MyomaS Aspect Transformation at Ultrasound During Relugolix Estradiol Noretisterone Treatment: MySaturn Study
Conditions: Uterine Bleeding, Uterine Leiomyomas, Uterine Hemorrhage, Uterine Neoplasms
Sponsor: Fondazione Policlinico Universitario Agostino Gemelli IRCCS

 
 
 
 
Fondazione Policlinico Universitario Agostino Gemelli IRCCS 
Università Cattolica del Sacro Cuore 
 
Protocol MySaturn V.1.0 of December, 6th, 2024 
 
 
 
     Pag. 1 | 11 
 
 
STUDY PROTOCOL 
 
TITLE 
 
MyomaS Aspect Transformation at Ultrasound during Relugolix Estradiol Noretisterone 
treatment: MySaturn study. 
 
 
ACRONYM: MySaturn 
 
 
Principal Investigator (PI): Dott.ssa Daniela Romualdi 
 
 
Sub-Investigators: Dott.ssa Giulia Zinicola, Dott.ssa Francesca Ciccarone 
 
 
Scientific supervisors: Prof. Giovanni Scambia; Dr Antonia Carla Testa 
 
 
 
 
 
 
 
 
Sponsor: Fondazione Policlinico Universitario A. Gemelli, IRCCS 
L.go Francesco Vito 1, 00168 Roma 
 
 
Funding: No Profit, no-coufunding 
 
Version: 1.0 
 
Date: December, 6th, 2024 
 
 

 
 
 
 
Fondazione Policlinico Universitario Agostino Gemelli IRCCS 
Università Cattolica del Sacro Cuore 
 
Protocol MySaturn V.1.0 of December, 6th, 2024 
 
 
 
     Pag. 2 | 11 
 
Background and rationale 
 
Background 
Uterine fibroids (myomas) are benign tumors that develop from the smooth muscular tissue of the 
uterus. The prevalence of uterine fibroids rises with age, affecting up to 70% of women in their fifth-
sixth decades. Risk factors are represented by African ethnicity, nulliparity, obesity, and diabetes. 
Although many fibroids remain clinically silent, approximately 25-50% of women develop 
significant symptoms. The clinical presentation may include one or more of the following symptoms: 
menorrhagia/metrorrhagia, chronic pelvic pain, dysmenorrhea, and “bulky” symptoms. The number, 
size and location of the fibroids determine the severity of symptoms, which may lead to severe 
impairment of quality-life and cause risks in terms of general and reproductive health [1].  
Myometrial lesions are non-cancerous neoplasms in almost all cases. Actually, the prevalence of 
unexpected sarcoma in women undergoing surgery for a myometrial lesion ranges from 1/2000 to 
1/350. Preoperative diagnosis of malignant mesenchymal tumors of the uterus (Mesenchymal Uterine 
Malignancies, MUMs) remains a significant challenge. Our group recently identified and validated a 
diagnostic algorithm based on women’s clinical characteristics and specific ultrasound parameters, 
which showed high accuracy in evaluating suspicious myometrial lesions [2]. Although ultrasound is 
the first-level diagnostic tool to evaluate women with myometrial lesions, data on ultrasound features 
of MUMs are mainly based on retrospective case series. Similarly, accurate diagnostic criteria able 
to discriminate between benign and malignant lesions have never been prospectively validated with 
magnetic resonance imaging (MRI) [2]. 
Recently the MUSA (Morphological Uterus Sonographic Assessment) consensus statement proposed 
the terms, definitions and measurements that may be used to describe and report the sonographic 
features of the myometrium. Myometrial pathology may be localized (one or more lesions) or diffuse 
(when > 50 % of the myometrium is involved). Each identified lesion should be described according 
to its location, size and site. The minimum distance from the lesion to the endometrium (inner lesion-
free margin) and to the serosal surface (outer lesion-free margin) of the uterus should be reported [2-
3].  
A uterine fibroid typically appears on ultrasound as a well-defined round lesion within the 
myometrium or attached to it, with variable echogenicity, often showing shadows at the edge of the 
lesion and/or internal fan-shaped shadowing. On color- or power-Doppler imaging, circumferential 
flow around the lesion is often visible [2-3]. Vascularization is typically low to moderate on color 
Doppler (color score 2-3).  Conversely, irregular margins, cystic areas, heterogeneous echotexture, 
and increased vascularization are some of the characteristics suggestive for atypical or suspicious 
myometrial lesion [2]. 
Stratifying patients based on the risk of malignancy is crucial for deciding subsequent therapeutic 
approaches. Currently, a wide range of treatments (pharmacological, surgical, interventional 
radiology) is available for women with myometrial lesions. Decision-making should be guided not 
only by the risk of malignancy but also by the type of symptoms, the severity of the clinical condition, 
age, and reproductive desires. 
In premenopausal women, when abnormal uterine bleeding is the predominant symptom, one of the 
most effective options is the combination therapy of relugolix (an oral GnRH receptor antagonist), 
estradiol, and norethisterone (Ryeqo®). This combination aims at suppressing the hypothalamic-
pituitary-ovarian axis to induce amenorrhea while providing a minimal hormonal supply in order to 
prevent the effects of complete estrogen deprivation (vasomotor symptoms, vulvovaginal atrophy, 
bone mass reduction). 

