Treatment Choices in a National Cohort of Canadian Women With Symptomatic Uterine Fibroids

ObjectivesTo describe treatment choices made at the time of enrollment in CAPTURE, a Canadian patient registry for women with symptomatic uterine fibroids (UFs), and to define demographic and clinical characteristics that independently predict these choices.MethodsWomen arranging appointments for UF care were eligible to enrol. At the time of the enrollment visit, women's self-reported treatment histories were noted, along with their clinical characteristics. Tretment options were discussed and chosen during that visit. Patients could choose medical and/or surgical treatment, or they could opt for no active treatment (i.e., “watchful waiting”); treatment decisions were not binding.ResultsThe most common medication proposed and chosen was ulipristal acetate (UPA), and the most common procedure was myomectomy. These treatments were also the most commonly identified in patients’ histories. Medication alone and medication in combination with surgery were the most common treatment approaches chosen (46% and 26%, respectively). Surgery alone and watchful waiting were chosen by 14% and 13% of patients, respectively. Significant predictors of active treatment included patient pregnancy plans, overall symptom severity, and prior treatment history (medical and surgical). Other parameters, including patient age and history of specific UF symptoms, appear to influence the choice of medical therapies (UPA, gonadotropin-releasing hormone agonists, or other options) and procedures (myomectomy or hysterectomy).ConclusionsThis real-world study documents the patient factors associated with the treatment decisions of women seeking care for symptomatic UFs in contemporary Canadian gynaecology practice. Subsequent analyses will follow the outcomes of these treatments over two years in this population.     

Assessment of Quality of Life,Sexual Quality of Life,and Pain Symptoms in Deep Infiltrating Endometriosis Patients With or Without Associated Adenomyosis and the Influence of a Flexible Extended Combined Oral Contraceptive Regimen: Results of a Prospective,Observational Study

BackgroundThe quality of life of women with deep infiltrating endometriosis (DIE) is impaired and may improve with combined oral contraceptives (COCs).AimTo compare the overall and sexual quality of life of patients diagnosed with DIE with or without associated adenomyosis (AD) with that of healthy controls and determine the influence of a COC containing 2 mg dienogest/30 μg ethinyl estradiol on these aspects.MethodsWe enrolled 42 women diagnosed with DIE; 31 diagnosed with DIE + AD by transvaginal ultrasound, and 39 non-AD/DIE controls. All patients were interviewed regarding pain symptoms (dysmenorrhea, dyspareunia, dyschezia, and dysuria), heavy menstrual bleeding using the Pictorial Blood Loss Assessment Chart, quality of life using the Short Form-36 questionnaire (SF-36), and sexual quality of life using the Sexual Quality of Life-Female questionnaire (SQOL-F) and the Brief Profile of Female Sexual Function (B-PFSF) before starting COCs and after 12 months of treatment.OutcomesThere was significant improvement in overall and sexual quality of life after treatment in DIE and DIE + AD patients.ResultsNon-AD/DIE controls showed significantly higher scores in the B-PFSF, the SQOL-F and the SF-36 questionnaires (P < .05) at baseline versus the other groups. DIE + AD patients showed poorer quality of sexual life and greater intensity in pain symptoms compared with DIE patients. After 12 months of treatment, there was a significant improvement in overall and sexual quality of life in the DIE and DIE + AD groups, with improvement in sexual quality of life being slightly greater in DIE + AD patients compared with DIE patients. Pain symptoms also decreased in both groups.Clinical ImplicationsPatients with DIE + AD showed greater impairment in overall and sexual quality of life compared with patients with isolated DIE which seems to improve with a COC containing 2 mg dienogest/30 μg ethinyl estradiol.Strengths & limitationsStrengths include the long-term follow up, assessment of the impact of two associated conditions, and administration of the same COC in all patients. Limitations include the relatively small sample size, and the fact that we did not assess the effectiveness of a flexible extended COC regimen containing 2 mg dienogest/30 μg ethinyl estradiol since the groups were different at baseline.ConclusionPatients diagnosed with DIE with or without AD have a decreased quality of life which may improve with a COC containing 2 mg dienogest/30 μg ethinyl estradiol. Further research is needed to confirm our results.Alcalde AM, Martínez-Zamora MÁ, Gracia M, et al. Assessment of Quality of Life, Sexual Quality of Life, and Pain Symptoms in Deep Infiltrating Endometriosis Patients With or Without Associated Adenomyosis and the Influence of a Flexible Extended Combined Oral Contraceptive Regimen: Results of a Prospective, Observational Study. J Sex Med 2022;19:311–318.     

