Diagnosis of gynecologic malignancy after the treatment of presumed benign fibroid disease with interventional radiology procedures: a retrospective cohort study.

OBJECTIVE: To ascertain the finding of future diagnosis of malignancy in women who undergo nonsurgical treatment for uterine fibroid disease with interventional radiology (IR) procedures. DESIGN: Mixed-methods retrospective cohort study. SETTING: Two tertiary care academic hospitals in Boston, Massachusetts. PATIENT(S): A total of 491 women who underwent radiologic intervention for fibroids between 2006 and 2016. INTERVENTION(S): Uterine artery embolization or high-intensity focused ultrasound ablation. MAIN OUTCOME MEASURE(S): Subsequent surgical interventions and diagnosis of gynecologic malignancy after the IR procedure. RESULT(S): During the study period, 491 women underwent treatment of fibroids with IR procedures; follow-up information was available for 346 cases. The mean age was 45.3 ± 4.8 years, and 69.7% were between the ages of 40 and 49 years. Regarding ethnicity, 58.9% of patients were white, and 26.1% were black. The most common symptoms were abnormal uterine bleeding (87%), pelvic pressure (62.3%), and pelvic pain (60.9%). A total of 106 patients underwent subsequent surgical treatment of fibroids. Of the 346 patients who had follow-up, 4 (1.2%) were diagnosed with leiomyosarcoma after their interventional treatment for fibroids. An additional 2 cases of endometrial adenocarcinoma and 1 case of a premalignant lesion of the endometrium were noted. CONCLUSION(S): The proportion of patients who went on to be diagnosed with leiomyosarcoma after conservative IR treatments appears to be higher than previously reported. A thorough preprocedural workup and patient counseling regarding the possibility of underlying uterine malignancy should be undertaken.

Hysteroscopic myomectomy for submucosal type 2 fibroids with cold enucleation technique and complete fibroid extraction using a double-lumen intracervical cannula.

OBJECTIVE: To introduce a new double-lumen intracervical cannula designed to allow a single-step hysteroscopic myomectomy with nonfragmented complete fibroid extraction after cold enucleation of submucosal type 2 fibroids, avoiding complications related to the use of energy and hypo-osmolar solutions. DESIGN: Video article depicting the use of a new double-lumen intracervical cannula for single-step hysteroscopic cold myomectomy, according to our institutional care guidelines and after obtaining the patient's informed consent. (The publication of this video has been authorized by the Institutional Ethics Committee of CES University in Medellín, Colombia.) SETTING(S): Private infertility clinic. PATIENT(S): A 45-year-old woman with abnormal uterine bleeding consisting of polymenorrhea and hypermenorrhea, nonresponsive to medical treatment, caused by three type 2 (FIGO leiomyoma subclassification system) submucosal fibroids of 17, 15, and 13 mm with more than 80% of intramyometrial component. INTERVENTION(S): Hysteroscopic enucleation of three submucosal fibroids performed by blunt dissection using the 30° Bettocchi hysteroscope's bevel under continuous observation of the avascular subcapsular plane of the fibroids. Once full enucleation was attained, cervical dilatation to 12 mm with Hegar plugs was performed followed by intracervical placement of a newly designed double-lumen intracervical cannula that allows the concomitant introduction of the Bettocchi diagnostic hysteroscope and a 5-mm laparoscopic tenaculum into the uterine cavity for complete nonfragmented fibroid extraction under direct visualization. MAIN OUTCOME MEASURE(S): Complete and unfragmented fibroid extraction in a single intervention, absence of surgical complications, and postoperative course. RESULT(S): Ambulatory hysteroscopic myomectomy of three submucosal type 2 fibroids was successfully performed by blunt enucleation and complete nonfragmented fibroid extraction using the double-lumen intracervical cannula. The total operative time was 32 minutes, and the total amount of distension media (normal saline) used was 800 mL with a liquid balance of 50 mL. No surgical or anesthesia-related complications occurred. In the postsurgical evaluation, the patient classified her pain as minimal, giving it a score of 1 on a pain scale of 1 to 5 (in which 1 is the lowest and 5 the highest pain perception). When asked about the level of satisfaction with the surgical procedure, the patient reported the highest degree of satisfaction with a score of 5 on a satisfaction scale of 1 to 5 (in which 1 is the lowest and 5 the highest satisfaction). The patient reported having postsurgical regular menstrual cycles every 28 days and 3 bleeding days without hypermenorrhea. CONCLUSION(S): An efficient hysteroscopic myomectomy of submucosal type 2 fibroids with deep intramyometrial component can be performed with complete and nonfragmented fibroid extraction in a single intervention by using a newly designed double-lumen intracervical cannula. This technique allows the completion of the surgery without the need of a resectoscope, electrosurgery, or hypo-osmolar uterine distension media, thus avoiding potential complications such as thermal-induced myometrial injury and hyponatremia; a second surgical intervention will not be required because the fibroid enucleation is complete. The procedure can be performed with the use of a diagnostic hysteroscope that is widely available in gynecologic practices. (Acknowledgment: The authors thank Dr. David Olive for the invaluable help and guidance with this surgical technique and video article.).

