanced multi-parametric quantitative MRI (mp-qMRI) exam with T2, T2*, and apparent diffusion coefficient (ADC) mapping and dynamic contrast-enhanced MRI. Up to 3 largest fibroids were identified and outlined on the T2-weighted sequence. Fibroid morphology and enhancement patterns were qualitatively assessed on dynamic contrast-enhanced MRI. The UFs' volumes and average T2, T2*, and ADC values were calculated. Pearson correlation coefficients were calculated between UF growth rate and T2, T2*, ADC, and baseline volume. Multiple logistic regression and receiver operating characteristic (ROC) analysis were performed to predict fast-growing UFs using combinations of up to 2 significant predictors. A significance level of alpha =0.05 was used.

Results

Forty-four fibroids in 20 women had growth rate measurement available, and 36 fibroids in 16 women had follow-up quantitative MRI available. The distribution of fibroid growth rate was skewed, with approximately 20% of the fibroids exhibiting fast growth (>10 cc/year). However, there were no significant changes in median baseline and follow-up values of symptom severity and health-related quality of life scores. There was no change in average T2, T2*, and ADC at follow-up exams and there was a moderate to strong correlation to the fibroid growth rate in baseline volume and average T2 and ADC in slow-growing fibroids (<10 cc/year). A multiple logistic regression to identify fast growing UFs (>10 cc/year) achieved an area under the curve (AUC) of 0.80 with specificity of 69% at 100% sensitivity.

Conclusions

The mp-qMRI parameters T2, ADC, and UF volume obtained at the time of initial fibroid diagnosis may be able to predict UF growth rate. Mp-qMRI could be integrated into the management of UFs, for individualized care and improved clinical outcomes.

The modern management of uterine fibroids-related abnormal uterine bleeding

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

The effectiveness of relugolix compared with leuprorelin for preoperative therapy before laparoscopic myomectomy in premenopausal women, diagnosed with uterine fibroids: protocol for a randomized controlled study (MyLacR study)

BACKGROUND

The oral gonadotropin-releasing hormone antagonist relugolix, which temporarily stops menstruation, is used to treat heavy menstrual bleeding, pelvic pressure, and low back pain in women with uterine fibroids. Treatment can also help women recover from low hemoglobin levels and possibly shrink the fibroids. However, evidence of preoperative use of relugolix before laparoscopic myomectomy is limited. Nevertheless, the treatment could reduce interoperative blood loss, decrease the risk of developing postoperative anemia, and shorten the operative time. Thus, we aim to test whether 12-week preoperative treatment with relugolix (40 mg orally, once daily) is similar to or not worse than leuprorelin (one injection every 4 weeks) to reduce intraoperative blood loss.

METHODS

Efficacy and safety of preoperative administration of drugs will be studied in a multi-center, randomized, open-label, parallel-group, noninferiority trial enrolling premenopausal women ≥ 20 years of age, diagnosed with uterine fibroids and scheduled for laparoscopic myomectomy. Participants (n = 80) will be recruited in the clinical setting of participating institutions. The minimization method (predefined factors: presence or absence of fibroids ≥ 9 cm and the International Federation of Gynecology and Obstetrics [FIGO] type 1-5 fibroids) with randomization is used in a 1:1 allocation. Relugolix is a 40-mg oral tablet taken once a day before a meal, for 12 weeks, up to the day before surgery. Leuprorelin is a 1.88 mg, or 3.75 mg subcutaneous injection, given in three 4-week intervals during patient visits before the surgery. For the primary outcome measure of intraoperative bleeding, the blood flow is collected from the body cavity, surgical sponges, and collection bag and measured in milliliters. Secondary outcome measures are hemoglobin levels, myoma size, other surgical outcomes, and quality-of-life questionnaire responses (Kupperman Konenki Shogai Index and Uterine Fibroid Symptoms-Quality of Life).

DISCUSSION

Real-world evidence will be collected in a clinical setting to use pre-treatment with an oral gonadotropin-releasing hormone antagonist to reduce intraoperative bleeding in women who undergo laparoscopic myomectomy.

TRIAL REGISTRATION

jRCTs031210564 was registered on 19 January 2022 in the Japan Registry of Clinical Trials ( https://jrct.niph.go.jp ).

Combined oral contraceptive utilization and uterine fibroid incidence: A prospective study in a cohort of African-American women

Published associations between combined oral contraceptive use and uterine fibroid development have lacked prospective imaging with ultrasound to distinguish between incident and prevalent fibroids. The Study of Environment, Lifestyle, and Fibroids prospectively followed fibroid-free, African-American women (the group with the highest disease burden in the U.S.) to identify incident cases. We examined associations between combined oral contraceptive use and the 40-month cumulative risk of fibroids. History of hormonal contraceptive use was collected via telephone interview at enrollment. Fibroid identification was performed using transvaginal ultrasonography at enrollment, and at 20 and 40-months of follow-up. Inverse probability weights for exposures and censoring were used to construct weighted risk ratios (wRR) and weighted risk different (wRD) estimators which control for differences in fibroid risk factors between exposure groups. In addition, unweighted fully adjusted log-binomial regression models (aRR) were run for comparison. Of the 1,308 participants in the analysis sample, 70% had used combined oral contraceptives and 17% developed fibroids by 40 months. We observed an inverse association between ever use of combined oral contraceptives and cumulative fibroid incidence (wRR: 0.78; 95% Confidence Interval (CI): 0.60, 1.00; wRD: -0.05, 95% CI: -0.11, 0; aRR: 0.76, 95% CI: 0.60, 0.98). Fibroid incidence was greater in participants who started using combined oral contraceptives after age 17 years than among younger initiators, though the restriction to ever-users made this estimate less precise (wRR: 1.25; 95% CI: 0.89, 1.76; wRD: 0.04, 95% CI: -0.02, 0.10). No consistent patterns of fibroid incidence were seen among ever-users for duration of, or years since, last combined oral contraceptives use.