Transvaginal Doppler-Guided Uterine Artery Occlusion for the Treatment of Symptomatic Fibroids: Summary Results From Two Pilot Studies

ObjectiveTo evaluate the feasibility, safety, and short-term efficacy of bilateral uterine artery occlusion, using a transvaginal Doppler-guided vascular clamp as a minimally invasive therapy for symptomatic uterine leiomyomas.MethodsWe conducted two prospective, non-randomized, phase I pilot studies (Canadian Task Force Classification II-2) at a university-affiliated teaching hospital. Between June 2004 and May 2005, 30 premenopausal women with symptomatic uterine leiomyomas underwent bilateral uterine artery occlusion using a transvaginal Doppler-guided vascular clamp. Bilateral uterine artery occlusion was performed for 5.8 ± 1.4 hours in the first 17 patients (Group 1) and from 6 to 9 hours (mean 7.05 ± 1.0 hours) in the latter 13 patients (Group 2). Outcome measures included dominant fibroid volume (cm³), uterine volume (cm³), and improvement of menorrhagia at one, three, and six months.ResultsBilateral occlusion of the uterine arteries was achieved in all 30 patients. In Group 1, the Ruta Menorrhagia Severity Scores decreased from baseline by 16%, 22% and 39% at one, three, and six months respectively. The dominant fibroid (DF) and uterine volumes decreased by 24% and 16% respectively at six months. In Group 2, the Ruta scores changed from baseline by + 3%, –24%, and –42% at one, three, and six months respectively. The DF and uterine volumes decreased by 29% and 16%, respectively at six months.ConclusionFollowing bilateral uterine artery occlusion using a transvaginal Doppler clamp, the dominant fibroid volume decreased by an average of 24%, uterine volume decreased by12%, and menorrhagia symptoms were reduced by up to 42%. Uterine artery occlusion may provide the gynaecologist with an alternative to uterine artery embolization (UAE). The system is simple, easy to apply, and short-term efficacy may be equivalent to UAE.     

First and Third Trimester Uterine Scar Thickness in Women With Previous Caesarean: A Prospective Comparative Study

Background

Lower uterine segment (LUS) thickness in the third trimester of gestation is associated with the risk of uterine scar defect at delivery. It was suggested that first trimester residual myometrial thickness (RMT) could also predict uterine scar defect at delivery.

Pregnancy in Women Aged 35 Years and Above: A Prospective Observational Study

Abstract

Pregnancy is affected by maternal age from conception till delivery. Various studies have been conducted globally to study this effect; few in developing countries. Maternal age is increasing in developing countries as well, so we have conducted this study.

Method

This was a prospective observational study consisting of 1,263 women booked at Jehangir hospital during a period of 2 years, fulfilling inclusion criteria and consenting for the study. They were divided into two groups; women aged 35 years and above and women less than 35 years of age. Pregnancy outcomes were studied in terms of antepartum, intrapartum and postpartum complications. Neonatal outcomes were studied in terms of birth weight and NICU admissions. Data was analyzed statistically using statistical package for social sciences version 17, by applying Chi square test and Fisher exact test. A p value below 0.05 was considered significant.

Results

Women aged 35 years and above constituted 9.63 % of the total study population. Most were multigravidae. Rate of assisted conception was significantly higher among women aged 35 years and above; early pregnancy loss was also high in this group. Pre-eclampsia and abruption were significantly higher among them. Neonatal outcomes were comparable.

Conclusion

Women with advanced maternal age are at higher risk of complications from conception till delivery and should be provided close supervision for better pregnancy outcome.     

