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Moawad G, Youssef Y, Fruscalzo A, Faysal H, Kheil M, Pirtea P, Guani B, Ayoubi JM, Feki A. The Present and the Future of Medical Therapies for Adenomyosis: A Narrative Review. J Clin Med 2023; 12:6130. [PMID: 37834773 PMCID: PMC10573655 DOI: 10.3390/jcm12196130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 09/11/2023] [Accepted: 09/15/2023] [Indexed: 10/15/2023] Open
Abstract
Uterine Adenomyosis is a benign condition characterized by the presence of endometrium-like epithelial and stromal tissue in the myometrium. Several medical treatments have been proposed, but still, no guidelines directing the management of adenomyosis are available. While a hysterectomy is typically regarded as the definitive treatment for adenomyosis, the scarcity of high-quality data leaves patients desiring fertility with limited conservative options. Based on the available data, the levonorgestrel-IUD appears to offer the most favorable outcomes. Other treatments, including GnRH antagonists, dienogest, prolactin, and oxytocin modulators, show promise; however, further data are required to establish their efficacy definitively. Furthermore, there are many emerging therapies that have been developed that seem worthy of consideration in the near future. The aim of this narrative review was to explore the current medical treatments available for adenomyosis and to provide a glimpse of future therapies under assessment. For this scope, we performed a literature search on PubMed and Medline from incept to September 2022 using the keywords: "medical treatment", "non-steroidal anti-inflammatory", "progesterone intrauterine device", "dienogest", "combined oral contraceptives", "gonadotropin releasing hormone agonist", "gonadotropin releasing hormone antagonist", "danazol", "aromatase inhibitors", "ulipristal acetate", "anti-platelet therapy", "dopamine", "oxytocin antagonists", "STAT3", "KRAS", "MAPK", "micro-RNA", "mifepristone", "valproic acid", "levo-tetrahydropalamatine", and "andrographolide". The search was limited to articles in English, with subsequent screening of abstracts. Abstracts were screened to select relevant studies.
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Affiliation(s)
- Gaby Moawad
- Department of Obstetrics and Gynecology, George Washington University, Washington, DC 20037, USA
- The Center for Endometriosis and Advanced Pelvic Surgery, Washington, DC 22101, USA
| | - Youssef Youssef
- Division of Minimally Invasive Gynecology, Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, NY 11220, USA
| | - Arrigo Fruscalzo
- Department of Obstetrics and Gynecology, HFR—Fribourg, Chemin des Pensionnats 2-6, 1708 Fribourg, Switzerland; (A.F.)
| | - Hani Faysal
- Department of Obstetrics and Gynecology, Indiana University, Indianapolis, IN 46202, USA
| | - Mira Kheil
- Department of Obstetrics and Gynecology, Henry Ford Health, Detroit, MI 48202, USA
| | - Paul Pirtea
- Department of Obstetrics and Gynecology and Reproductive Medicine, Hopital Foch–Faculté de Médecine Paris, 92150 Suresnes, France
| | - Benedetta Guani
- Department of Obstetrics and Gynecology, HFR—Fribourg, Chemin des Pensionnats 2-6, 1708 Fribourg, Switzerland; (A.F.)
| | - Jean Marc Ayoubi
- Department of Obstetrics and Gynecology and Reproductive Medicine, Hopital Foch–Faculté de Médecine Paris, 92150 Suresnes, France
| | - Anis Feki
- Department of Obstetrics and Gynecology, HFR—Fribourg, Chemin des Pensionnats 2-6, 1708 Fribourg, Switzerland; (A.F.)
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Singh S, Kumar P, Rathore SS, Singh Y, Garg N. Contemporary approaches in the management of uterine leiomyomas. Eur J Obstet Gynecol Reprod Biol 2023; 287:195-210. [PMID: 37385088 DOI: 10.1016/j.ejogrb.2023.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 04/24/2023] [Accepted: 06/20/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND Leiomyomas (fibroids), the most common benign solid tumours in females, originate from the myometrium and are associated with poor quality of life for patients. The current management of uterine leiomyomas mainly includes surgical interventions such as hysterectomy and myomectomy, either by laparoscopy or laparotomy, which have several complications and are not ideal for preserving fertility. Therefore, there is a need to develop or repurpose medical treatments that do not require surgical intervention. OBJECTIVE Many drugs are used to treat the symptoms associated with uterine fibroids. The main objective of this systematic review is to give an up-to-date account of potential pharmacological agents (non-surgical methods) for the management of uterine leiomyomas. SEARCH STRATEGY PubMed was searched for scientific and clinical literature using the keyword 'uterine fibroids' along with the drug names described in each section. For example, 'uterine fibroids' and 'ulipristal acetate' were the keywords used to search for literature on ulipristal acetate (UPA). RESULTS Various preclinical and clinical studies have shown that some drugs and herbal formulations exhibit activity in the management of uterine leiomyomas. Recent studies found that drugs such as UPA, elagolix, EC313, asoprisnol, nutritional supplements and herbal preparations were helpful in treating the symptoms associated with uterine leiomyomas. CONCLUSION Many drugs show efficacy in patients with symptomatic uterine fibroids. UPA is one of the most studied and prescribed medicines for uterine fibroids; however, its usage has been restricted due to a few recent incidences of hepatic toxicity. Herbal drugs and natural supplements have also shown promising effects on uterine fibroids. The synergistic effects of nutritional and herbal supplements have been reported in certain cases, and should be studied in detail. Further research is warranted to identify the mode of action of the drugs, and to determine the precise conditions that would explain the causes of toxicity in some patients.
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Affiliation(s)
- Shikha Singh
- Department of Prasuti Tantra, Faculty of Ayurveda, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Praveen Kumar
- Department of Medicinal Chemistry, Faculty of Ayurveda, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Saurabh Singh Rathore
- Department of Biotechnology, Mahatma Gandhi Central University, Raghunathpur, Motihari, East Champaran, Bihar, India
| | - Yashasvi Singh
- Department of Urology, CSSB, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Neha Garg
- Department of Medicinal Chemistry, Faculty of Ayurveda, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India.
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Goitia M, Andres M, Aquesolo L, Azkuenaga A, Cearsolo A, de los Bueis J, Diaz T, Diez S, Martinez Zilloniz N, Millan L, Silva J, Urquijo E. Tratamiento médico de los miomas uterinos. Del presente al futuro. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2023. [DOI: 10.1016/j.gine.2023.100845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
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Elbasueny B, Geerts M, Allaire C, Yong PJ, Bedaiwy MA. Medical Treatment of Adenomyosis. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2022. [DOI: 10.1007/s13669-022-00325-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Middelkoop MA, de Lange ME, Clark TJ, Mol BWJ, Bet PM, Huirne JAF, Hehenkamp WJK. OUP accepted manuscript. Hum Reprod 2022; 37:884-894. [PMID: 35143669 PMCID: PMC9071218 DOI: 10.1093/humrep/deac009] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 12/24/2021] [Indexed: 11/13/2022] Open
Abstract
Ulipristal acetate (UPA) is a medical treatment for uterine fibroids and was authorized for surgical pre-treatment in 2012 after the conduct of the PEARL I and II randomized controlled trials and for intermittent treatment after the observational PEARL III and IV trials. However, UPA came into disrepute due to its temporary suspension in 2017 and 2020 because of an apparent association with liver injury. This clinical opinion paper aims to review the process of marketing authorization and implementation of UPA, in order to provide all involved stakeholders with recommendations for the introduction of future drugs. Before marketing authorization, the European Medicines Agency (EMA) states that Phase III registration trials should evaluate relevant outcomes in a representative population, while comparing to gold-standard treatment. This review shows that the representativeness of the study populations in all PEARL trials was limited, surgical outcomes were not evaluated and intermittent treatment was assessed without comparative groups. Implementation into clinical practice was extensive, with 900 000 prescribed treatment cycles in 5 years in Europe and Canada combined. Extremely high costs are involved in developing and evaluating pre-marketing studies in new drugs, influencing trial design and relevance of chosen outcomes, thereby impeding clinical applicability. It is vitally important that the marketing implementation after authorization is regulated in such way that necessary evidence is generated before widespread prescription of a new drug. All stakeholders, from pharmaceutical companies to authorizing bodies, governmental funding bodies and medical professionals should be aware of their role and take responsibility for their part in this process.
