Medical Management of leipmyomas-emphasis for different geographical regions

Abstract

Leiomyomas are the common benign tumours of uterus. Surgery is the most common mode of treatment of symptomatic fibroids. With the advent of minimally invasive interventional procedures like uterine artery embolization (UAE), and focused ultrasound on MRI we got some lesser invasive techniques, although they have drawbacks regarding ovarian reserve etc for patients desiring fertility. Initially GnRH agonists like leuprolide acetate were the most effective medical agents introduced, but their drawback was bone density demineralization, hot flushes on long term use besides cost. Selective progesterone receptor modulators gradually got introduced with initial trials with mifepristone (RU486), followed by asoprisnil, ulipristalacetate. Since mifepristone had antiglucocorticoid and androgen receptor activity it was not approved by FDA for license, while four PEARL trials have got completed for UPA acetate 5&10mg regarding safety and efficacy and intermittent therapy with 5mg got FDA approval in Europe and Canada before surgery. Further trials indicated it may be the future drug of choice for patients desiring fertility for long term intermittent therapy and possibly avoiding surgery and its complications like adhesions, uterine scar and risk for rupture during pregnancy. However in countries where uripristal is not available still one is forced to use mifepristone. Detailed mechanism of all these drugs is discussed and a case report of a young unmarried girl with high BMI is reported where mifepristone intermittent was effective not only in relieving patients symptoms but effective in decreasing uterine and fibroid volume which highlights how in such young cases one can preserve future fertility without putting them at risk of surgery and sometimes myomectomy complications ending in hysterectomy.

Vitamin D-A Possible Natural Origin Agent for Medical Treatment of Uterine Leiomyomas in View of Safety, Cost Effectiveness Over SPRM’s-A Short Communication

“…Moreover, since UL's are derived from monoclonal stem cells, genome wide analysis of Vitamin D's effect is needed. Earlier we reviewed the different approaches for medical management of fibroids [11], instead of the surgical or radiologic management which are not desired by the patient specially if she wants preservation of fertility in future. Hormonal therapies are designed to blunt the growth stimulatory actions of E and P on UL growth like selective progesterone receptor modulators (SPRM) which are approved for a short time in view of complications like progesterone associated endometrial changes (PAEC) on long term use.…”

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“…Moreover, since UL's are derived from monoclonal stem cells, genome wide analysis of Vitamin D's effect is needed. Earlier we reviewed the different approaches for medical management of fibroids [11], instead of the surgical or radiologic management which are not desired by the patient specially if she wants preservation of fertility in future. Hormonal therapies are designed to blunt the growth stimulatory actions of E and P on UL growth like selective progesterone receptor modulators (SPRM) which are approved for a short time in view of complications like progesterone associated endometrial changes (PAEC) on long term use.…”

An Update on Pathophysiology and Medical Management of Endometriosis

“…SPRM's are defined as the class of progesterone receptor (PR) ligands which exhibit both agonistic and antagonistic [104], reviewed in detail for treatment of uterine fibroids]. Although results of studies of PRM in women are promising [105] [106], they are not used routinely as they interfere with reproduction and hence are not desirous for women desiring immediate fertility.…”