Quality of Life,Adverse Events,and Reintervention Outcomes after Laparoscopic Radiofrequency Ablation for Symptomatic Uterine Fibroids: A Meta-Analysis

In this review, we assessed the short-term (3 and 6 months) and long-term (12, 24, and 36 months) symptom relief and quality of life improvement, procedure-related adverse event rate, reintervention rate, and days missed from work after laparoscopic radiofrequency ablation. Using MeSH keywords “uterine fibroid” and “ablation technique,” a systematic search was performed in PubMed, Ovid, Embase, Cochrane Library, and Clinicaltrials.gov. Studies consisting of uterine fibroid symptoms and quality of life scores were considered eligible. Both comparative and noncomparative studies were included. Using a random-effects model, a meta-analysis was performed. Eight studies with a total of 581 patients were finally included in our review. Based on validated questionnaires, quality of life improved significantly until 36 months after laparoscopic radiofrequency ablation therapy, with a maximum improvement (Health-Related Quality of Life [HRQL] questionnaire score of +41.64 [95% confidence interval (CI), 38.94–44.34] and a transformed Symptom Severity Score [tSSS] of -39.37 [95% CI, 34.70–44.04]) at 12 months after laparoscopic radiofrequency ablation. All subscales of quality of life improved significantly, and most of the changes remained stable in long-term follow-up. The overall reintervention rate was 4.39% (95% CI, 1.60%–8.45%), and the median uterine volume reduction was 69.17 cm³ (95% CI, 35.87–102.46 cm³).The overall procedure-related adverse events rate was 1.78% (95% CI, 0.62%–3.53%), and patients missed an average of 4.35 days (95% CI, 2.55–6.15 days) of work. In conclusion, laparoscopic radiofrequency ablation therapy is an efficacious way to treat small-sized and nonpedunculated symptomatic uterine fibroids, providing stable long-term symptom relief and quality of life improvement with a low risk of adverse events and reintervention and just a few days of missed work.     

Efficacy and Safety of Oral GnRh Antagonists in Patients With Uterine Fibroids: A Systematic Review

ObjectiveThis review aimed to assess the efficacy and safety of GnRH antagonists in patients with symptomatic uterine fibroids.Data SourcesA literature search was performed on PubMed, Web of Science, Embase, Cochrane, and ClinicalTrials.gov using the MeSH and Emtree terms “leiomyoma” and “gonadotropin-releasing hormone.”Study SelectionAll clinical trials that provided efficacy and safety data in clinical terms (i.e., reduction in menstrual bleeding and discomfort, changes in the size of leiomyoma and uterine volume, etc.) were included. We excluded all preclinical studies, case reports, meta-analyses, review articles, and clinical studies irrelevant to the study question.Data Extraction and SynthesisTwo authors extracted data from 9 clinical studies. The extracted data included the study's characteristics, participants' baseline characteristics, treatment drugs, efficacy measures, and toxicity.ConclusionAmong oral GnRH antagonists, relugolix, elagolix, and linzagolix were safe in patients with uterine fibroids. These drugs, alone and in combination with E2/NETA (estradiol/norethindrone acetate), showed significantly better efficacy than placebo in improving bleeding, discomfort, uterine/leiomyoma sizes, and quality of life in premenopausal patients with symptomatic uterine fibroids. However, more randomized, double-blind, multicentre clinical trials are needed to confirm these results and to see long-term benefits.     

超促排卵对不孕女性子宫内膜蠕动波的影响

目的:研究不孕女性自然周期与控制性超促排卵(COH)周期子宫内膜蠕动波的特点。方法:64名排卵正常的不孕女性分别于自然周期LH峰日、排卵日、排卵后2 d和COH周期hCG注射后1 d、采卵日、采卵后2 d阴道超声监测子宫内膜蠕动波,且同时测定血清雌、孕激素水平。结果:自然周期子宫内膜蠕动波频率是COH周期的1.31倍;COH周期与自然周期各个观测日的子宫内膜蠕动波类型分布不同;子宫内膜蠕动波频率与生理水平血清雌二醇(E2)呈正相关,与孕酮(P)呈负相关,与超生理剂量的雌、孕激素无相关性。结论:COH治疗显著地改变了子宫内膜蠕动波的自然运动模式,在胚胎移植前仍表现为较强烈的子宫内膜运动。     