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Affiliation(s)
- Mei-An Middelkoop
- Department of Obstetrics and Gynaecology, Amsterdam Reproduction and Development, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Correspondence address. Amsterdam UMC, Location de Boelelaan, Postbus 7057, 1007 MB Amsterdam, The Netherlands. Tel: +31-20-444-4444; E-mail: https://orcid.org/0000-0003-0847-2566
| | - Maria E de Lange
- Department of Obstetrics and Gynaecology, Amsterdam Reproduction and Development, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - T Justin Clark
- Department of Obstetrics and Gynaecology, Birmingham Women’s and Children’s Hospital, Birmingham, UK
| | - Ben Willem J Mol
- Department of Obstetrics and Gynaecology, Monash University Monash Medical Centre, Clayton, Victoria, Australia
- Department of Obstetrics and Gynaecology, Aberdeen Centre for Women's Health Research, University of Aberdeen, Aberdeen, UK
- Department of Obstetrics and Gynaecology, University of Aberdeen Aberdeen, Aberdeen, UK
| | - Pierre M Bet
- Department of Clinical Pharmacology and Pharmacy, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Judith A F Huirne
- Department of Obstetrics and Gynaecology, Amsterdam Reproduction and Development, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Wouter J K Hehenkamp
- Department of Obstetrics and Gynaecology, Amsterdam Reproduction and Development, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Obstetrics and Gynaecology, Amsterdam Reproduction and Development, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Jha S, Ahmed N, Sinha HH. Safety and efficacy of two repeated cycles of ulipristal acetate in the management of symptomatic uterine fibroid among Indian women. PRZEGLAD MENOPAUZALNY = MENOPAUSE REVIEW 2021; 20:127-132. [PMID: 34703413 PMCID: PMC8525252 DOI: 10.5114/pm.2021.109509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 06/22/2021] [Indexed: 12/03/2022]
Abstract
INTRODUCTION To evaluate the safety and efficacy along with the impact on uterine and fibroid vascular indices of 2 repeat 12-week courses of ulipristal acetate (UPA) among Indian women. MATERIAL AND METHODS Ninety-four premenopausal women aged 18-45 years with at least 1 symptomatic fibroid of size ranging from 1 cm to 10 cm were included in the study. All participants received 2 courses of 5 mg of UPA orally for 12 weeks starting from the 5th day of their menstrual cycle with a 2-menstrual-cycle break in between. The efficacy was measured in terms of time to amenorrhoea, percentage of women who achieved amenorrhoea for the last 35 consecutive days, reduction in uterine and fibroid volume, as well as its vascularity at the end of the first and second treatment cycle. RESULTS Eighty-six women completed the first treatment cycle whereas only 65 women completed the second treatment course. Seventy-nine per cent of women achieved amenorrhoea for 35 consecutive days during the first treatment cycle. Median time to amenorrhoea was 7 days and 5 days during the first and second treatment cycle, respectively. Percentage reduction of the mean fibroid volume was 32% and 52% after the first and second treatment cycle, respectively. We observed an increase in fibroid vascular indices (pulsatility index and resistive index) suggesting reduction in fibroid vascularity. Serum oestradiol remained at mid-follicular phase. No serious drug emergent side effect was noted. CONCLUSIONS Two interrupted repeat course of 5mg UPA is well tolerated efficient and safe in symptomatic fibroid among Indian women.
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Affiliation(s)
- Sangam Jha
- All India Institute of Medical Sciences, Patna, India
| | - Naaz Ahmed
- All India Institute of Medical Sciences, Patna, India
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Osuga Y, Nakano Y, Yamauchi Y, Murakawa H. Phase III long-term study to evaluate the efficacy and safety of ulipristal acetate in Japanese patients with uterine fibroids. J Obstet Gynaecol Res 2021; 47:3269-3278. [PMID: 34109697 PMCID: PMC8453825 DOI: 10.1111/jog.14802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 03/14/2021] [Accepted: 04/10/2021] [Indexed: 11/29/2022]
Abstract
Aim To assess the efficacy and safety of long‐term intermittent administration of 10‐mg ulipristal acetate (UPA) for symptomatic uterine fibroids in Japanese women. Methods Open‐label, noncomparative study (Japan Primary Registries Network identifier: JapicCTI‐173737) conducted at 32 gynecological centers (November 2017–December 2019). Premenopausal women diagnosed with uterine fibroids associated with heavy menstrual bleeding received three 12‐week courses of 10‐mg UPA once daily. Amenorrhea, fibroid volume, endometrial histology, and safety were assessed. Results Of 155 patients enrolled, 140 received ≥1 dose of UPA and were analyzed. Across all courses, the rates of patients with amenorrhea for 35 days were >90%, and >99% of patients achieved uterine bleeding normalization. Median time to amenorrhea after each course started was 4–5 days; menstruation returned after treatment within a median of 25–27 days. Mean changes in fibroid volume from baseline were −21.5%, −31.4%, and −35.0% for Courses 1, 2, and 3, respectively. Patients experienced sustained improvements in anemia, pain, and quality of life during treatment. Most adverse events were mild/moderate in severity and decreased in frequency with each course. Seven serious adverse events (six patients) were reported; anemia, embolic cerebral infarction, and pituitary apoplexy (one patient each) were considered UPA‐related. Nonphysiological changes in endometrial histology were transient and benign. No safety concerns were detected in hormone concentrations or liver function tests. Conclusions Long‐term administration of 10‐mg UPA is effective for reducing symptoms associated with uterine fibroids in Japanese women. UPA was well tolerated and few safety concerns were reported.
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Affiliation(s)
- Yutaka Osuga
- Department of Gynecologic Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Yasuaki Nakano
- Clinical Development Department, ASKA Pharmaceutical Co., Ltd., Tokyo, Japan
| | - Yuji Yamauchi
- Clinical Development Department, ASKA Pharmaceutical Co., Ltd., Tokyo, Japan
| | - Hitoshi Murakawa
- Clinical Development Department, ASKA Pharmaceutical Co., Ltd., Tokyo, Japan
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Yoon EL, Yuk JS. Use of Ulipristal Acetate and Risk of Liver Disease: A Nationwide Cohort Study. J Clin Endocrinol Metab 2021; 106:1773-1782. [PMID: 33567071 DOI: 10.1210/clinem/dgab081] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Indexed: 02/08/2023]
Abstract
CONTEXT Large-scale clinical trials on the hepatotoxicity of ulipristal acetate (UPA) are lacking. OBJECTIVE This work aimed to determine the incidence of liver disease with UPA vs gonadotropin-releasing hormone (GnRH) agonists. METHODS A retrospective cohort study was conducted in South Korea of women with uterine fibroids from the Korean Health Insurance Data 2010 to 2018. Women with uterine fibroids were divided into 2 treatment groups: the UPA (5 mg/day) and GnRH agonist groups. Main outcome measures included the presence or absence of severe liver disease, mild liver disease, and liver transplantation. RESULTS Among the patients with uterine fibroids,17 207 patients were treated with GnRH agonists and 20 926 patients with UPA. After 1:1 propensity score matching for each group, there were 11 445 individuals. Neither group had a liver transplantation case. In the conditional logistic regression analysis, the incidence of total liver diseases (relative risk [RR] 1.111; 95% CI, 1.015-1.216) and mild liver diseases (RR 1.094; 95% CI, 1-1.196) was higher in the UPA group than in the GnRH agonist group, but that of severe liver diseases (RR 0.07; 95% CI, 0.001-4.412) and toxic liver disease (RR 1.256; 95% CI, 0.845-1.867) did not differ between the groups. CONCLUSION The incidence of severe liver disease, hepatic failure, and toxic liver disease was not different between the UPA and GnRH agonist groups. However, the incidence of mild liver disease was higher in the UPA group than in the GnRH agonist group. The incidence of hepatic damage with UPA was very low.
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Affiliation(s)
- Eileen L Yoon
- Department of Internal Medicine, Hanyang University Hospital, Hanyang University College of Medicine, Seongdong-gu, Seoul 04763, Republic of Korea
| | - Jin-Sung Yuk
- Department of Obstetrics and Gynecology, Sanggye Paik Hospital, School of Medicine, Inje University, Nowon-gu, Seoul 01757, Republic of Korea
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Chodankar RR, Murray A, Nicol M, Whitaker LHR, Williams ARW, Critchley HOD. The endometrial response to modulation of ligand-progesterone receptor pathways is reversible. Fertil Steril 2021; 116:882-895. [PMID: 33865567 DOI: 10.1016/j.fertnstert.2021.02.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/29/2021] [Accepted: 02/05/2021] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To study the impact of the progesterone receptor modulator (PRM), ulipristal acetate (UPA), on endometrial morphology and function. DESIGN Cross-sectional. SETTING University Research Institute. PATIENT(S) Endometrial biopsies from 16 patients with heavy menstrual bleeding with a structurally normal uterus or in association with structural abnormalities identified on radiological imaging (fibroids, adenomyosis or a combination of fibroids and adenomyosis). INTERVENTION(S) Participants received UPA (5 mg once daily) for three 12-week courses, each separated by 4 weeks without treatment. MAIN OUTCOME MEASURE(S) Gene expression by real-time quantitative reverse transcription polymerase chain reaction, immunohistochemistry, and digital image analysis were analyzed to investigate the endometrial impact of modulation of progesterone receptor pathways upon expression of steroid receptors, steroid metabolizing enzymes, cell proliferation, and progesterone-regulated genes in the same patients at 3 time points: before, during, and after discontinuation of PRM treatment. RESULT(S) Ulipristal acetate treatment resulted in increased messenger ribonucleic acid (mRNA) levels of steroid receptors compared with pretreatment secretory endometrium; decreased mRNA levels of 17- and 11-beta-hydroxysteroid dehydrogenases compared with pretreatment proliferative endometrium and pretreatment secretory endometrium; reduced cell proliferation compared with pretreatment proliferative endometrium; and altered mRNA levels of progesterone-regulated genes. A strong consistency between immunohistochemistry-digital image analysis and real-time quantitative reverse transcription polymerase chain reaction results was evident. Alterations in the mRNA levels and endometrial morphology returned to a pretreatment phenotype after the cessation of PRM exposure. CONCLUSION(S) The endometrial impact of the modulation of progesterone receptor pathways with PRM (UPA) treatment is reversible. CLINICAL TRIAL REGISTRATION NUMBER Ulipristal acetate versus conventional management of heavy menstrual bleeding (UCON) trial (EudraCT 2014-003408-65; REC14/LO/1602).
