Uterine fibroid management: from the present to the future

Abstract

Uterine fibroids (also known as leiomyomas or myomas) are the most common form of benign uterine tumors. Clinical presentations include abnormal bleeding, pelvic masses, pelvic pain, infertility, bulk symptoms and obstetric complications.Almost a third of women with leiomyomas will request treatment due to symptoms. Current management strategies mainly involve surgical interventions, but the choice of treatment is guided by patient's age and desire to preserve fertility or avoid ‘radical’ surgery such as hysterectomy. The management of uterine fibroids also depends on the number, size and location of the fibroids. Other surgical and non-surgical approaches include myomectomy by hysteroscopy, myomectomy by laparotomy or laparoscopy, uterine artery embolization and interventions performed under radiologic or ultrasound guidance to induce thermal ablation of the uterine fibroids.There are only a few randomized trials comparing various therapies for fibroids. Further investigations are required as there is a lack of concrete evidence of effectiveness and areas of uncertainty surrounding correct management according to symptoms. The economic impact of uterine fibroid management is significant and it is imperative that new treatments be developed to provide alternatives to surgical intervention.There is growing evidence of the crucial role of progesterone pathways in the pathophysiology of uterine fibroids due to the use of selective progesterone receptor modulators (SPRMs) such as ulipristal acetate (UPA). The efficacy of long-term intermittent use of UPA was recently demonstrated by randomized controlled studies.The need for alternatives to surgical intervention is very real, especially for women seeking to preserve their fertility. These options now exist, with SPRMs which are proven to treat fibroid symptoms effectively. Gynecologists now have new tools in their armamentarium, opening up novel strategies for the management of uterine fibroids.

Progesterone Receptor Isoforms, Nuclear Corepressor-1 and Steroid Receptor Coactivator-1 and B-Cell Lymphoma 2 and Akt and Akt Phosphorylation Status in Uterine Myomas after Ulipristal Acetate Treatment: A Systematic Immunohistochemical Evaluation

“…Uterine myomas are the most commonly found benign tumors in women of reproductive age and they can cause abnormal uterine bleeding, pelvic pressure and pain, and reproductive dysfunction [1, 2]. Progesterone is particularly essential to myoma development [3] with myomas exhibiting higher progesterone receptor (PR) levels compared with adjacent myometrium [4-8].…”

Fertility and ulipristal acetate case report of two spontaneous pregnancies in the same patient following one cycle of treatment

“…Recently, UPA was approved for this purpose as it showed comparable efficacy to leuprolide acetate with fewer side effects. 5,6 Moreover, it has been reported that the reduction in fibroid size is maintained for at least six months after the treatment. 5 Most of medical alternatives available for fibroids management have limitations: when it comes to fertility some prevent conception whereas others have little information regarding its effects on a future pregnancy.…”

“…5 Moreover, it reduces fibroids and uterine volume, and it is sustained for at least six months after treatment. 5,6 Although there is still few evidence concerning UPA and pregnancy, no adverse effects were reported so far, making it an option for women who desire to conceive in the short-term.…”

Safety of pregnancy in uterine fibroids

“…7,9 Other less common symptoms include pelvic pressure, vaginal bleeding, urinary frequency, and constipation. 7,10 The large-sized fibroids exert pressure effects on nearby organs as well. Anterior cervical fibroids compress the urinary bladder leading to frequent micturition.…”