Global, regional, and national time trends in incidence, prevalence, years lived with disability for uterine fibroids, 1990-2019: an age-period-cohort analysis for the global burden of disease 2019 study.

BACKGROUND: Uterine fibroids are the most common benign neoplasm of the uterus and a major source of morbidity for women. We report an overview of trends in uterine fibroids of incidence rate, prevalence rate, years lived with disability (YLDs) rate in 204 countries and territories over the past 30 years and associations with age, period, and birth cohort. METHODS: The incident case, incidence rate, age-standardized rate (ASR) for incidence, prevalent case, prevalence rate, ASR for prevalence, number of YLDs, YLD rate, and ASR for YLDs were derived from the Global Burden of Disease 2019 (GBD 2019) study. We utilized an age-period-cohort (APC) model to estimate overall annual percentage changes in the rate of incidence, prevalence, and YLDs (net drifts), annual percentage changes from 10 to 14 years to 65-69 years (local drifts), period and cohort relative risks (period/cohort effects) between 1990 and 2019. RESULTS: Globally, the incident cases, prevalent cases, and the number of YLDs of uterine fibroids increased from 1990 to 2019 with the growth of 67.07%, 78.82% and 77.34%, respectively. High Socio-demographic Index (SDI) and high-middle SDI quintiles with decreasing trends (net drift < 0.0%), and increasing trends (net drift > 0.0%) were observed in middle SDI, low-middle SDI, and low SDI quintiles in annual percentage change of incidence rate, prevalence rate and YLDs rate over the past 30 years. There were 186 countries and territories that showed an increasing trend in incidence rate, 183 showed an increasing trend in prevalence rate and 174 showed an increasing trend in YLDs rate. Moreover, the effects of age on uterine fibroids increased with age and peaked at 35-44 years and then declined with advancing age. Both the period and cohort effects on uterine fibroids showed increasing trend in middle SDI, low-middle SDI and low SDI quintiles in recent 15 years and birth cohort later than 1965. CONCLUSIONS: The global burden of uterine fibroids is becoming more serious in middle SDI, low-middle SDI and low SDI quintiles. Raising awareness of uterine fibroids, increasing medical investment and improving levels of medical care are necessary to reduce future burden.

Uterine leiomyoma is associated with the risk of developing endometriosis: A nationwide cohort study involving 156,195 women.

OBJECTIVE: Evidence for an association between uterine leiomyoma and increased risk of endometriosis is limited by small sample sizes and short follow-up periods. We assessed this association in a large nationwide sample with 14 years of data. DESIGN: Data were sourced from Taiwan's Longitudinal Health Insurance Database 2000 (LHID2000). MATERIALS AND METHODS: We identified 31,239 women aged ≥20 years diagnosed with uterine leiomyoma (International Classification of Disease, Ninth Revision, Clinical Modification [ICD-9-CM] code 218) between Jan 1, 2000 and Dec 31, 2012, who were matched with 124,956 controls (1:4) by 5-year age groups and year of diagnosis. Follow-up was from the date of LHID2000 entry to the first occurrence of endometriosis, loss to follow-up, insurance termination, or until December 31, 2013, whichever was earlier. RESULTS: In Cox regression analysis, the adjusted hazard ratio (aHR) for endometriosis in women with uterine leiomyoma was 6.44 (95% CI, 6.18, 6.72) compared with controls. The risk of endometriosis was significantly increased in women with uterine leiomyoma and comorbidities of tube-ovarian infection (aHR 2.86; 95% CI, 1.28, 6.36), endometritis (1.14; 1.06, 1.24), infertility (1.26; 1.16, 1.37), or allergic diseases (1.11; 1.05, 1.17). Having both uterine leiomyoma and endometritis significantly increased the risk of endometriosis (aHR 6.73; 95% CI, 6.07, 7.45) versus having only uterine leiomyoma (6.61; 6.33, 6.91) or endometritis (1.49; 1.31, 1.69). Similarly, having both uterine leiomyoma and infertility significantly increased the risk of endometriosis (aHR 6.95; 95% CI, 6.21, 7.78) versus having only uterine leiomyoma (6.66; 6.38, 6.96) or infertility (1.78; 1.57, 2.02). CONCLUSIONS: A diagnosis of uterine leiomyoma appears to increase the risk of endometriosis. Patients presenting with uterine fibroids should be encouraged to give informed consent for possible simultaneous surgical treatment of endometriosis.

The Value of Adenomyosis Type in Clinical Assessment: A Single-center Experience of 755 Nodular and Diffuse Adenomyosis Cases.