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Affiliation(s)
- Rohan R Chodankar
- Medical Research Council Centre for Reproductive Health, The University of Edinburgh, The Queen's Medical Research Institute, Edinburgh, United Kingdom
| | - Alison Murray
- Medical Research Council Centre for Reproductive Health, The University of Edinburgh, The Queen's Medical Research Institute, Edinburgh, United Kingdom
| | - Moira Nicol
- Medical Research Council Centre for Reproductive Health, The University of Edinburgh, The Queen's Medical Research Institute, Edinburgh, United Kingdom
| | - Lucy H R Whitaker
- Medical Research Council Centre for Reproductive Health, The University of Edinburgh, The Queen's Medical Research Institute, Edinburgh, United Kingdom
| | - Alistair R W Williams
- Medical Research Council Centre for Reproductive Health, The University of Edinburgh, The Queen's Medical Research Institute, Edinburgh, United Kingdom
| | - Hilary O D Critchley
- Medical Research Council Centre for Reproductive Health, The University of Edinburgh, The Queen's Medical Research Institute, Edinburgh, United Kingdom.
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Capmas P, Brun JL, Legendre G, Koskas M, Merviel P, Fernandez H. Ulipristal acetate use in adenomyosis: A randomized controlled trial. J Gynecol Obstet Hum Reprod 2020; 50:101978. [PMID: 33186772 DOI: 10.1016/j.jogoh.2020.101978] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 10/28/2020] [Accepted: 11/03/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To evaluate the effect of a 10 mg per day 12 week treatment of ulipristal acetate (UPA) on abnormal uterine bleeding due to adenomyosis. DESIGN A double-blind phase 2 randomized controlled pilot study. SETTING From May 2015 to February 2018 in five teaching hospitals. POPULATION Premenopausal women with abnormal uterine bleeding (with a pictorial blood loss assessment score (PBAC) higher than 100 at inclusion) and a sonographic or MRI diagnosis of adenomyosis. METHODS After random allocation, either UPA 10 mg or placebo were orally administered during 12 weeks. A 3:1 ratio was used. MAIN OUTCOME MEASURES The primary outcome was the rate of women with a PBAC score of less than 75 as evaluated over the 28 days following the 12-week treatment. Secondary outcomes included rate of amenorrhea, evolution of pain, quality of life and tolerance. RESULTS Thirty women were included in the UPA group and 10 in the placebo group. No woman in the placebo group versus 95.24 % of women in the UPA group had a PBAC score under 75 during the 28 day period following the 12-week treatment (p < 0.01). A significant decrease in pain was noticed between inclusion and 13 weeks in the UPA group (p < 0.01). At 6 months, there was no significant difference in PBAC score or pain between groups. No serious adverse event was recorded. CONCLUSION UPA could be an interesting option for treatment of abnormal uterine bleeding related to adenomyosis in women wishing to preserve their fertility.
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Affiliation(s)
- Perrine Capmas
- Gynecology Obstetric Department, Bicetre Hospital, GHU Sud, AP-HP, F-94276, Le Kremlin Bicetre, France; Inserm, Centre of Research in EPIDEMIOLOGY and Population Health (CESP), U1018, F-94276, Le Kremlin Bicetre, France; Medical School, University Paris Sud, F-94276, Le Kremlin Bicêtre, France.
| | - Jean-Luc Brun
- Gynecology Obstetric Department, Centre Aliénor D'aquitaine CHU Bordeaux, F-33076, Bordeaux, France
| | | | - Martin Koskas
- Gynecology Obstetric Department, CHU Bichat, F-75018, Paris, France
| | - Philippe Merviel
- Gynecology Obstetric Department, CHRU Brest, F-29200, Brest, France
| | - Hervé Fernandez
- Gynecology Obstetric Department, Bicetre Hospital, GHU Sud, AP-HP, F-94276, Le Kremlin Bicetre, France; Inserm, Centre of Research in EPIDEMIOLOGY and Population Health (CESP), U1018, F-94276, Le Kremlin Bicetre, France; Medical School, University Paris Sud, F-94276, Le Kremlin Bicêtre, France
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Liver Injury Associated with the Selective Progesterone Modulator Ulipristal. Drug Saf 2020; 43:1201-1204. [DOI: 10.1007/s40264-020-01004-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2020] [Indexed: 12/15/2022]
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Guideline No. 389-Medical Management of Symptomatic Uterine Leiomyomas - An Addendum. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2020; 41:1521-1524. [PMID: 31548041 DOI: 10.1016/j.jogc.2019.01.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES The aim of this guideline is to provide clinicians with an update to the 2015 Clinical Practice Guideline on the Management of Uterine Fibroids. As new information and evidence has become available since 2015, the Gynaecology Clinical Practice Committee of the Society for Obstetricians and Gynaecologists of Canada has determined that an addendum to that document was necessary to inform members about treatment modalities for uterine fibroids. OUTCOMES Implementation of this guideline update should optimize the decision-making process of women and their health care providers in proceeding with further investigation or therapy for uterine leiomyomas, having considered the disease process and available treatment options and reviewed the risks and anticipated benefits. EVIDENCE Published literature was retrieved through searches of PubMed, CINAHL, and Cochrane Systematic Reviews in February 2015 to April 2018, using appropriate controlled vocabulary (uterine fibroids, myoma, leiomyoma, myomectomy, myolysis, heavy menstrual bleeding, and menorrhagia) and key words (myoma, leiomyoma, fibroid, myomectomy, uterine artery embolization, hysterectomy, heavy menstrual bleeding, menorrhagia). The reference lists of articles identified were also searched for other relevant publications. Results were restricted to systematic reviews, randomized controlled trials or controlled clinical trials, and observational studies. There were no date limits, but results were limited to English or French language materials. Searches were updated on a regular basis and incorporated in the guideline to April 2018. Most of the unpublished data have not been evaluated scientifically. The product monograph was also reviewed up to December 31st, 2018. BENEFITS, HARMS, AND COSTS The majority of fibroids are asymptomatic and require no intervention or further investigations. For symptomatic fibroids such as those causing menstrual abnormalities (e.g., heavy, irregular, and prolonged uterine bleeding), iron deficiency anemia, or bulk symptoms (e.g., pelvic pressure/pain, obstructive symptoms), hysterectomy is a definitive solution. However, it is not the preferred solution for women who wish to preserve fertility and/or their uterus. The selected treatment should be directed towards an improvement in symptomatology and quality of life. The cost of the therapy to the health care system and to women with fibroids must be interpreted in the context of the cost of untreated disease conditions and the cost of ongoing or repeat investigative or treatment modalities. VALUES The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. RECOMMENDATIONS
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Critchley HOD, Maybin JA, Armstrong GM, Williams ARW. Physiology of the Endometrium and Regulation of Menstruation. Physiol Rev 2020; 100:1149-1179. [DOI: 10.1152/physrev.00031.2019] [Citation(s) in RCA: 95] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The physiological functions of the uterine endometrium (uterine lining) are preparation for implantation, maintenance of pregnancy if implantation occurs, and menstruation in the absence of pregnancy. The endometrium thus plays a pivotal role in reproduction and continuation of our species. Menstruation is a steroid-regulated event, and there are alternatives for a progesterone-primed endometrium, i.e., pregnancy or menstruation. Progesterone withdrawal is the trigger for menstruation. The menstruating endometrium is a physiological example of an injured or “wounded” surface that is required to rapidly repair each month. The physiological events of menstruation and endometrial repair provide an accessible in vivo human model of inflammation and tissue repair. Progress in our understanding of endometrial pathophysiology has been facilitated by modern cellular and molecular discovery tools, along with animal models of simulated menses. Abnormal uterine bleeding (AUB), including heavy menstrual bleeding (HMB), imposes a massive burden on society, affecting one in four women of reproductive age. Understanding structural and nonstructural causes underpinning AUB is essential to optimize and provide precision in patient management. This is facilitated by careful classification of causes of bleeding. We highlight the crucial need for understanding mechanisms underpinning menstruation and its aberrations. The endometrium is a prime target tissue for selective progesterone receptor modulators (SPRMs). This class of compounds has therapeutic potential for the clinical unmet need of HMB. SPRMs reduce menstrual bleeding by mechanisms still largely unknown. Human menstruation remains a taboo topic, and many questions concerning endometrial physiology that pertain to menstrual bleeding are yet to be answered.
