Fibroid Diameter Research Articles

Phthalates exposure and uterine fibroid burden among women undergoing surgical treatment for fibroids: a preliminary study

To examine the association between phthalate exposure and two measures of uterine fibroid burden: diameter of largest fibroid and uterine volume. Pilot, cross-sectional study. Academic medical center. Fifty-seven premenopausal women undergoing either hysterectomy or myomectomy for fibroids. None. The diameter of the largest fibroid and uterine dimensions were abstracted from medical records. Spot urine samples were analyzed for 14 phthalate biomarkers using mass spectrometry. We estimated associations between fibroid outcomes and individual phthalate metabolites, sum of di(2-ethylhexyl) phthalate metabolites (∑DEHP), and a weighted sum of anti-androgenic phthalate metabolites (∑AA Phthalates) using linear regression, adjusting for age, race/ethnicity, and body mass index. Fibroid outcomes were also examined dichotomously (divided at the median) using logistic regression. Most women were of black ethnicity, overweight or obese, and college educated. In multivariable models, higher levels of mono-hydroxyisobutyl phthalate, monocarboxyoctyl phthalate, monocarboxynonyl phthalate, mono(2-ethylhexyl) phthalate, mono(2-ethyl-5-hydroxyhexyl phthalate) (MEHHP), mono(2-ethyl-5-oxohexyl) phthalate (MEOHP), and mono(2-ethyl-5-carboxypentyl) phthalate (MECPP), ∑DEHP, and ∑AA Phthalates were positively associated with uterine volume. Associations were most pronounced for individual DEHP metabolites (MEHHP, MEOHP, MECPP), ∑DEHP, and ∑AA Phthalates. For example, a doubling in ∑DEHP and ∑AA Phthalates was associated with 33.2% (95% confidence interval 6.6-66.5) and 26.8% (95% confidence interval 2.2-57.4) increase in uterine volume, respectively. There were few associations between phthalate biomarkers and fibroid size. Exposure to some phthalate biomarkers was positively associated with uterine volume, which further supports the hypothesis that phthalate exposures may be associated with fibroid outcomes. Additional studies are needed to confirm these relationships.

Predictive Value of Texture Analysis in the Treatment of Magnetic Resonance-guided Focused Ultrasound Surgery for Symptomatic Uterine Fibroids

Objective To evaluate the predictive value of texture analysis in the treatment of magnetic resonance-guided focused ultrasound surgery(MRgFUS)for symptomatic uterine fibroids.Methods Totally 16 patients with symptomatic uterine fibroids who accepted MRgFUS in Peking Union Medical College Hospital from April 2010 to January 2013 were included. Enhanced magnetic resonance imaging(MRI)was performed before treatment,immediately after treatment,and during the 12-month follow-up. The TexRAD software was used to measure the texture parameters of the fibroids in T2WI sagittal images,and the texture indicators including means and standard deviations(SD),entropy,mean of positive pixels(MPP),skewness,and kurtosis were collected. The fibroid's volume and their change rates were calculated by measuring the relevant diameter of the target fibroid. The Uterine Fibroid Symptoms and Quality of Life(UFS-QOL)was used to calculate the symptom severity scores(SSS)and its change rate. The statistical difference of parameters among the groups was analyzed. The correlations between each texture parameter and the therapeutic outcome of the fibroids were analyzed respectively.Results The average volume for fibroids before treatment was(96.5±84.9)cm 3,which was reduced to(55.1±71.0)cm 3 after treatment for 12 months,and the volume change rate(εV%)was(49±20)%. The standardized SSS score before treatment was(34.18±15.29)scores,decreased to(17.78±11.84)scores 12 months after treatment,with a change rate of(45±32)%,and the non-perfused volume ratio(NPV%)was(62±20)%. There were significant differences among the parameters mean,SD,entropy,and MPP among three groups(all P<0.05),and the changes of them were regular,all of which showed a significant decrease immediately after treatment and a significant increase 12 months after treatment,and the increase degree was higher than the preoperative level. SD(SSF2:r=0.503,P=0.047;SSF4:r=0.529,P=0.035;SSF6:r=0.519,P=0.039)and entropy(SSF2:r=0.527,P=0.036;SSF4:r=0.517,P=0.040;SSF6:r=0.495,P=0.050)of the after-treatment group moderately associated with the εV%. Entropy of the before-treatment group was moderately associated with NPV%(SSF2:r=0.507,P=0.045;SSF4:r=0.543,P=0.030;SSF6:r=0.548,P=0.028).Conclusion There is a certain correlation between the changes of MRI texture parameters before and after treatment and the effect of MRgFUS in the treatment of uterine fibroids,and texture analysis may have certain value in the predicting the effect of MRgFUS on uterine fibroids.

