Advancements and Emerging Therapies in the Medical Management of Uterine Fibroids: A Comprehensive Scoping Review.

Uterine fibroids, benign tumors originating from uterine smooth muscle cells, vary in prevalence depending on patient ethnicity, hormonal exposure, and genetics. Due to their high incidence, these neoplasms pose a significant burden on healthcare systems. Current treatment strategies range from routine monitoring in asymptomatic cases to surgical procedures such as myomectomy or hysterectomy in symptomatic patients, with an increasing trend toward uterus-preserving or non-surgical alternatives. This review examines the existing medical treatments for uterine fibroids and delves into the potential of emerging therapies. A scoping review of the literature was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. Medical therapies are divided into hormonal and non-hormonal treatments; however, long-term, safe, and effective treatments in the treatment of uterine fibroids are limited. In addition to established therapies, there is an increasing number of studies investigating the effect of substances such as vitamin D or green tea extract on uterine fibroids. Some studies investigate acupuncture as a possible alternative therapy. While existing treatments offer symptomatic relief and preparation for surgery, our findings point to a significant need for further research into long-term solutions, especially owing to recent limitations in the use of ulipristal acetate due to risk of liver damage. Initial studies involving vitamin D and epigallocatechin gallate are encouraging; however, additional research is required to establish definitive therapeutic roles.

Endovascular Treatment of Pelvic Venous Congestion Syndrome in Nulliparous Patients-Preliminary Results of 10 Years of Experience.

PURPOSE: The aim of this article is to present our experience with minimally-invasive treatment for nulliparous patients with pelvic venous congestion syndrome (PVCS) with special attention to anatomical considerations, procedural and clinical outcome. MATERIALS AND METHODS: In this retrospective, monocentric study, 21 patients with PVCS treated from January 2014 to June 2023 were included. The preprocedural imaging evaluation of PVCS was based on color Doppler ultrasound, contrast-enhanced CT and/or MRI. In all cases insufficient ovarian veins and/or internal iliac branches were occluded with coils and sclerosant. Procedural and clinical outcomes were measured 30 and 90 days after the procedure. RESULTS: Average duration of pelvic pain was 44.8 ± 54.2 months (from 6 to 200) with the mean VAS-recorded pain intensity of 8.5 ± 1.1 (range from 7 to 10 where 0 was "no pain" and 10 "worst pain possible"). Most common symptoms included dysmenorrhea, dyspareunia and dysuria. Complete embolization was observed in in all cases. Targeted vessels included left ovarian vein (13/21, 62%), both ovarian veins (7/21, 33%) and left pudendal with left ovarian (1/21, 5%). Residual PVCS was noted in 1 patient. Mean VAS at 90-days after the procedure was 2.4 ± 1.4 (range from 0 to 6, p < 0.001). Nineteen patients (90%) were satisfied with the clinical outcome (13 "very satisfied", 6 "satisfied") and reported improvement in quality of life. Two patients (9.5%) reported to be "neutral" as the VAS reduction was less than 50%. CONCLUSION: Our study confirms that endovascular coil embolization is safe and effective in treatment of nulliparous patients with PVCS that provides very high rate of clinical success and overall satisfaction.

The effect of adjuvant mitotane therapy of the adrenocortical carcinoma on the endometrium and its clinical consequences in menstruating women. Literature review and authors' own experiences.

Adrenocortical carcinoma (ACC) is a malignant tumour that originates from the adrenal cortex. It is a highly aggressive cancer characterised by a poor prognosis with an annual incidence estimated to be up to 2 cases per million. In the adult population, ACC is diagnosed typically between 40 and 50 years of age, more often in women. Complete surgical resection of the tumour is the primary treatment method for ACC. Unfortunately, despite properly performed adrenalectomy, regional recurrences or distant metastases are detected in up to 90% of the patients. For that reason, adjuvant therapy is recommended. Mitotane is the most effective adrenal-specific agent used in adjuvant and palliative therapy. Two menstruating patients, after adrenalectomy due to ACC, during adjuvant mitotane therapy, have been included in the study. The study aimed to assess the effect of mitotane therapy on the endometrium and its clinical consequences, based on the analysis of these two cases and a review of the literature. It seems that menorrhagia may be expected during adjuvant mitotane therapy of ACC in menstruating women. Heavy uterine bleeding during menstruation may appear several months after the beginning of therapy. The likely mechanism for heavy menstrual bleeding is complex. Menorrhagia can occur due to the toxic effect of mitotane in the form of a haemorrhagic diathesis, while long-term treatment (over ten months) can lead to relative hypoestrogenism resulting in endometrial hyperplasia. Clinical signs of hypoestrogenism during mitotane treatment, have been described (including pre-puberty girls) and should be considered as a side-effect of the therapy. Menorrhagia may lead to severe anaemia, so this should be considered when planning mitotane treatment. Continuous gestagen therapy is helpful in the treatment of the above disorders. After over 60 years of experience with mitotane usage, knowledge about it is still insufficient, and further studies are required.