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Affiliation(s)
- Hilary O. D. Critchley
- MRC Centre for Reproductive Health, The University of Edinburgh, The Queen's Medical Research Institute, Edinburgh, United Kingdom
| | - Jacqueline A. Maybin
- MRC Centre for Reproductive Health, The University of Edinburgh, The Queen's Medical Research Institute, Edinburgh, United Kingdom
| | - Gregory M. Armstrong
- MRC Centre for Reproductive Health, The University of Edinburgh, The Queen's Medical Research Institute, Edinburgh, United Kingdom
| | - Alistair R. W. Williams
- MRC Centre for Reproductive Health, The University of Edinburgh, The Queen's Medical Research Institute, Edinburgh, United Kingdom
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Donnez O, Donnez J. Gonadotropin-releasing hormone antagonist (linzagolix): a new therapy for uterine adenomyosis. Fertil Steril 2020; 114:640-645. [PMID: 32507315 DOI: 10.1016/j.fertnstert.2020.04.017] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 04/08/2020] [Accepted: 04/08/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To compare the efficacy of a selective progesterone receptor modulator, ulipristal acetate, and a gonadotropin-releasing hormone antagonist, linzagolix, in a case of severe uterine adenomyosis. DESIGN Case report. SETTING Private clinic and infertility research unit. PATIENT One patient born in 1981 who presented because of heavy menstrual bleeding, pelvic pain, and dysmenorrhea due to diffuse and disseminated uterine adenomyosis confirmed by magnetic resonance imaging (MRI). INTERVENTION The patient received a first treatment of 5 mg UPA daily for one course of 3 months. This therapy was discontinued because MRI revealed a worsened aspect. One year later, a once-daily dose of 200 mg linzagolix administered orally was initiated for 3 months, followed by another 3-month course of 100 mg once daily. MAIN OUTCOME MEASURES Clinical symptoms and MRI aspect. RESULTS During treatment with UPA, the symptoms (pelvic pain, dysmenorrhea, bulk symptoms) worsened and MRI revealed aggravation of the adenomyotic lesions. During the 12-week course of once-daily 200 mg linzagolix, the patient remained in amenorrhea and noted a very significant improvement in symptoms. On MRI, the uterine volume had fallen from 875 cm3 to 290 cm3, and the adenomyotic lesions had significantly regressed. During the 100-mg linzagolix course (weeks 13-24), the patient reported continued alleviation of her symptoms. CONCLUSION To our knowledge, this is the first reported use of linzagolix, a new oral gonadotropin-releasing hormone antagonist that significantly reduced lesion size and improved quality of life in a patient with severe adenomyosis, who was previously nonresponsive to treatment with a selective progesterone receptor modulator, ulipristal acetate.
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Affiliation(s)
- Olivier Donnez
- Institut du Sein et de Chirurgie Gynécologique d'Avignon, Polyclinique Urbain V, Avignon, France; Elsan Group, Avignon, France
| | - Jacques Donnez
- Société de Recherche pour l'Infertilité, Brussels, Belgium; Catholic University of Louvain, Belgium.
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Del Forno S, Degli Esposti E, Salucci P, Leonardi D, Iodice R, Arena A, Raimondo D, Paradisi R, Seracchioli R. Liver function, tolerability and satisfaction during treatment with ulipristal acetate in women with fibroids: a single center experience. Gynecol Endocrinol 2020; 36:445-447. [PMID: 31646908 DOI: 10.1080/09513590.2019.1680626] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The aim of the study was to evaluate liver function in women treated with ulipristal acetate (UPA) and to assess the tolerability and satisfaction during treatment. This Cross-sectional study included women with symptomatic uterine fibroids subjected to one or more 3-month treatment courses of 5 mg UPA daily. Following European Medical Agency's prescriptions, women were asked about symptoms potentially related to liver damage and had blood tests done, to assess serum levels of aspartate aminotransferase (AST) and alanine aminotransferase (ALT). Data on side effects, tolerability and satisfaction with the therapy were obtained during a phone interview. A total of 162 women completed the study with a mean treatment duration of 1.8 ± 0.9 cycles. No increased AST and ALT serum levels were detected and no woman reported symptoms suggestive of liver injury. The majority of women reported improvement of fibroids-related symptoms and a high degree of satisfaction with treatment. More than half of women had side effects, in most cases not as severe as to discontinue therapy. Ulipristal acetate did not worsen liver function or cause severe organ injury and showed high tolerability and satisfaction profiles. Therefore, we believe that it can still be considered a valuable option in the treatment of uterine fibroids.
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Affiliation(s)
- Simona Del Forno
- Gynecology and Human Reproduction Physiopathology, DIMEC, S. Orsola Hospital University of Bologna, Bologna, Italy
| | - Eugenia Degli Esposti
- Gynecology and Human Reproduction Physiopathology, DIMEC, S. Orsola Hospital University of Bologna, Bologna, Italy
| | - Paolo Salucci
- Gynecology and Human Reproduction Physiopathology, DIMEC, S. Orsola Hospital University of Bologna, Bologna, Italy
| | - Deborah Leonardi
- Gynecology and Human Reproduction Physiopathology, DIMEC, S. Orsola Hospital University of Bologna, Bologna, Italy
| | - Raffaella Iodice
- Gynecology and Human Reproduction Physiopathology, DIMEC, S. Orsola Hospital University of Bologna, Bologna, Italy
| | - Alessandro Arena
- Gynecology and Human Reproduction Physiopathology, DIMEC, S. Orsola Hospital University of Bologna, Bologna, Italy
| | - Diego Raimondo
- Gynecology and Human Reproduction Physiopathology, DIMEC, S. Orsola Hospital University of Bologna, Bologna, Italy
| | - Roberto Paradisi
- Gynecology and Human Reproduction Physiopathology, DIMEC, S. Orsola Hospital University of Bologna, Bologna, Italy
| | - Renato Seracchioli
- Gynecology and Human Reproduction Physiopathology, DIMEC, S. Orsola Hospital University of Bologna, Bologna, Italy
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Irahara M, Maejima Y, Shinbo N, Yamauchi Y, Mizunuma H. Ulipristal acetate for Japanese women with symptomatic uterine fibroids: A double-blind, randomized, phase II dose-finding study. Reprod Med Biol 2020; 19:65-74. [PMID: 31956287 PMCID: PMC6955589 DOI: 10.1002/rmb2.12304] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 10/05/2019] [Indexed: 12/30/2022] Open
Abstract
PURPOSE A multicenter, randomized, double-blind, placebo-controlled trial was conducted to evaluate the efficacy, safety, and appropriate dose of ulipristal acetate (UPA) in Japanese women with symptomatic uterine fibroids (UFs). METHODS A total of 121 premenopausal women with UFs were enrolled to receive either placebo, UPA-2.5 mg, UPA-5 mg, UPA-10 mg, or leuprorelin acetate (LEU), a reference drug, for 12 weeks. The primary end point was the rate of patients having achieved amenorrhea for 35 days at Week 12. RESULTS The rates for amenorrhea were 4.5%, 60.0%, 72.7%, 88.0%, and 76.2% in the placebo, UPA-2.5 mg, UPA-5 mg, UPA-10 mg, and LEU groups, respectively. The median times to amenorrhea were 20.0, 5.0, 5.0, and 23.0 days for treatment with UPA-2.5 mg, UPA-5 mg, UPA-10 mg, and LEU, respectively. A significant dose-response of UPA for the rate of amenorrhea was observed. The overall incidence rates of adverse events were 45.8% in the placebo group, 56.5%-80.0% in the UPA groups, and 100.0% in the LEU group. There were no notable safety issues with UPA. CONCLUSIONS Ulipristal acetate was effective and well tolerated in Japanese women with UFs. The recommended dose of UPA is considered to be 10 mg.
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Pregnancy Outcomes Following Ulipristal Acetate for Uterine Fibroids: A Systematic Review. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 40:1066-1076.e2. [PMID: 30103881 DOI: 10.1016/j.jogc.2018.05.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 05/08/2018] [Accepted: 05/09/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To determine pregnancy and fetal outcomes following treatment with ulipristal acetate (UPA) for symptomatic uterine fibroids. METHODS We conducted a systematic review and case series. We searched MEDLINE, EMBASE, PubMed, Web of Science, and Cochrane Register from inception to February 2017. From January 2014 to July 2017, we carried out a multi-centre retrospective chart review. All human studies that reported at least one pregnancy following UPA treatment were included. The case series included patients who conceived during/following UPA treatment. Titles and abstracts were screened for eligibility by two independent reviewers, and full texts were evaluated for inclusion and study quality. Data from the systematic review and case series were synthesized and reported separately. RESULTS Seven studies were included (six case reports, one retrospective series) and contributed 24 post-UPA pregnancies (19 live births, six spontaneous abortions [SA]). The case series contributed 47 post-UPA pregnancies (31 live births, 13 SA, 1 fetal death, 2 terminations, 1 ongoing). In total, 71 pregnancies were evaluated (44 underwent myomectomy post-UPA; 27 without interval surgery). Five pregnancies occurred during UPA use (10-36 days of exposure) and resulted in three live births, one SA, and one termination. Five women who did not undergo interval myomectomy experienced delivery complications related to their fibroid. CONCLUSIONS This is the first systematic review and largest reported case series evaluating pregnancy outcomes following UPA treatment for uterine fibroids. UPA alone, or in conjunction with surgery, can permit conception and favorable pregnancy outcomes.
