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Symptoms of uterine myomas: data of an epidemiological study in Germany

DOI:10.1007/s00404-016-4239-y
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Dolores Foth
Dolores Foth
Friedrich-Wilhelm Röhl at Otto-von-Guericke-Universität Magdeburg
Friedrich-Wilhelm Röhl
Cornelia Friedrich
Cornelia Friedrich
Cornelia Friedrich
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Heike Tylkoski
Heike Tylkoski
Heike Tylkoski
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Abstract and Figures

PurposeCurrently, no reliable data are available concerning the type and frequency of symptoms in premenopausal women with uterine myomas. Methods2296 women were examined by means of vaginal ultrasound for the presence of myomas in seven gynaecological outpatient departments in Germany. From this population, 1314 premenopausal women between the ages of 30 and 55 years were evaluated to determine the type and frequency of myoma-related symptoms and their relationship to anamnestic factors, and the number, size, and location of the myomas. Standardised questionnaires were used to record the symptoms. ResultsPrevalence: In almost every second premenopausal woman (n = 639; 48.6%), uterine myomas were diagnosed. The frequency of myomas increased continuously with age and was highest in women between 46 and 50 years (65.2%). Age itself was found to be the main risk factor for the presence of myomas (p < 0.001). Symptoms: 54.3% (n = 347) of the women suffered from myoma-related symptoms. The four main symptoms were identified as: Heavy menstrual bleeding (40.7%), dysmenorrhoea (28.2%), lower abdominal pain (14.9%), and intermenstrual bleeding (14.1%). In the majority of cases, the symptoms occurred simultaneously. Determinants for symptoms: Symptoms did not follow a clear age-related trend, whilst the number and size of the myomas did determine the presence of symptoms. The main influencing factor for the presence of intermenstrual bleeding was the location of the myomas. Conclusions The high prevalence of uterine myomas highlights the importance of the diagnosis uterine myomas in standard gynaecological practice: The presence of only one myoma caused symptoms in 46.5% and small myomas of up to 2 cm in diameter resulted in symptoms in 39.5%.
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GENERAL GYNECOLOGY
Symptoms of uterine myomas: data of an epidemiological study
in Germany
Dolores Foth
1
•Friedrich-Wilhelm Ro
¨hl
2
•Cornelia Friedrich
3
•Heike Tylkoski
4
•
Thomas Rabe
5
•Thomas Ro
¨mer
6
•Ann Kitay
2
•Hans-Joachim Ahrendt
7
Received: 16 May 2016 / Accepted: 8 November 2016 / Published online: 21 November 2016
Springer-Verlag Berlin Heidelberg 2016
Abstract
Purpose Currently, no reliable data are available con-
cerning the type and frequency of symptoms in pre-
menopausal women with uterine myomas.
Methods 2296 women were examined by means of vaginal
ultrasound for the presence of myomas in seven gynaeco-
logical outpatient departments in Germany. From this
population, 1314 premenopausal women between the ages
of 30 and 55 years were evaluated to determine the type
and frequency of myoma-related symptoms and their
relationship to anamnestic factors, and the number, size,
and location of the myomas. Standardised questionnaires
were used to record the symptoms.
Results Prevalence: In almost every second pre-
menopausal woman (n=639; 48.6%), uterine myomas
were diagnosed. The frequency of myomas increased
continuously with age and was highest in women between
46 and 50 years (65.2%). Age itself was found to be the
main risk factor for the presence of myomas (p\0.001).
Symptoms: 54.3% (n=347) of the women suffered from
myoma-related symptoms. The four main symptoms were
identified as: Heavy menstrual bleeding (40.7%), dys-
menorrhoea (28.2%), lower abdominal pain (14.9%), and
intermenstrual bleeding (14.1%). In the majority of cases,
the symptoms occurred simultaneously. Determinants for
symptoms: Symptoms did not follow a clear age-related
trend, whilst the number and size of the myomas did
determine the presence of symptoms. The main influencing
factor for the presence of intermenstrual bleeding was the
location of the myomas.
Conclusions The high prevalence of uterine myomas
highlights the importance of the diagnosis uterine myomas
in standard gynaecological practice: The presence of only
one myoma caused symptoms in 46.5% and small myomas
of up to 2 cm in diameter resulted in symptoms in 39.5%.
Keywords Uterine myomas Prevalence of myomas
Heavy menstrual bleeding, dysmenorrhoea, lower
abdominal pain
Introduction
Uterine myomas are the most frequent benign solid
tumours of the female genital tract. Myomas are subject to
considerable individual variability in terms of their
appearance and clinical relevance. They develop submu-
cosally, intramurally, subserously, intracervically, and/or
In memory of Prof. Hans-Joachim Ahrendt.