Environmental Phthalates Exposure and Measures of Uterine Fibroid Size among a Racially Diverse Population of Premenopausal Women

Background. Etiology of uterine leiomyoma (fibroids) is poorly understood. Endocrine disruptors, such as phthalates, may contribute to fibroid pathobiology because ovarian hormones are critical to fibroid growth.Objectives. We examined the association between phthalates exposure and two measures of fibroid size: diameter of largest fibroid and uterine volume.Study Design. We conducted a cross-sectional study of 61 premenopausal women undergoing surgery for their fibroids between 2014-2017 in an urban academic hospital in Washington DC. Spot urine samples were collected during a pre-operative clinical visit and analyzed for 14 phthalate metabolites and two non-phthalate plasticizer metabolites using mass spectrometry. Information on fibroid and uterine characteristics was obtained from MRI and/or ultrasound imaging. We examined associations with individual biomarkers, metabolite sums by parent compounds, and a potency-weighted sum of antiandrogenic phthalates (&amp;#931;androgen-disruptor). Size of the largest fibroid and uterine volume were modeled as dichotomous outcomes (divided at the median) using logistic regression adjusting for age, race/ethnicity, BMI, and time since diagnosis.Results. The majority of the sample was African American (63.9%), overweight or obese (75.1%), and had completed college or graduate school (68.3%). In multivariate models, women with higher concentrations of di(2-ethylhexyl) phthalate (DEHP) and diisononyl phthalate (DiNP) metabolites, and &amp;#931;androgen-disruptors had significantly greater uterine volumes compared to women with lower concentrations. &amp;#8721;DEHP metabolites and &amp;#8721;DINP metabolites were associated with 3.05 (95% CI 1.08-8.63) and 1.87 (95% CI 1.07, 3.29) increased odds of greater uterine volume, respectively.Conclusions. In this preliminary study, exposure to some phthalates was associated with larger uterine volume, a marker of disease severity and fibroid growth. Larger, prospective studies are needed to confirm these relationships.

PD50-05 DO LUTS CORRELATE WITH UTERINE FIBROID SIZE AND LOCATION?

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Non-neurogenic Voiding Dysfunction I1 Apr 2018PD50-05 DO LUTS CORRELATE WITH UTERINE FIBROID SIZE AND LOCATION? Robyn K Shaffer, Amy D Dobberfuhl, Angela Fast, Kim N Vu, David Hovsepian, Deirdre Lum, Pejman Ghanouni, and Bertha Chen Robyn K ShafferRobyn K Shaffer More articles by this author , Amy D DobberfuhlAmy D Dobberfuhl More articles by this author , Angela FastAngela Fast More articles by this author , Kim N VuKim N Vu More articles by this author , David HovsepianDavid Hovsepian More articles by this author , Deirdre LumDeirdre Lum More articles by this author , Pejman GhanouniPejman Ghanouni More articles by this author , and Bertha ChenBertha Chen More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.2333AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Uterine fibroids are prevalent and often co-exist with lower urinary tract symptoms (LUTS) in women. Fibroid bulk is thought to correlate with LUTS and pelvic floor symptom severity. However, these associations are under-studied and data are based mostly on ultrasound measurements. Correlations between LUTS and specific fibroid or pelvic dimensions may impact treatment counseling. We examined the correlation between LUTS and fibroids using MR imaging. METHODS A retrospective review (2013-2016) on Stanford Fibroid Clinic patients identified 238 patients with a complete Pelvic Floor Distress Inventory survey (PFDI; score 0-300, worse symptoms with higher scores) and pelvic MRI. PFDI scores and sub-scores, including urogenital (UDI-6) and colorectal anal (CRAD-8) distress inventory scores, were correlated to MRI data. Data were analyzed in STATA. RESULTS Patients had a mean age of 47.3 years (SD 7.2 years) and a mean PFDI score of 77.5 (SD 52.7). Pearson correlation analysis showed that dominant fibroid volume was inversely correlated with colorectal distress (CRAD-8 r=-0.14, p<0.05). Women with an anteverted uterus tilted towards the bladder reported worse stress incontinence scores [2.2 (n=176) vs 1.5 (n=45); p<0.05]. There was no association between fibroid location on the uterus (anterior, posterior, fundal) or within the uterine wall (intramural, submucosal, subserosal) and LUTS. Analysis of fibroids location relative to bony landmarks demonstrated that 29% of women had fibroids within the true pelvis only while 71% had fibroids extending into the abdomen. Women with anterior displacement of the abdominal wall visible on MRI due to fibroid mass effect reported fewer pelvic floor symptoms [PFDI 68.7 vs 82.0; p<0.05] and fewer colorectal symptoms [CRAD-8 12.5 vs 20.7; p<0.001] than those without abdominal wall distension. Worse pelvic floor and urogenital symptoms correlated to women with a deeper sacral curvature (PFDI r=0.16, p<0.05; UDI-6 r=0.15, p<0.05). Worse colorectal symptoms correlated with higher ratio of dominant fibroid diameter to the pelvic diameter (distance measured from sacral promontory to the superior symphysis) (CRAD-8 r=0.19, p<0.01). CONCLUSIONS Contrary to common belief, LUTS appear to inversely correlate with uterine volume. Women with a smaller pelvis or deeper sacral curvature relative to fibroid size may report worse symptoms unless the fibroid is displaced into the abdomen. Fibroid size relative to bony parameters may help providers counsel patients on whether removal of fibroids will provide symptom relief. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e971-e972 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Robyn K Shaffer More articles by this author Amy D Dobberfuhl More articles by this author Angela Fast More articles by this author Kim N Vu More articles by this author David Hovsepian More articles by this author Deirdre Lum More articles by this author Pejman Ghanouni More articles by this author Bertha Chen More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Effect of type 3 intramural fibroids on in vitro fertilization–intracytoplasmic sperm injection outcomes: a retrospective cohort study