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Neri M, Melis GB, Giancane E, Vallerino V, Pilloni M, Piras B, Loddo A, Paoletti AM, Mais V. Clinical Utility Of Elagolix As An Oral Treatment For Women With Uterine Fibroids: A Short Report On The Emerging Efficacy Data. Int J Womens Health 2019; 11:535-546. [PMID: 31695514 PMCID: PMC6815212 DOI: 10.2147/ijwh.s185023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 10/09/2019] [Indexed: 12/22/2022] Open
Abstract
Uterine fibroids (UFs) are the most common gynaecological benign disease. Even though often asymptomatic, UFs can worsen women’s health and their quality of life, causing heavy bleeding and anaemia, pelvic discomfort and reduced fertility. Surgical treatment of UFs could be limited by its invasiveness and the desire to preserve fertility. Thus, effective medical therapies for the management of this condition are needed. Common drugs used to control bleeding, such us hormonal contraceptive or levonorgestrel-releasing intrauterine system, have no effect on fibroids volume. Among other more efficient treatments, the gonadotropin-releasing hormone (GnRH) agonist or the selective progesterone-receptor modulators have a non-neutral safety profile; thus, they are used for limited periods or for cyclic treatments. Elagolix is a potent, orally bioavailable, non-peptide GnRH antagonist that acts by a competitive block of the GnRH receptor. The biological effect is a dose-dependent inhibition of gonadal axis, without a total suppression of estradiol concentrations. For this reason, even though comparative studies between elagolix and GnRH agonists have not been performed, elagolix has been associated with a better profile of adverse events. Recently, elagolix received US FDA approval for the treatment of moderate to severe pain caused by endometriosis. Several clinical trials assessed the efficacy of elagolix for the treatment of heavy bleeding caused by UFs and the definitive results of Phase III studies are expected. Available data on elagolix and UFs showed that the drug, with or without low-dose hormone add-back therapy, is able to significantly reduce menstrual blood loss, lead to amenorrhea and improve haemoglobin concentrations in the majority of participants in comparison with placebo. The safety and tolerability profile appeared generally acceptable. The concomitant use of add-back therapy can prevent bone loss due to the hypoestrogenic effect and can improve safety during elagolix treatment.
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Affiliation(s)
- Manuela Neri
- Department of Obstetrics and Gynaecology, University of Cagliari, Italy.,Department of Surgical Sciences, University of Cagliari, Italy.,Maternal Child Department, University Hospital of Cagliari, Italy
| | - Gian Benedetto Melis
- Department of Obstetrics and Gynaecology, University of Cagliari, Italy.,Department of Surgical Sciences, University of Cagliari, Italy.,Maternal Child Department, University Hospital of Cagliari, Italy
| | - Elena Giancane
- Department of Obstetrics and Gynaecology, University of Cagliari, Italy.,Department of Surgical Sciences, University of Cagliari, Italy.,Maternal Child Department, University Hospital of Cagliari, Italy
| | - Valerio Vallerino
- Department of Obstetrics and Gynaecology, University of Cagliari, Italy.,Department of Surgical Sciences, University of Cagliari, Italy.,Maternal Child Department, University Hospital of Cagliari, Italy
| | - Monica Pilloni
- Department of Obstetrics and Gynaecology, University of Cagliari, Italy.,Department of Surgical Sciences, University of Cagliari, Italy.,Maternal Child Department, University Hospital of Cagliari, Italy
| | - Bruno Piras
- Department of Obstetrics and Gynaecology, University of Cagliari, Italy.,Department of Surgical Sciences, University of Cagliari, Italy.,Maternal Child Department, University Hospital of Cagliari, Italy
| | - Alessandro Loddo
- Department of Obstetrics and Gynaecology, University of Cagliari, Italy.,Department of Surgical Sciences, University of Cagliari, Italy.,Maternal Child Department, University Hospital of Cagliari, Italy
| | - Anna Maria Paoletti
- Department of Obstetrics and Gynaecology, University of Cagliari, Italy.,Department of Surgical Sciences, University of Cagliari, Italy.,Maternal Child Department, University Hospital of Cagliari, Italy
| | - Valerio Mais
- Department of Obstetrics and Gynaecology, University of Cagliari, Italy.,Department of Surgical Sciences, University of Cagliari, Italy.,Maternal Child Department, University Hospital of Cagliari, Italy
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19
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Directive clinique No 389 - Prise en charge médicamenteuse des léiomyomes utérins symptomatiques – Addenda. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 41:1525-1528. [DOI: 10.1016/j.jogc.2019.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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20
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Lee O, Sullivan ME, Xu Y, Rogers C, Muzzio M, Helenowski I, Shidfar A, Zeng Z, Singhal H, Jovanovic B, Hansen N, Bethke KP, Gann PH, Gradishar W, Kim JJ, Clare SE, Khan SA. Selective Progesterone Receptor Modulators in Early-Stage Breast Cancer: A Randomized, Placebo-Controlled Phase II Window-of-Opportunity Trial Using Telapristone Acetate. Clin Cancer Res 2019; 26:25-34. [DOI: 10.1158/1078-0432.ccr-19-0443] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 06/19/2019] [Accepted: 09/26/2019] [Indexed: 11/16/2022]
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Dolmans MM, Donnez J, Fellah L. Uterine fibroid management: Today and tomorrow. J Obstet Gynaecol Res 2019; 45:1222-1229. [PMID: 31141843 DOI: 10.1111/jog.14002] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 04/28/2019] [Indexed: 12/11/2022]
Abstract
Current treatments for fibroids are mainly surgical and expensive, so alternatives need to be found. It is, therefore, vital to develop and evaluate alternatives to surgical procedures, especially when fertility preservation is the goal. Selective progesterone receptor modulators (SPRMs) are synthetic compounds that have either an agonistic or antagonistic impact on target tissues determined by their binding to progesterone receptors. Their mixed activity depends on recruitment of cofactors that regulate transcription along so-called genomic pathways, as well as nongenomic interactions with other signaling pathways. There is no doubt that surgery remains indicated in some instances, but we must now establish whether use of SPRMs (notably ulipristal acetate) allows less invasive surgery or even complete avoidance of surgery. Long-term intermittent administration of ulipristal acetate will undoubtedly change our approach to the management of uterine fibroids according to the International Federation of Gynecology and Obstetrics classification, which provides a comprehensive basis for different treatment options. When considering less invasive techniques (uterus-sparing options like myomectomy), the choice is guided by the size, number and location of fibroids, as well as the personal experience of the gynecologist and available equipment. There is now a growing body of evidence pointing to the crucial role of progesterone pathways in the pathophysiology of uterine fibroids. SPRMs should, therefore, be considered an alternative to surgical therapy, or at least an adjunct to surgery, as illustrated in the algorithms. © 2019 Japan Society of Obstetrics and Gynecology.
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Affiliation(s)
- Marie-Madeleine Dolmans
- Gynecology Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium.,Pôle de Gynécologie, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium
| | - Jacques Donnez
- Université Catholique de Louvain, Société de Recherche pour l'Infertilité (SRI), Brussels, Belgium
| | - Latifa Fellah
- Radiology Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
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22
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Ulipristal Acetate for Treatment of Symptomatic Uterine Leiomyomas: A Randomized Controlled Trial. Obstet Gynecol 2019; 131:431-439. [PMID: 29420395 DOI: 10.1097/aog.0000000000002462] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To assess efficacy and tolerability of ulipristal acetate, a selective progesterone receptor modulator, for treatment of symptomatic uterine leiomyomas. METHODS This phase 3, double-blind, placebo-controlled study enrolled premenopausal women (aged 18-50 years) with abnormal uterine bleeding, one or more discrete leiomyomas, and uterine size 20 weeks of gestation or less. Patients were randomized 1:1:1 to 5 mg ulipristal, 10 mg ulipristal, or placebo once daily for 12 weeks followed by 12-week drug-free follow-up. Coprimary endpoints were rate of and time to amenorrhea, defined as no bleeding for the last 35 consecutive days of treatment. Secondary endpoints included rates of amenorrhea from day 11 and change from baseline to endpoint in the Revised Activities subscale of the Uterine Fibroid Symptom and Quality of Life questionnaire, which includes questions pertaining to physical and social activities. Safety assessments included adverse event monitoring and endometrial biopsies. A sample size of 150 was planned to compare separately each dose of ulipristal with placebo. RESULTS From March 2014 to March 2016, 157 patients were randomized. Demographics were similar across treatment groups. Amenorrhea was achieved by 25 of 53 (47.2% [97.5% CI 31.6-63.2]) and 28 of 48 (58.3% [97.5% CI 41.2-74.1]) patients treated with 5 mg and 10 mg ulipristal, respectively, compared with 1 of 56 (1.8% [97.5% CI 0.0-10.9]) placebo-treated patients (both P<.001). Time to amenorrhea was shorter for both ulipristal doses compared with placebo (P<.001), and both doses of ulipristal resulted in improved quality of life compared with placebo (P<.001). Common adverse events (5% or greater in either ulipristal group during treatment) were hypertension, elevated blood creatinine phosphokinase, and hot flushes. Serious adverse events occurred in four patients, but none was considered related to treatment. Endometrial biopsies were benign. CONCLUSION Ulipristal at 5 mg and 10 mg were well tolerated and superior to placebo in rate of and time to amenorrhea in women with symptomatic uterine leiomyomas. CLINICAL TRIAL REGISTRATION Clinicaltrials.gov number, NCT02147197.