Cesarean Myomectomy: Reflections on Clinical and Surgical Controversies between a New Trans-Decidual Technique vs. Traditional Method

Up to 70-80% of women of reproductive age may be affected with the most common uterine tumors, known as fibroids or myomas. These benign tumors are the second most prevalent cause of surgery among premenopausal women. Predictions show that the occurrence of myomas in pregnancy will increase, and that the risk of having myomas during pregnancy increases with advanced maternal age. Although most women with fibroids do not experience any symptoms during pregnancy, up to 30% of women experience problems during pregnancy, childbirth, and the puerperium. The viability of myoma excision during cesarean surgery (CS) is a contentious issue raised by the rising incidence of myomas in pregnancy and CS rates. A new surgical procedure for removing fibroids using a trans-endometrial approach, which involves making an incision through the decidua itself, has put into doubt the long-standing practice of cesarean myomectomy (CM) with a trans-serosal approach. Some authors have recently advocated for this last approach, highlighting its advantages and potential uses in real-world situations. The purpose of this paper is to critique the present approach to cesarean myomectomy by analyzing the clinical and surgical distinctions between the two approaches and providing illustrations of the CM methods.

Enhancing Uterine Fibroid Care: Clinician Perspectives on Diagnosis, Disparities, and Strategies for Improving Health Care

Objective

To explore clinicians' perspectives on diagnosing, treating, and managing uterine fibroids, identifying gaps and challenges in health care delivery, and offering recommendations for improving care.

Materials and Methods

A qualitative design was used to conduct 14 semistructured interviews with clinicians who treat fibroid patients in central Indiana. Interviews were audio recorded, transcribed verbatim, and analyzed using thematic analysis techniques. Constant comparative analysis was used to identify emergent themes.

Results

Four themes emerged. (1) Lack of patient fibroid awareness: Patients lacked fibroid awareness, leading to challenges in explaining diagnoses and treatment. Misconceptions and emotional distress highlighted the need for better education. (2) Inequities in care and access: Health care disparities affected Black women and rural patients, with transportation, scheduling delays, and financial constraints hindering access. (3) Continuum of care: Clinicians prioritized patient-centered care and shared decision-making, tailoring treatment based on factors like severity, location, size, cost, fertility goals, and recovery time. (4) Coronavirus disease 2019 (COVID-19) impact: The pandemic posed challenges and opportunities, prompting telehealth adoption and consideration of nonsurgical options.

Conclusions

Clinician perspectives noted patient challenges with fibroids, prompting calls for enhanced education, interdisciplinary collaboration, and accessible care to address crucial aspects of fibroid management and improve women's well-being.

Practice Implications

Clinicians identified a lack of patient awareness and unequal access to fibroid care, highlighting the need for improved education and addressing disparities. Findings also emphasized the importance of considering multidimensional aspects of fibroid care and adapting to challenges posed by the COVID-19 pandemic, recommending broader education, affordability, interdisciplinary collaboration, and research for better fibroid health care.

Gene variants polymorphisms and uterine leiomyoma: an updated review

Uterine leiomyoma, commonly referred to as fibroids, is a benign tumor that develops in the muscular wall of the uterus. These growths are non-cancerous and can vary in size, ranging from tiny nodules to larger masses. Uterine leiomyomas often occur during a woman's reproductive years and can lead to symptoms such as heavy menstrual bleeding, pelvic pain, and pressure on nearby organs. While the exact cause is not fully understood, hormonal factors, particularly estrogen and progesterone, are believed to play a role in their development. The exploration of connections between genetic variants and uterine leiomyoma has captivated scientific attention for numerous years. The results from investigations remain a subject of intrigue within the scientific community. To date, the findings regarding the relationships between single nucleotide polymorphisms (SNPs) and uterine leiomyoma have exhibited some inconsistencies. However, amidst these inconsistencies, several promising outcomes have emerged that hold the potential to shape future research endeavors. These promising leads could pave the way for the development of innovative targeted therapies and novel prognostic biomarkers. This review specifically centers on accentuating the existing literature data concerning genetic variants that have been explored for their potential connections to uterine leiomyoma. Additionally, it underscores the prospects of employing genetic variations as diagnostic and prognostic biomarkers for individuals diagnosed with uterine leiomyoma.

Uterine Fibroid Prevalence in a Predominantly Black, Chicago-Based Cohort

(1) Objectives: To investigate the effect of individual-level, neighborhood, and environmental variables on uterine fibroid (UF) prevalence in a Chicago-based cohort. (2) Methods: Data from the Chicago Multiethnic Prevention and Surveillance Study (COMPASS) were analyzed. Individual-level variables were obtained from questionnaires, neighborhood variables from the Chicago Health Atlas, and environmental variables from NASA satellite ambient air exposure levels. The Shapiro-Wilk test, logistic regression models, and Spearman's correlations were used to evaluate the association of variables to UF diagnosis. (3) Results: We analyzed 602 participants (mean age: 50.3 ± 12.3) who responded to a question about UF diagnosis. More Black than White participants had a UF diagnosis (OR, 1.32; 95% CI, 0.62-2.79). We observed non-significant trends between individual-level and neighborhood variables and UF diagnosis. Ambient air pollutants, PM2.5, and DSLPM were protective against UF diagnosis (OR 0.20, CI: 0.04-0.97: OR 0.33, CI: 0.13-0.87). (4) Conclusions: Associations observed within a sample in a specific geographic area may not be generalizable and must be interpreted cautiously.

Relugolix combination therapy in Black/African American women with symptomatic uterine fibroids: LIBERTY Long-Term Extension study

BACKGROUND

In the LIBERTY Long-Term Extension study, once-daily relugolix combination therapy (40 mg relugolix, estradiol 1 mg, norethindrone acetate 0.5 mg) substantially improved uterine fibroid-associated heavy menstrual bleeding throughout the 52-week treatment period in the overall study population.

OBJECTIVE

Black or African American women typically experience a greater extent of disease and symptom burden of uterine fibroids vs other racial groups and have traditionally been underrepresented in clinical trials. This secondary analysis aimed to assess the efficacy and safety of relugolix combination therapy in the subgroup population of Black or African American women with uterine fibroids in the LIBERTY Long-Term Extension study.

