Examining the Relationship Between Symptomatic Burden and Self-reported Productivity Losses Among Patients With Uterine Fibroids in the United States

The Burden of Pain Symptoms in Individuals with Uterine Fibroids-Results from a Prospective Observational Study in the USA

Purpose

To characterize the burden of uterine fibroids (UF) in individuals experiencing heavy menstrual bleeding (HMB) and moderate-to-severe UF-associated pain in terms of symptoms experienced, impact on work and activities, and pain medication use both on menstrual and non-menstrual days.

Patients and Methods

This prospective, real-world, observational study enrolled 350 participants in the USA with a self-reported UF diagnosis, HMB, and moderate-to-severe pain due to UF. Data collection took place from February 9 to July 19, 2021. Over 4 months, participants used an online platform to self-report daily menstrual status, bleeding intensity, UF-associated pain severity, and pain medication use, and to complete weekly work and productivity questionnaires. Results were analyzed descriptively and are reported for the overall population, by pain medication subgroups-defined based on the most potent medication taken-and menstrual versus non-menstrual days/weeks.

Results

The analysis population consisted of 307 participants with ≤5 consecutive missing days of daily survey responses or ≥75% completion rate of the daily surveys. Mean age of participants (standard deviation; SD) was 37.2 (6.3) years. At baseline, 54.1% of participants reported not currently taking medication for treatment of HMB. Over the study period, mean UF-associated pain scores (SD; scale range 0-10) were higher on menstrual days (3.5 [2.7]) than non-menstrual days (1.0 [1.8]), and this was consistent across medication use subgroups. Pain medications were used more frequently on menstrual days than non-menstrual days (22.9% versus 3.7% days of pain medication use, respectively). Participants reported 31.5% work impairment on menstrual weeks versus a 12.7% work impairment on non-menstrual weeks.

Conclusion

In this study, UF-associated pain symptoms coincided with a reduction in individuals' ability to take part in both work and non-work activities and an increase in pain medication use, particularly during menstrual weeks. These results highlight the need for improved diagnosis and pain management strategies in UF.

The effect of uterine fibroid region and depth on endometrial stress and strain: a finite element approach

Uterine fibroids are common benign gynecological tumors that are observed in up to 80% of premenopausal women. It is understood that as the fibroid size increases, the surrounding tissues will be subject to greater loads. However, the effect of fibroid region on the uterine structure is not as clear. To better understand the mechanical loading of the endometrium due to the presence of a uterine fibroid, we developed a finite element model of the uterus to examine the effect of both fibroid depth and region in relation to the endometrium. The finite element model of the uterus, endometrium, and a uterine fibroid were created from a 3D segmentation of a patient's magnetic resonance images. This model was then loaded into ANSYS Mechanical 2023 R1, and then deformation, stress, and strain of the endometrium was measured for 24 fibroid positions (8 regions × 3 depths). The highest endometrial loads (deformation, stress, strain) were observed when the fibroid region was superior to the uterus and the depth was deep. Superior regions generated 10-20% higher loads on the endometrium in comparison to other regions, while deep locations had 5-10% higher endometrium loads when compared to superficial depths across almost all regions. A simple uterus model was used to show the effect of fibroid position on loads acting on the endometrium. This can provide insight into mechanisms of abnormal uterine bleeding and infertility and better inform clinical decision making.

Productivity loss due to polycystic ovary syndrome and its relationship to race, mental health and healthcare delivery indices

Objective

To study the impact of polycystic ovary syndrome (PCOS) on work-related impairments and explore relationships with race, mental health, and healthcare delivery indices.

Design

A cross-sectional internet-based survey.

Setting

North American women with PCOS between August 2022 and October 2022.

Patients

Individuals with a self-reported diagnosis of PCOS.

Interventions

Not applicable.

Main Outcome Measures

The primary outcome was missed work because of PCOS. The secondary outcomes included leave from work, impacts on the quality of work, and feelings of being held back at work because of PCOS.

Results

Of 1,105 respondents, 1,058 reported having PCOS diagnosed by a physician. Of this group, 50.4% reported missing work because of PCOS, 72% felt that PCOS impacted the quality of their work, and 51.5% felt held back at work by PCOS. Multivariate analyses revealed that missing work because of PCOS was independently associated with black race, lack of insurance, requiring multiple doctors for a PCOS diagnosis, needing ≥3 doctors for current care, decreased satisfaction with care, and symptoms of anxiety and depression.

Conclusions

Polycystic ovary syndrome significantly impacts employment-related productivity. Factors such as race, mental health, and healthcare delivery appear to play a crucial role in the extent of this impact.

Relationship between somatic symptoms with menstruation and intention to leave work among university hospital nurses in Japan: a cross-sectional study

PURPOSE

This study investigated the association between menstrual symptoms and the intention to leave work among female nurses in Japan.