Women's sexual health improvement: sexual quality of life and pelvic floor muscle assessment in asymptomatic women.

Introduction: Problems related to the quality of sexual life in gynecological practice are usually neglected. This study aimed to highlight the significance of this area of concern and evaluate the usefulness of tools, such as patient-reported outcomes (PROs) and pelvic floor examination, to improve women's sexual wellbeing and to identify predictors of poor quality of sexual life during the well-woman annual visit. Methods: A cross-sectional study was designed to examine 300 healthy women to determine whether the sexual quality of life (SQOL) questionnaire (on electronic devices) and pelvic floor muscle assessment (the vulva, anus, muscles, and periurethral (VAMP) protocol) of asymptomatic women during the annual bimanual examination (BME) help differentiate patients who would benefit from discussing sexual problems with a gynecologist. Dyspareunia was an exclusion criterion. Results: The majority of subjects experienced high sexual wellbeing (82.0% with SQOL score of ≥84), with a mean of 85.7 points. SQOL scores were lower for psychiatric disorders or symptoms (37.0% of subjects), although they did not correlate with age, BMI, parity, contraception use, history of vulvovaginal symptoms, neurosurgical/orthopedic problems, and rectal, bowel, or bladder symptoms. Patients with dyspareunia (16.0% of participants, although they denied it during the face-to-face consultation) had a 3.6 times higher prevalence of low or moderate quality of sexual life. The VAMP protocol score was low in asymptomatic women, 33.0% met positive criteria (VAMP+, NRS ≥3) for pelvic floor dysfunction (overactivity), although at borderline levels. VAMP+ was positively correlated with chronic pain and genitourinary symptoms, but neither with dyspareunia nor incontinence, and was unrelated to the SQOL score (p = 0.151). Conclusion: Women's sexual health is a global health priority. Finding a way to start a discussion with an asymptomatic patient is crucial to increasing patients' interest in disclosing a sexual health problem to be resolved. PROs or simple questions about sexual wellbeing direct the discussion mainly toward the at-risk group for sexual deterioration: those with mental health problems and women with dyspareunia. Dyspareunia is considered a predictor of decreased quality of sexual life, a major sexual disorder that should not be overlooked. Gynecological consultation should resolve concerns, identify the problem, and refer for professional sexual care if still needed.

Noninvasive diagnostic imaging of pelvic venous disorders.

It is estimated that chronic pelvic pain (CPP) may affect up to 24% of women. Unfortunately, very often, despite extensive diagnostics, the cause of CPP remains unknown. The pathophysiology of CPP could be explained to a large extent by the occurrence of pelvic venous disorders (PVD). Although pelvic venography is still considered the gold standard for the diagnosis of PVD, noninvasive diagnostic imaging techniques seem to be instrumental in the initial identification of patients with PVD. This literature review aimed to analyze and evaluate the usefulness of noninvasive diagnostic imaging techniques like transvaginal ultrasonography, transabdominal ultrasonography, magnetic resonance, and computed tomography in the diagnosis and identification of patients with PVD. Forty-one articles published between 1984 and 2023 were included in this literature review. Based on this literature review, we conclude that the clinical application of noninvasive diagnostic techniques in the diagnosis of PVD seems to be very promising. Future studies investigating the role of noninvasive diagnostic imaging techniques in the diagnosis of PVD are required.

The Role of Nutrition in Pathogenesis of Uterine Fibroids.

Uterine fibroids are benign tumors that arise from the smooth muscle tissue of the uterus and are the most common tumors in women. Due to their high prevalence, costs for the health care system and the substantial impact on women's quality of life, they are a significant public health concern. Previous literature on the impact of diet on the occurrence, growth and symptoms of fibroids is limited. Recently, many papers have been written on this topic. A scoping review of PubMed and Cochrane databases was performed using the following keywords: uterine fibroids, antioxidants, diet, diet, vegetarian, vegetables, fruits, meat and soy foods, dairy products, tea, vitamin D, vitamin C, ascorbic acid. Preliminary research has shown a beneficial effect of vegetable and fruit consumption on the occurrence of fibroids. A relationship between hypovitaminosis D and an increased risk of fibroids has also been demonstrated. Studies on epigallocatechin gallate showed its apoptosis-promoting and antifibrinolytic effect in fibroid cells. Initial results are promising, but further randomized trials are needed to draw firm conclusions about the effects of diet and nutrients on uterine fibroids.

Oral estradiol/micronized progesterone may be associated with lower risk of venous thromboembolism compared with conjugated equine estrogens/medroxyprogesterone acetate in real-world practice.