&Dolores Foth
dfoth@t-online.de
1
MVZ PAN Institut fu
¨r Endokrinologie und
Reproduktionsmedizin, Zeppelinstr. 1, 50667 Cologne,
Germany
2
Institut fu
¨r Biometrie und Medizinische Informatik (IBMI),
Medizinische Fakulta
¨t der Otto-von-Guericke-Universita
¨t
Magdeburg, Leipziger Str. 44, 39120 Magdeburg, Germany
3
Frauenarztpraxis, Schalaunische Straße 6-7,
06366 Ko
¨then (Anhalt), Germany
4
Praxis fu
¨r Gyna
¨kologie und Geburtshilfe, Leipziger Straße
45B, 39120 Magdeburg, Germany
5
Universita
¨ts-Frauenklinik, Voßstr. 9, 69115 Heidelberg,
Germany
6
Klinik fu
¨r Gyna
¨kologie und Geburtshilfe, EVK Ko
¨ln-
Weyertal, Weyertal 76, 50931 Cologne, Germany
7
Praxis fu
¨r Frauenheilkunde und Klinische Forschung,
Halbersta
¨dter Str. 122, 39112 Magdeburg, Germany
123
Arch Gynecol Obstet (2017) 295:415–426
DOI 10.1007/s00404-016-4239-y
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
... Several studies investigated the correlation between submucous myoma characteristics and anemia with conflicting results [15][16][17][18][19][20][21][22]. ...
... Therefore, it is fundamental to identify the more relevant factors that influence hemoglobin levels in women with myomas to provide objective criteria for establishing the appropriateness of surgery. Several studies have investigated the correlation between menstrual bleeding patterns and myoma characteristics with conflicting results [15][16][17][18][19][20][21][22]. ...
... They found that symptomatic women with at least one submucous myoma are not at higher risk of becoming anemic than symptomatic women with non-submucous myomas. An epidemiological study in Germany obtained similar results [22]. The number and size of myomas, as determined by ultrasound, were significant risk factors for the presence of heavy menstrual bleeding, but there was no link between myoma location and heavy menstrual bleeding [22]. ...
Characteristics of Submucous Myomas and the Risk of Anemia
Article
Full-text available
Background and Objectives: Uterine fibroids still represent the most common indication for hysterectomy for benign pathologies. In the United States, more than 479,000 hysterectomies are performed annually, 46.6% for myomas and 47.7% in women aged from 18 to 44 years. By applying appropriateness criteria to this procedure, it has been estimated that overuse ranges from 16 to 70%. One of the main reasons that induce patients and gynecologists to consider hysterectomy is represented by severe anemia. Materials and Methods: This is a retrospective cohort study of 202 patients with uterine fibroids diagnosed by transvaginal ultrasound who underwent a hysteroscopic procedure. Myoma grade, size, location, and number were assessed by transvaginal scan and office hysteroscopy and correlated to the pre-treatment hemoglobin level. Results: Univariate analysis showed that anemia does not have a statistically significant association with myoma number and with age considered as a numerical predictor. In the patients with myoma type 0, there is a possibility of 81% having anemia regardless of menorrhagia. On the contrary, in patients with myoma type 1 or type 2, the possibility of having anemia varies according to the presence or absence of menorrhagia. If there is menorrhagia, the risk of moderate anemia is only present for myomas >60 mm. Conclusions: The results of this study may contribute to defining objective criteria for the management of submucous myomas and anemia. Our data suggest that submucosal myomas type 0 > 10 mm should always be treated, putting patients at risk for anemia. Myomas type 2 and 3 should be treated for the risk of anemia in the presence of menorrhagia episodes or if > of 60 mm. Adequate management of anemia and myomas could reduce the rate of unnecessary hysterectomies.
... An online survey of 21,479 women from Brazil, Canada, France, Germany, Italy, South Korea, the UK and the US on the other hand found a self-reported incidence of 4.5-17.8% in women of reproductive age (12), indicating the importance of sample population, age bracket and genetic background to reported susceptibility. In up to 40% of patients, uterine fibroids cause HMB (13), and more than half of the patients experience combinations of symptoms such as HMB, pelvic pain, or infertility (14,15). FIGURE 1 | Hypothetical scenarios of a link between uterine fibroids and heavy menstrual bleeding. ...
... Uterine fibroids are classified according to their location relative to the uterine anatomy in the FIGO system (16), but while intermenstrual bleeding as a symptom of uterine fibroids has been shown to correlate with the position and number of fibroids (13), the causal link to HMB is unknown. The classification of both HMB and the FIGO system are not without problems, as consistency between surgeons is lacking [ Figure 1, (17)]. ...