To evaluate the influence of type 3 intramural fibroids on invitro fertilization-intracytoplasmic sperm injection (IVF-ICSI) outcomes. Retrospective cohort study. University-based reproductive medicine center. All women undergoing IVF-ICSI from January 1, 2009, to December 31, 2016, in our unit. Each woman was matched with three separate control subjects of the same age (±1year), number of cycles, type of infertility (primary or secondary), type of protocol used for controlled ovarian hyperstimulation (COH), and no uterine fibroids identified by transvaginal ultrasound. Implantation, clinical pregnancy, clinical miscarriage, and live birth rates. We included 151 patients with type 3 intramural fibroids and 453 matched control subjects who underwent IVF-ICSI. The rate of "other protocol" used in COH was significantly higher in women with type 3 fibroids than in the control subjects (P<.001). The experimental group had a significantly lower implantation rate. Type 3 fibroids also resulted in a lower frequency of live births and clinical pregnancy. There was no significant difference between the groups in the rate of clinical miscarriage. Compared with the corresponding control subjects, patients with type 3 fibroids with a single fibroid diameter (SD) or total reported fibroid diameter (TD) >2.0cm also had significantly lower rates of live birth, clinical pregnancy, and implantation. Type 3 fibroids with SD or TD ≤2.0cm had no significant difference in IVF-ICSI outcomes compared with corresponding control subjects. Our results suggest that type 3 fibroids exert a negative impact on the rates of implantation, clinical pregnancy, and live birth in patients undergoing IVF-ICSI, but do not significantly increase the clinical miscarriage rate. The deleterious impact of type 3 fibroids was remarkable in women with type 3 fibroids with TD or SD >2.0cm.

Ulipristal acetate for uterine fibroids: 2 years of real world experience in a UK hospital

Ulipristal acetate (UPA), is a selective progesterone-receptor modulator, it decreases fibroid size and reduces menstrual bleeding. We reviewed its use at the Heart of England Foundation Trust (HEFT), one of the largest prescribing trusts in the UK. The electronic records of patients treated with UPA from January 2013 to August 2015 were reviewed. One hundred and thirty four patients received UPA, 20 women (15%) received a second course. Eighty percent reported subjective global improvements in symptoms after the first course; 45.5% described amenorrhoea or light bleeding compared to 4.5% prior to treatment. Fewer patients were anaemic (Hb <11 g/dL) following treatment (8.2% versus 33.6%). The majority of fibroids (34%) reduced or remained the same size (25%). Two-thirds of women treated for symptom control avoided surgical intervention. UPA improves symptoms and modifies the use of surgery in treating fibroids. Correcting anaemia prior to major surgery reduces the risk of blood transfusion and optimises a patient’s condition as part of an enhanced recovery pathway.Impact StatementWhat is already known on this subject: In women with heavy menstrual bleeding secondary to fibroids, UPA has been shown to reduce fibroid size and control uterine bleeding, inducing amenorrhoea in the majority. Initially, only licenced for pre-operative use, an expansion of the licence has included on-going intermittent use for symptomatic fibroids.What the results of this study add: Our review is the largest published cohort of women treated with UPA. It demonstrates symptomatic improvements and advantageous modifications in fibroid size in women of all ethnicities and ages. Our inclusion of women with a uterine size greater than 16 weeks and fibroid diameter larger than 10 cm demonstrates the benefits of UPA with increased fibroid dimensions.What the implications are of these findings for clinical practice and/or further research: These findings can allow clinicians to consider alternative surgical interventions or even avoid surgery completely in a proportion of patients with fibroids. Correcting anaemia and optimising a patient’s pre-operative condition reduces post-operative complications and ongoing morbidity. However, 25% of fibroids failed to respond to UPA treatment, further research into the characteristics of women and fibroids that show favourable clinical outcomes will allow identification of those women who are likely to benefit from treatment and prevent futile use in others.