STUDY DESIGN

Black or African American premenopausal women (aged 18-50 years) with uterine fibroids and heavy menstrual bleeding who completed the 24-week randomized, placebo-controlled, double-blind LIBERTY 1 (identifier: NCT03049735) or LIBERTY 2 (identifier: NCT03103087) trials were eligible to enroll in the 28-week LIBERTY Long-Term Extension study (identifier: NCT03412890), in which all women received once-daily, open-label relugolix combination therapy. The primary endpoint of this subanalysis was the proportion of Black or African American treatment responders: women who achieved a menstrual blood loss volume of <80 mL and at least a 50% reduction in menstrual blood loss volume from the pivotal study baseline to the last 35 days of treatment by pivotal study randomized treatment group. The secondary outcomes included rates of amenorrhea and changes in symptom burden and quality of life.

RESULTS

Overall, 241 of 477 women (50.5%) enrolled in the LIBERTY Long-Term Extension study self-identified as Black or African American. In Black or African American women receiving continuous relugolix combination therapy for up to 52 weeks, 58 of 70 women (82.9%; 95% confidence interval, 72.0%-90.8%) met the treatment responder criteria for reduction in heavy menstrual bleeding (primary endpoint). A substantial reduction in menstrual blood loss volume from the pivotal study baseline to week 52 was demonstrated (least squares mean percentage change: 85.0%); 64.3% of women achieved amenorrhea; 59.1% of women with anemia at the pivotal study baseline achieved a substantial improvement (>2 g/dL) in hemoglobin levels; and decreased symptom severity and distress because of uterine fibroid-associated symptoms and improvements in health-related quality of life through 52 weeks were demonstrated. The most frequently reported adverse events during the cumulative 52-week treatment period were hot flush (12.9%), headache (5.7%), and hypertension (5.7%). Bone mineral density was preserved through 52 weeks.

CONCLUSION

Once-daily relugolix combination therapy improved uterine fibroid-associated heavy menstrual bleeding in most Black or African American women who participated in the LIBERTY Long-Term Extension study. The safety and efficacy profile of relugolix combination therapy in Black or African American women was consistent with previously published results from the overall study population through 52 weeks. Findings from this subanalysis will assist shared decision-making by helping providers and Black or African American women understand the efficacy and safety of relugolix combination therapy as a pharmacologic option for the management of uterine fibroid-associated symptoms.

Uterine leiomyomata claim rate estimates and demographic characteristics by county. Florida, 2010-2019

To describe the demographic characteristics and estimate the uterine leiomyomata claim rates (ULCRs) by women 18 years and older in Florida, we conducted a cross-sectional analysis of the 2010-2019 administrative claims for uterine leiomyomata and associated study variables (age, race, ethnicity, county of residence, anatomic site, length of stay, and additional diagnoses). ULCR ratios were estimated by race and ethnicity, using ULCR for non-Hispanic White women as the reference group. We identified 232,475 claims, most of which were among non-Hispanic White women in their forties. The overall ULCR estimate [95 percent CI] was 284.8 [284.21, 285.39] per 100,000 women 18 years and older, with a small, nonsignificant trend to increase over time (R2 = .310; p = .094). Black, Hispanic, and other women of color presented with higher ULCR ratios (4.84, 1.87, and 1.58, respectively). Urban counties had significantly higher ULCRs than suburban and rural counties. While non-Hispanic White women had the highest frequency of ULCRs, women of color-especially Black women-presented with significantly higher ULCR ratios. The epidemiologic profile of uterine leiomyomata in terms of age, race, ethnicity, and geographic location points to unmet healthcare needs among specific demographic and geographic groups of women in Florida.

Assessment of a Digital Symptom Checker Tool's Accuracy in Suggesting Reproductive Health Conditions: Clinical Vignettes Study

BACKGROUND

Reproductive health conditions such as endometriosis, uterine fibroids, and polycystic ovary syndrome (PCOS) affect a large proportion of women and people who menstruate worldwide. Prevalence estimates for these conditions range from 5% to 40% of women of reproductive age. Long diagnostic delays, up to 12 years, are common and contribute to health complications and increased health care costs. Symptom checker apps provide users with information and tools to better understand their symptoms and thus have the potential to reduce the time to diagnosis for reproductive health conditions.

OBJECTIVE

This study aimed to evaluate the agreement between clinicians and 3 symptom checkers (developed by Flo Health UK Limited) in assessing symptoms of endometriosis, uterine fibroids, and PCOS using vignettes. We also aimed to present a robust example of vignette case creation, review, and classification in the context of predeployment testing and validation of digital health symptom checker tools.

METHODS

Independent general practitioners were recruited to create clinical case vignettes of simulated users for the purpose of testing each condition symptom checker; vignettes created for each condition contained a mixture of condition-positive and condition-negative outcomes. A second panel of general practitioners then reviewed, approved, and modified (if necessary) each vignette. A third group of general practitioners reviewed each vignette case and designated a final classification. Vignettes were then entered into the symptom checkers by a fourth, different group of general practitioners. The outcomes of each symptom checker were then compared with the final classification of each vignette to produce accuracy metrics including percent agreement, sensitivity, specificity, positive predictive value, and negative predictive value.

RESULTS

A total of 24 cases were created per condition. Overall, exact matches between the vignette general practitioner classification and the symptom checker outcome were 83% (n=20) for endometriosis, 83% (n=20) for uterine fibroids, and 88% (n=21) for PCOS. For each symptom checker, sensitivity was reported as 81.8% for endometriosis, 84.6% for uterine fibroids, and 100% for PCOS; specificity was reported as 84.6% for endometriosis, 81.8% for uterine fibroids, and 75% for PCOS; positive predictive value was reported as 81.8% for endometriosis, 84.6% for uterine fibroids, 80% for PCOS; and negative predictive value was reported as 84.6% for endometriosis, 81.8% for uterine fibroids, and 100% for PCOS.