... This structure can be seen as a "ring of fire" in ultrasound Doppler imaging, and it is separated from the myometrium by a clear cleft, as observed in histological images. The bursting of the vessels contained within the pseudocapsule could explain the HMB observed in women with uterine fibroids, in which case the symptom should correlate with the position of the fibroids, as the pseudocapsule only develops around intramural fibroids; this seems to be the case (13). The pseudocapsule is made up of the same cell types and shows the same biologic structure as the neighboring myometrium (83); however, the vasculature of the pseudocapsule might harbor structural defects that rend it susceptible to breaking, leading to HMB. ...
Uterine Fibroids (Leiomyomata) and Heavy Menstrual Bleeding
Article
Full-text available
  • Mar 2022
Uterine Fibroids, or leiomyomata, affect millions of women world-wide, with a high incidence of 75% within women of reproductive age. In ~30% of patients, uterine fibroids cause menorrhagia, or heavy menstrual bleeding, and more than half of the patients experience symptoms such as heavy menstrual bleeding, pelvic pain, or infertility. Treatment is symptomatic with limited options including hysterectomy as the most radical solution. The genetic foundations of uterine fibroid growth have been traced to somatic driver mutations ( MED12, HMGA2, FH −/− , and COL4A5-A6 ). These also lead to downstream expression of angiogenic factors including IGF-1 and IGF-2, as opposed to the VEGF-driven mechanism found in the angiogenesis of hypoxic tumors. The resulting vasculature supplying the fibroid with nutrients and oxygen is highly irregular. Of particular interest is the formation of a pseudocapsule around intramural fibroids, a unique structure within tumor angiogenesis. These aberrations in vascular architecture and network could explain the heavy menstrual bleeding observed. However, other theories have been proposed such as venous trunks, or venous lakes caused by the blocking of normal blood flow by uterine fibroids, or the increased local action of vasoactive growth factors. Here, we review and discuss the evidence for the various hypotheses proposed.
... [30][31][32][33] UF is associated with significant morbidity and substantial socioeconomic costs. [34][35][36] Data from a global systematic review of the cost of UF showed that the total direct and indirect cost after diagnosis or from surgical care ranged from US$11 717 to US$25 023 per patient per year. 37 In USA, the annual cost of UF to the economy was estimated to be between US$5.9 and US$34.4 billion with obstetrical complications contributing the highest fraction of the economic burden. ...
Epidemiology of uterine fibroid in black African women: a systematic scoping review
Article
Full-text available
  • Aug 2022
Objective Studies, mainly from high-income countries, suggest that there are ethnic and racial variations in prevalence of uterine fibroids (UF). However, there have been few studies of the epidemiology of UF in sub-Saharan Africa (SSA). We reviewed published articles on the epidemiology of UF in SSA. Design This was a scoping review of literature. Settings We searched three databases (PubMed, African Wide Information (EBSCO) and African Journals OnLine (AJOL)). The search for eligible articles was conducted between December 2019 and January 2021. Primary and secondary outcome measures To describe the reported prevalence/incidence of, and risk factors for UF in SSA. Results Of the 1052 articles retrieved, 9 met the inclusion criteria for review. The articles were from Nigeria (4/9), Ghana (2/9), Cameroon (1/9), Kenya (1/9) and South Africa (1/9). Two studies from pathology departments and three studies from radiology departments reported prevalence of UF. We did not find any study on the incidence or genomics of UF in SSA. Of the three studies that reported on the risk factors of UF, only one case–control study that was conducted using retrospective data of attendees at a gynaecological clinic conducted multivariable analysis. Conclusion There is lack of robust epidemiological studies of the prevalence, incidence and risk factors of UF in SSA. There is urgent need to study epidemiological and genomics risk factors of UF in SSA because UF is the most common gynaecological neoplasm in this population where it is associated with significant morbidity and occasional, usually perioperative, mortality.
... Fibroids cause different symptoms, and hypermenorrhoea is the main symptom with the prevalence of 40-54%. The next common symptoms are dysmenorrhea and lower abdominal pain [3,4]. In 48% cases, fibroids are the cause of severe hypermenorrhoea with anaemia [5]. ...