OBJECTIVES: The Women's Health Initiative study reported an increased risk of venous thromboembolism among menopausal women treated with conjugated equine estrogens/medroxyprogesterone acetate (CEE/MPA) versus placebo. Newer hormone therapies may have a lower venous thromboembolism risk. The study compared the risk of venous thromboembolism between women treated with the combined oral product 17ß-estradiol/micronized progesterone (E2/P4) and those treated with oral CEE/MPA regimens. STUDY DESIGN: In a retrospective longitudinal study using real-world claims data from April 2019 to June 2021, women aged 40 years or more treated with oral E2/P4 or oral CEE/MPA who did not have a venous thromboembolism diagnosis before first dispensing claim of CEE/MPA or E2/P4 identified on or after May 1st 2019 (index date) were observed for 6 months or more after the index date. Oral E2/P4 and oral CEE/MPA had been prescribed by the treating physician in real-world practice and were observed through pharmacy dispensing records. MAIN OUTCOME MEASURES: Venous thromboembolism risk was compared between women receiving oral E2/P4 versus oral CEE/MPA. RESULTS: The study included 36,061 women treated with oral E2/P4 or oral CEE/MPA. In the analyses weighted by the inverse probability of treatment for control of potential confounding factors, the incidence of venous thromboembolism was significantly lower for oral E2/P4 compared with oral CEE/MPA (37/10,000 women-years for oral E2/P4 vs 53/10,000 women-years for oral CEE/MPA; incidence rate ratio 0.70, 95 % confidence interval: 0.53-0.92). CONCLUSIONS: Real-world evidence suggests that the risk of venous thromboembolism is significantly lower among women treated with oral E2/P4 compared with oral CEE/MPA.

Risk of venous thromboembolism during the use of oral estrogen-progestogen hormone therapies in light of most recent research findings.

Two important studies evaluating the safety profile of oral estrogen-progestogen hormonal therapies conducted in standard clinical practice with respect to the venous system were recently published. A large prospective controlled cohort study (PRO-E2) based on the non-inferiority design has shown that the relative risk of developing venous thrombosis (VTE) in women using combined oral hormonal contraceptives (COHC) containing 17ß-estradiol (1.5 mg) and nomegestrol acetate (2.5 mg) (E2/NOMAC) was not statistically different from that in users of COHC containing ethinylestradiol and levonorgestrel (EE/LNG). The aim of the recently presented study was to compare the risk of VTE in patients treated with a product for oral continuous combined menopausal hormone therapy containing 1 mg of 17ß-estradiol and 100 mg of micronized progesterone (1 mgE2/100 mgP4) with patients taking conjugated equine estrogens and medroxyprogesterone acetate (CEE/MPA). The study was based on an analysis of records retrieved from a US health insurance database, and was therefore concerned the real-life clinical practice. The hazard ratio of VTE when comparing 1 mgE2/100 mgP4 with CEE/MPA was 0.70 (95% CI: 0.53-0.92). The difference was found to be statistically significant (p < 0.05). The rewieved studies provide further evidence that the use of hormones bioidentical with endogenous steroids in oral contraception and menopausal hormone therapy creates an opportunity to combine high efficacy with a favorable safety profile.

A Successful New Case of Twin Pregnancy in a Patient with Swyer Syndrome-An Up-to-Date Review on the Incidence and Outcome of Twin/Multiple Gestations in the Pure 46,XY Gonadal Dysgenesis.

BACKGROUND: The aim of the present study is to report a rare occurrence of a successful twin pregnancy in a woman with pure 46,XY gonadal dysgenesis. RESULT(S): A patient with Swyer syndrome (pure 46,XY gonadal dysgenesis) presented with a twin pregnancy after in vitro fertilization. Due to unidentified conditions, the patient developed selective intrauterine growth restriction in one of the fetuses. Twins were born at 33 weeks of pregnancy due to the risk of asphyxia. Nonetheless, the patient did not develop gonadal malignancies before the pregnancy and, despite receiving estrogen, remained amenorrheic. CONCLUSION(S): The aim of this case report is to show the course of twin pregnancy in patients with Swyer syndrome through assisted reproduction. Due to certain disorders in the development of their reproductive organs, such as the less mature uterus, such pregnancies may be associated with an increased risk. The above case report demonstrates the need to systematize methods of pregnancy management in patients with Swyer syndrome, such as: preparation for the pregnancy, assessment of the uterus, medications used, and necessary checkups. Capsule: This case report and review shows clinicians that patients with Swyer syndrome may become pregnant. Twin pregnancies may occur without any major problems through assisted reproduction.

Minimally invasive treatment options for uterine fibroids - state-of-the art 2021.