BACKGROUND: To investigate the incidence of nodular and diffuse adenomyosis, concomitant pathologies and also to compare the demographic and clinic differences among patients with adenomyosis and their surgery indications. METHODS: This retrospective study was conducted in Tepecik Research Hospital, Izmir, Turkey between 2014 and 2016. Patients were divided into two groups of nodular and diffuse adenomyosis. The following variables were evaluated for both groups: age, gravidity, parity, menopausal status, indication for hysterectomy, ultrasonographic parameters, gynecological symptoms (abnormal uterine bleeding [AUB], pelvic pain and pelvic pressure, postmenopausal vaginal bleeding), preoperative and postoperative histopathological assessment, and coexisting pathologies. RESULTS: Of the total 3457 cases of hysterectomies, 755 (95% CI: 20.4-23.1) were confirmed with adenomyosis. There were 217 (95% CI: 23.9-30.0) postmenopausal women. Adenomyosis was most commonly detected in patients in the age of 40 to 50 (57.6%). The most common symptoms were AUB (n: 336) (95% CI: 40.9-48.0), pelvic pain or pressure (n:139) (18.4%), and postmenopausal vaginal bleeding (n: 119) (95% CI: 13.1-18,4). Seventy-four (95% CI: 7.9-11.9) of the patients had nodular and 681(95% CI: 88.0-92.3) had diffuse adenomyosis. Demographic data, age, parity, gravidity, endometrial thickness, and menopausal status were similar between the groups. AUB was more frequently detected in nodular adenomyosis (56.8%). Myoma uteri was the main hysterectomy indication in both groups. In addition, treatment-resistant AUB for nodular adenomyosis and endometrial pathologies for diffuse adenomyosis were the most frequent indications for hysterectomy after myoma uteri. CONCLUSION: The most common form of adenomyosis was the diffuse form. Endometrial pathologies were more frequently associated with diffuse adenomyosis. Asymptomatic and incidental adenomyosis were more common with the diffuse form. AUB was more frequently detected with nodular adenomyosis.

Epidemiology and management of uterine fibroids.

Uterine leiomyomas are one of the most common and yet understudied diseases in women. These tumors, commonly known as fibroids, affect women mainly during their reproductive years and are diagnosed in up to 70% of white women and more than 80% of women of African ancestry during their lifetime. This disease has a profound impact on health care delivery and costs worldwide. Though most women with fibroids are asymptomatic, approximately 30% of them will present with severe symptoms which can include abnormal uterine bleeding, anemia, pelvic pain and pressure, back pain, urinary frequency, constipation, or infertility, and will require intervention. Furthermore, fibroids have been associated with poor obstetrical outcomes. The current options for symptomatic fibroid treatment include expectant, medical, and surgical management, and interventional radiology procedures. This article reviews the recent progress and available management strategies for uterine fibroids and highlights areas where further research is needed to find new therapeutic targets and better personalize treatments.

[Disease burden on uterine fibroids in China, 1990 and 2016].

Objective: To assess the disease burden on uterine fibroids in China in 1990 and 2016. Methods: Data were extracted from the Global Burden of Disease Study 2016. Burdens of uterine fibrosis among different age groups and provinces were measured in 1990 and 2016, with key indicators including number of cases, prevalence rates, disability-adjusted life year (DALY) and the rates of DALY. The WHO world standard population, 2010-2035 was used to calculate the age- standardized rates. Results: In 1990 and 2016, there were 13 695 567 and 27 169 312 women aged 15 years and older, suffered from uterine fibrosis respectively, with prevalence rate as 2.48% and 4.10%, DALY as 146 045.05 life years and 281 976.67 life years, and the DALY rate as 26.40/100 000 and 42.50/100 000, in 1990 and 2016 respectively. Both the prevalence rate and the DALY rate increased with age, reaching the peak on the 45-49 years-old, in both 1990 and 2016. Women aged 40-54 years accounted for 55.60% (1990) and 66.74% (2016) of the total cases while 48.37% (1990) and 60.65% (2016) of the total DALY. The first three provinces with highest DALYs were Shandong (1990: 12 574.67 life year; 2016: 22 728.12 life year), Henan (1990: 10 849.29 life year; 2016: 18 454.32 life year) and Jiangsu (1990: 10 501.55 life year; 2016: 18 274.10 life year), while the three provinces with leading standardized DALY rates were Heilongjiang (1990: 48.20/100 000; 2016: 47.00/100 000), Shanxi (1990: 44.50/100 000; 2016: 47.70/100 000) and Tianjin (1990: 43.80/100 000; 2016: 46.40/100 000) in both 1990 and 2016. Compared with 1990, the number of cases with uterine fibroids increased by 13 473 745 (with rate of change as: 98.38%), standardized prevalence rate increased by 1.88%, DALY value increased by 135 931.62 life years (with the rate of change as 93.08%) and standardized DALY rate increased by 5.92% among Chinese women, in 2016. Conclusion: Menopausal women were the ones hard hit by uterine fibrosis. Compared with data from 1990, the disease burden of uterine fibrosis increased rapidly in China, in 2016.

No. 371-Morcellation During Gynaecologic Surgery: Its Uses, Complications, and Risks of Unsuspected Malignancy.

OBJECTIVE: This guideline provides guidance to gynaecologists regarding the use of tissue morcellation in gynaecologic surgery. OUTCOMES: Morcellation may be used in gynaecologic surgery to allow removal of large uterine specimens, thus providing women with a minimally invasive surgical option. Adverse oncologic outcomes of tissue morcellation should be mitigated through improved patient selection, preoperative investigations, and novel techniques that minimize tissue dispersion. EVIDENCE: Published literature was retrieved through searches of PubMed and Medline in the spring of 2014 using appropriate controlled vocabulary (leiomyosarcoma, uterine neoplasm, uterine myomectomy, hysterectomy) and key words (leiomyoma, endometrial cancer, uterine sarcoma, leiomyosarcoma, and morcellation). Results were restricted to systematic reviews, randomized control trials/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 July 2017. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. 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. BENEFITS, HARMS, AND COSTS: Gynaecologists offer women minimally invasive surgery, and this may involve tissue morcellation and the use of a power morcellator for specimen retrieval. Women should be counselled that in the case of unexpected uterine (sarcoma, endometrial), cervical, and/or tubo-ovarian cancer, the use of a morcellator is associated with increased risk of tumour dissemination. Tissue morcellation should be performed only after complete investigation, appropriate patient selection, and informed consent and by surgeons with appropriate training in the safe practices of tissue morcellation. SUMMARY STATEMENTS: RECOMMENDATIONS.