Transcervical intrauterine radiofrequency ablation of fibroids in high-risk patients with bleeding disorder
Article
Objectives: To show the advantages of transcervical radiofrequency ablation (TRFA) in high-risk patients with bleeding disorder. Material and methods: It is a retrospective analysis. The study included only patients with known pre-existing conditions (obesity, cardiac and neurological disease, coagulation disorder, anaemia) or post-surgical conditions who were treated with the Sonata® System for fibroid-related bleeding complaints at Academic Hospital Cologne Weyertal between January 2015 and March 2021. These patients were classified as high-risk patients. The fibroids were mostly determined due transvaginal sonography. Thirty patients were included, and 43 fibroids were determined. Results: Therapy with the Sonata® system could be performed without complications in all cases. In our analysis, improvement of fibroid-related symptoms was observed in 89% of cases. Conclusions: The Sonata® System is on the one hand minimally invasive, uncomplicated and fast and on the other hand a successful method of fibroid therapy, which is particularly suitable for high-risk patients with various pre-existing conditions, for whom a minimally invasive, bloodless and short surgical procedure has great advantages.
Delayed expulsion of a large fibroid after transcervical radiofrequency ablation: A case report
Article
Full-text available
  • Mar 2023
Fibroids are the most common type of benign uterine tumor, which occur up to 68.6% of women. Hypermenorrhea is the most common symptom with a general prevalence of 40%-54%, followed by dysmenorrhea and low abdominal pain. Transcervical fibroids ablation was developed as a minimally invasive, incisionless treatment of fibroids in a short time. This method is safe and effective with an excellent record of safety. We present the case of a 40-year-old woman, who attended in our fibroid excellence center. She reported severe hypermenorrhea and dysmenorrhea. Family planning was definitely completed. Using vaginal ultrasonography a FIGO 2-5 fibroid of 5 cm in diameter was detected. Different treatment options were discussed: medical treatment, laparoscopic fibroidectomy, hysterectomy, and transcervical radiofrequency ablation with Sonata System. Because of advantages of transcervical radiofrequency ablation (minimal invasive treatment without incision, effectivity of method, short surgical time) the patient decided on this method. Three months later, the patient came to the first follow up. She reported a significant improvement of hypermenorrhea. A vaginal ultrasonography was carried out. The fibroid changed its position from FIGO 2-5 to FIGO 2. The patient was very satisfied with the result. After 2 months, she attended in our department again because of severe clear vaginal discharge. She had no bleeding, no pain as well as no fever. We examined her immediately. A fibroid expulsion was detected. The fibroid was removed vaginally. There was no severe bleeding during the operation and the fibroid could be removed completely. The surgery time was 25 minutes.
Validation of Self-Report of Uterine Fibroid diagnosis using Trans-Vaginal Ultrasound Scan
Preprint
Full-text available
  • Dec 2022
Objective: Self-report of uterine fibroids (UF) has been used for epidemiologic research in different environments. Given the dearth of studies on the epidemiology of UF in Sub-Saharan Africa (SSA), it is valuable to evaluate its performance as a potential tool for much needed research on this commonest neoplasm in SSA women. Method: We conducted a cross-sectional study of self-report of UF compared with trans-vaginal ultra-sound diagnosis (TVUS) among 486 women who are members of the African Collaborative Center for Microbiome and Genomics Research(ACCME) Study Cohort in central Nigeria. We used log-binomial regression models to compute the classification, sensitivity, specificity, and predictive values of self-report adjusted for significant covariates. Results: The prevalence of UF on TVUS was 45.1% (219/486) compared to 5.4% (26/486) based on self-report of abdominal ultrasound scan and 7.2% (35/486) based on report of healthcare practitioner’s diagnosis. Self-report correctly classified 39.5% of the women in multivariable adjusted models compared to TVUS. The multivariable adjusted sensitivity of self-report of healthcare worker diagnosis was 38.8%, specificity was 74.5%, PPV was 55.6%, and NPV was 59.8%. For self-report of abdominal ultrasound diagnosis, the multivariable adjusted sensitivity was 40.6%, specificity 75.3%, PPV was 57.4%, and NPV was 60.6%. Conclusion: Self-report significantly under-reports the prevalence of UF and it is not accurate enough for epidemiological research of UF. Future studies of UF should use population-based designs and more accurate diagnostic tools such as TVUS.