 
Protocol MySaturn V.1.0 of December 6th, 2024  
 
 
 
     Pag. 3 | 11 
 
Previous clinical studies on this drug have focused on its efficacy in reducing menstrual blood loss 
and alleviating pain symptoms in women with symptomatic fibroids. In particular, phase III studies 
reported that over 70% of patients treated with this drug experience a reduction in menstrual bleeding 
within the first 24 weeks of therapy. Furthermore, the safety profile of the relugolix-estradiol-
norethisterone combination appears favorable, with a low risk of severe adverse events and good 
long-term tolerability [4][5][6]. 
Currently, the effects of this treatment on fibroid size, uterine volume, and, most importantly, on the 
ultrasound features remain unclear. 
 
Rationale 
Based on the critical role of ultrasound evaluation in the diagnostic and therapeutic management of 
women with myometrial formations, the aim of this study is to analyze potential changes in ultrasound 
parameters during treatment with relugolix/estradiol/norethisterone. Specifically, the study aims at 
determining whether this pharmacological therapy can induce changes in myometrial formations that 
could impact patient stratification during the oncological risk assessment. 
 

 
 
 
 
Fondazione Policlinico Universitario Agostino Gemelli IRCCS 
Università Cattolica del Sacro Cuore 
 
Protocol MySaturn V.1.0 of December, 6th, 2024 
 
 
 
     Pag. 4 | 11 
 
OBJECTIVES 
 
Primary Objective 
To 
observe 
the 
ultrasound 
features 
of 
myometrial 
lesions 
during 
treatment 
with 
relugolix/estradiol/norethisterone at baseline, and after 3 months, 6 months, and 12 months from 
treatment initiation, and to identify any change over time. 
 
Secondary Objectives 
To observe during treatment with relugolix/estradiol/norethisterone, the effect on symptoms (e.g., 
abnormal uterine bleeding, pelvic discomfort, urinary disorders, dyschezia, dyspareunia, chronic 
pelvic pain and to record any adverse effect of the drug. 
 

 
 
 
 
Fondazione Policlinico Universitario Agostino Gemelli IRCCS 
Università Cattolica del Sacro Cuore 
 
Protocol MySaturn V.1.0 of December, 6th, 2024 
 
 
 
     Pag. 5 | 11 
 
METHODS 
 
Study design 
Monocentric, observational study, ambispective study  
 
Target Population  
Patients with ultrasound diagnosis of uterine fibroids, symptomatic for abnormal uterine bleeding, 
eligible for oral medical therapy with relugolix/estradiol/norethisterone. The retrospective cohort 
will be included starting from July 1st 2023.  
 
Study duration 
3 years (2 years for enrollment and 1 year for follow-up) 
 

 
 
 
 
Fondazione Policlinico Universitario Agostino Gemelli IRCCS 
Università Cattolica del Sacro Cuore 
 
Protocol MySaturn V.1.0 of December, 6th, 2024 
 
 
 
     Pag. 6 | 11 
 
Inclusion criteria 
1. Age ≥ 18 years. 
2. Pre-menopausal status. 
3. Ultrasound diagnosis of benign myometrial lesion. 
4. Symptomatic patients presenting with abnormal uterine bleeding (menorrhagia/metrorrhagia). 
5. Availability of ultrasound images in digital format. 
6. Signature of Informed Consent 
 
 
It is Specified that patients with a clinical indication for surgery may be included in the study if 
symptomatic for abnormal uterine bleeding. 
  