METHODS

This cross-sectional study investigated female nurses (n = 317) at two university hospitals. The items measured were their characteristics (e.g., age, body mass index), "intention to leave" work, somatic symptoms related with menstruation, self-reported menstrual characteristics (e.g., pain), physical workloads (e.g., working hours and night shifts) and psychological workloads, measured with the Copenhagen Burnout Inventory (CBI), and the Job Content Questionnaire (JCQ). Participants with at least four somatic symptoms (e.g., cold, fatigue) which are present during their menstrual cycles were considered to have "somatic symptoms associated with menstruation." We also measured serum ovarian and gonadotropin-releasing hormones.

RESULTS

Approximately 40% of women answered "intention to leave" work, and 17% had "somatic symptoms associated with menstruation." Multiple logistic regression analysis suggested that nurses reporting "somatic symptoms associated with menstruation" were more likely to have "intention to leave" work: the adjusted odds ratios (AOR, 95% confidence interval [CI]) were 2.15 (1.12-4.11) in the personal-burnout model, 2.23 (1.16-4.31) in the work-related burnout model, 2.91 (1.52-5.56) in the client-related burnout model; 2.96 (1.50-5.82) in the JCQ model. There was no association between serum and gonadotropin hormones and the intention to leave.

CONCLUSION

Somatic symptoms with menstruation were associated with intention to leave work among female Japanese nurses. Intervention for somatic symptoms with menstruation might support nurses to continue work.

Uterine Fibroids: Assessing Unmet Needs from Bench to Bedside

Uterine fibroids (leiomyomas) are noncancerous growths that can have deleterious effects on the health and quality of life for millions of women. Attempts to better understand the factors that influence prevalence and disparities associated with fibroids have been made; however, significant knowledge gaps continue to persist, which hinder care for individuals living with fibroids. The Society for Women's Health Research convened an interdisciplinary Uterine Fibroids Working Group to review the current state of knowledge about uterine fibroids and recommend areas in which to prioritize efforts to address research gaps and improve diagnosis, treatment, and access to care for patients with this chronic disease. Throughout a 2-day roundtable meeting, participants discussed updates on key literature, research, clinical practice, and public health data on uterine fibroids. Overarching themes and recommendations were identified and determined by consensus agreement of the participants at the conclusion of the meeting. Systematic studies of the etiology and pathology of uterine fibroids are needed to address important knowledge gaps and unmet clinical needs regarding the multifaceted management of fibroids and their effects on overall health and quality of life. The Working Group recommends addressing key deficits within the spheres of research, clinical care, and federal policy. Immediate needs include increasing research investment, improving fibroid assessment using pelvic imaging, implementing longitudinal study designs, addressing factors that contribute to disease disparities (especially among women of color), developing fertility-friendly treatment options, expanding awareness and education beyond gynecologic specialists, and advancing personalized patient care through shared decision-making approaches.

Elagolix Treatment for Up to 12 Months in Women With Heavy Menstrual Bleeding and Uterine Leiomyomas

Up to 12 months of elagolix with add-back therapy provided sustained reduction in menstrual blood loss with an acceptable safety profile in women with uterine leiomyomas.

To investigate the safety and efficacy of elagolix, an oral gonadotropin-releasing hormone antagonist, with hormonal add-back therapy for up to 12 months in women with heavy menstrual bleeding associated with uterine leiomyomas.

Drug-Drug Interaction Studies of Elagolix with Oral and Transdermal Low-Dose Hormonal Add-Back Therapy

BACKGROUND AND OBJECTIVE

Elagolix is an oral, non-peptide, gonadotropin-releasing hormone receptor antagonist. It is approved for the treatment of moderate-to-severe pain associated with endometriosis and is being investigated for the treatment of heavy menstrual bleeding associated with uterine fibroids. Use of low-dose hormonal add-back therapy can reduce hypoestrogenic effects associated with elagolix, thus there is a need to determine if there is a pharmacokinetic interaction between elagolix and low-dose hormonal add-back therapy.

METHODS

Two multiple-dose, open-label, single-sequence, non-randomized studies for elagolix 300 mg twice daily with oral (n = 24) and transdermal (n = 36) low-dose add-back therapy (estradiol [E2]/norethindrone acetate [NETA]; 1 mg/0.5 mg oral and 0.51 mg/4.8 mg transdermal) in healthy postmenopausal women were conducted, with pharmacokinetic sampling for E2, estrone (E1), and NETA up to 72 or 96 h after dosing. Pharmacokinetic parameters for hormones were estimated using noncompartmental methods.

RESULTS

No change in norethindrone maximum plasma concentration or area under the concentration-time curve was observed when oral E2/NETA was administered with elagolix. For E2, there was a 2-fold increase in maximum plasma concentration and a 1.5-fold increase in the area under the concentration-time curve, and for E1 there was a 1.7-fold increase in maximum plasma concentration when oral E2/NETA was administered with elagolix. Exposures for norethindrone, E2, and E1 were unchanged when transdermal E2/NETA was applied with elagolix administration.

CONCLUSIONS

Although changes in E2/E1 exposures were observed when oral E2/NETA was co-administered with elagolix, these changes are not considered clinically relevant; and no dose adjustments are recommended when elagolix is co-administered with oral or transdermal low-dose add-back therapy.