OBJECTIVES: Uterine leyomyomas are benign, monoclonal tumors that can cause abnormal uterine bleeding, pelvic pain, dyspareunia and/or obstruction of bladder or rectum. Women's growing interest in treatments that avoid surgery and/or preserve the uterus has contributed to the development of minimally invasive methods. Conducting a literature review and assessment of the effectiveness and safety of minimally invasive methods of treating fibroids, with particular emphasis on high intensity focused ultrasound. MATERIAL AND METHODS: Systematic review of MEDLINE, Cochrane and PubMed was performed using the following key words: uterine artery embolization, high-intensity focused ultrasound, microwave ablation, radiofrequency ablation, minimally invasive, leiomyoma, fertility, pregnancy. English abstracts relevant to the topic were selected. Full-text articles were carefully analyzed. RESULTS: Uterine artery embolization is a proven, widely accepted method that is effective in appropriately qualified cases. Although high focused ultrasound is still an experimental procedure, preliminary studies seem to be promising. If its efficacy and safety are confirmed in randomized controlled trials, this method may find its place in clinical practice. Microwave and radiofrequency ablation are interesting minimally invasive methods with the future potential to be recognized as a method of treating fibroids. CONCLUSIONS: Minimally invasive methods are becoming an important treatment option for fibroids. Further research is needed to recognize these procedures as a fully-fledged alternative to surgical treatment.

Vulvodynia in prepubertal girls: diagnosis.

OBJECTIVES: To identify specific features of vulvodynia in prepubertal girls, highlight potential triggers and concomitant diseases, outline diagnostic criteria is neglected problem in adolescent gynecology. MATERIAL AND METHODS: A retrospective study, based on medical records of an outpatient clinic, a cohort of 54 vulvodynia cases was evaluated, aged 3-10 years, seen between January 2016 and July 2018. RESULTS: The study cohort presented with pain (61%), sometimes aggravated at night, pruritus (44%) and a range of other varied and unusual vulvar complaints (26%). Concomitant diseases and/or psychological problems were present in 61% of cases. Overactive pelvic muscles accompanying symptoms like urological or gastrological problems were noted in half of children. Several potential triggers were identified in a third of the cases that were emotionally stressful to the children. From the commencement of symptoms, 93% of the girls have consulted more than one doctor with 43% seeing more than three doctors, without receiving a diagnosis of vulvodynia. CONCLUSIONS: A diagnosis of vulvodynia needs to be considered in the absence of vulva pathology with wide range of vulvar pain, pruritus and discomfort. All persistent or recurrent vulvar discomfort must be taken into consideration as a vulvodynia symptom, also various non-specific, worrisome complaints. Comorbid urological and gastrological symptoms associated with overactive pelvic muscles should not be overlooked. Chronic pain can be triggered by the psychological distress in some prepubertal girls. Proper diagnosis may prevent long-term negative sequelae, what emphasizes the need for professional education of healthcare providers in adolescent vulvar pain and discomfort.

Endovascular embolization as a treatment for symptomatic adenomyosis - results of preliminary study.

OBJECTIVES: To present preliminary results of minimally invasive endovascular embolization as a treatment of symptomatic adenomyosis or adenomyosis with fibroids and to assess the long-term clinical outcome. MATERIAL AND METHODS: Between 2015 and 2020 twelve patients with symptomatic adenomyosis or adenomyosis with fibroids underwent uterine artery embolization (UAE). All patients were evaluated in terms of patient's overall satisfaction, relief of clinical symptoms, reintervention and hysterectomy as well as menopause rates. RESULTS: Mean age on admission was 48 years. Reported symptoms included: dysmenorrhea with the mean VAS score of 7.8, menorrhagia and problems with urination. Successful embolization was achieved in all patients (100%). A reduction in pelvic pain intensity assessed using VAS was observed in 11/12 (92%) of the patients - pain decreased by 6.2 points on average (from 7.8 to 1.6 pts). In one patient (8%) the recurrence of pain was observed. All patients reported decrease of menstrual bleeding and consequently improvement of everyday life quality. Avoidance of hysterectomy was achieved in 83% of the women. Five patients experience absence of menstrual periods for at least 12 months after the embolization resulting in menopause rate of 42%. Ten patients (83%) reported to be very or fairly satisfied with the results and would recommend this treatment to a friend. CONCLUSIONS: Uterine artery embolization might be safe and effective method of treatment for patients with symptomatic adenomyosis with or without fibroids with very high rate of satisfied patients.

Position Statement by Experts of the Polish Menopause and Andropause Society on menopausal hormone therapy with an oral combination drug containing oestradiol 1 mg and progesterone 100 mg.

At a meeting held on 20 May 2021, reviewed the available literature on the use of the medicinal product Bijuva® for the relief of menopausal symptoms.