 
Exclusion criteria 
 
1. Age < 18 years. 
2. Postmenopausal women. 
3. Myometrial lesion ≤ 10 mm. 
4. Myometrial formation suspected of malignancy on ultrasound (e.g., STUMP – Uterine 
Leiomyosarcoma). 
5. Asymptomatic patients with uterine fibromatosis. 
6. Personal history of malignant or premalignant uterine neoplasia (e.g., STUMPs, 
leiomyosarcoma, atypical endometrial hyperplasia, endometrial carcinoma, cervical 
carcinoma). 
7. Patients with ovarian pathology. 
8. Patients currently undergoing treatment for another malignancy. 
9. Patients lacking available digital ultrasound images or whose image quality is insufficient to 
adequately characterize the target lesion’s ultrasound features. 
 
Suspicious myometrial lesions are defined based on clinical experience and according to the criteria 
established by the Mylunar study (2). 
 

 
 
 
 
Fondazione Policlinico Universitario Agostino Gemelli IRCCS 
Università Cattolica del Sacro Cuore 
 
Protocol MySaturn V.1.0 of December, 6th, 2024 
 
 
 
     Pag. 7 | 11 
 
Variables and procedures  
  
All women enrolled in the study will sign an informed consent form.  
Patients retrospectively identified from the institutional registry may be included in the protocol if 
clinical data and ultrasound examinations are available, prior written consent. Recorded data will be 
retrieved from the examinations at baseline (before treatment) and 3 months, 6 months, and 12 
months after treatment initiation.  
Patients enrolled prospectively will be managed according to the activities and procedures depicted 
in Table 1. Clinical and ultrasound data will be recorded at baseline (before treatment) and 3 months, 
6 months, and 12 months after treatment initiation.  
Study data will be collected according to a dedicated eCRF that includes clinical, ultrasound, and 
pathological information (Appendix 1 MySaturn study).  
The eCRF will be implemented using RED Cap platform (ref: https://projectredcap.org)  
Study data will be collected and managed using REDCap electronic data capture tools hosted at  
Fondazione Policlinico Universitario А. Gemelli, IRCCS (https://redcap-irccs.policlinicogemelli.it/). 
REDCap (Research Electronic Data Capture) is a secure, web-based application designed to support 
data capture for research studies, providing 1) an intuitive interface for validated data entry; 2) audit 
trails for tracking data manipulation and export procedures; 3) automated export procedures for 
seamless data downloads to common statistical packages; and 4) procedures for importing data from 
external sources. People officially registered as study investigators or data managers will receive a 
user login to access the REDCap web platform and enter/manage data.  
 
 

 
 
 
 
Fondazione Policlinico Universitario Agostino Gemelli IRCCS 
Università Cattolica del Sacro Cuore 
 
Protocol MySaturn V.1.0 of December, 6th, 2024 
 
 
 
     Pag. 8 | 11 
 
ENDPOINTS  
 
Primary endpoint  
Modifications in the volume of the index myometrial lesion during treatment with 
relugolix/estradiol/norethisterone; 
 
Secondary endpoints (referred to the primary objectives) 
 
Description of the ultrasound characteristics of the fibroids in the study population during treatment 
with relugolix/estradiol/norethisterone. 
Based on current literature, the following features have been preselected for analysis: 
 
 
• 
Max diameter of the index myometrial lesion 
•          Uterine volume 
 
• 
Outer contour: regular or irregular; 
 
• 
Echogenicity of the myometrial formation: mixed or homogeneous; 
 
• 
Presence of cystic areas; 
 
• 
Presence of acoustic shadows; 
 
• 
Vascularization of the lesions, expressed on a 1 to 4 ordinal scale; 
 
• 
“Cooked aspect.” 
 
Volume of the index myometrial lesion is considered the primary endpoint of this study and the other 
features as key secondary endpoints.  
 