Effects of a microbubble ultrasound contrast agent on high-intensity focused ultrasound for uterine fibroids: a randomised controlled trial

Objective: To investigate the effects of a microbubble ultrasound contrast agent on high-intensity focused ultrasound (HIFU) treatment of uterine fibroids.Methods: A total of 120 patients with solitary uterine fibroid were randomly assigned into Groups A, B, C and D. Patients in Groups A and B received 1.5 ml of SonoVue, Groups C and D received 1.5 ml of saline before HIFU ablation. HIFU sonication started at 6 min after administration of SonoVue or saline in Groups A and C, whereas it started at 10 min in Groups B and D. On day 1 after HIFU, magnetic resonance imaging was performed. Patients were followed up via phone or clinic visit during the first week after HIFU.Results: No significant difference was observed in terms of age, fibroid location, diameter of fibroids, signal intensity on T2-weighted imaging, or tumour volume among the four groups (p > 0.05). The use of SonoVue significantly shortened the treatment time and sonication time. The sonication start time of 6 min, relative to 10 min, had significant effects on the treatment time and sonication time. The use of intravenous SonoVue followed by HIFU ablation 6 min later significantly increased the rate of significant grey-scale changes (55.9%) and the non-perfused volume ratio (94.2% ± 10.6%). No significant differences were observed in the incidence of intra-procedure and post-HIFU adverse effects among the four groups (p > 0.05).Conclusions: SonoVue could be safely used to enhance the ablation effects of HIFU treatment of uterine fibroids.

Utility of Laparoscopic Uterine Myomectomy as a Treatment for Infertility with No Obvious Cause Except for Uterine Fibroids.

Objectives:Uterine fibroids are capable of causing infertility, but there are no definite criteria for which laparoscopic uterine myomectomy (LM) is known to be beneficial. To investigate the usefulness of LM, we examined pregnancy rates in patients with infertility with no obvious cause except for the presence of uterine fibroids.Materials and Methods:We retrospectively reviewed the clinical records at Suzuki Memorial Hospital between June 2010 and August 2014. We found 60 eligible patients (LM group, 46; non-LM group, 14). The criteria for performing LM were a maximal fibroid diameter of 40 mm or more or the presence of >4 fibroids.Results:The duration of infertility before the first visit was significantly longer in the LM group; although there was no significant difference in the mean patient age and body mass index. Pregnancy was achieved in 45.7% of patients (21/46) in the LM group and 28.6% (4/14) in the non-LM group. There were no pregnancies in patients with >10 fibroids. The postoperative pregnancy rate in the LM group was comparable to previously reported pregnancy rates.Conclusions:Our criteria for performing LM in patients with no obvious cause for infertility except for uterine fibroids seem appropriate, especially when the fibroids are large and the number of fibroids is between 4 and 9. However, our results suggest that the effectiveness of LM is low in patients with 10 or more uterine fibroids.

Uterinefibroid size modifications during pregnancy and puerperium: evidence from the first systematic review of literature.

The influence of pregnancy on uterine fibroid size still remains an unsolved dilemma. Basing on current knowledge, physicians are not able to inform patients about the likelihood of uterine fibroids to modify their size during pregnancy. Study aim was to summarize available evidence concerning the size modifications of uterine fibroids during each trimester of pregnancy and during puerperium. The review was reported following the PRISMA guidelines and registered in PROSPERO (registration number: CRD42017071117). A literature search was conducted in electronic database (PubMed, Embase, Sciencedirect, the Cochrane library and Clinicaltrials.gov) until July 2017. All studies evaluating fibroids' changes during pregnancy and puerperium by ultrasound or magnetic-resonance-imaging were included. Descriptive characteristics of studies and patients were collected. The modifications of uterine fibroid diameter and volume were the outcome measures. Concerning the first trimester of pregnancy, all authors reported a significant growth of uterine fibroids. Contradictory evidence was found about uterine fibroid modifications during the second and third trimesters, mainly supporting a slowdown during mid pregnancy and a subsequent size reduction during late pregnancy. Concerning the overall modifications during pregnancy and puerperium, poor evidence quality suggests that uterine fibroids do not modify their volume/slightly enlarge during pregnancy and subsequently reduce in size during puerperium. Uterine fibroids seem to be subject to a non-linear trend of modifications during pregnancy and puerperium, which may vary from myoma to myoma. Adequate evidence supports uterine fibroid systematic enlargement during the first trimester of pregnancy, while inconsistent evidence is available about the changes of uterine fibroids during second and third trimesters. In addition, the overall modifications of myomas during pregnancy and puerperium remain unclear.