The effect of small size uterine fibroids on pregnancy outcomes in high-risk pregnancies

Abstract Objective To evaluate the obstetric outcomes of singleton high-risk pregnancies with a small size uterine fibroid. Methods This retrospective cohort study was conducted among 172 high-risk pregnant women who were followed-up by a single surgeon between 2016 and 2019. Pregnant women with preconceptionally diagnosed small size (< 5 cm) single uterine fibroids (n = 25) were compared with pregnant women without uterine fibroids (n = 147) in terms of obstetric outcomes. Results There was no statistically significant difference between the groups in terms of adverse pregnancy outcomes. The size of the fibroids was increased in 60% of the cases, and the growth percentage of the fibroids was 25% during pregnancy. Intrapartum and short-term complication was not observed in women who underwent cesarean myomectomy. Conclusion Small size uterine fibroids seem to have no adverse effect on pregnancy outcomes even in high-risk pregnancies, and cesarean myomectomy may be safelyperformed in properly selected cases.

Spontaneous expulsion of a submucosal uterine fibroid without embolization in a pre-menopausal woman.

Uterine leiomyomas are benign tumors that develop from smooth muscle tissue and are present in up to 77% of women in menacme. They are often asymptomatic but can cause pelvic pain, compression, abnormal uterine bleeding, and degeneration. We present the first case report of a perimenopausal woman who exhibited complete and spontaneous expulsion of uterine fibroids without embolization or use of medication. She complained of a mass extruding from the vaginal orifice associated with bleeding and pain for a couple of hours. The anatomopathological findings showed a myomatous lesion. Complete expulsion of a uterine fibroid is a rare condition that may be associated with profuse hemorrhage and can pose a risk to the patient. When it occurs during perimenopause, it can mimic several clinical conditions. Therefore, gynecologists must remain alert to make the correct diagnosis and treatment.

Leiomyomas in an African Caribbean hysterectomy population considered to be ethnically related to African Americans.

BACKGROUND: Uterine leiomyoma has been reported to be a worse problematic disease for African American than Caucasian women in the US. Data are almost non-existent for other populations of African ancestry. Our aim was to investigate the hypothesis of an equivalent influence of ethnicity on uterine leiomyomas for women of a French African-Caribbean population. BASIC PROCEDURES: Retrospective analysis of hysterectomies performed from 2010 to 2015 at the teaching hospital of Guadeloupe (French West Indies), where most inhabitants are of West African origin, was carried out. Data of the 899 hysterectomies, including those for malignancy, were collected, in particular, uterine weight. MAIN FINDINGS: The indications were leiomyoma in 66.5 % of cases and leiomyomas were found in 91 % of all cases. The mean age and uterine weight were 51.7 years and 464 g for the entire population, 50.2 years and 488 g for the population without malignancies, and 47.0 years and 567 g for the population with leiomyomas. PRINCIPAL CONCLUSIONS: The data were compared to those reported in the literature for several populations, notably African Americans and Caucasians in the US and mainland France. This comparison supports the hypothesis that Guadeloupean women, an African-Caribbean population, have characteristics in terms of uterine leiomyoma that are close to those of African Americans. Although confirmation is required, these results highlight the need for specific research, therapeutic approaches, and improved early management of these populations.

High soy isoflavone or soy-based food intake during infancy and in adulthood is associated with an increased risk of uterine fibroids in premenopausal women: a meta-analysis.

