Ulipristal acetate for uterine fibroid-related symptoms – a case report and review of the literature

Abstract

Introduction: Uterine fibroids are the most commonly encountered benign uterine tumors in women of reproductive age. Although most women are asymptomatic (80%), fibroids, according to their type and location, can cause several symptoms and impact quality of life. To date, no medical treatment is able to eliminate fibroids. Ulipristal acetate (UPA) is an orally active synthetic selective progesterone receptor modulator (SPRM) characterized by a tissue-specific progesterone antagonist effect that reduces the proliferation of leiomyoma cells and induces apoptosis. Its pharmacological and pharmacodynamic characteristics, its efficacy and good tolerance make UPA a new important tool in the management of uterine fibroids. Aim: Analyze the efficacy of selective progesterone receptor modulators (SPRMs) in the treatment of uterine fibroid-related symptoms based in the description of a relevant clinical setting and review of the literature. Case report: A 32 years old woman, nulligesta, presented with excessive per vagina (PV) bleeding and symptomatic anemia. After hemodynamic stabilization and red blood cell transfusion, hysteroscopy was performed. The examination revealed multiple submucosal fibroids type 0, I (the larger ones with 33, 31 and 20 mm) and II (under 1 cm). She began treatment with ulipristal acetate with significant reduction of uterine abnormal bleeding after 1 month and amenorrhea was achieved after 3 months. At this time it was performed resectoscope. The hemoglobin prior to treatment was 13.6 g/dL. After medical and surgical treatment, she iniated oral contraception with good control of uterine bleeding after 1 year of initial therapy intervention. Discussion: No currently available medical treatment is able to eliminate fibroids. Therefore, there is no indication for medical treatment in the absence of symptoms. The choice of therapy is influenced by several factors, including the severity of symptoms (pain, bleeding), infertility related to fibroids, the tumor characteristics (volume, localization), the patient's age, wish to preserve the uterus, and wish to preserve fertility/desire to become pregnant. UPA can be used to control symptoms associated with fibroids and can allow surgery to be scheduled under better circumstances (e.g., a higher hemoglobin level, or myoma size reduction). Conclusion: Currently, no validated medical treatment is able to eliminate fibroids, and hence, surgery still represents the most effective treatment for symptomatic fibroids. UPA may be a good option for women seeking pregnancy, for women who wish to avoid surgery, or before surgery to reduce the invasiveness of the operation. New algorithms should be discussed, as there is no doubt that there is a place for medical therapy with SPRMs in the current fibroid's management.