Burden, Prevalence, and Treatment of Uterine Fibroids: A Survey of U.S. Women.

BACKGROUND: Most women will experience uterine fibroids by the age of 50, yet few data exist describing the overall patient experience with fibroids. The objective of this population-based survey was to characterize symptom burden, patient awareness, and treatment decision-making for fibroids, including a comparison among women of varying backgrounds. MATERIALS AND METHODS: Women (≥18 years) were recruited via email from GfK KnowledgePanel®, a representative panel of US households, or identified with opt-in consumer panels. The Uterine Fibroid Symptom and Health-Related Quality of Life (UFS-QOL) questionnaire and Aberdeen Menorrhagia Severity Scale (AMSS) were included. RESULTS: Eligible women were grouped into three cohorts: "at-risk" (symptoms suggestive of fibroids without clinical diagnosis, n = 300), "diagnosed" (n = 871), and fibroid-related "hysterectomy" (n = 272). Cohort and intracohort race/ethnicity and income analyses revealed differences in symptom burden, awareness/perception, and treatment history. Based on UFS-QOL scores, at-risk women reported significantly greater symptom severity and decreased health-related QOL versus diagnosed women; Hispanic women reported greater symptom severity versus white and black women. At-risk women also reported heavy menstrual bleeding and significant impact on work productivity. Among diagnosed women, 71% used pharmacologic therapy for symptom relief, and 30% underwent surgical or procedural treatment. Initial discussions with healthcare providers significantly impacted treatment outcomes; the hysterectomy cohort was most likely to first discuss hysterectomy. CONCLUSIONS: Women with fibroids or symptoms suggestive of fibroids experience significant distress that reduces QOL, particularly racial minorities and women in lower income brackets. Survey results suggest that many women are likely undiagnosed, underscoring the need for improved awareness and education.

A partially linear proportional hazards model for current status data.

For analyzing current status data, a flexible partially linear proportional hazards model is proposed. Modeling flexibility is attained through using monotone splines to approximate the baseline cumulative hazard function, as well as B-splines to accommodate nonlinear covariate effects. To facilitate model fitting, a computationally efficient and easy to implement expectation-maximization algorithm is developed through a two-stage data augmentation process involving carefully structured latent Poisson random variables. Asymptotic normality and the efficiency of the spline estimator of the regression coefficients are established, and the spline estimators of the nonparametric components are shown to possess the optimal rate of convergence under suitable regularity conditions. The finite-sample performance of the proposed approach is evaluated through Monte Carlo simulation and it is further illustrated using uterine fibroid data arising from a prospective cohort study on early pregnancy.

Women with Newly Diagnosed Uterine Fibroids: Treatment Patterns and Cost Comparison for Select Treatment Options.

The primary objective of this study was to describe surgical treatment patterns among women with newly diagnosed uterine fibroids (UF). A secondary objective was to estimate the medical costs associated with other common surgical interventions for UF. Claims-based commercial and Medicare data (2011-2016) were used to identify women aged ≥30 years with continuous enrollment for at least 12 months before and after a new diagnosis of UF. Receipt of a surgical or radiologic procedure (hysterectomy, myomectomy, endometrial ablation, uterine artery embolization, and curettage) was the primary outcome. Health care resource utilization and costs were calculated for women with at least 12 months of continuous enrollment following a UF surgical procedure. Among women who met selection criteria, 31.7% of patients underwent a surgical procedure; 20.9% of these underwent hysterectomy. An increase was observed over time in the percentage of women undergoing outpatient hysterectomy (from 27.0% to 40.2%) and hysteroscopic myomectomy (from 8.0% to 11.5%). The cost analysis revealed that total health care costs for hysteroscopic myomectomy ($17,324) were significantly lower (P < 0.001) than those for women who underwent inpatient hysterectomy ($24,027) and those for women undergoing the 3 comparison procedures. Hysterectomy was the most common surgical intervention. Patients undergoing inpatient hysterectomy had the highest health care costs. Although less expensive, minimally invasive approaches are becoming more common; they are performed infrequently in patients with newly diagnosed UF. The results of this study may be useful in guiding decisions regarding the most appropriate and cost-effective surgical treatment for UF.

Incidence and burden of gynecologic disorders, active component service women, U.S. Armed Forces, 2012-2016.