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Lewis TD, Malik M, Britten J, Parikh T, Cox J, Catherino WH. Ulipristal acetate decreases active TGF-β3 and its canonical signaling in uterine leiomyoma via two novel mechanisms. Fertil Steril 2019; 111:806-815.e1. [PMID: 30871768 DOI: 10.1016/j.fertnstert.2018.12.026] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 12/11/2018] [Accepted: 12/28/2018] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To characterize the effect of ulipristal acetate (UPA) treatment on transforming growth factor (TGF) canonical and noncanonical signaling pathways in uterine leiomyoma tissue and cells. UPA decreased extracellular matrix in surgical specimens; we characterize the mechanism in this study. DESIGN Laboratory study. SETTING University. INTERVENTION(S) Exposure of leiomyoma cell lines to UPA. MAIN OUTCOME MEASURE(S) RNAseq was performed on matched myometrium and leiomyoma surgical specimens of placebo- and UPA-treated patients. Changes in gene expression and protein were measured using quantitative polymerase chain reaction and western immunoblot analysis, respectively. RESULT(S) In surgical specimen, mRNA for TGF-β3 was elevated 3.75-fold and TGFR2 was decreased 0.50-fold in placebo leiomyomas compared with myometrium. Analysis of leiomyomas from UPA-treated women by western blot revealed significant reductions of active TGF-β3 (0.64 ± 0.12-fold), p-TGFR2 (0.56 ± 0.23-fold), pSmad 2 (0.54 ± 0.04-fold), and pSmad 3 (0.65 ± 0.09-fold) compared with untreated leiomyomas. UPA treatment demonstrated statistically significant reduction in collagen 1, fibronectin, and versican proteins. Notably, there was a statistically significant increase of the extracellular matrix protein fibrillin in leiomyoma treated with UPA (1.48 ± 0.41-fold). Data from in vitro assays with physiologic concentrations of UPA supported the in vivo findings. CONCLUSION(S) TGF-β pathway is highly up-regulated in leiomyoma and is directly responsible for development of the fibrotic phenotype. UPA attenuates this pathway by reducing TGF-β3 message and protein expression, resulting in a reduction in TGF-β canonical signaling. In addition, UPA significantly increased fibrillin protein expression, which can serve to bind inactive TGF-β complexes. Therefore, UPA inhibits leiomyoma fibrosis by decreasing active TGF-β3 and diminishing signaling through the canonical pathway. CLINICAL TRIAL REGISTRATION NUMBER NCT00290251.
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Affiliation(s)
- Terrence D Lewis
- Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, Bethesda, Maryland; Program in Reproductive Endocrinology and Gynecology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Minnie Malik
- Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Joy Britten
- Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Toral Parikh
- Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, Bethesda, Maryland; Program in Reproductive Endocrinology and Gynecology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Jeris Cox
- Fort Belvoir Community Hospital, Fort Belvoir, Virginia
| | - William H Catherino
- Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, Bethesda, Maryland; Program in Reproductive Endocrinology and Gynecology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland.
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Farris M, Bastianelli C, Rosato E, Brosens I, Benagiano G. Uterine fibroids: an update on current and emerging medical treatment options. Ther Clin Risk Manag 2019; 15:157-178. [PMID: 30774352 PMCID: PMC6350833 DOI: 10.2147/tcrm.s147318] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Uterine fibroids are the most common gynecological disorder, classically requiring surgery when symptomatic. Although attempts at finding a nonsurgical cure date back to centuries, it is only around the middle of the last century that serious attempts at a medical treatment were carried out. Initially, both progestins and estrogen–progestin combinations have been utilized, although proof of their usefulness is lacking. A major step forward was achieved when peptide analogs of the GnRH were introduced, first those with superagonist properties and subsequently those acting as antagonists. Initially, the latter produced side effects preventing their routine utilization; eventually, this problem was overcome following the synthesis of cetrorelix. Because both types of analogs produce hypoestrogenism, their use is limited to a maximum of 6 months and, for this reason, today they are utilized as an adjuvant treatment before surgery with overall good results. Over the last decade, new, nonpeptidic, orally active GnRH-receptor blockers have also been synthesized. One of them, Elagolix, is in the early stages of testing in women with fibroids. Another fundamental development has been the utilization of the so-called selective progesterone receptor modulators, sometimes referred to as “antiprogestins”. The first such compound to be applied to the long-term treatment of fibroids was Mifepristone; today, this compound is mostly used outside of Western Countries, where the substance of choice is Ulipristal acetate. Large clinical trials have proven the effectiveness of Ulipristal in the long-term medical therapy of fibroids, although some caution must be exercised because of the rare occurrence of liver complications. All selective progesterone receptor modulators produce unique endometrial changes that are today considered benign, reversible, and without negative consequences. In conclusion, long-term medical treatment of fibroids seems possible today, especially in premenopausal women.
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Affiliation(s)
- Manuela Farris
- Department of Gynecology, Obstetrics and Urology, Sapienza, University of Rome, Rome, Italy, .,The Italian Association for Demographic Education, Rome, Italy,
| | - Carlo Bastianelli
- Department of Gynecology, Obstetrics and Urology, Sapienza, University of Rome, Rome, Italy,
| | - Elena Rosato
- Department of Gynecology, Obstetrics and Urology, Sapienza, University of Rome, Rome, Italy,
| | - Ivo Brosens
- Faculty of Medicine, KU Leuven, Leuven, Belgium
| | - Giuseppe Benagiano
- Department of Gynecology, Obstetrics and Urology, Sapienza, University of Rome, Rome, Italy,
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Abstract
Uterine fibroids are the most common tumors affecting premenopausal women, responsible for bleeding, pain, and reduced quality of life. When symptomatic, their management mainly involves surgery, which is all too often radical (hysterectomy). While surgical options sparing the uterus (hysteroscopic and laparoscopic myomectomy) and other non-surgical approaches do indeed exist, drug-based therapies are associated with lower costs and morbidity rates. Since progesterone is required for fibroid growth, gonadotropin agonists have been used to control bleeding and decrease fibroid volume, but they only represent a temporary remedy due to adverse events. Ulipristal acetate (UPA), a selective progesterone receptor modulator, is indicated for fibroid management. It is safe, provides fast control of bleeding, and causes sustained fibroid volume reduction in the vast majority of cases (80%). Indeed, UPA-treated fibroids shrink by a combination of inhibition of cell proliferation, stimulation of cell death, and fibrosis resorption. In the case of symptom recurrence, repeated intermittent 3-month courses of daily UPA considerably maximize the impact of treatment, sometimes resulting in complete disappearance of treated fibroids. Despite the therapeutic dose of UPA being very well tolerated, patients with liver anomalies or disorders should be excluded at screening according to European Medicines Agency-Pharmacovigilance Risk Assessment Committee (PRAC) recommendations. We therefore propose new algorithms for fibroid management in premenopausal women with symptomatic fibroids, depending on their localization, the patient's wishes, and clinical response, while monitoring liver enzymes and bilirubin, as recommended by the PRAC, in order to minimize the risks of possible liver toxicity.