Treatment Choices in a National Cohort of Canadian Women With Symptomatic Uterine Fibroids

OBJECTIVES

To describe treatment choices made at the time of enrollment in CAPTURE, a Canadian patient registry for women with symptomatic uterine fibroids (UFs), and to define demographic and clinical characteristics that independently predict these choices.

METHODS

Women arranging appointments for UF care were eligible to enrol. At the time of the enrollment visit, women's self-reported treatment histories were noted, along with their clinical characteristics. Tretment options were discussed and chosen during that visit. Patients could choose medical and/or surgical treatment, or they could opt for no active treatment (i.e., "watchful waiting"); treatment decisions were not binding.

RESULTS

The most common medication proposed and chosen was ulipristal acetate (UPA), and the most common procedure was myomectomy. These treatments were also the most commonly identified in patients' histories. Medication alone and medication in combination with surgery were the most common treatment approaches chosen (46% and 26%, respectively). Surgery alone and watchful waiting were chosen by 14% and 13% of patients, respectively. Significant predictors of active treatment included patient pregnancy plans, overall symptom severity, and prior treatment history (medical and surgical). Other parameters, including patient age and history of specific UF symptoms, appear to influence the choice of medical therapies (UPA, gonadotropin-releasing hormone agonists, or other options) and procedures (myomectomy or hysterectomy).

CONCLUSIONS

This real-world study documents the patient factors associated with the treatment decisions of women seeking care for symptomatic UFs in contemporary Canadian gynaecology practice. Subsequent analyses will follow the outcomes of these treatments over two years in this population.

Elagolix for Heavy Menstrual Bleeding in Women with Uterine Fibroids

BACKGROUND

Uterine fibroids are hormone-responsive neoplasms that are associated with heavy menstrual bleeding. Elagolix, an oral gonadotropin-releasing hormone antagonist resulting in rapid, reversible suppression of ovarian sex hormones, may reduce fibroid-associated bleeding.

METHODS

We conducted two identical, double-blind, randomized, placebo-controlled, 6-month phase 3 trials (Elaris Uterine Fibroids 1 and 2 [UF-1 and UF-2]) to evaluate the efficacy and safety of elagolix at a dose of 300 mg twice daily with hormonal "add-back" therapy (to replace reduced levels of endogenous hormones; in this case, estradiol, 1 mg, and norethindrone acetate, 0.5 mg, once daily) in women with fibroid-associated bleeding. An elagolix-alone group was included to assess the impact of add-back therapy on the hypoestrogenic effects of elagolix. The primary end point was menstrual blood loss of less than 80 ml during the final month of treatment and at least a 50% reduction in menstrual blood loss from baseline to the final month; missing data were imputed with the use of multiple imputation.

RESULTS

A total of 412 women in UF-1 and 378 women in UF-2 underwent randomization, received elagolix or placebo, and were included in the analyses. Criteria for the primary end point were met in 68.5% of 206 women in UF-1 and in 76.5% of 189 women in UF-2 who received elagolix plus add-back therapy, as compared with 8.7% of 102 women and 10% of 94 women, respectively, who received placebo (P<0.001 for both trials). Among the women who received elagolix alone, the primary end point was met in 84.1% of 104 women in UF-1 and in 77% of 95 women in UF-2. Hot flushes (in both trials) and metrorrhagia (in UF-1) occurred significantly more commonly with elagolix plus add-back therapy than with placebo. Hypoestrogenic effects of elagolix, especially decreases in bone mineral density, were attenuated with add-back therapy.

CONCLUSIONS

Elagolix with add-back therapy was effective in reducing heavy menstrual bleeding in women with uterine fibroids. (Funded by AbbVie; Elaris UF-1 and Elaris UF-2 ClinicalTrials.gov numbers, NCT02654054 and NCT02691494.).

The association between chronic psychological stress and uterine fibroids risk: A meta-analysis of observational studies

The association between chronic psychological stress and uterine fibroids (UFs) risk remains unclear. In this study, a meta-analysis of observational studies was performed to explore the reported association between them. A literature search was performed in PubMed, EMBASE, and Web of Science to identify relevant published articles. A random-effect model was used to examine pooled odds ratio (OR) and 95% confidence interval (CI). Additionally, subgroup analyses and two-stage random-effect dose-response meta-analysis were performed. A total of six articles with seven studies were included in this meta-analysis. For the highest versus lowest category of chronic psychological stress, the pooled OR was 1.24 (95% CI [1.15, 1.34]; p = .000). Through subgroup analyses, we found a positive association between chronic psychological stress and UFs risk especially in non-Hispanic Blacks studies (OR, 1.24, 95% CI [1.14, 1.34], p = .000). When evaluating for a dose-response, we found a weak correlation between chronic psychological stress and UFs risk, especially for the severe (OR, 1.17, 95% CI [1.07, 1.29]) and very severe (OR, 1.23, 95% CI [1.07, 1.41]) categories. Our meta-analysis shows a statistically significant association between chronic psychological stress and UFs risk particularly for non-Hispanic Blacks. Interventions aiming to reduce chronic psychological stress may be useful to decrease the prevalence of UFs.