CONCLUSIONS

The single-condition symptom checkers have high levels of agreement with general practitioner classification for endometriosis, uterine fibroids, and PCOS. Given long delays in diagnosis for many reproductive health conditions, which lead to increased medical costs and potential health complications for individuals and health care providers, innovative health apps and symptom checkers hold the potential to improve care pathways.

LIBERTY randomized withdrawal study: relugolix combination therapy for heavy menstrual bleeding associated with uterine fibroids

BACKGROUND

In the pivotal LIBERTY 1 and 2 trials and long-term extension study, once-daily relugolix combination therapy (40 mg relugolix, 1 mg estradiol, 0.5 mg norethindrone acetate) reduced menstrual blood loss volume and pain among women with uterine fibroids. Relugolix combination therapy was well tolerated with preservation of bone mineral density through 52 weeks.

OBJECTIVE

This study aimed to report the 2-year relugolix combination therapy efficacy and safety results of the phase 3 LIBERTY randomized withdrawal study.

STUDY DESIGN

Women with uterine fibroid-associated heavy menstrual bleeding who completed the 24-week LIBERTY 1 or 2 trials, followed by the 28-week long-term extension study (up to 52 weeks total treatment), and who met the responder criteria (menstrual blood loss volume <80 mL and ≥50% reduction from pivotal study baseline at week 48 [week 24 of long-term extension]) were randomized in a 1:1 ratio to either blinded treatment with relugolix combination therapy or placebo for 52 weeks (total treatment period, 104 weeks). For women who had a relapse of heavy menstrual bleeding during the study (menstrual blood loss volume ≥80 mL), open-label relugolix combination therapy was offered. The primary endpoint was the proportion of women who maintained menstrual blood loss volume <80 mL through week 76 (week 24 of randomized withdrawal study). Secondary endpoints included time to menstrual blood loss volume ≥80 mL, proportion of women who maintained a menstrual blood loss volume of <80 mL through week 104 (over the 52-week randomized treatment period), the proportion of women who achieved or maintained amenorrhea at week 76 at the end of treatment, and the change in Uterine Fibroid Symptom-Quality of Life Bleeding and Pelvic Discomfort Scale and symptom severity scores. Analyses were performed for the modified intent-to-treat population, including all randomized women who received ≥1 dose of the study drug.

RESULTS

Of the 229 randomized women (relugolix combination therapy, n=115; placebo, n=114), 228 received the study drug and 175 (76.7%) completed the randomized withdrawal study. Through week 76, 78.4% of women on relugolix combination therapy maintained menstrual blood loss volume <80 mL vs 15.1% in the placebo group (difference, 63.4%; 95% confidence interval, 52.9%-73.9%; P<.0001). At week 104, 69.8% of women on relugolix combination therapy maintained menstrual blood loss volume <80 mL vs 11.8% in the placebo group (difference, 58.0%; 95% confidence interval, 47.0%-69.1%; P<.0001). Through week 104, 88.3% of women on placebo relapsed with heavy menstrual bleeding (median time to relapse, 5.9 weeks). Among the 89 women in the placebo group who relapsed and received open-label rescue treatment, 87 women responded to relugolix combination therapy with a menstrual blood loss volume <80 mL. The proportion of women who achieved or maintained amenorrhea were 57.4% vs 13.3% at week 76 (difference, 44.1%; 95% confidence interval, 33.10%-55.1%; P<.0001) and 58.3% vs 10.6% at week 104 (difference, 47.6%; 95% confidence interval, 37.0%-58.3%; nominal P<.0001) for relugolix combination therapy and the placebo group, respectively. Relugolix combination therapy was generally well tolerated; no new safety signals were identified, and the adverse event profile over the second year was consistent with that reported through the first year of treatment. Bone mineral density remained stable in women who received relugolix combination therapy from week 52 to week 104. In women continuously treated with relugolix combination therapy up to 2 years, bone mineral density was generally preserved.

CONCLUSION

After 2 years of treatment with relugolix combination therapy, there was evidence of durability of the effect in maintaining low menstrual blood loss volume in women with symptomatic uterine fibroids. Most women had return of heavy menstrual bleeding and associated symptoms after treatment cessation, which improved upon retreatment with relugolix combination therapy. Relugolix combination therapy was well tolerated, the adverse event profile remained consistent, and the mean bone mineral density was generally preserved through 2 years of treatment.

Validity and Reliability of The Persian Version of Uterine Fibroid Symptom and Health-Related Quality of Life Questionnaire: A Psychometric Study

BACKGROUND

Women with uterine fibroids (UFs) experience many clinical manifestations that affect their quality of life (QOL). The Uterine Fibroid Symptom and Health-related Quality of Life (UFS-QOL) questionnaire is an English instrument specifically designed to assess fibroid-related symptoms and their impact on QOL. This study aims to investigate the reliability and validity of the Persian version of the UFS-QOL questionnaire in Iranian women with UF.

MATERIALS AND METHODS

In this psychometric study, women with UFs who presented to Imam Hossein Hospital (Tehran, Iran) between August 2022 and January 2023 were enrolled in this study. A forward-backward approach was applied to translate the UFS-QOL questionnaire into Persian. The reliability of the UFS-QOL questionnaire was assessed by internal consistency and test-retest correlation. Confirmatory factor analysis (CFA) was used to assess convergent validity between items and subscales of the UFS-QOL questionnaire. Pearson's correlation coefficient was used to assess convergence validity between subscales of the UFS-QOL and the World Health Organization Quality of Life Brief Version 26 questionnaire (WHOQOL-BREF-26).