Numerous studies have examined the association of soy isoflavones or soy-based food intake with the risk of uterine fibroids (UF), but the results are inconsistent. The purpose of this meta-analysis was to quantitatively assess whether high soy isoflavones intake is associated with an increased risk of UF. PUBMED and EMBASE databases were reviewed to screen for relevant published studies up to December 2018. Using key words of uterine fibroid and isoflavone, we identified 4 studies focusing on infancy intake and 7 studies evaluating intake during adulthood. The pooled odds ratio (OR) and corresponding 95% confidence interval (95% CI) were calculated using a random-effect model. In addition, subgroup analyses and 2-stage random-effect dose-response were also performed. When comparing high vs low intake of soy isoflavones, we found that there were positive associations of UF among patients being fed soy formula during infancy (OR, 1.19; 95% CI, 0.99-1.43; P = .06) and with high consumption of soy-based foods in adulthood (OR, 2.50; 95% CI, 1.09-5.74; P = .03), respectively. Additionally, dose-response analysis showed the pooled ORs (95% CIs) of UF risk for low, moderate, and high intake of soy isoflavones were 1.00 (0.87-1.14), 1.08 (0.94-1.24), and 1.23 (0.99-1.53) when compared to occasional intake, respectively. Our findings suggest that high soy isoflavones or soy-based food intake during infancy and in adulthood is associated with an increased risk of uterine fibroids in premenopausal women. There is a need for large-scale prospective cohort studies using more accurate measurements of soy isoflavones to further ascertain our study findings.

Impact of uterine contractility on quality of life of women undergoing uterine fibroid embolization.

BACKGROUND: Although changes in uterine contractility pattern after uterine fibroid embolization (UFE) has already been assessed by cine magnetic resonance imaging (MRI), their impact on quality of life outcomes has not been evaluated. The purpose of this study was to evaluate the impact of uterine contractility on the quality of life of women undergoing UFE measured by the Uterine Fibroid Symptom and Quality of Life questionnaire (UFS-QOL). RESULTS: A total of 26 patients were included. MRI scans were acquired 30-7 days before and 6 months after UFE for all patients. The UFS-QOL was applied in person on first MRI exam day and 1 year after UFE and the outcomes were analyzed according to the groups of evolution pattern of uterine contractility: Group A: Unchanged Uterine Contractility Pattern, 38%; Group B: Favorable Modified Uterine Contractility Pattern, 50%; and Group C: Loss of Uterine Contractility, 11%. All UFE patients presented a reduction in the mean score for symptoms and increase in mean scores on quality of life. All patients in this cohort presented a reduction in mean symptom score and increase in the mean score of quality of life subscales. Group A had more relevant complaints regarding their sense of self-confidence; Group B presented worse sexual function scores before UFE, which improved after UFE compared to Group A. CONCLUSIONS: Significant improvement in symptoms, quality of life, and uterine contractility was observed after UFE in women of reproductive age with symptomatic fibroids. Functional uterine contractility seems to have a positive impact on quality of life and sexual function in this population. LEVEL OF EVIDENCE: Level 3, Non-randomized controlled cohort/follow-up study.

Evaluation of Uterine Contractility by Magnetic Resonance Imaging in Women Undergoing Embolization of Uterine Fibroids.

PURPOSE: To assess uterine contractility using ultrafast magnetic resonance imaging (cine MRI) before and after uterine fibroid embolization (UFE). MATERIALS AND METHODS: This is a prospective study of uterine contractility in 26 patients (age 30-41 years) undergoing UFE for symptomatic uterine fibroids. Cine MRI was performed before and 6 months after UFE. Two radiologists evaluated uterine contractility and classified it as absent, ordered, or disordered. Patients were then grouped into three distinct patterns of progression: unchanged contractility (group A), modified contractility (B), and loss of contractility (C). These findings were then confronted with factors that might have interfered with uterine contractility pattern (uterine volume, location of dominant fibroid, fibroid/myometrium index, and fibroid necrosis pattern). RESULTS: Of the 26 patients, 8 (30.7%) had no contractility before the procedure, while 18 (69.2%) exhibited some form of contractility (11 [61%] ordered, 7 [39%] disordered). All 8 patients who had no contractility at baseline exhibited contractility after UFE (5 ordered, 3 disordered). Of the 11 who had ordered contractility at baseline, 9 remained ordered and 2 lost contractility after UFE. Of the 7 with disordered contractility at baseline, 1 remained disordered, 5 progressed to ordered contractility, and 1 lost contractility. Overall, 10 patients (38%) had no change in contractility after UFE (group A), 13 (50%) had a positive change (group B), and 3 (11%) lost contractility (group C). The potential interference factors assessed had no statistically significant effect in any group. CONCLUSION: In women of reproductive age with symptomatic fibroids, uterine contractility improved significantly after UFE. LEVEL OF EVIDENCE: Level 3-non-randomized controlled cohort/follow-up study.