MRI Enhancement as a Predicator of Uterine Fibroid Volume Reduction after Embolism

Aim of the Study: To evaluate the response of necrotic fibroids to UAE and to identify whether pre-UAE enhancement or other factors are predictors of fibroid shrinkage. Materials and methods: This is a retrospective review of all women who underwent UAE for symptomatic fibroids from January 2013 till July 2017, who experienced a follow-up MRI 5-6 months after UAE were included. There were 54 fibroids (37 non-enhancing and 17 enhancing) among 24 women with a mean age of 56 (range 40-59) years. All fibroids were assessed for size, position, enhancement on subtraction images, and Apparent Diffusion Constant (ADC). Results: Enhancing fibroids had an average decrease in diameter by 23 ± 6%, not significantly different compared to that non-enhancing fibroids which decreased by 19 ± 3% (p=0.491). Multiple linear regression with percent change in fibroid diameter as the dependent variable and patient age, fibroid position, and pre-UAE fibroid diameter, enhancement, and ADC as independent variables, showed that ADC (p<0.005) and pre-UAE diameter (p<0.005) were the only significant independent variables. Conclusion: Pre-UAE size and ADC, but not contrast enhancement, predicted fibroid diameter reduction. Enhancing and non-enhancing fibroids had similar size reduction after UAE. Non-enhancement should not be considered a contraindication to UAE.

EP28.08: Ultrasound preoperative evaluation in the prediction of laparoscopic myomectomy complications

To investigate whether a preoperative detailed transvaginal ultrasound evaluation can predict complications during and after laparoscopic myomectomy. This prospective study included women of reproductive age with a single symptomatic fibroid, classified as type 4,5 or 6 according to FIGO classification, scheduled for laparoscopic myomectomy. Transvaginal scanning was performed one month before surgery by the same technician who collected ultrasound data regarding the uterus (volume and vascularisation, considering uterine arteries PI and RI) and the fibroid (type, position, main diameter, volume and vascularisation, considering supplying vessel PI and RI). Surgery was performed by a second physician and the outcome parameters considered were: surgical time, intraoperative blood loss, pre-and post-operative hemoglobin, use of abdominal drains, duration of hospital stay, post-operative fever and need of blood transfusion. 23 women were enrolled in the study. The mean uterine volume was 381.9±189.4 mm3 and it had a correlation with the length of surgery (p=0.045). The mean diameter of fibroids evaluated was 62.2±24.2 mm with a mean volume of 131.7±117 mm3. A significant association was found between fibroid position and surgical time, in particular lateral myomectomies had the longest duration (p=0.049). No other correlations were found among the ultrasound preoperative parameters and the different complications during and after surgery. Dividing myomas in two groups considering their larger diameter, fibroids of 50 mm or more showed higher length of surgery, more blood loss and higher difference between pre and post-operative hemoglobin, but these results did not reach significance (p>0.05). Ultrasound calculation of uterine and fibroid volume can be useful in the estimation of surgical time but determination of uterine and fibroid vascularisation seems not to be a predictor for the risks of complications during and after myomectomy.

P14.06: Ulipristal acetate in the treatment of fibroids: report of the initial experience of a tertiary centre in Portugal

Ulipristal acetate (UPA) is a novel alternative in the medical management of fibroids. Its efficacy and safety as a preoperative treatment have already been shown; besides the fast and effective control of the fibroid-associated bleeding, another advantage is the reduction in the size of fibroids, which lasts for at least 6 months after the treatment. The objective of this study was to evaluate the results of the treatment with UPA in a tertiary hospital in Portugal – the primary outcome was defined as the reduction in the size of the dominant fibroid (the authors defined the biggest diameter as the standard measurement). Retrospective analysis of standardised medical records of all women to whom UPA was prescribed between January of 2013 and December of 2016 at Centro Hospitalar de São João. The inclusion criteria were: women older than 18-years–old who underwent a 3-month treatment with UPA and who had an imagiological exam describing the size of the dominant fibroid within 6 months preceding the treatment and another one up to three months after its completion. Statistical analysis was performed using SPSS Statistics®, version 22.0, IBM® software, with a p value inferior to 0.05 indicating statistical significance. From the 155 women to whom UPA was prescribed, only 73 cases were eligible. The mean age of the patients was 42.41 years old; 32% of them were nulliparous. The mean reduction in the dominant fibroid diameter after one cycle of UPA was 5.23mm (SD= 13.60mm): it was statistically significant (p< 0,05). Despite the small number of patients included, the reported results go in line with other studies published so far. As so, the authors believe that UPA is a valid alternative in the treatment of fibroids.