Implementation of a Clinical Protocol to Reduce Urinary Tract Infections Among Women With Urinary Retention After Pelvic Reconstructive Surgery: A Prospective Quality Improvement Study

ObjectiveWe implemented and assessed a clinical practice quality improvement protocol aimed at decreasing postoperative urinary tract infections (UTIs) among patients with transurethral catheters.MethodsThis was a quality improvement study with pre- and post-intervention comparisons. Patients requiring postoperative transurethral catheters underwent 3 interventions: (1) shortening the time from surgery to repeat voiding trials to 3–5 days for pelvic reconstructive surgeries and to 1–3 days for mid-urethral slings, (2) avoiding routine urine cultures at the time of voiding trials, and (3) recommending 2 L of water intake daily until 3 days after the voiding trial. The primary outcome was the percentage of patients receiving antibiotics for UTIs within 6 weeks. Secondary outcomes included rates of failing office voiding trials, UTI symptoms/cultures, adherence to hydration, and health care resource utilization.ResultsWe included 31 patients before and 40 patients after the intervention. The 2 cohorts had similar demographic and clinical characteristics. Among patients requiring catheterization, rates of antibiotic treatment for UTIs decreased from 65% to 40% after the intervention (P = 0.04). UTI symptoms and urine cultures sent for analysis decreased significantly (P = 0.04 and P = 0.005, respectively). There was high adherence (84%) to increased hydration. Rates of failing office voiding trials remained similar. The number of phone calls decreased by 43% (P = 0.003), and there was no increase in office or emergency department visits. Multivariate regression showed that UTIs were 2.04 times more likely before than after the intervention.ConclusionOur quality improvement intervention was practical to implement and effective in reducing postoperative UTIs among patients with urinary catheters.     

Short-Term Effect of TVT-SECUR Procedure on Quality of Life and Sexual Function in Women With Stress Urinary Incontinence

Study ObjectiveTo investigate whether patient quality of life and sexual function are improved after the tension-free vaginal tape SECUR (TVT-S) procedure (H-type).DesignProspective study (Canadian Task Force classification II-3).SettingSingle-center hospital.PatientsThirty-three women with stress urinary incontinence (SUI) (high urethral mobility) and no concomitant pelvic floor prolapse underwent TVT-S between October 2009 and October 2011.InterventionTVT-S procedure.Measurements and Main ResultsBefore and after surgery(6 and 12 months), all patients completed the Chinese version of the Incontinence Quality of Life Questionnaire (I-QOL). In addition, 28 sexually active patients who underwent the TVT-S procedure completed the short-form Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ-12) before and after surgery (6 and 12 months). We used a paired t test to compare I-QOL scores before and after surgery. The Wilcoxon signed-rank test was used to compare the preoperative and postoperative PISQ scores. The objective cure rate was 78% (26 of 33 patients) at 12 months after surgery. The objective improvement rate was 12.1% (4 of 33 patients). The subjective satisfaction rate was 90%. Three operations (9.1%) were considered failures. Two patients underwent a TVT procedure after TVT-S because of recurrence. No patients reported severe pain; the mean (SD) visual analog scale pain score was 1.8 (1.2) after surgery. Only 1 patient (3%) was found to have sling erosion at 12 months postoperatively. The I-QOL score was 28.3 (14.2) before surgery and increased to 69.5 (18.9) at 12 months after the TVT-S procedure. The I-QOL score improved significantly after surgery (p <.001). The total PISQ-12 score at 6 months after surgery in all sexually active patients was 33.82 (0.87), compared with 31.57 (1.20) before surgery (p <.05). Physical domain scores on the PISQ-12 demonstrated significant improvement, increasing from 12.61 (0.75) to 14.36 (0.49) (p <.05). No significant difference was found between I-QOL and PISQ-12 scores at 6 and 12 months after surgery. There was no significant difference in total PISQ-12 scores in premenopausal patients before and after surgery (p >.05).ConclusionsAlthough the objective cure rate was not high, the TVT-S procedure is a minimally invasive, safe, and effective surgical procedure for treatment of SUI (high urethral mobility) and can improve the quality of life and sexual function in women with SUI.     