This report describes the incidence, burden, and co-occurrence of four common gynecologic disorders among active component service women during 2012-2016. Overall incidence rates were highest for menorrhagia (100.9 per 10,000 person-years [p-yrs]), followed by uterine fibroids (63.2 per 10,000 p-yrs), endometriosis (30.8 per 10,000 p-yrs), and polycystic ovary syndrome (PCOS, 25.3 per 10,000 p-yrs). Annual incidence rates and medical encounters for menorrhagia decreased by roughly 50% from 2012 through 2015, and then increased slightly in 2016. Annual incidence rates of PCOS decreased modestly between 2012 and 2016, whereas rates for endometriosis and uterine fibroids remained relatively stable. Service women in the Army, older service women, and non-Hispanic black service women had overall higher rates of menorrhagia, uterine fibroids, and endometriosis. Incidence of PCOS was highest among women aged 25-29 years, non-Hispanic black service women, and service women in the Air Force. Approximately one-quarter (25.6%) of women with incident endometriosis, one-third (33.6%) of women with incident uterine fibroids, and 7% of women with PCOS had a co-occurring incident diagnosis for menorrhagia during the surveillance period. Additional research focused on the severity of these conditions would allow for a fuller examination of the impact of these disorders on the readiness of the force and on healthcare utilization.

Examining the Relationship Between Symptomatic Burden and Self-reported Productivity Losses Among Patients With Uterine Fibroids in the United States.

OBJECTIVE: To evaluate the impact of uterine fibroid symptoms on employment and household productivity. METHODS: An online survey of US women between 18 and 54 was conducted. Productivity was assessed using the health related productivity questionnaire (HRPQ). Descriptive statistics and logistic multivariable regressions examined the relationship between uterine fibroids (UF) symptom experience and employment and household productivity. RESULTS: Of 1365 eligible women, 873 (64.0%) were employed. Women lost an average of 0.8 hours to employment-related absenteeism and 4.4 hours due to employment-related presenteeism for 5.1 hours of employment productivity lost/week. Women lost an average of 1.4 hours due to household-related absenteeism and 1.6 hours due to household-related presenteeism for a total of 3.0 hours of household lost productivity. Productivity losses increased with increases in symptom burden. CONCLUSION: UF has a substantial impact on employment-related and household-related productivity.

Disparities in Fibroid Incidence, Prognosis, and Management.

Health disparities in fibroid prevalence, prognosis, and treatment exist for underserved women. Access to fibroid treatment alternatives can have significant effect on choices and outcomes of fibroid disease.

Effect of Direct Marketing for Uterine Artery Embolization on Rates of Leiomyomas, Incidental Findings, and Management After Pelvic MRI.

PURPOSE: The aim of this study was to determine whether a self-referred population screened by an interventional radiology (IR) clinic and a non-IR, physician-referred population differed with regard to suitability for uterine artery embolization (UAE) for symptomatic leiomyomas on the basis of preprocedure MRI. METHODS: This was an institutional review board-approved, HIPAA-compliant retrospective study of 301 women evaluated in an IR clinic for possible UAE from January 2009 to September 2012. Subjects were retrospectively divided into two groups: self-referred via direct marketing (group A, n = 203; mean age, 41.8 years; range, 22-58 years) and physician referred (group B, n = 98; mean age, 42.9 years; range, 30-65 years). RESULTS: There was no significant difference between groups in presenting symptoms (multiple symptoms, bleeding, bulk-related symptoms, pain). After initial screening, 73.4% of group A (149 of 203) and 79.6% of group B (78 of 98) underwent MRI (P = .242). On the basis of MRI findings, 91.3% of group A (136 of 149) and 94.9% of group B (74 of 78) had uterine leiomyomas (P = .328). Adenomyosis without leiomyoma was present in 4.0% of group A (6 of 149) and 3.8% of group B (3 of 78) (P = .947). Incidental findings requiring further clinical or imaging evaluation were found in 20.8% of group A (31 of 149) and 24.4% of group B (19 of 78) (P = .539). After MRI, 41.6% of group A (62 of 149) and 48.7% of group B (38 of 78) proceeded to UAE (P = .306). CONCLUSIONS: After initial screening, similar proportions of self-referred and physician-referred patients were candidates for UAE. The rates of confirmed leiomyomas and incidental findings on MRI were similar between groups.

Rates of colpopexy and colporrhaphy at the time of hysterectomy for prolapse.

BACKGROUND: It has been shown that addressing apical support at the time of hysterectomy for pelvic organ prolapse (POP) reduces recurrence and reoperation rates. In fact, national guidelines consider hysterectomy alone to be inadequate treatment for POP. Despite this, anterior and posterior colporrhaphy are frequently performed without a colpopexy procedure and hysterectomy alone is often utilized for treatment of prolapse. OBJECTIVE: The objectives of this study were to: (1) determine rates of concomitant procedures for POP in hysterectomies performed with POP as an indication, (2) identify factors associated with performance of a colpopexy at the time of hysterectomy for POP, and (3) identify the influence of surgical complexity on perioperative complication rates. STUDY DESIGN: This is a retrospective cohort study of hysterectomies performed for POP from Jan. 1, 2013, through May 7, 2014, in a statewide surgical quality database. Patients were stratified based on procedures performed: hysterectomy alone, hysterectomy with colporrhaphy and without apical suspension, and hysterectomy with colpopexy with or without colporrhaphy. Demographics, medical history and intraoperative care, and perioperative care were compared between the groups. Multivariable logistic regression models were created to identify factors independently associated with use of colpopexy and factors associated with increased rates of postoperative complications. RESULTS: POP was an indication in 1557 hysterectomies. Most hysterectomies were vaginal (59.6%), followed by laparoscopic or robotic (34.1%), and abdominal (6.2%). Hysterectomy alone was performed in 43.1% (95% confidence interval [CI], 40.6-45.6) of cases, 32.8% (95% CI, 30.4-35.1) had a colporrhaphy without colpopexy, and 24.1% (95% CI, 22-26.3) had a colpopexy with or without colporrhaphy. Use of colpopexy was independently associated with patient age >40 years, POP as the only indication for surgery (odd ratio [OR], 1.6; 95% CI, 1.185-2.230), laparoscopic surgery (OR, 3.2; 95% CI, 2.860-5.153), and a surgeon specializing in urogynecology (OR, 8.2; 95% CI, 5.156-12.923). The overall perioperative complication rate was 6.6%, with the majority being considered minor. Complications were more likely when the procedure was performed with an abdominal approach (OR, 2.3; 95% CI, 1.088-4.686), with the use of a colpopexy procedure (OR, 3.1; 95% CI, 1.840-5.194), and by a surgeon specializing in urogynecology (OR, 2.2; 95% CI, 1.144-4.315). CONCLUSION: Colpopexy and colporrhaphy may be underutilized and are potential targets for quality improvement. Performance of additional procedures at the time of hysterectomy increased the rate of perioperative complications. Long-term consequences of these surgical practices deserve additional study.