RESULTS

Overall, we assessed 226 women with UFs. All subscales of the UFS-QOL questionnaire had acceptable internal consistency (Cronbach's alpha>0.7). Test-retest analysis indicated significant positive correlations between two measurements of all subscales of the UFS-QOL questionnaire: symptom severity (P<0.001), concern (P<0.001), activities (P<0.001), energy/mood (P<0.001), control (P<0.001), self-consciousness (P=0.002), and sexual function (P<0.001). The Kaiser-Meyer-Olkin (KMO) measure value was 0.920, and the result of Bartlett's test of sphericity was significant (P<0.001). CFA identified six factors for the health-related QOL (HRQL) questionnaire, which explained 73.827% of the total variation. Most subscales of the UFS-QOL questionnaire correlated with domains of the WHOQOL-BREF-26 questionnaire (P<0.05).

CONCLUSION

The Persian version of the UFS-QOL questionnaire is a valid and reliable instrument to evaluate UFrelated symptoms and QOL among Iranian women.

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

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

Efficacy and safety of vilaprisan in women with uterine fibroids: data from the ASTEROID 3 randomized controlled trial

OBJECTIVE

Vilaprisan is a highly potent selective progesterone receptor modulator shown to reduce heavy menstrual bleeding, induce amenorrhea, and diminish uterine fibroid volume in phase 2 studies. The objective of ASTEROID 3 was to demonstrate the superiority of vilaprisan compared with placebo in the treatment of heavy menstrual bleeding in women with uterine fibroids.

DESIGN

Randomized, double-blind, placebo-controlled, multicenter phase 3 study.

SETTING

Hospitals and medical centers.

PATIENT(S)

Women with ≥1 uterine fibroid of ≥3 cm and heavy menstrual bleeding of >80 mL/cycle.

INTERVENTION(S)

Women were randomly assigned to 1 of 4 treatment arms, which were planned to comprise 2 treatment periods of 12 weeks, each with vilaprisan (2 mg/d) or placebo that were continuous or separated by a break of one bleed.

MAIN OUTCOME MEASURE(S)

Amenorrhea (primary end point; <2 mL in the last 28 days of treatment) and heavy menstrual bleeding response (key secondary end point; <80 mL/cycle and >50% reduction in bleeding from baseline) were measured with the alkaline hematin method. Change in volume of the 3 largest fibroids from baseline to end of treatment was assessed by ultrasound. Safety was monitored throughout the study.

RESULT(S)

Overall, 75 women completed the first 12 weeks of treatment. Statistically significant and clinically meaningful differences were observed between the vilaprisan- and placebo-treated groups in both the full analysis and per-protocol sets. In the per-protocol set (n = 36 and n = 12 for the vilaprisan and placebo groups, respectively), amenorrhea was observed more frequently in women treated with vilaprisan than in those who received placebo (83.3% vs. 0%, P<.0001), with a median time to onset of 3 days in the vilaprisan group. Similarly, more vilaprisan- than placebo-treated women achieved a response in heavy menstrual bleeding (91.7% vs. 25.0%, P<.0001). Serious adverse events were reported for 22 (27.8%) of 79 women and were evenly distributed among the 4 groups receiving vilaprisan and/or placebo. None of these events led to study discontinuation or were related to the liver, and no new safety findings were identified compared with the earlier phase 2 ASTEROID studies.

CONCLUSION(S)

Vilaprisan is efficacious and well tolerated over 12 weeks in the treatment of heavy menstrual bleeding associated with uterine fibroids. Further investigations of the long-term efficacy and safety of vilaprisan are warranted.

CLINICAL TRIAL REGISTRATION NUMBER

NCT03400943 (ClinicalTrials.gov).

The combination of natural compounds Crila and epigallocatechin gallate showed enhanced antiproliferative effects on human uterine fibroid cells compared with single treatments

OBJECTIVE

To investigate the combined effects of Crila and green tea extract, epigallocatechin gallate (EGCG), compared with single treatments, on human uterine fibroid cells.

DESIGN

Human uterine leiomyoma (HuLM) cells were treated with different concentrations of Crila, alone or in combination with EGCG, and several experiments were employed.

SETTING

A laboratory study.

PATIENTSS

N/A.

INTERVENTIONS

Crila, EGCG.

MAIN OUTCOME MEASURES

Cell proliferation assay, drug synergy using combination index, protein and gene expression analysis of proliferation marker proliferating cell nuclear antigen, and apoptosis marker BAX using western blotting and quantitative polymerase chain reaction, respectively.

RESULTS

Results showed that tested Crila concentrations, when combined with 25 and 50 μM EGCG, exerted synergistic growth inhibitory effects on HuLM viability. This inhibitory effect on HuLM cell viability was because of decreased cell proliferation, as shown by a decrease in the proliferation marker proliferating cell nuclear antigen at messenger RNA and protein levels, rather than inducing apoptosis.

CONCLUSION

Our study concludes that the utility of natural compounds may provide a safe and cost-effective alternative to currently used short-term hormonal therapies against uterine fibroids.

Occurrence and Risk Factors for Perioperative Treatment Discontinuation during Magnetic Resonance-Guided High-Intensity Focused Ultrasound (MR-HIFU) Therapy in Symptomatic Uterine Fibroids-A Retrospective Case-Control Study

BACKGROUND

The main aim of our study involves the analysis of reasons and risk factors for perioperative treatment discontinuation in patients with symptomatic uterine fibroids (UFs) who were qualified for magnetic resonance-guided high-intensity focused ultrasound (MR-HIFU) and in whom the procedure was discontinued.

METHODS

The presented research included 372 women who were primarily eligible for MR-HIFU, but the procedure was interrupted. The reasons and risk factors for treatment discontinuation were analyzed. A statistical comparison of two cohorts (patients in whom the treatment was discontinued and completed) was conducted based on epidemiological factors, UF characteristics and the implementation of uterotonics.

RESULTS

The mean discontinuation rate was 18.28% (n = 68). The main reason was the malposition of the intestines (52.94% of all cases). The thermoablation of subserosal UFs was a statistically significant risk factor of perioperative treatment discontinuation (OR 4.62, CI 95% 2.04-10.56), while the therapy of intramural UFs considerably decreased the risk (OR 0.21, CI 95% 0.08-0.51). The volume of the targeted UF was negatively correlated with the risk of discontinuation (OR 0.991, CI 95% 0.986-0.996). Augmentation with oxytocin, but not misoprostol, during the procedure significantly decreased the risk of potential discontinuation (OR 0.15, CI 95% 0.045-0.387, p < 0.001).