Adnexal Torsion in Postmenopausal Women: Clinical Presentation and Risk of Ovarian Malignancy

Study ObjectiveTo investigate the clinical presentation, operative outcome, and incidence of malignancy in postmenopausal women who were diagnosed with adnexal torsion.DesignRetrospective cohort study (Canadian Task Force classification II-2).SettingTertiary university-affiliated hospital.PatientsPostmenopausal women diagnosed with adnexal torsion between 1995 and 2014 (study group) were reviewed and compared with 220 premenopausal patients diagnosed with adnexal torsion during the same time period.InterventionDemographic data, clinical signs and symptoms, and intra- and postoperative characteristics were compared between the 2 groups.Measurements and Main ResultsDuring the study period 44 postmenopausal women were diagnosed with adnexal torsion. Continuous dull pain was the most common presenting symptom in the postmenopausal group (57%), whereas acute-onset sharp pain was the predominant symptom in the premenopausal group (86%). The time interval from admission to surgery was significantly longer in the postmenopausal group (24 vs 6 hours, p < .001). Laparoscopic surgery was performed in 84.5% of the cases in the premenopausal group, whereas it was carried out in only 50% of cases in the postmenopausal group (p < .001). Four women in the postmenopausal group were diagnosed with malignancy, whereas only 1 case of malignancy was found in the premenopausal group (9% vs .4%, respectively; p = .003).ConclusionsAdnexal torsion in postmenopausal women is an uncommon event with a unique presentation. Because ovarian malignancy is not an uncommon finding in this group of patients, preparation for more extensive surgery should be contemplated.     

Uterine Peristalsis in Women With Repeated IVF Failures: Possible Therapeutic Effect of Hyoscine Bromide

BackgroundUterine peristalsis, which is influenced by hormonal and cholinergic effects, may have a role in successful implantation and continuing pregnancy.CasesWe encountered abnormal uterine peristalsis in three women who had had repeated in vitro fertilization (IVF) treatment failures. They subsequently had successful pregnancies when hyoscine bromide was administered at the time of embryo transfer.ConclusionIt is possible that decreasing uterine peristalsis with use of an anticholinergic agent during IVF treatment facilitates retention of embryos and increases the probability of successful pregnancy.     

The Importance of Surgical Staging in Women With Uterine Serous Carcinoma: Experience in a Single Institution Reveals a Survival Benefit

ObjectiveTo assess the appropriate extent of surgical staging in women with clinically early stage uterine serous carcinoma (USC).MethodsWe conducted a single-institution retrospective cohort study of all women with USC between 2007 and 2012. Treatment practices, outcomes, and factors affecting survival were analyzed using univariate and multivariate analysis.ResultsEighty-four patients were identified, 76 of whom were included in the analysis. Preoperative pathology correctly identified USC in 73.3% of cases. Surgical stage distribution was 44.7% stage I, 7.9% stage II, 31.6% stage III, and 15.8% stage IV. Women thought to have early stage disease preoperatively encompassed 84.2% (64) of the cohort. Fifty-two (81.3%) of these women with clinically early stage disease had complete surgical staging. Thirty-four (53.1%) were determined to have surgical stage I, and the remaining 30 (46.9%) had occult advanced stage disease. Median follow-up was 43.2 months. Univariate analysis found a significant increase in progression-free survival and overall survival for women with clinically early stage disease with positive lymphovascular space invasion (P < 0.001 and P = 0.002, respectively), positive peritoneal cytology (P = 0.022 and P = 0.04, respectively), early stage (P < 0.001 and P = 0.004, respectively), and elevated serum CA125 at diagnosis (P = 0.003 and P = 0.001, respectively). On multivariate analysis, early stage (hazard ratio [HR] 9.87; 95% CI 2.79 to 34.92, P < 0.001) and complete surgical staging (HR 2.96; 95% CI 1.05 to 8.37, P = 0.040) were associated with prolonged progression-free survival, while overall survival was not affected by complete surgical staging (HR 1.92; 95% CI 0.64 to 5.76, P = 0.79).ConclusionComplete surgical staging prolongs the progression-free survival of women with clinical early-stage uterine serous cancer. Although this does not extend to overall survival, this enables patients to have an improved quality of life with a longer interval without the burden of disease.     

