Stewart, E A

Uterine fibroids (leiomyomas) are present in >75% of women and can cause serious morbidity. They are by far the leading cause of hysterectomy. Fibroids are a complex mixture of cells that include fibroblasts and smooth muscle cells. Rich in extracellular matrix, they typically arise through somatic mutations, most commonly MED12. Their lack of growth inhibition and their ability to have facets of malignancy yet be histologically and biologically benign provide opportunities to explore basic processes. To date, the mechanisms responsible for growth and development of leiomyomas are an enigma. This review provides an overview of current understanding and future directions for clinical and basic research of fibroids.

ObjectivesTo report patterns and patient characteristics associated with initiation of and persistence with medical therapies for uterine fibroid‐related heavy menstrual bleeding.DesignRetrospective cohort study.SettingUS commercial insurance claims database.Population41 561 women aged 18–54 years with uterine fibroids and heavy menstrual bleeding who initiated medical therapies from January 2000 through December 2013.MethodMultinomial logistic regression was used to assess patient characteristics associated with initiation and persistence. Cox proportional hazards regression was used on propensity score‐matched cohorts to examine change from index medication.Main outcomes measuresInitiation of and persistence with four first‐line medical therapies: short‐ and long‐acting reversible contraceptive steroids, leuprolide acetate, and tranexamic acid.ResultsMost women (79.4%) took short‐acting reversible contraceptive steroids as first‐line therapy (index medication), whereas 9.5%, 8.5%, and 2.7% used long‐acting reversible contraceptive steroids, leuprolide acetate, and tranexamic acid, respectively. During follow‐up, 16 594 women (39.9%) switched to nonindex medication (18.4%) or procedural treatment (81.6%). In comparison with women taking short‐acting steroids, those receiving long‐acting steroids were less likely to switch [hazard ratio (HR) 0.84, 95% CI 0.79–0.91], whereas women taking leuprolide acetate (HR 2.44, 95% CI 2.27–2.62) or tranexamic acid (HR 1.44, 95% CI 1.26–1.65) were more likely to switch. Older age, emergency department visits, anaemia, and inflammatory disease diagnoses at baseline were associated with increased probability of discontinuing the index medication or switching to another therapy.ConclusionsWomen with uterine fibroid‐related heavy menstrual bleeding were more likely to persist with their initial therapy of long‐acting reversible contraceptive steroid compared with other medical options.Tweetable Abstract80% women with fibroid‐related heavy menstrual bleeding use SARC, but LARC users are more persistent.

Objective:To evaluate the cost–effectiveness of the following three treatments of uterine fibroids in a population of premenopausal women who wish to preserve their uteri: myomectomy, magnetic resonance-guided focused ultrasound (MRgFUS) and uterine artery embolization (UAE).Materials & methods:A decision analytic Markov model was constructed. Cost–effectiveness was calculated in terms of US$ per quality-adjusted life year (QALY) over 5 years. Two types of costs were calculated: direct costs only, and the sum of direct and indirect (productivity) costs. Women in the hypothetical cohort were assessed for treatment type eligibility, were treated based on eligibility, and experienced adequate or inadequate symptom relief. Additional treatment (myomectomy) occurred for inadequate symptom relief or recurrence. Sensitivity analysis was conducted to evaluate uncertainty in the model parameters.Results: In the base case, myomectomy, MRgFUS and UAE had the following combinations of mean cost and mean QALYs, respectively: US$15,459, 3.957; US$15,274, 3.953; and US$18,653, 3.943. When incorporating productivity costs, MRgFUS incurred a mean cost of US$21,232; myomectomy US$22,599; and UAE US$22,819. Using probabilistic sensitivity analysis (PSA) and excluding productivity costs, myomectomy was cost effective at almost every decision threshold. Using PSA and incorporating productivity costs, myomectomy was cost effective at decision thresholds above US$105,000/QALY; MRgFUS was cost effective between US$30,000 and US$105,000/QALY; and UAE was cost effective below US$30,000/QALY.Conclusion:Myomectomy, MRgFUS, and UAE were similarly effective in terms of QALYs gained. Depending on assumptions about costs and willingness to pay for additional QALYs, all three treatments can be deemed cost effective in a 5-year time frame.