CONCLUSION

Although the discontinuation rate seems to be relatively low, further prospective randomized trials are needed to confirm our results. The establishment of particular eligibility criteria for the treatment is a crucial issue in this area. Resigning from the procedure in cases at a high risk of discontinuation might increase patient safety and shorten the time to introduce the most appropriate therapy.

Dysbiosis of vaginal and cervical microbiome is associated with uterine fibroids

Dysbiosis of the female reproductive tract is closely associated with gynecologic diseases. Here, we aim to explore the association between dysbiosis in the genital tract and uterine fibroids (UFs) to further provide new insights into UF etiology. We present an observational study to profile vaginal and cervical microbiome from 29 women with UFs and 38 healthy women, and 125 samples were obtained and sequenced. By comparing the microbial profiles between different parts of the reproductive tract, there is no significant difference in microbial diversity between healthy subjects and UF patients. However, alpha diversity of UF patients was negatively correlated with the number of fibroids. Increased Firmicutes were observed in both the cervical and vaginal microbiome of UF patients at the phylum level. In differential analysis of relative abundance, some genera were shown to be significantly enriched (e.g., Erysipelatoclostridium, Mucispirillum, and Finegoldia) and depleted (e.g., Erysipelotrichaceae UCG-003 and Sporolactobacillus) in UF patients. Furthermore, the microbial co-occurrence networks of UF patients showed lower connectivity and complexity, suggesting reduced interactions and stability of the cervical and vaginal microbiota in UF patients. In summary, our findings revealed the perturbation of microbiome in the presence of UFs and a distinct pattern of characteristic vaginal and cervical microbiome involved in UFs, offering new options to further improve prevention and management strategies.

Care Delivery for Patients with Leiomyomas: Failures, Real-Life Experiences, Analysis of Barriers, and Proposed Restorative Remedies

In this narrative review, we describe historical and contemporary influences that prevent patients with fibroids from getting appropriate medical care. Using patient stories as examples, we highlight how misogyny on all levels hurts patients and prevents medical teams from doing their best. Importantly, inequity and disparities result in massive gaps in care delivery. We suggest that we, as gynecologists and surgeons, must join public discourse on this topic to highlight the inadequacies of care delivery and the reasons behind it, suggest potential solutions, and join patients and communities in formulating and implementing remedies.

Relugolix combination therapy in European women with symptomatic uterine fibroids: a subgroup analysis from the randomized phase 3 LIBERTY pivotal trials

OBJECTIVE

In the 24-week, phase 3 LIBERTY 1 (L1) and LIBERTY 2 (L2) trials, relugolix combination therapy (relugolix-CT (relugolix 40 mg, estradiol 1 mg, norethisterone acetate 0.5 mg)) reduced uterine fibroid (UF)-associated symptoms. This post hoc analysis assessed safety and efficacy of relugolix-CT in European women from L1/L2.

METHODS

Premenopausal women (aged 18-50 years) with UF-associated heavy menstrual bleeding (HMB) were randomized 1:1:1 in L1 (N = 388) and L2 (N = 382) to relugolix-CT or placebo for 24 weeks, or delayed relugolix-CT (relugolix 40 mg then relugolix-CT; 12 weeks each). Primary endpoint: proportion of responders (menstrual blood loss (MBL) <80 mL and reduction of ≥50% from baseline MBL volume) over the last 35 days of treatment. Secondary endpoints: MBL volume, amenorrhea, UF-associated pain, symptom severity, distress related to bleeding and pelvic discomfort, health-related quality of life (HRQoL). Safety endpoints included adverse event (AE) reporting and bone mineral density (BMD) assessment.

RESULTS

In European women from L1/L2 (N = 124, 16%), a significantly greater proportion of treatment responders was observed with relugolix-CT vs. placebo (85.4% vs. 19.1%, respectively; nominal p < .0001). There were statistically significant improvements with relugolix-CT vs. placebo for several secondary endpoints: reduction in MBL volume, amenorrhea rate, proportion achieving mild-to-no pain, reduction in symptom severity and distress from bleeding and pelvic discomfort, and improvement in HRQoL. Incidence of AEs and percentage changes in BMD from baseline to week 24 were similar for relugolix-CT and placebo.

CONCLUSIONS

In European women with UF and HMB, once-daily relugolix-CT vs. placebo improved UF-associated symptoms and preserved BMD.

EZH2 activates Wnt/β-catenin signaling in human uterine fibroids, which is inhibited by the natural compound methyl jasmonate

OBJECTIVE

To investigate the link between EZH2 and Wnt/β-catenin signaling and its role in uterine fibroids (UFs) pathogenesis and explore the potential effect of natural compound methyl jasmonate (MJ) against UFs.

DESIGN

EZH2 overexpression or inhibition was achieved in human uterine leiomyoma (HuLM) cells using EZH2-expressing adenovirus or chemical EZH2 inhibitor (DZNep), respectively. The HuLM and normal uterine smooth muscle cells were treated with 0.1-3 mM of MJ, and several experiments were employed.

SETTING

Laboratory study.

PATIENTS(S)

None.

INTERVENTION(S)

Methyl jasmonate.

MAIN OUTCOME MEASURE(S)

Protein expression of EZH2, β-catenin, and proliferating cell nuclear antigen (PCNA) was measured by Western blot as well as gene expression alterations of Wnt ligands (Wnt5A, Wnt5b, and Wnt9A), WISP1, CTNNB1, and its responsive gene PITX2 using quantitative real-time polymerase chain reaction. The protein and ribonucleic acid (RNA) levels of several markers were measured in MJ-treated or untreated HuLM cells, including EZH2 and β-catenin, extracellular matrix markers collagen type 1 (COL1A1) and fibronectin (FN), proliferation markers cyclin D1 (CCND1) and PCNA, tumor suppressor marker p21, and apoptotic markers (BAX, cytochrome c, and cleaved caspase 3).