Rates of Spontaneous and Therapeutic Abortions Following Use of Antidepressants in Pregnancy: Results From a Large Prospective Database

ObjectiveThe use of antidepressants during pregnancy remains a controversial issue, and there is little information on the risk of spontaneous abortions following antidepressant exposure in early pregnancy. We sought to examine whether use of antidepressants increases the rates of spontaneous abortion (SA) and therapeutic abortion (TA) in women exposed in early pregnancy.MethodsIn a cohort of women who contacted the Motherisk program during pregnancy, we compared two groups of women, one exposed and the other not exposed to antidepressants during pregnancy, and calculated the associated rates of SA and TA.ResultsAmong 937 women exposed to antidepressants prior to and during early pregnancy, there were 122 SAs (13.0%) including three ectopic pregnancies, and in the comparison group there were 75 SAs (8.0%) and no ectopic pregnancies. The relative risk was 1.63 (95% CI 1.24–2.14). Three-fold more women reported a TA in the exposed group, 26 (2.4%) compared to 8 (0.7%) in the non-exposed group (RR 3.25; 95% CI 1.48–7.14). A sub-analysis revealed that in both groups, of 338 women with a prior SA, 58 (17.2%) reported having a SA in the current pregnancy, compared with 61/652 (9.4%) with no prior SA (χ2 = 12.09, P < 0.001). In the antidepressant group, the incidence was 20.7%, and in the non-exposed group, it was 13.3%. Logistic regression confirmed that only antidepressant exposure and prior SA were significantly associated with current SA.ConclusionExposure to antidepressants in the first trimester of pregnancy appears to be associated with a small but statistically significant increased risk of SA and decision to terminate a pregnancy. The risk for SA is further elevated with a history of previous SA. However, any underlying depression must be taken into consideration when evaluating these results.     

Prediction of Spontaneous Preterm Birth in At-risk Women Using Thrombospondin 1 from Cervicovaginal Fluid: A Prospective Observational Study

Introduction Thrombospondin 1, desmoplakin and stratifin are putative biomarkers for the prediction of preterm birth. This study aimed to validate the predictive capability of these biomarkers in patients at risk of preterm birth. Materials and Methods We included 109 women with symptoms of threatened spontaneous preterm birth between weeks 20 0/7 and 31 6/7 of gestation. Inclusion criteria were uterine contractions, cervical length of less than 25 mm, or a personal history of spontaneous preterm birth. Multiple gestations were also included. Samples of cervicovaginal fluid were taken before performing a digital examination and transvaginal ultrasound. Levels of cervicovaginal thrombospondin 1, desmoplakin and stratifin were quantified by enzyme-linked immunosorbent assays. The primary endpoint was spontaneous preterm birth before 34 + 0 weeks of gestation. Results Sixteen women (14.7%) delivered before 34 + 0 weeks. Median levels of thrombospondin 1 were higher in samples where birth occurred before 34 weeks vs. ≥ 34 weeks of gestation (4904 vs. 469 pg/mL, p < 0.001). Receiver operator characteristics analysis resulted in an area under the curve of 0.86 (p < 0.0001). At an optimal cut-off value of 2163 pg/mL, sensitivity, specificity, positive predictive value and negative predictive value were 0.94, 0.77, 0.42 and 0.99, respectively, with an adjusted odds ratio of 32.9 (95% CI: 3.1 – 345, p = 0.004). Multiple gestation, cervical length, and preterm labor had no impact on the results. Survival analysis revealed a predictive period of more than eight weeks. Levels of desmoplakin and stratifin did not differ between groups. Conclusion Thrombospondin 1 allowed long-term risk estimation of spontaneous preterm birth. Key words: biomarker, cervical length, desmoplakin, preterm birth, preterm labor, stratifin, test characteristics, thrombospondin 1