Ineffectiveness of Magnetic Resonance Imaging Enhancement to Predict Fibroid Volume Reduction After Uterine Artery Embolization

Fibroid nonenhancement is considered a relative contraindication to uterine artery embolization (UAE) for symptomatic fibroids. This retrospective study assessed the impact of UAE on nonenhancing fibroids to determine imaging predictors of fibroid shrinkage. All women who underwent UAE for symptomatic fibroids between May 2009 and July 2014 and had follow-up magnetic resonance imaging 6 months after UAE were included. There were 59 fibroids (5 nonenhancing, 54 enhancing) among 18 women aged 40 to 53 (mean 46) years. All fibroids were assessed for size, position, and enhancement on subtraction and apparent diffusion constant (ADC) images. Enhancing fibroids had an average decrease in diameter of 19% ± 3%, not significantly different than nonenhancing fibroids, which decreased 23% ± 6% (P = 0.49). Multiple linear regression with percent change in fibroid diameter as the dependent variable and patient age, fibroid position, and pre-UAE fibroid diameter, enhancement, and ADC as independent variables showed that ADC (P = 0.04) and pre-UAE diameter (P = 0.03) were the only significant independent variables. In conclusion, pre-UAE size and ADC, but not contrast enhancement, predicted fibroid diameter reduction. Enhancing and nonenhancing fibroids had a similar size reduction after UAE. Nonenhancement should not be considered a contraindication to UAE.

Endoscopic treatment of symptomatic fibroids at reproductive age and beyond

Objectives: To evaluate the feasibility of endoscopic treatment of symptomatic uterine fibroids based on patient and fibroid characteristics in reproductive, pre-menopausal and post-menopausal women.Material and methods: The medical records of women with symptomatic uterine fibroids who underwent surgical procedures from 2010 to 2015 were retrospectively reviewed.Results: A total of 819 patients, of which 710 (86.6%) underwent endoscopic procedures. The mean age of women who underwent laparoscopic myomectomy (LM) was 36.77 ± 6.54 and hysteroscopic myomectomy (HSCM) was 43.10 ± 10.26. The mean cumulative diameter of fibroids in the LM was 8.94 ± 3.1 and 3.68 ± 1.64 cm in the HSCM. Furthermore, LM and HCSM were performed when the mean diameter of the largest fibroid was up to 18.50 and 5.5 cm, respectively. The mean age of women in laparoscopic supracervical hysterectomy (LSH) was 46.02 ± 6.13 and total laparoscopic hysterectomy (TLH) was 47.30 ± 8.12. The mean cumulative diameter of fibroids in the LSH was greater than in the TLH, at 8.94 ± 3.1 and 7.63 ± 3.60 cm, respectively.Conclusions: Uterus-preserving procedures are feasible, even if the largest fibroid diameter is more than 10 cm in LM and equal to 5.5 cm in HSCM. For pre- and post-menopausal women, TLH is the definitive treatment modality for uterine fibroids, and LSH represents an alternative to TLH.

Effects of TGF-β on uterine fibroids of women of childbearing age and uterine artery embolization

Purpose: To evaluate the effects of transforming growth factor-β (TGF-β) on uterine fibroids of women of childbearing age and uterine artery embolization (UAE) using Embosphere microspheres.Material and methods: A total of 128 eligible women were randomly divided into an experimental group and a control group (n = 64) who received UAE using Embosphere microspheres and panhysterectomy, respectively. Another 128 healthy women receiving physical examination in the same period were also enrolled. Serum TGF-β levels were detected by enzyme-linked immunosorbent assay (ELISA). Serum TGF-β level, size of uterine fibroid and prognosis were followed up.Results: The serum TGF-β level of patients was significantly higher than that of healthy subjects. After treatment, the red blood cell counts and hemoglobin levels of the two patient groups significantly increased compared with those before (p < .05). After UAE, the diameter of uterine fibroids was significantly smaller than that before treatment, and the TGF-β level significantly decreased (p < .05). The expression of TGF-β in uterine fibroids was significantly higher than that in surrounding normal tissue (p < .05).Conclusion: With the uterus retained, the therapeutic effect of UAE was similar to that of panhysterectomy. TGF-β expression level was associated with growth of uterine fibroid in women of childbearing age, which can be used as a target for treatment.