Development of the Bleeding and Pelvic Discomfort Scale for Use in Women With Heavy Menstrual Bleeding Associated With Uterine Fibroids
Article
Objectives This study aimed to define a cardinal symptom burden measure based on items from the Uterine Fibroid Symptom and Quality of Life questionnaire for use as a clinical trial endpoint. Methods Exploratory factor analysis was computed to assess the Uterine Fibroid Symptom and Quality of Life symptom severity scale factor structure, using phase 2 data. Pooled blinded data from phase 3 studies were used for the confirmatory factor analysis and the psychometric evaluation of the new measure. Exit interviews in 30 patients from phase 3 studies provided additional qualitative evidence. A meaningful change threshold was determined using anchor-based analyses supported by patient feedback in the exit interviews. Results Three factors emerged from the exploratory factor analysis. Factor 1, called the bleeding and pelvic discomfort (BPD) scale, consists of cardinal symptoms, measuring menstrual distress owing to heavy bleeding, passing blood clots, and feeling tightness or pressure in pelvic area. Patients generally understood the items in the scale and the recall period as intended. The BPD scale had good item performance and internal consistency reliability, strong item-to-total correlations, good item discrimination, known-groups validity, and ability to detect change. A 20-point change on the BPD scale was determined as the clinically meaningful change threshold. Conclusions The BPD scale assesses symptom burden owing to bleeding, passing blood clots, and pelvic pressure. The subscale is based on a subset of items selected to measure the cardinal symptoms of uterine fibroids in a clinical trial setting. The responder threshold evaluates whether patients experience a meaningful treatment benefit over the on-treatment period.
Relugolix Combination Therapy for Uterine Leiomyoma–Associated Pain in the LIBERTY Randomized Trials
Article
Objective: To assess the effect of once-daily relugolix combination therapy (relugolix-CT: relugolix 40 mg, estradiol 1 mg, and norethindrone acetate 0.5 mg) compared with placebo on moderate-to-severe pain in women with uterine leiomyomas and heavy menstrual bleeding. Methods: Two replicate, multinational, double-blind, 24-week, randomized, phase 3 studies (LIBERTY 1 and 2) were conducted in premenopausal women with uterine leiomyoma-associated heavy menstrual bleeding (80 mL or greater per cycle for two cycles or 160 mL or greater during one cycle). A predefined secondary objective was to determine the effect of relugolix-CT on moderate-to-severe uterine leiomyoma-associated pain in the pain subpopulation (women with maximum pain scores of 4 or higher on the 0-10 numerical rating scale at baseline, with pain score reporting compliance of 80% (ie, 28 days or more over the last 35 days of treatment). This key secondary endpoint was defined as the proportion of women achieving minimal-to-no uterine leiomyoma-associated pain (maximum numerical rating scale score 1 or lower) at week 24; menstrual and nonmenstrual pain were evaluated in prespecified secondary analyses. Treatment comparisons were performed in the pooled LIBERTY 1 and 2 pain subpopulation using the Cochran-Mantel-Haenszel test stratified by baseline menstrual blood loss volume. Results: Across both trials, 509 women were randomized to relugolix-CT or placebo (April 2017-December 2018). Of these, 277 (54.4%) met pain subpopulation requirements. With relugolix-CT, 45.2% (95% CI 36.4-54.3) of women achieved minimal-to-no pain compared with 13.9% (95% CI 8.8-20.5) with placebo (nominal P<.001). The proportions of women with minimal-to-no pain during menstrual days and during nonmenstrual days were significantly higher with relugolix-CT (65.0% [95% CI 55.6-73.5] and 44.6% [95% CI 32.3-57.5], respectively) compared with placebo (19.3% [95% CI 13.2-26.7], nominal P<.001, and 21.6% [95% CI 12.9-32.7], nominal P=.004, respectively). Conclusion: Over 24 weeks, relugolix-CT significantly reduced moderate-to-severe uterine leiomyoma-associated pain with a more pronounced effect on menstrual pain. These data support that relugolix-CT had clinically meaningful effects on women's experience of uterine leiomyoma-associated pain. Clinical trial registration: ClinicalTrials.gov: LIBERTY 1, NCT03049735; LIBERTY 2, NCT03103087. Funding source: Myovant Sciences GmbH.
Combined procedure of the transcervical radiofrequency ablation (TRFA) system and surgical hysteroscopy. Increased risk or safe procedure?