Diagnóstico ultrasonográfico de las masas pélvicas ginecológicas / Ultrasonographic Diagnosis of Gynecologic Pelvic Masses

Introducción: el ultrasonido constituye el examen diagnóstico ideal para el estudio de los tumores ginecológicos. Es un método efectivo, fácil de realizar, económico y no invasivo. Objetivo: caracterizar las masas pélvicas ginecológicas analizadas por ultrasonido. Métodos: se realizó un estudio observacional descriptivo transversal en el Hospital Universitario Ginecobstétrico Provincial Ana Betancourt de Mora desde enero hasta diciembre de 2013. El universo estuvo constituido por 312 féminas. El tamaño de la muestra fue de 151 pacientes seleccionadas al azar. Los datos se obtuvieron del libro de registro del salón de operaciones ginecológicas. La información se obtuvo de las historias clínicas. Se confeccionó una hoja de vaciamiento que se convirtió en el registro definitivo de la investigación y se determinaron estadísticas descriptivas. Resultados: la mayoría de las masas ginecológicas fueron fibroma uterino. Dentro de los hallazgos imagenológicos la mayoría de las masas tenían localización uterina, mostraron una tumoración única, fueron hipoecogénicos. Los diagnósticos clínicos y ultrasonográficos coincidieron por Anatomía Patológica. Conclusiones: el ultrasonido es de gran utilidad en el diagnóstico de las masas pélvicas(AU)

Introduction: Ultrasound is the ideal diagnostic test for the study of gynecologic tumors. It is an effective method, easy to perform, economical and non-invasive. Objective: Characterize gynecological pelvic masses by ultrasound. Methods: Atraverse descriptive observational study was carried out from January to December 2013; at the Provincial Obtetrics-Gynecology University Hospital. The study universe consisted of 312 women, 151 patients was the size of the sample, selected at random. The data were obtained from the registration book of the gynecological surgery room and from the clinical histories. A data sheet that became the definitive record of the investigation was constructed. Descriptive statistical was determined. Results: Most of the gynecological masses were uterine fibromas. Most of the masses, within the imaging discoveries, had uterine localization. They showed a unique tumor, they were hypoecogenic and clinical and ultrasonographic diagnosis pathologically agreed. Conclusions: ultrasound is useful in the diagnosis of pelvic masses(AU)

Miomectomía en gestante de 14 semanas: a propósito de un caso / Myomectomy in a 14-week pregnant woman: about a case

ANTECEDENTES: La prevalencia de los miomas uterinos en la gestación es de 0,3 a 2,6% de los cuales un 10% se complican durante el embarazo. El manejo quirúrgico de los miomas en la gestación se reserva solo para los casos complicados. CASO CLÍNICO: Paciente de 36 años, primigesta, que consulta a las 11 semanas de gestación por cuadro de distensión abdominal, edema en extremidades inferiores y sangrado vaginal escaso. El examen físico y la ecografía evidencia un mioma de 23 cm de diámetro y saco gestacional con embrión vivo a nivel de hipocondrio izquierdo. En controles posteriores la paciente empeora clínicamente debido al crecimiento del mioma, presentado dolor abdominal intenso, aumento de edemas en ambas extremidades inferiores. Los estudios de imagen informan ectasia pielocalicial bilateral y compresión de venas ilíacas. Ante los hallazgos y clínica se realiza miomectomía sin incidencias a las 14 semanas de gestación. El postoperatorio y controles posteriores son normales y se programa cesárea a las 37 semanas de gestación. DISCUSIÓN: La miomectomía en la gestación conlleva riesgos de hemorragia y aborto. Se reserva para casos puntuales que no respondan al manejo expectante. La recomendación actual y la experiencia indican que se debe realizar en el segundo trimestre de gestación. CONCLUSIÓN: La miomectomía en la gestación es una técnica que se debe plantear en casos seleccionados y que presenta pocas complicaciones.