Fibroids and IVF: retrospective studies or randomised clinical trials?

The opening statement in the manuscript by Christopoulos et al. cannot be misunderstood. “Uterine fibroids are the commonest benign tumours in women of reproductive age etc”. Clearly, uterine fibroids are a serious health issue. The obvious follow-up question is whether fibroids negatively impact reproduction and, if so, what the most effective and safe intervention is to treat fibroids. Given this serious issue, one would expect ample research generating high-level evidence on the clinical significance of fibroids and interventions. However, this is not the case. The authors review of the literature including multiple systematic reviews clearly indicates that research to date has been limited to retrospective cohort studies or case–control studies, fraught with their intrinsic biases, confounding and clinical heterogeneity. So, it comes as no surprise that these reviews, that represent the highest level of evidence presently available, provide no evidence-based recommendations on clinical management of fibroids to improve reproductive outcomes. The aim of the present study is to assess the impact of non-cavity-distorting fibroids on in vitro fertilisation (IVF) pregnancy outcomes. Unfortunately this study will also not provide us the definitive answer, as once again we are presented with yet another observational study. This is a retrospective, matched, single-centre cohort study in 194 women. In addition, the authors missed the opportunity to explore the impact of fibroid diameter, as they used a predetermined cut-off based upon one Chinese case–control study. The authors correctly point out that “the negative impact of uterine fibroids on pregnancy rates after IVF does not de facto suggest that surgical management in the form of open or laparoscopic myomectomy could alleviate this effect and that to date randomised controlled trials on the surgical management of such fibroids are lacking”. The reason for this is then – to a certain extent – attributed to short- and long-term complications after surgery. This means that myomectomy is offered to these patients in routine care, but not as part of randomised controlled trials (RCTs) out of fear for complications. Does that make sense and, more importantly, is it ethical? The authors then present as their final conclusion that “given the expected morbidity associated with surgical management of fibroids, data from RCTs on the use of medical agents to treat fibroids prior to assisted conception treatment may currently be preferable”. This seems reasonable at first sight, but the data on effectiveness of the drug Ulipristal acetate in reference to reproductive outcomes consist of only a few case reports, and data on safety are non-existent and, as such, RCTs are premature. So, we as gynaecologists have been and still are practicing myomectomies in women of reproductive age without the underpinning evidence and without even trying to provide the evidence. On the other hand, as soon as a new drug enters the market of which we know very little, we start randomising immediately. It is a strange world. None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

A Prospective Multicenter Registry of Patients Undergoing Hysteroscopic Morcellation of Uterine Polyps and Myomas.

Background: Hysteroscopic morcellation removes uterine pathology under direct visualization with continuous real-time tissue fragment removal. Objective: The aim of this study was to explore the feasibility of hysteroscopic morcellation across a diverse set of facilities, including both surgical and office-based settings. Design: This was a prospective, single-arm, multicenter registry development (Canadian Task Force classification II-3). Materials and Methods: Thirty-four U.S. obstetrics and gynecology facilities enrolled subjects into the registry. Inclusion criteria were women ages 18–65 with indications for hysteroscopic myomectomy and/or polypectomy who were treated with the MyoSure® Hysteroscopic Tissue Removal System (Hologic Inc., Marlborough, MA). Intrauterine lesion type/size and removal parameters, adverse events (AEs), and physician satisfaction ratings were recorded. Results: A total of 559 pathologies (187 fibroids; 372 polyps) were removed from 278 registered subjects (mean age: 43.9 ± 9.0 years), with 250 procedures (89.9%) performed in an ambulatory surgery center or hospital outpatient setting and 28 (10.1%) in a gynecologic office setting. Most patients (n = 206, 74.1%) were treated for abnormal uterine bleeding, and 42 (15.1%) were treated for infertility. Mean fibroid diameter was 2.2 ± 1.2 cm. Mean polyp diameter was 1.3 ± 1.0 cm. Overall mean percentage of pathology removed was 95.4% (polyps 99.3%, fibroids 86.8%). Five AEs included four incidents of blunt cervical trauma and a single postoperative case of pedal edema; all were considered mild and resolved spontaneously. Postprocedure surveys indicated that 95% of reporting physicians were “satisfied” or “highly satisfied” with device performance. Conclusions: Hysteroscopic morcellation of intrauterine pathology was accomplished safely with a high degree of physician satisfaction in 278 patients treated in diverse healthcare settings that are reflective of general community practice in the United States. (J GYNECOL SURG 32:318)

High metabolic characteristics of uterine fibroids in 18F-FDG PET/CT imaging and the underlying mechanisms.