Article
Full-text available
Introduction: The advantage of transcervical radiofrequency ablation (TRFA) is that it is minimally invasive, incision-free, and treats a wide spectrum of fibroids, including those that are not accessible by surgical hysteroscopy (FIGO 3, 4, 5, 6, and 2-5). However, there are no publications describing a combined procedure of operative hysteroscopy and TRFA yet, so it was still unknown whether a combined procedure is associated with additional risks. Aim: To report the combined technique of transcervical intrauterine radiofrequency ablation of fibroids and surgical hysteroscopy. Material and methods: Our study was designed to show the results of our case series with 21 patients. The retrospective study included only patients who were treated with the combined procedure of surgical hysteroscopy with fibroid and/or endometrial resection and fibroid ablation using the Sonata System. Results: The combined procedure was performed without any complications in all cases. Two days after surgery, no increased morbidity was observed compared to only conventional surgical hysteroscopy and/or therapy with the TRFA. All patients were satisfied with the procedure. No late complications were observed within the first 6 months postoperatively. Seventeen patients with bleeding symptoms were asked about their subjective assessment of improvement. Fifteen patients reported significant improvement in symptoms and 1 patient reported only minimal improvement. Only 1 patient, who underwent TRFA and endometrial resection, did not report any improvement. No increase in symptoms was observed. Conclusions: Although TRFA is an approved method, it is not yet widely used worldwide. The combined procedure has been rarely used. The aim of our work is to show through our case series that transcervical radiofrequency ablation can be combined with surgical hysteroscopy for fibroid and/or endometrial resection without any additional risk.
Management of Uterine Fibroids
Chapter
  • Dec 2021
This authoritative textbook provides a much-needed guide for postgraduate trainees preparing for the European Board and College of Obstetrics and Gynaecology (EBCOG) Fellowship examination. Published in association with EBCOG, it fully addresses the competencies defined by the EBCOG curriculum and builds the clinical practice related to these competencies upon the basic science foundations. Volume 2 covers the depth and breadth of gynaecology, and draws on the specialist knowledge of four highly experienced Editors and over 100 contributors from across Europe, reflecting the high-quality training needed to ensure the safety and quality of healthcare for women. It incorporates key international guidelines throughout, along with colour diagrams and photographs for easy understanding. This is an invaluable resource, not only for postgraduate trainees planning to sit the EFOG examination, but also for practising specialists looking to update their knowledge and skills to meet the ever-evolving complexity of clinical practice.
Prevalence of uterine myomas in women in Germany: data of an epidemiological study
Article
Full-text available
Purpose: Currently, no reliable data are available concerning the prevalence of uterine myomas in Germany. In this prospective study, we examined the prevalence of myomas in women older than 30 years by means of vaginal ultrasound. Methods: 2296 women, who consented to the procedure, were examined by means of vaginal ultrasound for the presence of myomas in seven gynaecological outpatient departments in Germany. Results: Prevalence: myomas were detected in 41.6 % of all women. Age dependence: With increasing age, the prevalence of uterine myomas rose from 21.3 % (30-35 years) to 62.8 % (46-50 years). Later, the number of myomas decreased again from 56.1 % (51-55 years) to 29.4 % in women older than 55 years. Menarche/BMI: no correlation could be found between the age at first menstrual period or the body mass index and the occurrence of myomas. Parity: since the group of nulliparous women and the group of women with more than four deliveries stand out by increased occurrence of myomas, a non-linear correlation seems to exist, necessitating more in-depth discussion with regard to age dependency. Conclusions: The results of this study suggest that more than 40 % of women over 30 years of age suffered from myomas and more than 50 % of all women in Germany may develop uterine myomas at some time in their life.
Proceedings from the Third National Institutes of Health International Congress on Advances in Uterine Leiomyoma Research: comprehensive review, conference summary and future recommendations
Article
Full-text available
  • Apr 2014
BACKGROUND Uterine fibroids are the most common gynecologic tumors in women of reproductive age yet the etiology and pathogenesis of these lesions remain poorly understood. Age, African ancestry, nulliparity and obesity have been identified as predisposing factors for uterine fibroids. Symptomatic tumors can cause excessive uterine bleeding, bladder dysfunction and pelvic pain, as well as associated reproductive disorders such as infertility, miscarriage and other adverse pregnancy outcomes. Currently, there are limited noninvasive therapies for fibroids and no early intervention or prevention strategies are readily available. This review summarizes the advances in basic, applied and translational uterine fibroid research, in addition to current and proposed approaches to clinical management as presented at the ‘Advances in Uterine Leiomyoma Research: 3rd NIH International Congress’. Congress recommendations and a review of the fibroid literature are also reported.
Uterine fibroids: Current perspectives
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  • Jan 2014
Uterine fibroids are a major cause of morbidity in women of a reproductive age (and sometimes even after menopause). There are several factors that are attributed to underlie the development and incidence of these common tumors, but this further corroborates their relatively unknown etiology. The most likely presentation of fibroids is by their effect on the woman's menstrual cycle or pelvic pressure symptoms. Leiomyosarcoma is a very rare entity that should be suspected in postmenopausal women with fibroid growth (and no concurrent hormone replacement therapy). The gold standard diagnostic modality for uterine fibroids appears to be gray-scale ultrasonography, with magnetic resonance imaging being a close second option in complex clinical circumstances. The management of uterine fibroids can be approached medically, surgically, and even by minimal access techniques. The recent introduction of selective progesterone receptor modulators (SPRMs) and aromatase inhibitors has added more armamentarium to the medical options of treatment. Uterine artery embolization (UAE) has now been well-recognized as a uterine-sparing (fertility-preserving) method of treating fibroids. More recently, the introduction of ultrasound waves (MRgFUS) or radiofrequency (VizAblate™ and Acessa™) for uterine fibroid ablation has added to the options of minimal access treatment. More definite surgery in the form of myomectomy or hysterectomy can be performed via the minimal access or open route methods. Our article seeks to review the already established information on uterine fibroids with added emphasis on contemporary knowledge.