Prevalence, morbidity, and current medical management of uterine leiomyomas.

BACKGROUND: Uterine leiomyoma is the most common pelvic tumor in women, but the actual prevalence is unknown. OBJECTIVES: To review the literature on the prevalence of uterine leiomyoma, presenting symptoms, and medical management. SEARCH STRATEGY: On April 1-30, 2014, a PubMed search for studies reported in English was conducted using the terms "uterine leiomyoma," "prevalence," and "symptoms." Another search was performed using the terms "uterine leiomyoma" and "treatment." SELECTION CRITERIA: All trial types other than internet-only studies were included. Animal studies were excluded from the prevalence/symptom review, but included in the medical management review. DATA COLLECTION AND ANALYSIS: Prevalence rates were recorded on the basis of imaging modality, cohort studied, ethnic origin, and age. MAIN RESULTS: Studies involving asymptomatic women revealed a trend in prevalence similar to that in symptomatic women, and showed that leiomyomas are more common in this cohort than previously recognized. Affected patients can present with many complaints, but no single symptom has been shown to be specific for this tumor. Various medical therapies are reviewed, summarizing efficacy and toxicity. CONCLUSIONS: Further research needs to be conducted on the prevalence in asymptomatic women. Current and future medical management options provide promising results in symptom reduction.

Healthcare utilization and costs among women diagnosed with uterine fibroids: a longitudinal evaluation for 5 years pre- and post-diagnosis.

OBJECTIVE: To evaluate the healthcare utilization, treatments, and costs incurred by women with uterine fibroids (UF), compared to those without UF, for 5 years before and 5 years after diagnosis. RESEARCH DESIGN AND METHODS: This is a longitudinal, retrospective case-control study. A total of 84,954 women with a diagnosis of UF, along with matched controls of women without UF, were selected from the Truven Health MarketScan claims database (2000-2010). The date of diagnosis of the UF patient was assigned as the index date for both the UF patient and her matched control. MAIN OUTCOME MEASURES: Healthcare resource utilization, treatments, and costs (in 2010 USD) were evaluated annually for the 5 year periods before and after the index date. RESULTS: UF patients had more outpatient and emergency room visits than controls before diagnosis, and more inpatient, outpatient, and emergency room visits than controls after diagnosis. Annual total healthcare costs were significantly higher for patients than controls during the last 3 years pre-index and all 5 years post-index. Overall, the difference was $12,623 over 10 years, with a difference of $1435 in the 5 years pre-diagnosis and a difference of $11,188 in the 5 years post-diagnosis. The cost difference between UF patients and controls was highest in the first year post-diagnosis, reaching $6131, and the difference was even larger when comparing clinically symptomatic UF patients to controls. The use of medications and surgical procedures related to UF peaked in the year post-diagnosis, with 39% of patients receiving a surgical treatment within the year. KEY LIMITATIONS: UF patients included in the study did not include undiagnosed and potentially asymptomatic UF patients; the impact of disease severity on the costs of UF patients was not evaluated. CONCLUSIONS: Patients with UF incurred significantly higher healthcare utilization and costs than those without UF, both pre- and post-diagnosis.

Effect of menses on standardized assessment of sexual dysfunction among women with uterine fibroids: a cohort study.

OBJECTIVE: To determine if assessment of sexual dysfunction by the Female Sexual Function Index (FSFI) is related to whether the FSFI is administered during or between menses, in women with symptomatic uterine fibroids. DESIGN: Prospective cohort. SETTING: Academic medical centers. PATIENT(S): Premenopausal women who had symptomatic uterine fibroids and were enrolled in fibroid treatment trials. INTERVENTION(S): Administration of FSFI during and between menses. MAIN OUTCOME MEASURE(S): Mean FSFI scores in each of 6 domains, and a discordance score to report individual differences in assessment. RESULT(S): Thirty-three women completed the FSFI, during menstruation, and at a time in their cycle when they were not menstruating. The mean FSFI scores for each domain did not differ based on when in the menstrual cycle the instrument was administered. However, on an individual level, nearly half of the women reported sexual dysfunction differently during menses than between menses. Of those that reported differences, the pain and desire domains improved; the lubrication and satisfaction domains worsened during menses. CONCLUSION(S): Although the mean values of the domain scores were not different, women did report differences in sexual functioning during vs. between menses. Timing of the questionnaire in relation to menses should be considered in sexual-dysfunction assessment for women with uterine fibroids. CLINICAL TRIALS REGISTRATION NUMBER: NCT00995878.