Secondary endpoints (referred to the secondary objectives) 
 
Description of the clinical characteristics of the study population during treatment with 
relugolix/estradiol/norethisterone. The following clinical variables will be recorded: 
 
           •        Effect on abnormal uterine bleeding, measured as the number of sanitary pads used 
during the cycle in patients who do not develop amenorrhea; 
 
• 
Hemoglobin, serum iron, and ferritin levels at baseline, 3, 6, and 12 months; 
 
• 
Dyspareunia, assessed using NRS or VAS scales; 
 
• 
Chronic pelvic pain, assessed using NRS or VAS scales; 
 
• 
Compression-related symptoms; 
 
• 
Pollakiuria and dyschezia; 
 
• 
Dyspareunia; 
 
 
 
 
 

 
 
 
 
Fondazione Policlinico Universitario Agostino Gemelli IRCCS 
Università Cattolica del Sacro Cuore 
 
Protocol MySaturn V.1.0 of December, 6th, 2024 
 
 
 
     Pag. 9 | 11 
 
STATISTICAL ANALYSIS PLAN 
 
Sample size calculation 
 
Using a repeated measurements analysis of variance model for the primary endpoint with 4 time-
points, a sample size of 111 patients will have a power=80% at a significance level of 5% to detect 
small effect size in term of f (f=0.10) assuming a correlation among repeated measures of 0.6. 
 
Statistical analysis 
 
Descriptive analyses of patients’ characteristics will be provided.   For continuous variables, the mean 
and standard deviation (SD) or the median and interquartile range (IQR) will be calculated as 
appropriate. The normality assumption about the distribution of continuous variables will be tested 
using the Kolmogorov-Smirnov test. Categorical variables will be summarized with frequencies 
absolute counts and percentages. Repeated measures ANOVA will be implemented to assess 
temporal trend in quantitative variables while dichotomous items will be analyzed using a mixed-
effect generalized linear model. All statistical analysis will be performed using R software (www.r-
project.org). 
 
 
SAFETY                                                                                                                                                                     
Definitions                                                                                                                                                                 
Adverse event: any untoward medical occurrence in a patient administered a medicinal product and 
which does not necessarily have to have a causal relationship with this treatment.                   
Adverse reaction: a response to a medicinal product which is noxious and unintended. Adverse 
reactions may arise from use of the product within or outside the terms of the marketing authorisation 
or from occupational exposure. Use outside the marketing authorisation includes off-label use, 
overdose, misuse, abuse and medication errors. 
Serious adverse reaction: any untoward medical occurrence that at any dose results in death, is life-
threatening, requires inpatient hospitalisation or prolongation of existing hospitalisation, results in 
persistent or significant disability or incapacity, or is a congenital anomaly/birth defect or represents 
a new important medical event.                                                                                                                                  
 
Regulatory management of adverse events                                                                                                              
Any adverse event will be collected, recorded and assessed for seriousness and relatedness with 
study drug(s) or any other medicinal products in use, in order to identify suspected adverse 
reactions (ADRs). 
All ADRs, regardless of the seriousness and expectedness, will be reported to National Competent 
Authority - AIFA, via the National Pharmacovigilance Network through the figure of Local 
Pharmacovigilance Responsible, as requested by the applicable law for the post-marketing 
pharmacovigilance activities (DM 30.04.2015 and GVP, module VI) and to the EC per local 
applicable rules. For the retrospective study with secondary analysis of clinical data, there is no 
further need of ADR reporting to national Competent Authority - AIFA, since all the reporting 
obligations have been fulfilled at the time of ADR presentation (DM 30.04.2015 and GVP module 
VI, section C 1.2.1.2.). 
 

 
Protocol MySaturn V.1.0 of December 6th, 2024  
 
 
 
     Pag. 10 | 11 
 
 
 
ETHICAL CONSIDERATIONS 
 
Prior to initiation of a study site, the Sponsor will obtain approval from Ethics Committee to 
conduct the study in accordance with regulatory requirements. The study will be conducted in 
accordance with Good Clinical Practice (GCP), all applicable subject privacy requirements, and the 
guiding principles of the declaration of Helsinki. 
 
Informed Consent  
Patients eligible for this study will be required to sign the Informed Consent Form in the context of 
a follow-up outpatient visit in which a study collaborator should be present. It will also be necessary 
to be able to use the data of patients who did not give Informed Consent because they are deceased, 
as failure to include this population would reduce the sample size producing negative consequences 
for the study in terms of significance of the results.  
A copy of the written consent signed by the patient will be kept by the center in the appropriate 
section of the trial site file.  
 