RESULT(S)

EZH2 overexpression significantly increased the gene expression of several Wnt ligands (PITX2, WISP1, WNT5A, WNT5B, and WNT9A), which increased nuclear translocation of β-catenin and PCNA and eventually HuLM cell proliferation. EZH2 inhibition blocked Wnt/β-catenin signaling activation where the aforementioned genes significantly decreased as well as PCNA, cyclin D1, and PITX2 protein expression compared with those in untreated HuLM. Methyl jasmonate showed a potent antiproliferative effect on HuLM cells in a dose- and time-dependent manner. Interestingly, the dose range (0.1-0.5 mM) showed a selective growth inhibitory effect on HuLM cells, not on normal uterine smooth muscle cells. Methyl jasmonate treatment at 0.5 mM for 24 hours significantly decreased both protein and RNA levels of EZH2, β-catenin, COL1A1, FN, CCND1, PCNA, WISP1, and PITX2 but increased the protein levels of p21, BAX, cytochrome, c and cleaved caspase 3 compared with untreated HuLM. Methyl jasmonate-treated cells exhibited down-regulation in the RNA expression of 36 genes, including CTNNB1, CCND1, Wnt5A, Wnt5B, and Wnt9A, and up-regulation in the expression of 34 genes, including Wnt antagonist genes WIF1, PRICKlE1, and DKK1 compared with control, confirming the quantitative real-time polymerase chain reaction results.

CONCLUSION(S)

Our studies provide a novel link between EZH2 and the Wnt/β-catenin signaling pathway in UFs. Targeting EZH2 with MJ interferes with the activation of wnt/β-catenin signaling in our model. Methyl jasmonate may offer a promising therapeutic option as a nonhormonal and cost-effective treatment against UFs with favorable clinical utility, pending proven safe and efficient in human clinical trials.

Search for key genes, key signaling pathways, and immune cell infiltration in uterine fibroids by bioinformatics analysis

Uterine fibroids grow in the myometrium and are benign tumors. The etiology and molecular mechanism are not fully understood. Here, we hope to study the potential pathogenesis of uterine fibroids by bioinformatics. Our aim is to search for the key genes, signaling pathways and immune infiltration about the development of uterine fibroids. The GSE593 expression profile was downloaded from the Gene Expression Omnibus database, which contains 10 samples, including 5 uterine fibroids samples and 5 normal controls. Bioinformatics methods were used to find differentially expressed genes (DEGs) in tissues and further analyze the DEGs. R (version 4.2.1) software was used for Kyoto Encyclopedia of Genes and Genomes (KEGG) and Gene Ontology (GO) pathway enrichment analysis of DEGs in uterine leiomyoma tissues and normal control. STRING database was used to generate protein-protein interaction (PPI) networks of key genes. Then, CIBERSORT was used to assess the infiltration of immune cells in uterine fibroids. A total of 834 DEGs were identified, of which 465 were up-regulated and 369 were down-regulated. GO andKEGG pathway analysis showed that the DEGs were mainly concentrated in extracellular matrix and cytokine related signaling pathways. We identified 30 key genes in DEGs from the PPI network. There were some differences in infiltration immunity between the 2 tissues. This study indicated that screening key genes, signaling pathways and immune infiltration by comprehensive bioinformatics analysis is helpful to understand the molecular mechanism of uterine fibroids and provide new insights into understanding the molecular mechanism.

Keloids, hypertrophic scars, and uterine fibroid development: a prospective ultrasound study of Black and African American women

OBJECTIVE

To examine the association between keloids, hypertrophic scars, and uterine fibroid incidence as well as growth. Both keloids and fibroids are fibroproliferative conditions that have been reported to be more prevalent among Blacks than Whites, and they share similar fibrotic tissue structures, including extracellular matrix composition, gene expression, and protein profiles. We hypothesized that women with a history of keloids would have greater uterine fibroid development.

DESIGN

A prospective community cohort study (enrollment 2010-2012) with 4 study visits over 5 years to conduct standardized ultrasounds to detect and measure fibroids ≥0.5 cm in diameter, assess the history of keloid and hypertrophic scars, and update covariates.

SETTING

Detroit, Michigan area.

PATIENTS

A total of 1,610 self-identified Black and/or African American women aged 23-35 years at enrollment without a previous clinical diagnosis of fibroids.

EXPOSURE(S)

Keloids (raised scars that grow beyond the margins of the original injury) and hypertrophic scars (raised scars that stay within the bounds of the original injury). Because of the difficulties in distinguishing keloids and hypertrophic scars, we separately examined the history of keloids and the history of either keloids or hypertrophic scars (any abnormal scarring) and their associations with fibroid incidence and growth.

MAIN OUTCOME MEASURE(S)

Fibroid incidence (new fibroid after a fibroid-free ultrasound at enrollment) was assessed using Cox proportional-hazards regression. Fibroid growth was assessed using linear mixed models. The estimates for the change in log volume per 18 months were converted to the estimated percentage difference in volume for scarring vs. no-scarring. Both incidence and growth models were adjusted for time-varying demographic, reproductive, and anthropometric factors.

RESULT(S)

Of the 1,230 fibroid-free participants, 199 (16%) reported ever having keloids, 578 (47%) reported keloids or hypertrophic scars, and 293 (24%) developed incident fibroids. Neither keloids (adjusted hazard ratio = 1.04; 95% confidence interval: 0.77, 1.40) nor any abnormal scarring (adjusted hazard ratio = 1.10; 95% confidence interval: 0.88, 1.38) were associated with fibroid incidence. Fibroid growth differed little by scarring status.

CONCLUSION(S)

Despite molecular similarities, self-reported keloid and hypertrophic scars did not show an association with fibroid development. Future research may benefit from the examination of dermatologist-confirmed keloids or hypertrophic scars; however, our data suggest little shared susceptibility for these 2 types of fibrotic conditions.