The management of uterine leiomyomas.

OBJECTIVES: The aim of this guideline is to provide clinicians with an understanding of the pathophysiology, prevalence, and clinical significance of myomata and the best evidence available on treatment modalities. OPTIONS: The areas of clinical practice considered in formulating this guideline were assessment, medical treatments, conservative treatments of myolysis, selective uterine artery occlusion, and surgical alternatives including myomectomy and hysterectomy. The risk-to-benefit ratio must be examined individually by the woman and her health care provider. OUTCOMES: Implementation of this guideline 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 2013, 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 control trials/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 January 2014. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, and national and international medical specialty societies. 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 defficiency 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 Caadian Task Force on Preventive Health Care (Table 1). Summary Statements 1. Uterine fibroids are common, appearing in 70% of women by age 50; the 20% to 50% that are symptomatic have considerable social and economic impact in Canada. (II-3) 2. The presence of uterine fibroids can lead to a variety of clinical challenges. (III) 3. Concern about possible complications related to fibroids in pregnancy is not an indication for myomectomy except in women who have had a previous pregnancy with complications related to these fibroids. (III) 4. Women who have fibroids detected in pregnancy may require additional maternal and fetal surveillance. (II-2) 5. Effective medical treatments for women with abnormal uterine bleeding associated with uterine fibroids include the levonorgestrel intrauterine system, (I) gonadotropin-releasing hormone analogues, (I) selective progesterone receptor modulators, (I) oral contraceptives, (II-2) progestins, (II-2) and danazol. (II-2) 6. Effective medical treatments for women with bulk symptoms associated with fibroids include selective progesterone receptor modulators and gonadotropin-releasing hormone analogues. (I) 7. Hysterectomy is the most effective treatment for symptomatic uterine fibroids. (III) 8. Myomectomy is an option for women who wish to preserve their uterus or enhance fertility, but carries the potential for further intervention. (II-2) 9. Of the conservative interventional treatments currently available, uterine artery embolization has the longest track record and has been shown to be effective in properly selected patients. (II-3) 10. Newer focused energy delivery methods are promising but lack long-term data. (III) Recommendations 1. Women with asymptomatic fibroids should be reassured that there is no evidence to substantiate major concern about malignancy and that hysterectomy is not indicated. (III-D) 2. Treatment of women with uterine leiomyomas must be individualized based on symptomatology, size and location of fibroids, age, need and desire of the patient to preserve fertility or the uterus, the availability of therapy, and the experience of the therapist. (III-B) 3. In women who do not wish to preserve fertility and/or their uterus and who have been counselled regarding the alternatives and risks, hysterectomy by the least invasive approach possible may be offered as the definitive treatment for symptomatic uterine fibroids and is associated with a high level of satisfaction. (II-2A) 4. Hysteroscopic myomectomy should be considered first-line conservative surgical therapy for the management of symptomatic intracavitary fibroids. (II-3A) 5. Surgical planning for myomectomy should be based on mapping the location, size, and number of fibroids with the help of appropriate imaging. (III-A) 6. When morcellation is necessary to remove the specimen, the patient should be informed about possible risks and complications, including the fact that in rare cases fibroid(s) may contain unexpected malignancy and that laparoscopic power morcellation may spread the cancer, potentially worsening their prognosis. (III-B) 7. Anemia should be corrected prior to proceeding with elective surgery. (II-2A) Selective progesterone receptor modulators and gonadotropin-releasing hormone analogues are effective at correcting anemia and should be considered preoperatively in anemic patients. (I-A) 8. Use of vasopressin, bupivacaine and epinephrine, misoprostol, peri-cervical tourniquet, or gelatin-thrombin matrix reduce blood loss at myomectomy and should be considered. (I-A) 9. Uterine artery occlusion by embolization or surgical methods may be offered to selected women with symptomatic uterine fibroids who wish to preserve their uterus. Women choosing uterine artery occlusion for the treatment of fibroids should be counselled regarding possible risks, including the likelihood that fecundity and pregnancy may be impacted. (II-3A) 10. In women who present with acute uterine bleeding associated with uterine fibroids, conservative management with estrogens, selective progesterone receptor modulators, antifibrinolytics, Foley catheter tamponade, and/or operative hysteroscopic intervention may be considered, but hysterectomy may become necessary in some cases. In centres where available, intervention by uterine artery embolization may be considered. (III-B).

