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

Mei-An Middelkoop,Judith A.F Huirne,Marijke C Jansen Van Der Weide,Judith E Bosmans,Wouter J.K Hehenkamp

doi:10.1016/j.ejogrb.2020.10.058

Abstract

ObjectivesFibroids are the most common benign tumours found in the uterus and can cause various symptoms. In 20–50 % of the women, an intervention is required. When conservative options fail, invasive options such as hysterectomy, uterine artery embolization or myomectomy are eligible options. Ulipristal acetate (UPA) was launched as the sole available long term pharmaceutical treatment, with the potential to avoid surgery. It is suggested that UPA improves quality of life, reduces symptoms and fibroid volumes. However, UPA is an expensive medicine, is possibly associated with liver injury and has never been directly compared to surgical treatment. The aim of this trial is to compare UPA to surgical treatment on both effectiveness and cost-effectiveness. Primary outcome is the reduction in symptom severity scores (part of the Uterine Fibroid Symptom and Quality of Life questionnaire) at 24 months of follow-up compared to baseline. Secondary outcomes include quality of life, societal costs, societal participation, liver function variation, patient satisfaction and preference. Outcomes will be analysed according to intention-to-treat principle. Study DesignThe MYOMEX-2 trial is an open-label, multicentre, non-inferiority randomized controlled trial. Patients are pre-menopausal women with symptomatic fibroids eligible for surgical treatment (hysterectomy, myomectomy or UAE). Fibroid symptoms may comprise (but are not limited to) heavy menstrual bleeding, bulk symptoms or pain. Patients are randomised 2:1 in a parallel group design between two treatment arms: 119 patients in the UPA group and 60 patients in the surgery group. Follow up comprises of online questionnaires, outpatient visits and phone appointments on several follow up moments, up to 24 months after surgery or start UPA. Registration detailsMYOMEX-2 trial; protocol version 4, date 22−02-2019; NTR6860; NL62638.029.18. All items from the World Health Organization Trial Registration Data Set are provided in the online supplementary file (Appendix-B).

Highlights

Fibroids are the most common benign tumours found in the uterus arising in up to 70–80 % of women [1,2,3]
The trial was supported by the Dutch patient organization Stichting Bekkenbodem4All that represents over a million patients with gynaecological complaints, including e.g. heavy menstrual bleeding, prolapse complaints and uterine fibroids
Ulipristal acetate (UPA) is registered for pre-treatment and long term intermittent treatment in patients who are not eligible for surgical treatment

Summary

Introduction

Fibroids are the most common benign tumours found in the uterus arising in up to 70–80 % of women [1,2,3]. Most common symptoms are heavy menstrual bleeding, anaemia, pelvic pain, pressure symptoms and infertility [4,1, 5, 6] Because of these symptoms, 20–50 % of women with uterine fibroids require a clinical intervention, usually invasive and expensive [3,7]. Ulipristal acetate (UPA; or ulipristal) was introduced and approved by the European Medicine Agency (EMA) in 2012 as a new alternative treatment option for symptomatic uterine fibroids. It is a long-term oral treatment, to be taken once daily for four consecutive 12-week courses

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