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Affiliation(s)
- J Donnez
- a Société de Recherches pour l'Infertilité , Professor Emeritus, Université Catholique de Louvain , Brussels , Belgium
| | - G E Courtoy
- b Pôle de Gynécologie, Institut de Recherche Expérimentale et Clinique , Université Catholique de Louvain , Brussels , Belgium
| | - M-M Dolmans
- b Pôle de Gynécologie, Institut de Recherche Expérimentale et Clinique , Université Catholique de Louvain , Brussels , Belgium.,c Gynecology Department , Cliniques Universitaires St-Luc , Brussels , Belgium
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Liver safety parameters of ulipristal acetate for the treatment of uterine fibroids: a comprehensive review of the clinical development program. Expert Opin Drug Saf 2018; 17:1225-1232. [PMID: 30460871 DOI: 10.1080/14740338.2018.1550070] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
INTRODUCTION Uterine fibroids are benign tumors within the uterine wall affecting women. Ulipristal acetate 5 mg was first authorized in the European Union on 23 February 2012, with a post-marketing exposure estimated to be more than 765,000 patients so far. During the post-marketing experience, sporadic cases of liver injury and hepatic failure were reported. A detailed review of the clinical trials carried out in the development of ulipristal acetate 5 mg was undertaken to further assess the liver safety data reported during the clinical trials. AREAS COVERED A detailed review of clinical data from Phase I to Phase III of patients exposed to ulipristal acetate at any investigated dose levels and for any treatment duration was conducted and the liver function test values are presented. In addition, a literature review on drug-induced liver injury is provided. EXPERT OPINION The experts present an evaluation of the liver safety findings observed during the clinical development and their views on the role of these findings in predicting the occurrence of drug-induced liver injury, the benefits of the treatment, the safety and the implications to the current clinical practice.
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Abstract
PURPOSE OF REVIEW To evaluate the literature on repeat use of emergency contraception and pericoital approaches to contraception. RECENT FINDINGS Women are very interested in an oral, on-demand contraceptive option, were one available. Ulipristal acetate and a combination of levonorgestrel (LNG) and meloxicam (a cyclo-oxygenase-2 inhibitor) both appear to be more effective at disrupting ovulation than LNG alone. Recent advisories from the United Kingdom regarding daily dosing of ulipristal for fibroids emphasize the need for more safety data. SUMMARY Repeat pericoital dosing of 1.5-mg LNG is approximately as effective as other on-demand contraceptive methods and is overall very safe. The most common side effect is irregular bleeding. Repeat on-demand ulipristal acetate or meloxicam/other cyclo-oxygenase-2 inhibitors have potential as an on-demand option either alone or in combination but have not been evaluated for contraceptive efficacy in a large-scale study. Given the high unmet need for contraception, even among women with access to available options, there is a distinct need for options that address needs of women who are interested in an on-demand option. On-demand oral contraception has the potential to expand the convenience of contraceptive options and overall contraceptive use.
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Therapy with Ulipristal Acetate in a Hypertensive Patient. Case Rep Med 2018; 2018:1091520. [PMID: 30515219 PMCID: PMC6236705 DOI: 10.1155/2018/1091520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 09/28/2018] [Accepted: 10/01/2018] [Indexed: 11/17/2022] Open
Abstract
Ulipristal acetate (UPA) is a medical therapy for patients with symptomatic uterine fibroids. The drug has shown efficacy in the control of heavy menstrual bleeding and, as a consequence, in anaemia improvement. We report the case of a hypertensive patient treated with two courses of UPA. In addition to its observed benefits on hypermenorrhea caused by uterine fibroids, no exacerbation of the underlying disease was observed. No adverse effects were observed, and blood pressure levels were well controlled throughout.
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Liver injury and ulipristal acetate: an overstated tragedy? Fertil Steril 2018; 110:593-595. [DOI: 10.1016/j.fertnstert.2018.06.044] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 06/28/2018] [Indexed: 11/20/2022]
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Ulipristal acetate for the management of large uterine fibroids associated with heavy bleeding: a review. Reprod Biomed Online 2018; 37:216-223. [DOI: 10.1016/j.rbmo.2018.04.040] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 04/04/2018] [Accepted: 04/06/2018] [Indexed: 12/15/2022]
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Guo SW, Groothuis PG. Is it time for a paradigm shift in drug research and development in endometriosis/adenomyosis? Hum Reprod Update 2018; 24:577-598. [DOI: 10.1093/humupd/dmy020] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 05/21/2018] [Indexed: 12/19/2022] Open
Affiliation(s)
- Sun-Wei Guo
- Shanghai OB/GYN Hospital, Fudan University, Shanghai, China
- Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Fudan University, Shanghai, China
| | - Patrick G Groothuis
- Principal Scientist Pharmacology, Preclinical Department, Synthon Biopharmaceuticals bv, Nijmegen, The Netherlands
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Singh SS, Belland L, Leyland N, von Riedemann S, Murji A. The past, present, and future of selective progesterone receptor modulators in the management of uterine fibroids. Am J Obstet Gynecol 2018; 218:563-572.e1. [PMID: 29274830 DOI: 10.1016/j.ajog.2017.12.206] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 12/14/2017] [Accepted: 12/14/2017] [Indexed: 12/12/2022]
Abstract
Uterine fibroids are common in women of reproductive age and can have a significant impact on quality of life and fertility. Although a number of international obstetrics/gynecology societies have issued evidence-based clinical practice guidelines for the management of symptomatic uterine fibroids, many of these guidelines do not yet reflect the most recent clinical evidence and approved indication for one of the key medical management options: the selective progesterone receptor modulator class. This article aims to share the clinical experience gained with selective progesterone receptor modulators in Europe and Canada by reviewing the historical development of selective progesterone receptor modulators, current best practices for selective progesterone receptor modulator use based on available data, and potential future uses for selective progesterone receptor modulators in uterine fibroids and other gynecologic conditions.
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Czuczwar P, Stepniak A, Milart P, Paszkowski T, Wozniak S. Comparison of the influence of three fibroid treatment options: supracervical hysterectomy, ulipristal acetate and uterine artery embolization on ovarian reserve - an observational study. J Ovarian Res 2018; 11:45. [PMID: 29859107 PMCID: PMC5984745 DOI: 10.1186/s13048-018-0420-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 05/23/2018] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND To assess and compare the influence of three fibroid treatment options: supracervical hysterectomy, ulipristal acetate and uterine artery embolization on ovarian reserve. METHODS Prospective, observational, open-label study performed at the 3rd Chair and Department of Gynecology of the Medical University of Lublin, Poland. Premenopausal Caucasian women with symptomatic uterine fibroids were recruited into 3 groupspatients qualified for supracervical hysterectomies; patients qualified for preoperative ulipristal acetate (UPA) treatment scheduled for supracervical hysterectomies or myomectomies; patients qualified for uterine artery embolization (UAE). The following markers of ovarian reserve were investigated: antral follicle count (AFC), anti-Mullerian hormone (AMH), inhibin B (INHB), follicle stimulating hormone (FSH) and estradiol (E2). These markers were assessed before and 3 months after supracervical hysterectomies, before and 3 months after UAEs, and before and after 3 months of UPA treatment, before the scheduled surgeries. Baseline characteristics (age, parity, dominant fibroid volume, hemoglobin level, BMI, as well as AFC, AMH, INHB, FSH and E2) were compared between the study groups by Kruskall-Wallis ANOVA. Pre- and post-interventional values of AFC, AMH, INHB, FSH and E2 in the studied groups were compared with the Wilcoxon matched pairs test. RESULTS Twenty-six, 27 and 30 patients were included in the final analysis in the supracervical hysterectomy, UPA and UAE groups, respectively. Three months after supracervical hysterectomy INHB and E2 significantly decreased, while AFC, AMH and FSH remained unchanged. After 3 months of UPA treatment the values of all the assessed markers of ovarian reserve were not significantly different in comparison to baseline. Conversely, three months after UAE the values of AFC, AMH, INHB, and E2 were significantly decreased, while FSH was significantly increased. CONCLUSIONS Of the compared fibroid treatment methods UAE seems to have the greatest impact on ovarian function and should not be offered to patients concerned about their ovarian function. Supracervical hysterectomy did not affect the most accurate markers of ovarian reserve, and therefore appears to be safe in terms of ovarian function. UPA did not change any of the studied markers of ovarian reserve and seems a reasonable option when ovarian function is concerned.