Objectifs : La présente directive clinique a pour objectif d'aider les cliniciens à mieux comprendre la pathophysiologie, la prévalence et l'importance clinique des myomes, et de leur faire part des meilleures données probantes disponibles quant aux modalités de traitement. Options : Dans le cadre de la rédaction de la présente directive clinique, nous avons tenu compte des aspects suivants de la pratique clinique : évaluation, traitements médicaux, traitements conservateurs par myolyse, occlusion sélective de l'artère utérine et solutions de rechange chirurgicales (dont la myomectomie et l'hystérectomie). Le rapport risques-avantages doit faire l'objet d'une analyse personnalisée dans le cadre des discussions menées entre la patiente et son fournisseur de soins. Issues : La mise en œuvre de la présente directive clinique devrait optimiser le processus décisionnel pour les patientes et les fournisseurs de soins en ce qui a trait à la tenue d'autres explorations ou à la façon d'assurer la prise en charge des léiomyomes utérins, en ayant tenu compte du processus pathogénique (et des options disponibles en matière de traitement) et en ayant passé en revue les risques et les avantages anticipés. Résultats : La littérature publiée a été récupérée par l'intermédiaire de recherches menées dans PubMed, CINAHL et Cochrane Systematic Reviews en février 2013 au moyen d'un vocabulaire contrôlé (p. ex. « uterine fibroids ¼, « myoma ¼, « leiomyoma ¼, « myomectomy ¼, « myolysis ¼, « heavy menstrual bleeding ¼ et « menorrhagia ¼) et de mots clés (p. ex. « myoma ¼, « leiomyoma ¼, « fibroid ¼, « myomectomy ¼, « uterine artery embolization ¼, « hysterectomy ¼, « heavy menstrual bleeding ¼, « menorrhagia ¼) appropriés. Des recherches ont également été menées dans les listes de références des articles identifiés en vue d'en tirer d'autres publications pertinentes. Les résultats ont été restreints aux analyses systématiques, aux essais comparatifs randomisés / essais cliniques comparatifs et aux études observationnelles. Aucune restriction n'a été appliquée en matière de date, mais les résultats ont été limités aux documents rédigés en anglais ou en français. Les recherches ont été mises à jour de façon régulière et intégrées à la directive clinique jusqu'en janvier 2014. La littérature grise (non publiée) a été identifiée par l'intermédiaire de recherches menées dans les sites Web d'organismes s'intéressant à l'évaluation des technologies dans le domaine de la santé et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et auprès de sociétés de spécialité médicale nationales et internationales. Avantages, désavantages et coûts : La majorité des fibromes sont asymptomatiques et ne nécessitent aucune intervention ni aucune autre mesure exploratoire. Dans le cas des fibromes symptomatiques, tels que ceux qui sont à l'origine d'anomalies menstruelles (p. ex. saignements utérins abondants, irréguliers et prolongés), d'une anémie ferriprive ou de symptômes de masse (p. ex. pression / douleur pelvienne, symptômes obstructifs), l'hystérectomie constitue une solution définitive; toutefois, cette solution n'est pas à privilégier pour ce qui est des femmes qui souhaitent préserver leur fertilité et/ou leur utérus. Le traitement choisi devrait viser une amélioration de la symptomatologie et de la qualité de vie. Les coûts du traitement (pour le système de santé et les patientes présentant des fibromes) doivent être interprétés dans le contexte des coûts associés aux pathologies non traitées et à la mise en œuvre continue ou répétée de modalités d'exploration ou de traitement. Valeurs : La qualité des résultats est évaluée au moyen des critères décrits par le Groupe d'étude canadien sur les soins de santé préventifs (Tableau). Déclarations sommaires 1. Les fibromes utérins sont courants (leur incidence étant de 70 % à l'âge de 50 ans). De 20 % à 50 % de ces fibromes sont symptomatiques et exercent des effets sociaux et économiques considérables au Canada. (II-3) 2. La présence de fibromes utérins peut mener à diverses difficultés cliniques. (III) 3. Les préoccupations au sujet de possibles complications associées à la présence de fibromes pendant la grossesse ne constituent pas une indication justifiant la tenue d'une myomectomie, sauf chez les femmes qui ont déjà connu une grossesse ayant présenté des complications associées à ces fibromes. (III) 4. Les femmes chez qui des fibromes sont détectés pendant la grossesse pourraient nécessiter la mise en œuvre de modalités additionnelles de surveillance maternelle et fœtale. (II-2) 5. Parmi les traitements médicaux efficaces pouvant être offerts aux femmes qui connaissent des saignements utérins anormaux associés à la présence de fibromes utérins, on trouve le système intra-utérin à libération de lévonorgestrel, (I) les analogues de la gonadolibérine, (I) les modulateurs sélectifs des récepteurs de la progestérone, (I) les contraceptifs oraux, (II-2) les progestatifs (II-2) et le danazol. (II-2) 6. Parmi les traitements médicaux efficaces pouvant être offerts aux femmes qui connaissent des symptômes de masse associés à la présence de fibromes, on trouve les modulateurs sélectifs des récepteurs de la progestérone et les analogues de la gonadolibérine. (I) 7. L'hystérectomie constitue le moyen le plus efficace d'assurer la prise en charge des fibromes utérins symptomatiques. (III) 8. Bien que la myomectomie constitue une option pour les femmes qui souhaitent conserver leur utérus ou rehausser leur fertilité, elle expose la patiente à un risque de devoir subir d'autres interventions. (II-2) 9. Parmi les traitements interventionnels conservateurs actuellement disponibles, l'embolisation de l'artère utérine est celui pour lequel nous disposons du plus grand nombre de données; de plus, l'efficacité de cette intervention a été démontrée chez des patientes adéquatement sélectionnées. (II-3) 10. Des méthodes novatrices faisant appel à l'application d'énergie focalisée s'avèrent prometteuses; toutefois, nous ne disposons pas de données à long terme à leur sujet. (III) Recommandations 1. Rien n'indique que la présence de fibromes asymptomatiques devrait susciter des préoccupations importantes au sujet de leur malignité potentielle; de plus, le recours à l'hystérectomie dans un tel cas n'est pas indiqué, ce qui devrait rassurer les femmes qui présentent de tels fibromes. (III-D) 2. La prise en charge des femmes qui présentent des léiomyomes utérins doit être personnalisée en fonction de la symptomatologie, de la taille et de l'emplacement des fibromes, de l'âge de la patiente et de ses besoins et souhaits en matière de préservation de la fertilité ou de l'utérus, de la disponibilité du traitement et de l'expérience du thérapeute. (III-B) 3. Chez les femmes qui ne souhaitent pas préserver leur fertilité et/ou leur utérus et qui ont bénéficié de services de counseling à l'égard des solutions de rechange et des risques, l'hystérectomie (menée au moyen de l'approche la moins effractive possible) peut être offerte à titre de traitement définitif contre les fibromes utérins symptomatiques et est associée à un taux élevé de satisfaction. (II-2A) 4. La myomectomie hystéroscopique devrait être considérée comme étant un traitement chirugical conservateur de première intention pour la prise en charge des fibromes endocavitaires symptomatiques. (II-3A) 5. Dans le cas de la myomectomie, la planification de la chirurgie devrait être fondée sur les résultats d'une intervention d'imagerie cherchant à déterminer, de façon précise, l'emplacement, la taille et le nombre des fibromes. (III-A) 6. Lorsqu'il s'avère nécessaire d'avoir recours au morcellement pour retirer un prélèvement, la patiente devrait être avisée des risques et des complications possibles (dont la possibilité, dans de rares cas, d'en venir à constater la présence inattendue d'une tumeur maligne et de voir celle-ci être disséminée par l'utilisation du morcellement motorisé laparoscopique, ce qui pourrait aggraver le pronostic). (III-B) 7. L'anémie devrait être corrigée avant la tenue d'une chirurgie planifiée. (II-2 A) Les modulateurs sélectifs des récepteurs de la progestérone et les analogues de la gonadolibérine constituent des moyens efficaces de corriger l'anémie, et leur utilisation préopératoire devrait être envisagée dans le cas des patientes anémiques. (I-A) 8. L'utilisation de vasopressine, de bupivacaïne et d'épinéphrine, de misoprostol, d'un garrot péricervical ou d'une matrice gélatine-thrombine atténue la perte sanguine au cours de la myomectomie et devrait être envisagée. (I-A) 9. L'occlusion de l'artère utérine par embolisation ou au moyen de méthodes chirurgicales peut être offerte à certaines femmes présentant des fibromes utérins symptomatiques qui souhaitent préserver leur utérus. Les femmes qui choisissent d'avoir recours à l'occlusion de l'artère utérine pour la prise en charge de leurs fibromes devraient être avisées des risques possibles et du fait que les issues en matière de fertilité et de grossesse pourraient en être affectées. (II-3A) 10. Chez les femmes qui connaissent des saignements utérins aigus associés à la présence de fibromes utérins, bien que la mise en œuvre d'une prise en charge conservatrice (œstrogènes, modulateurs sélectifs des récepteurs de la progestérone, antifibrinolytiques, sonde de Foley et/ou intervention hystéroscopique opératoire) puisse être envisagée, la tenue d'une hystérectomie pourrait devenir nécessaire dans certains cas. Au sein des centres qui disposent des capacités nécessaires, la mise en œuvre d'une embolisation de l'artère utérine pourrait être envisagée. (III-B).