Genitourinary symptoms and their effects on quality of life in women with uterine myomas
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This study was designed to determine the presence of genitourinary symptoms and their effects on quality of life (QOL) in women with uterine myomas. A total of 145 women with ultrasonography (US) diagnosis of anterior myoma were divided into two groups according to myoma size: (1) those ≤5 cm (n = 75), and (2) those >5 cm (n = 70). The control group comprised previously matched 94 women with a normal-appearing uterus on US. Study participants answered the Urogenital Distress Inventory (UDI-6) and the Incontinence Impact Questionnaire (IIQ-7). Pelvic examination was performed, and urinary symptoms were recorded. The chi-square test and Fischer's exact test were used to compare qualitative data. The Kruskal-Wallis test and Dunn's test were used to compare groups. Statistical significance was set at P <0.05. The frequency of genitourinary symptoms was significantly higher in women with myomas, including stress urinary incontinence (SUI), urgency, frequency, urge urinary incontinence (UUI), and dyspareunia. SUI and mixed urinary incontinence (MUI) were the most common symptoms associated with myoma size. Total UDI-6 scores were significantly higher in women with myomas than in control patients (P < 0.0001). UDI scores associated with UI and obstructive symptoms were higher in women with myomas >5 cm than in other women. IIQ scores regarding physical activity, travel, and emotional health were significantly higher in women with myomas >5 cm than in other women (P < 0.001). Urinary tract dysfunction is associated with anterior myomas, increasing in association with myoma size, and significantly affects QOL.
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Full-text available
  • May 2013
Gegenwärtig gehört die Entfernung der Gebärmutter in vielen Ländern zu den häufigsten gynäkologischen Eingriffen. Ziel der vorliegenden Auswertung ist es, die Prävalenz der Hysterektomie in Deutschland nach soziodemografischen Faktoren und möglichen gesundheitlichen Einflussfaktoren zu analysieren. Basis sind die im Rahmen der „Studie zur Gesundheit Erwachsener in Deutschland“ (DEGS1) erhobenen Daten des Gesundheitsmonitorings des Robert Koch-Instituts (RKI). Insgesamt wurde bei 17,5% (n = 689) der befragten Frauen (Alter: 18 bis 79 Jahre) eine Gebärmutterentfernung durchgeführt. Bei den meisten Frauen (49,1%) fand diese im Alter von 40 bis 49 Jahren statt. Von 6,1% der hysterektomierten Frauen wurde eine Krebserkrankung der Gebärmutter oder der Eierstöcke angegeben. Bei 19,7% der Frauen mit Hysterektomie wurde gleichzeitig eine Eierstockentfernung durchgeführt. Signifikante Unterschiede in den Prävalenzen für eine Hysterektomie zeigen sich mit Blick auf den Sozialstatus, den Wohnort im Jahr 1988, die Anzahl der Lebendgeburten und das Körpergewicht. DEGS1 ist die erste Studie, in der deutschlandweit und bevölkerungsrepräsentativ die Prävalenz der Gebärmutterentfernung erhoben wird. Weitere vertiefende Analysen – auch mit den DEGS-Daten – sind notwendig, um die Bedeutung der einzelnen Einflussfaktoren genauer untersuchen und Trendabschätzungen vornehmen zu können.
A 41-Year-Old Woman With Menorrhagia, Anemia, and Fibroids Review of Treatment of Uterine Fibroids
Article
  • Jan 2009
Uterine fibroids are common tumors that can cause heavy menstrual bleeding, pelvic pressure symptoms, and reproductive disorders. The incidence of fibroids peaks in the fifth decade of age and they are more common in African American women. Often, fibroids are asymptomatic and require no treatment. However, the case of Ms P, a 41-year-old woman with recurrent uterine fibroids, menorrhagia, anemia, and fatigue who wishes to retain fertility, illustrates the symptoms that require treatment. Evaluation usually begins with a pelvic examination and an ultrasound to determine both the size and location of the fibroids within the uterus. Standard treatment of symptomatic fibroids is surgical removal by myomectomy or hysterectomy, depending in part on the desire for future fertility; new treatment options include uterine artery embolization via interventional radiologic techniques as well as various medical interventions. Several new therapies show promise but are still experimental at this time. The evidence for treatment options for Ms P and symptomatic patients with fibroids in general is discussed.