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Affiliation(s)
- Piotr Czuczwar
- 3rd Department of Gynecology of the Medical University of Lublin, ul. Jaczewskiego 8, 20-954 Lublin, Poland
| | - Anna Stepniak
- 3rd Department of Gynecology of the Medical University of Lublin, ul. Jaczewskiego 8, 20-954 Lublin, Poland
| | - Pawel Milart
- 3rd Department of Gynecology of the Medical University of Lublin, ul. Jaczewskiego 8, 20-954 Lublin, Poland
| | - Tomasz Paszkowski
- 3rd Department of Gynecology of the Medical University of Lublin, ul. Jaczewskiego 8, 20-954 Lublin, Poland
| | - Slawomir Wozniak
- 3rd Department of Gynecology of the Medical University of Lublin, ul. Jaczewskiego 8, 20-954 Lublin, Poland
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Melis GB, Neri M, Piras B, Paoletti AM, Ajossa S, Pilloni M, Marotto MF, Corda V, Saba A, Giancane E, Mais V. Vilaprisan for treating uterine fibroids. Expert Opin Investig Drugs 2018; 27:497-505. [DOI: 10.1080/13543784.2018.1471134] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Gian Benedetto Melis
- Dipartimento di Scienze Chirurgiche, Clinica Ostetrica e Ginecologica, Azienda Ospedaliero Universitaria di Cagliari, Policlinico Universitario Duilio Casula, University of Cagliari, Italy
| | - Manuela Neri
- Dipartimento di Scienze Chirurgiche, Clinica Ostetrica e Ginecologica, Azienda Ospedaliero Universitaria di Cagliari, Policlinico Universitario Duilio Casula, University of Cagliari, Italy
| | - Bruno Piras
- Dipartimento Materno Infantile, clinica ostetrica e ginecologica, policlinico universitario Duilio Casula, Azienda Ospedaliero Universitaria di Cagliari, Cagliari, Italy
| | - Anna Maria Paoletti
- Dipartimento di Scienze Chirurgiche, Clinica Ostetrica e Ginecologica, Azienda Ospedaliero Universitaria di Cagliari, Policlinico Universitario Duilio Casula, University of Cagliari, Italy
| | - Silvia Ajossa
- Dipartimento Materno Infantile, clinica ostetrica e ginecologica, policlinico universitario Duilio Casula, Azienda Ospedaliero Universitaria di Cagliari, Cagliari, Italy
| | - Monica Pilloni
- Dipartimento Materno Infantile, clinica ostetrica e ginecologica, policlinico universitario Duilio Casula, Azienda Ospedaliero Universitaria di Cagliari, Cagliari, Italy
| | - Maria Francesca Marotto
- Dipartimento Materno Infantile, clinica ostetrica e ginecologica, policlinico universitario Duilio Casula, Azienda Ospedaliero Universitaria di Cagliari, Cagliari, Italy
| | - Valentina Corda
- Dipartimento di Scienze Chirurgiche, Clinica Ostetrica e Ginecologica, Azienda Ospedaliero Universitaria di Cagliari, Policlinico Universitario Duilio Casula, University of Cagliari, Italy
| | - Alessandra Saba
- Dipartimento di Scienze Chirurgiche, Clinica Ostetrica e Ginecologica, Azienda Ospedaliero Universitaria di Cagliari, Policlinico Universitario Duilio Casula, University of Cagliari, Italy
| | - Elena Giancane
- Dipartimento di Scienze Chirurgiche, Clinica Ostetrica e Ginecologica, Azienda Ospedaliero Universitaria di Cagliari, Policlinico Universitario Duilio Casula, University of Cagliari, Italy
| | - Valerio Mais
- Dipartimento di Scienze Chirurgiche, Clinica Ostetrica e Ginecologica, Azienda Ospedaliero Universitaria di Cagliari, Policlinico Universitario Duilio Casula, University of Cagliari, Italy
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Donnez J, Arriagada P, Donnez O, Dolmans MM. Emerging treatment options for uterine fibroids. Expert Opin Emerg Drugs 2018; 23:17-23. [PMID: 29486606 DOI: 10.1080/14728214.2018.1446943] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Uterine fibroids (also known as leiomyomas or myomas) are the most common form of benign uterine tumors. Current management strategies involve mainly surgical interventions, but the choice of treatment is guided by patient age and desire to preserve fertility or avoid 'radical' surgery such as hysterectomy. Areas covered: There is growing evidence of the crucial role of progesterone pathways in the pathophysiology of uterine fibroids, leading to increasing use of selective progesterone receptor modulators (SPRMs) such as ulipristal acetate. We searched all published studies on medical management of fibroids with SPRMs. Expert opinion: The need for alternatives to surgical intervention is very real, especially for women seeking to preserve their fertility. These options now exist, with SPRMs proven to treat fibroid symptoms effectively. Gynecologists now have new tools in their armamentarium, opening up novel strategies for the management of uterine fibroids.
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Affiliation(s)
- Jacques Donnez
- a Catholic University of Louvain, Société de Recherche pour l'Infertilité (SRI) , Brussels , Belgium
| | | | - Olivier Donnez
- c Institut du Sein et de Chirurgie Gynécologique d'Avignon, Polyclinique Urbain V (ELSAN Group) , Avignon , France
| | - Marie-Madeleine Dolmans
- d Gynecology Department , Cliniques Universitaires St-Luc , Brussels , Belgium.,e Pôle de Gynécologie , Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain , Brussels , Belgium
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The current place of medical therapy in uterine fibroid management. Best Pract Res Clin Obstet Gynaecol 2018; 46:57-65. [DOI: 10.1016/j.bpobgyn.2017.10.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 10/10/2017] [Accepted: 10/10/2017] [Indexed: 12/26/2022]
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Shortrede JE, Montt-Guevara MM, Pennacchio G, Finiguerra M, Giannini A, Genazzani AD, Simoncini T. Ulipristal Acetate Interferes With Actin Remodeling Induced by 17β-Estradiol and Progesterone in Human Endometrial Stromal Cells. Front Endocrinol (Lausanne) 2018; 9:350. [PMID: 30013514 PMCID: PMC6036300 DOI: 10.3389/fendo.2018.00350] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 06/11/2018] [Indexed: 12/16/2022] Open
Abstract
Ulipristal acetate (UPA) is a selective progesterone receptor modulator (SPRM) used for emergency contraception and for the medical management of symptomatic uterine fibroids (UF). Treatment with UPA turns in amenorrhea and UF volume reduction. Treatment with UPA is associated with the frequent development of benign, transitory endometrial changes known as SPRM-associated endometrial changes (PAECs). Why PAECs develop and their biological or cellular basis is unknown. Sex steroids, including estrogen and progesterone, are established modulators of the actin cytoskeleton in various cells, including endometrial cells. This explains several morphological and functional changes in endometrial cells. We thus hypothesized that UPA may alter the appearance of the endometrium by interfering with the actions of 17β-estradiol (E2) or progesterone (P4) on actin dynamics. We isolated and cultured human endometrial stromal cells (ESC) from endometrial biopsies from healthy fertile women. Treatment with E2 or P4 stimulated visible actin rearrangements with actin remodeling toward the membrane. Activation through phosphorylation of the actin regulatory proteins, Moesin, and focal adhesion kinase (FAK), hacked actin remodeling induced by E2 and P4. Membrane re-localization of Paxillin and Vinculin were also induced by E2 and P4, showing the formation of focal adhesion complexes. All these E2 and P4 actions were inhibited by co-treatment with UPA, which was otherwise inactive if given alone. The cytoskeletal changes induced by E2 and P4 turned into increased motility of ESC, and UPA again blocked the actions E2 and P4. In conclusion, we find that UPA interferes with the cytoskeletal actions of E2 and P4 in ESC. This finding helps understanding the mode of actions of SPRMs in the endometrium and may be relevant for other potential clinical applications of UPA.
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Affiliation(s)
- Jorge E. Shortrede
- Molecular and Cellular Gynecological Endocrinology Laboratory, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Maria M. Montt-Guevara
- Molecular and Cellular Gynecological Endocrinology Laboratory, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Gisela Pennacchio
- Institute of Experimental Medicine and Biology of Cuyo, Technology and Scientific Center (CCT)-National Research Council of Argentina, Mendoza, Argentina
| | - Michele Finiguerra
- Molecular and Cellular Gynecological Endocrinology Laboratory, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Andrea Giannini
- Molecular and Cellular Gynecological Endocrinology Laboratory, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Alessandro D. Genazzani
- Department of Obstetrics and Gynecology, Center for Gynecological Endocrinology, University of Modena and Reggio Emilia, Modena, Italy
| | - Tommaso Simoncini
- Molecular and Cellular Gynecological Endocrinology Laboratory, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
- *Correspondence: Tommaso Simoncini
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Ferrero S, Vellone VG, Barra F. Pharmacokinetic drug evaluation of ulipristal acetate for the treatment of uterine fibroids. Expert Opin Drug Metab Toxicol 2017; 14:107-116. [DOI: 10.1080/17425255.2018.1417389] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Simone Ferrero
- Academic Unit of Obstetrics and Gynecology, Ospedale Policlinico San Martino, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
| | - Valerio Gaetano Vellone
- Department of Surgical and Diagnostic Sciences, Ospedale Policlinico San Martino, University of Genoa, Genoa, Italy
| | - Fabio Barra
- Academic Unit of Obstetrics and Gynecology, Ospedale Policlinico San Martino, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
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Abstract
Uterine fibroids are the commonest benign tumours of women and affect all races with a cumulative lifetime risk of around 70%. Despite their high prevalence and the heavy economic burden of treatment, fibroids have received remarkably little attention compared to common female malignant tumours. This article reviews recent progress in understanding the biological nature of fibroids, their life cycle and their molecular genetic origins. Recent progress in surgical and interventional management is briefly reviewed, and medical management options, including treatment with selective progesterone receptor modulators, are also discussed.
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Affiliation(s)
- Alistair R W Williams
- Department of Pathology, Royal Infirmary of Edinburgh, University of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK
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Garnock-Jones KP, Duggan ST. Ulipristal Acetate: A Review in Symptomatic Uterine Fibroids. Drugs 2017; 77:1665-1675. [DOI: 10.1007/s40265-017-0812-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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