'My partner will think I'm weak or overthinking my pain': how being superwoman inhibits Black women's sexual pain disclosure to their partners

Black women experience persistent sexual pain that may often last longer than White women. Despite the value of sexual communication to alleviate sexual pain concerns, many women do not disclose sexual pain to their partners. Limited research explores barriers to disclosing sexual pain to partners among Black women. This study seeks to fill this gap. Relying on an integration of Sexual Script theory and Superwoman Schema, the study explored the barriers that premenopausal, cisgender Black women from the Southern USA perceived when disclosing sexual pain to their primary partners. We identified five common themes from women's open-ended responses to an online survey: (a) distressing emotions associated with disclosure; (b) limited knowledge and communication skills; (c) protecting partner's feelings and ego; (d) invading privacy; and (e) taking sole responsibility for managing sexual pain. Findings suggest a combination of intrapsychic, interpersonal and cultural factors influence Black women's perceived ability to have direct and open dyadic communication about sexual pain with their partners. Implications for Black women's sexual health and relationship outcomes are discussed.

Cyclic processes in the uterine tubes, endometrium, myometrium, and cervix: pathways and perturbations

This review leads the 2023 Call for Papers in MHR: 'Cyclical function of the female reproductive tract' and will outline the complex and fascinating changes that take place in the reproductive tract during the menstrual cycle. We will also explore associated reproductive tract abnormalities that impact or are impacted by the menstrual cycle. Between menarche and menopause, women and people who menstruate living in high-income countries can expect to experience ∼450 menstrual cycles. The primary function of the menstrual cycle is to prepare the reproductive system for pregnancy in the event of fertilization. In the absence of pregnancy, ovarian hormone levels fall, triggering the end of the menstrual cycle and onset of menstruation. We have chosen to exclude the ovaries and focus on the other structures that make up the reproductive tract: uterine tubes, endometrium, myometrium, and cervix, which also functionally change in response to fluctuations in ovarian hormone production across the menstrual cycle. This inaugural paper for the 2023 MHR special collection will discuss our current understanding of the normal physiological processes involved in uterine cyclicity (limited specifically to the uterine tubes, endometrium, myometrium, and cervix) in humans, and other mammals where relevant. We will emphasize where knowledge gaps exist and highlight the impact that reproductive tract and uterine cycle perturbations have on health and fertility.

Progesterone Signaling and Uterine Fibroid Pathogenesis; Molecular Mechanisms and Potential Therapeutics

Uterine fibroids (UFs) are the most important benign neoplastic threat to women's health worldwide, with a prevalence of up to 80% in premenopausal women, and can cause heavy menstrual bleeding, pain, and infertility. Progesterone signaling plays a crucial role in the development and growth of UFs. Progesterone promotes the proliferation of UF cells by activating several signaling pathways genetically and epigenetically. In this review article, we reviewed the literature covering progesterone signaling in UF pathogenesis and further discussed the therapeutic potential of compounds that modulate progesterone signaling against UFs, including selective progesterone receptor modulator (SPRM) drugs and natural compounds. Further studies are needed to confirm the safety of SPRMs as well as their exact molecular mechanisms. The consumption of natural compounds as a potential anti-UFs treatment seems promising, since these compounds can be used on a long-term basis-especially for women pursuing concurrent pregnancy, unlike SPRMs. However, further clinical trials are needed to confirm their effectiveness.

Complementary and Alternative Medicine Use Among Women with Symptomatic Uterine Fibroids

Objective: The aim of this study is to examine complementary and alternative medicine (CAM) use among women with symptomatic uterine fibroids in the United States. Materials and Methods: In this cross-sectional analysis of baseline data from a multicenter, prospective cohort study of premenopausal women undergoing surgery for symptomatic fibroids and who enrolled in the Uterine Leiomyoma Treatment with Radiofrequency Ablation study from 2017 to 2019, we contrast women indicating use of at least one CAM modality specifically for fibroid symptoms against women using CAM for other reasons and CAM nonusers. Multivariable logistic regression models were performed to identify participant characteristics independently associated with CAM use for fibroids. Results: Among 204 women, 55% were Black/African American and the mean age was 42 (standard deviation 6.6) years. CAM use was common (67%), with 42% (95% confidence interval [CI]: 35%-49%) reporting use of CAM specifically to treat fibroid symptoms. Most commonly, CAM treatments used for fibroids were diet (62%) and herbs (52%), while CAM treatments for other reasons were exercise (80%) and massage (43%). On average, each participant who reported CAM use utilized three different types of CAM modalities. In a multivariable model, participants were more likely to use CAM for fibroids if they had pelvic pressure (odds ratio [OR] 2.50, 95% CI: 1.07-5.87, p = 0.04), a body-mass index lower than average (OR 0.76, 95% CI: 0.60-0.97, p = 0.03), and a lower health-related quality of life score (OR 0.61, 95% CI: 0.46-0.81, p = 0.001). Conclusions: In this diverse sample of women with symptomatic fibroids, CAM use was highly prevalent. Our findings highlight the need for providers to query patients about CAM use and understand the role of CAM in fibroid management. ClinicalTrials.gov Identifier: NCT02100904.

A View on Uterine Leiomyoma Genesis through the Prism of Genetic, Epigenetic and Cellular Heterogeneity

Uterine leiomyomas (ULs), frequent benign tumours of the female reproductive tract, are associated with a range of symptoms and significant morbidity. Despite extensive research, there is no consensus on essential points of UL initiation and development. The main reason for this is a pronounced inter- and intratumoral heterogeneity resulting from diverse and complicated mechanisms underlying UL pathobiology. In this review, we comprehensively analyse risk and protective factors for UL development, UL cellular composition, hormonal and paracrine signalling, epigenetic regulation and genetic abnormalities. We conclude the need to carefully update the concept of UL genesis in light of the current data. Staying within the framework of the existing hypotheses, we introduce a possible timeline for UL development and the associated key events—from potential prerequisites to the beginning of UL formation and the onset of driver and passenger changes.