EXECUTIVE SUMMARY
Women who have high levels of both testosterone and estrogen in midlife might face a greater risk of developing benign uterine fibroids than women with low levels of the hormones, results of a new study indicate.
- Many women develop uterine fibroid tumors (leiomyomas) as they grow older. Research data indicate the prevalence of ultrasound-identified tumors as 33% in women 40 to 60 years of age, compared to 11-18% in women ages 30-40, and 4% in women ages 20-30.
- The presence of uterine fibroid tumors is the most common indication cited for hysterectomy and represents more than 30% of such procedures. Treatment options include watchful waiting; treatment with drugs or hormones, embolization, or ultrasound thermal ablation; and invasive procedures such as partial or total hysterectomy.
Women who have high levels of both testosterone and estrogen in midlife might face a greater risk of developing benign uterine fibroids than women with low levels of the hormones, results of a new study indicate.1
Many women develop uterine fibroid tumors (leiomyomas) as they grow older. Research data indicate the prevalence of ultrasound-identified tumors as 33% in women 40 to 60 years of age, compared to 11-18% in women ages 30-40 and 4% in women ages 20-30.2 The presence of uterine fibroid tumors is the most common indication cited for hysterectomy, representing more than 30% of such procedures.3 Treatment options include watchful waiting; treatment with drugs or hormones, embolization, ultrasound thermal ablation; and invasive procedures such as partial or total hysterectomy.
The current 13-year longitudinal study looked at hormone levels and the incidence of uterine fibroids in women participating in the Study of Women’s Health around the Nation (SWAN), a multi-site longitudinal, epidemiologic study designed to examine the health of women during their middle years. Among the 3,240 women enrolled at the beginning of the study, 43.6% completed the follow-up visits. During their follow-up visits, participants had their blood tested for estrogen and androgen levels. In addition, enrollees were asked whether they had been diagnosed with or treated for uterine fibroids.
Among the study participants, 512 women reported having a single incidence of fibroids, and an additional 478 women had recurrent cases. Data indicate that participants who had high levels of testosterone in the blood were 1.33 times more likely to develop a single incidence of fibroids than women who had low levels of testosterone. Women who had high levels of testosterone and estrogen faced an even greater risk, researchers report. Although women with high levels of both hormones were more likely to report a single incidence of fibroids, they also were less likely to have a recurrence than women with low levels of the hormones, they note.1
The research suggests women undergoing the menopausal transition who have higher testosterone levels have an increased risk of developing fibroids, particularly if they also have higher estrogen levels, stated Jason Wong, ScD, a post-doctoral fellow in the Stanford University School of Medicine. The study represents the first longitudinal investigation of the relationship between androgen and estrogen levels and the development of uterine fibroids, said Wong in a release accompanying the paper.
The study’s findings are particularly interesting because testosterone previously was unrecognized as a factor in the development of uterine fibroids, said Jennifer Lee, MD, PhD, associate professor at the Stanford University School of Medicine and a study co-author.
“The research opens up new lines of inquiry regarding how fibroids develop and how they are treated,” noted Lee in a press statement. “Given that managing uterine fibroids costs an estimated $34.4 billion in annual medical expenditures nationwide, it is important to identify new ways to better treat this common condition.”
WHAT OPTION IS BEST?
The Duke Clinical Research Institute in Durham, NC, is working with nine centers across the United States in a five-year project to evaluate the effectiveness of different treatment strategies for women with uterine fibroids. The project, a collaboration between the Patient-Centered Outcomes Research Institute and the Agency for Healthcare Research and Quality, is designed to help patients and clinicians make more informed choices about treatment options. (Contraceptive Technology Update reported on the study kickoff; see “Duke Clinical Research Institute’s initiative to look at options for uterine fibroids,” December 2014.)
The study is focused on developing a multi-center registry of women who have received surgical treatments for uterine fibroids. This registry, COMPARE-UF (Comparing Options for Management: Patient-centered REsults for Uterine Fibroids), will establish the infrastructure necessary to support patient-centered comparative clinical effec-tiveness research.
Therapies for isolated heavy menstrual bleeding associated with fibroids include tranexamic acid, an oral antifibrinolytic agent that is taken only on the days of heavy menstrual bleeding. This approach decreases bleeding and improves quality of life with minimal side effects.4 Use of a levonorgestrel-releasing intrauterine device (IUD) or oral contraceptives can decrease menstrual bleeding and provides birth control.
Providers also might consider hysteroscopic myomectomy, an outpatient surgical procedure that allows women with submucosal fibroids to return to work within a few days. Another procedure is endometrial ablation, which uses heat, cold, or mechanical means to reduce menstrual bleeding.
In 2014, the Food and Drug Administration warned against the use of laparoscopic power morcellators in most women undergoing myomectomy or hysterectomy for treatment of fibroids. The FDA warned that uterine tissue might contain unsuspected cancer. The use of laparoscopic power morcellators during fibroid surgery might spread cancer, and it decreased the long-term survival of patients.
Therapies for women for whom the size of the fibroid(s) causes symptoms include gonadotropin-releasing hormone agonists, medications that turn off the ovaries’ production of hormones, which reduces menstrual bleeding and causes considerable reduction in uterine volume. Uterine artery embolization, a minimally invasive interventional radiologic technique offers shorter hospital stays and less time to resumption of usual activities.
Providers also might look at MRI-guided focused ultrasound surgery, a fibroid-specific therapy that uses ultrasound thermal ablation to treat fibroids with no incisions and no hospital stay.
Radiofrequency ablation during laparoscopy is useful for destruction of fibroids during laparoscopy.4
REFERENCES
- Wong JY, Gold EB, Johnson WO, et al. Circulating sex hormones and risk of uterine fibroids: Study of Women’s Health Across the Nation (SWAN). J Clin Endocrinol Metab 2016; 101(1):123-130.
- Lurie S, Piper I, Woliovitch I, et al. Age-related prevalence of sonographically confirmed uterine myomas. J Obstet Gynaecol 2005; 25:42-44.
- Myers ER, Barber MD, Gustilo-Ashby T, et al. Management of uterine leiomyomata: What do we really know? Obstet Gynecol 2002;100(1):8-17.
- Stewart EA. Clinical practice. Uterine fibroids. N Engl J Med 2015; 372(17):1646-1655.