To investigate the high metabolic characteristics of uterine fibroids in fluorine-18 fluorodeoxyglucose (F-FDG) PET/computed tomographic imaging and the underlying mechanisms. A total of 47 patients with uterine fibroids who underwent PET/computed tomographic imaging and ultrasound examination from November 2011 to May 2015 were retrospectively analyzed. The characteristics of F-FDG uptake by uterine fibroids were analyzed and their correlations with age, menopause, menstrual cycle, hormone indexes, tumor markers as well as the number and maximum diameter of fibroids in ultrasound images were explored using univariate analysis and multivariate logistic regression analysis. (a) The total positive F-FDG uptake rate and maximum standardized uptake value (SUVmax) were 40.4% (19/47) and 4.38±2.57 (1.74-10.81), respectively, in patients with uterine fibroids; (b) univariate analysis showed that age, menopause, estrogen, follicle-stimulating hormone, luteinizing hormone as well as the number of fibroids were correlated positively with F-FDG uptake in uterine fibroids (P<0.05); and (c) multivariate logistic regression analysis showed that only the number of fibroids was meaningfully correlated with F-FDG uptake in uterine fibroids (odds ratio=30.000, P<0.05). Uterine fibroids have a higher positive F-FDG uptake rate and highly variable SUVmax. The SUVmax is especially higher in younger and premenopausal patients. Multiple fibroids play a decisive role in the positive F-FDG uptake rate possibly because of the quantitative to qualitative changes in the effects of estrogen on the proliferation of uterine fibroids.

Ulipristal acetate in the treatment of fibroids: report of the initial experience of a tertiary center in Portugal

Introduction: Ulipristal acetate (UPA) – an oral selective progesterone receptor modulator – is a novel alternative in the medical management of fibroids. Its efficacy and safety as a preoperative treatment have already been shown and, when compared to leuprolide, has a significantly better tolerability profile. Besides the fast and effective control of the fibroid-associated bleeding, another advantage of the treatment with UPA is the reduction in the size of fibroids, which lasts for at least 6 months after the treatment. The objective of this study was to evaluate the results of the treatment with UPA in a tertiary hospital in Portugal – the primary outcome was defined as the reduction in the size of the dominant fibroid (the authors defined the biggest diameter as the standard measurement); the secondary outcomes were the self-reported reduction in the fibroid-associated bleeding and the number of patients submitted to surgery after one cycle of UPA. Material and methods: Retrospective analysis of standardized medical records of all women to whom UPA was prescribed between January of 2013 and June of 2015 at Centro Hospitalar de São João (Oporto). The inclusion criteria were defined as follows: women older than 18-years–old who underwent a 3-month treatment with UPA and who had an imagiological exam describing the size of the dominant fibroid in the 6 months preceding the treatment and another one up to three months after its completion. Statistical analysis was performed using SPSS Statistics®, version 22.0, IBM® software, with a p value inferior to 0.05 indicating statistical significance. Results: From the 80 women to whom UPA was prescribed in the defined time period, only 40 cases were eligible for this study. The mean age of the patients was 38,6 years old; 40% of them were nulliparous (n = 16). The mean reduction in the dominant fibroid diameter after one cycle of UPA was 2.25 mm (SD = 9.94 mm). There was no statistical significance in the reduction of the fibroids size (p > 0.05). 80% of the patients reported a reduction in uterine bleeding; only about one third (37,5%) of the women underwent surgery/uterine artery embolization after the treatment with UPA. Conclusion: Despite the small number of patients included, the reported results go in line with other studies published so far. As so, the authors believe that UPA is a valid alternative in the treatment of fibroids, particularly useful for the control of uterine bleeding.

Obstetrical Outcomes of Ultrasound Identified Uterine Fibroids in Pregnancy.

Objective We aimed to determine if fibroids in pregnancy, categorized by size, are associated with adverse obstetrical outcomes. Study Design Demographic, clinical, and delivery data were collected from charts of women with singleton gestations who delivered at >20 weeks gestation with fibroids identified at routine anatomy scan and their randomly selected age-matched controls. Largest fibroid diameter was used to categorize small fibroids (≤5 cm) and large fibroids (>5 cm). Results We included 450 patients: 264 patients with fibroids (174 small, 90 large fibroids) and 186 age-matched controls. Women with large fibroids had significantly greater blood loss than women with small fibroids and women with no fibroids (p-value <0.0001 and <0.0001 after adjusting for delivery mode). When fibroid size was compared individually, there was a significantly higher rate of primary cesarean section in both small and large fibroid groups when compared with women with no fibroids (p-values 0.044 and 0.003 after adjusting for body mass index). Conclusion Women with fibroids in pregnancy have higher rates of primary cesarean delivery and are at significant risk for increased blood loss at the time of delivery.