Prevalence, morbidity, and current medical management of uterine leiomyomas
Article
Uterine leiomyoma is the most common pelvic tumor in women, but the actual prevalence is unknown. To review the literature on the prevalence of uterine leiomyoma, presenting symptoms, and medical management. 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." 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. Prevalence rates were recorded on the basis of imaging modality, cohort studied, ethnic origin, and age. 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. Further research needs to be conducted on the prevalence in asymptomatic women. Current and future medical management options provide promising results in symptom reduction. Copyright © 2015. Published by Elsevier Ireland Ltd.
Epidemiological and genetic clues for molecular mechanisms involved in uterine leiomyoma development and growth
Article
BACKGROUND Uterine leiomyomas (fibroids) are highly prevalent benign smooth muscle tumors of the uterus. In the USA, the lifetime risk for women developing uterine leiomyomas is estimated as up to 75%. Except for hysterectomy, most therapies or treatments often provide only partial or temporary relief and are not successful in every patient. There is a clear racial disparity in the disease; African-American women are estimated to be three times more likely to develop uterine leiomyomas and generally develop more severe symptoms. There is also familial clustering between first-degree relatives and twins, and multiple inherited syndromes in which fibroid development occurs. Leiomyomas have been described as clonal and hormonally regulated, but despite the healthcare burden imposed by the disease, the etiology of uterine leiomyomas remains largely unknown. The mechanisms involved in their growth are also essentially unknown, which has contributed to the slow progress in development of effective treatment options.
Pictorial blood loss assessment chart for quantification of menstrual blood loss: a systematic review
Article
To evaluate the diagnostic accuracy of pictorial blood loss assessment chart (PBLAC) compared to objective measurements of menstrual blood loss (MBL), a systematic search of MEDLINE, EMBASE, Cumulative Index to Nursing & Allied Health Literature (CINAHL), Web of Science, and EBM Reviews-Cochrane Central Register of Controlled Trials from inception until September 30, 2014 was performed. Terms referring to “pictorial blood loss assessment chart,” “menstrual blood loss evaluation,” and “alkaline hematin” were used. The ability of PBLAC to predict significant blood loss, compared to alkaline hematin as a standard objective method, represents our primary outcome. Out of 255 reports identified by the primary search, seven reports were included in the review. Quality of these reports was assessed. Compared to alkaline hematin, PBLAC sensitivity and specificity ranged from 58 to 98 % and 7.5 to 97 %, respectively, with likelihood ratios (LR) for positive ranging from 1.1 to 7.8 and LR for negative tests ranging from 0.04 to 0.48. Diagnostic odds ratio ranged from 2.6 to 86.9. Although diagnostic testing was not always supportive in terms of sensitivity, specificity, and LRs, most studies support the use of PBLAC as a semi-objective method that can be implemented in research and clinical practice.
Effect of fibroids not distorting the endometrial cavity on the outcome of in vitro fertilization treatment: A retrospective cohort study
Article
  • Jan 2014
To investigate the effect of fibroids that do not distort the endometrial cavity on IVF/intracytoplasmic sperm injection (ICSI) outcomes and to identify certain fibroid subgroups that may be deleterious to fertility outcomes. Retrospective cohort study. University-based reproductive medicine center. A total of 10,268 patients undergoing IVF/ICSI between 2009 and 2011 in our unit. Transvaginal ultrasound and hysteroscopy; controlled ovarian hyperstimulation and IVF/ICSI; strict matching criteria. Cycle cancellation, clinical pregnancy, miscarriage, and delivery rates. We included 249 patients with fibroids who underwent IVF/ICSI. Higher day 3 FSH levels were found in women with fibroids compared with in control subjects. No significant differences were found in IVF/ICSI outcomes between the two groups. Patients with intramural fibroids with the largest diameter <2.85 cm or the sum of reported diameters <2.95 cm had a significantly higher delivery rate than patients with larger fibroids. A significant negative effect on delivery rate was noted when intramural fibroids with the largest diameter greater than 2.85 cm were considered, compared with matched controls without fibroids. Our results suggest that although non-cavity-distorting fibroids do not affect IVF/ICSI outcomes, intramural fibroids greater than 2.85 cm in size significantly impair the delivery rate of patients undergoing IVF/ICSI.