 
Confidentiality 
 
Information about study participants will be kept confidential and managed under the applicable 
laws and regulations. 
The investigator must ensure pseudonymized of the patients. Patients must not be identified by 
names in any documents submitted to the study promoter. Patient enrolment log must be kept strictly 
confidential to enable patient identification at the site 
The investigator/institution should take measures to prevent accidental or premature destruction of 
these documents. Essential documents should be retained for a period of not less than seven years 
from the completion of the Clinical Trial. 
 
 
Sponsorship and financing  
 
The study is spontaneous, not sponsored by pharmaceutical companies.  
 
Insurance  
 
Given the observational nature of the study, no insurance policy will be necessary. 
 
 

 
 
 
 
Fondazione Policlinico Universitario Agostino Gemelli IRCCS 
Università Cattolica del Sacro Cuore 
 
Protocol MySaturn V.1.0 of December, 6th, 2024 
 
 
 
     Pag. 11 | 11 
 
References 
1. Stewart EA, et al. Uterine fibroids. Lancet. 2022; 400(10352):1341-1351.  
2. Ciccarone F, Biscione A, Robba E, et al. A clinical ultrasound algorithm to identify uterine 
sarcoma and smooth muscle tumors of uncertain malignant potential in patients with 
myometrial lesions: the MYometrial Lesion UltrasouNd And mRi study. Am J Obstet 
Gynecol 2024;XXX:XXeXX.  
3. Van den Bosch T, Dueholm M, Leone FP, Valentin L, Rasmussen CK, Votino A, Van 
Schoubroeck D, Landolfo C, Installé AJ, Guerriero S, Exacoustos C, Gordts S, Benacerraf B, 
D'Hooghe T, De Moor B, Brölmann H, Goldstein S, Epstein E, Bourne T, Timmerman D. 
Terms, definitions and measurements to describe sonographic features of myometrium and 
uterine masses: a consensus opinion from the Morphological Uterus Sonographic Assessment 
(MUSA) 
group. 
Ultrasound 
Obstet 
Gynecol. 
2015 
Sep;46(3):284-98. 
doi: 
10.1002/uog.14806. Epub 2015 Aug 10. PMID: 25652685. 
4. Maria Syl D. De La Cruz, MD, and Edward M. Buchanan, MD. Uterine Fibroids: Diagnosis 
and Treatment. Am Fam Physician. 2017;95(2):100-107  
5. Al-Hendy A, Lukes AS, Poindexter AN 3rd, Venturella R, Villarroel C, Critchley HOD, Li 
Y, McKain L, Arjona Ferreira JC, Langenberg AGM, Wagman RB, Stewart EA. Treatment 
of Uterine Fibroid Symptoms with Relugolix Combination Therapy. N Engl J Med. 2021 Feb 
18;384(7):630-642. 
doi: 
10.1056/NEJMoa2008283. 
PMID: 
33596357; 
PMCID: 
PMC8262231.  
6. Al-Hendy A, Lukes AS, Poindexter AN 3rd, Venturella R, Villarroel C, McKain L, Li Y, 
Wagman RB, Stewart EA. Long-term Relugolix Combination Therapy for Symptomatic 
Uterine 
Leiomyomas. 
Obstet 
Gynecol. 
2022 
Dec 
1;140(6):920-930. 
doi: 
10.1097/AOG.0000000000004988. Epub 2022 Nov 2. PMID: 36357960; PMCID: 
PMC9665945.  
7. Al-Hendy A, Venturella R, Arjona Ferreira JC, Li Y, Soulban G, Wagman RB, Lukes AS. 
LIBERTY randomized withdrawal study: relugolix combination therapy for heavy menstrual 
bleeding associated with uterine fibroids. Am J Obstet Gynecol. 2023 Dec;229(6):662.e1-
662.e25. doi: 10.1016/j.ajog.2023.08.030. Epub 2023 Sep 2. PMID: 37666383. 
8. Education and Practical Standards Committee, European Federation of Societies for 
Ultrasound in Medicine and Biology Minimum training recommendations for the practice of 
medical ultrasound. Ultraschall Med, 27 (2006), pp. 79-105