Subjective social status and depression symptoms: a prospective study of women with noncancerous pelvic problems.

OBJECTIVE: Subjective social status (SSS) may be a stronger determinant of health than objective measures of socioeconomic status. We sought to examine the effect of community and national SSS on symptoms of depression in a racially/ethnically diverse sample of adult women with noncancerous uterine conditions. METHODS: We conducted a secondary analysis of data obtained from 634 women who enrolled in the Study of Pelvic Problems, Hysterectomy, and Intervention Alternatives (SOPHIA) in 2003 and 2004. SOPHIA was a longitudinal study of women aged 31 to 54 who were experiencing abnormal uterine bleeding, symptomatic fibroids, or pelvic pain. The primary outcome for this analysis consisted of symptoms suggesting major or other depressive disorder, as measured by the Patient Health Questionnaire-9, 2 years after study enrollment. We hypothesized that women who had low community and national SSS at baseline, as measured by the MacArthur SSS ladder, would be at higher risk of experiencing symptoms of depression at follow-up. RESULTS: Women with low community SSS had an increased odds of experiencing depression symptoms 2 years later compared with women with high SSS, after adjusting for age, pelvic problem impact and baseline depression (odds ratio, 2.93; 95% CI, 1.11-7.77). Odds remained elevated after further adjusting for income and education. Results for the national ladder were not significant. CONCLUSION: Low perceived community social status is predictive of symptoms suggestive of major or other depressive disorder among women with noncancerous uterine conditions. Asking about perceived community social status can help clinicians to identify patients who may be at increased risk for depressive disorders. Asking about perceived national social status does not seem to add value beyond that provided by income and education.