BACKGROUND: The prevalence of uterine fibroids in pregnancy is 0.3 to 2.6%, 10% of which complicate during pregnancy. The surgical management of fibroids in pregnant women is reserved for complicated cases. CASE REPORT: The patient is 36 years old, first pregnancy, consulting at 11 weeks of gestation with bloating, edema in the lower extremities and mild vaginal bleeding. Physical examination and ultrasound evidence a 23 cm diameter fibroid and gestational sac with live embryo in the left upper abdominal quadrant. In subsequent tests the patient worsens clinically due to fibroid growth, presenting intense abdominal pain, increased edema in both lower extremities. Imaging studies report pyelocalyceal bilateral ectasia and compression of iliac veins. Given these findings and symptoms a myomectomy is performed without incidents at 14 weeks of gestation. Postoperative and subsequent tests are normal and caesarean section is preformed at 37 weeks of gestation. DISCUSSION: myomectomy in pregnancy carries risks of bleeding and abortion. It is reserved for cases that do not respond to expectant management. The current recommendation and experience indicate that it has to be performed in the second trimester. CONCLUSION: Myomectomy in pregnancy is a technique that should be considered in selected cases and has few complications.

Urinary isoflavone and lignan phytoestrogen levels and risk of uterine fibroid in Jamaican women.

BACKGROUND: Isoflavones and lignans are phytoestrogens, and therefore, are able to bind to and activate estrogen receptors. The resultant estrogenic or antiestrogenic effect is dependent on the concentration of these phytoestrogens relative to endogenous estrogens and the site of their action, among others. Thus, isoflavones and lignans act as selective estrogen receptor modulators; having a beneficial effect in some tissues while simultaneously causing deleterious changes in others. OBJECTIVE: This case-control study investigates the relationship between urinary concentrations of genistein, daidzein, equol, and enterolactone, and the presence of uterine leiomyomas (fibroids) in Jamaican women. DESIGN: Phytoestrogen concentration in spot urine samples from 157 uterine fibroid cases and 171 fibroid-free controls diagnosed by ultrasonography, were assessed by Time-resolved Fluoroimmnoassay. Statistical evaluations were performed using SPSS 12.0. RESULTS: The median concentration of urinary enterolactone was significantly different between uterine fibroid cases and controls (p=0.029). However, this was not observed to affect risk of uterine fibroid, as trends across quartiles of urine enterolactone did not differ significantly between cases and controls. Median urinary genistein (p=0.510), daidzein (p=0.838), equol (p=0.621), total isoflavones (0.510) and total phytoestrogens (p=0.084) were similar for both groups. Binary logistic regression analysis of quartiles of urine genistein, daidzein, equol, enterolactone, total isoflavones, and total phytoestrogens showed no association with uterine fibroid. CONCLUSIONS: Uterine fibroid cases had a higher median urine concentration of enterolactone compared with controls. However, this was not observed to affect ones risk of fibroid. Neither was urine genistein, daidzein, equol total isoflavones, and total phytoestrogens observed to be associated with risk of uterine fibroid.

La embolización selectiva de arterias uterinas como alternativa en el tratamiento del fibroma uterino / Selective Embolization of Uterine Artery as an Alternative in the Treatment of Uterine Fibroids

El fibroma uterino se presenta entre el 25 y 50 % de las mujeres mayores de 30 años, y sus manifestaciones clínicas más importantes son: el dolor pélvico y el sangrado vaginal. Su diagnóstico se basa en el examen clínico y se confirma con métodos imaginológicos. Los tratamientos tradicionales han sido la hormonoterapia, la cirugía y, en los últimos años, la cirugía de mínimo acceso. El objetivo de este trabajo es reportar los beneficios del empleo de la emboloterapia de las arterias uterinas como terapéutica alternativa de tratamiento de los fibromas uterinos sintomáticos, según las referencias de varios autores.

Uterine fibroid occurs between 25 and 50% of women over 30 years, and its main clinical manifestations are pelvic pain and vaginal bleeding. Diagnosis is based on clinical examination and confirmed with imaging methods. Traditional treatments are hormone therapy, surgery, and, in recent years, minimal access surgery. The aim of this paper is to report the benefits of the use of embolotherapy for uterine artery as a therapeutic alternative for the treatment of symptomatic uterine fibroids, according to references by various authors.