Uterine fibroids – what’s new?

Uterine fibroids are the commonest benign tumours of 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 tumours. This article reviews recent progress in understanding the biological nature of fibroids, their life cycle and their molecular genetic origins. Recent progress in surgical and interventional management is briefly reviewed, and medical management options, including treatment with selective progesterone receptor modulators, are also discussed

Progestogens or progestogen-releasing intrauterine systems for uterine fibroids

Background Uterine fibroids are themost common premenopausal benign uterine tumours. Fibroids can cause symptoms including heavymenstrual bleeding, pelvic pressure and pain. Progestogens can be administered by various routes. Intramuscular injection of depot medroxyprogesterone acetate (DMPA) has dual actions (stimulatory or inhibitory) on fibroid cell growth. Progestogen-releasing intrauterine systems (IUS) decrease menstrual blood loss associated with fibroids by inducing endometrial atrophy and reduction of uterine fibroid size. Currently, their effectiveness for the treatment of uterine fibroids has not been evaluated. Objectives To determine the effectiveness of progestogens or progestogen-releasing intrauterine systems in treating premenopausal women with uterine fibroids. Search methods We searched theMenstrualDisorders and SubfertilityGroup Specialised Register (inception to 17 August 2012), CENTRAL (inception to 17 August 2012) and Database of Abstracts of Reviews of Effects (DARE) in The Cochrane Library, MEDLINE (inception to 17 August 2012), Ovid EMBASE (1 January 2010 to 17 August 2012), Ovid PsycINFO (inception to 17 August 2012), CINAHL database, and trials registers for ongoing and registered trials.Selection criteria All identified published or unpublished randomised controlled trials (RCTs) assessing the effect of progestogens or progestogen-releasing intrauterine systems in treating premenopausal women with uterine fibroids. Data collection and analysis We assessed all potentially eligible studies identified as a result of the search strategy. Two review authors extracted data from each included study using an agreed form and assessed the risk of bias. We resolved discrepancies through discussion. Main results This review included three studies. However, data for progestogen-releasing intrauterine systems were available from only one study that compared 29 women with a levonorgestrel (LNG)-IUS versus 29 women with a combined oral contraceptive (COC) for treating uterine fibroids. There was a significant reduction of menstrual blood loss (MBL) in women receiving the LNG-IUS compared to the COC using the alkaline hematin test (mean difference (MD) 77.5%, 95% CI 71.3% to 83.67%, 58 women) and a pictorial assessment chart (PBAC) (MD 34.5%, 95% CI 14.9% to 54.1%, 58 women). The reduction in uterine fibroid size was significantly greater in the leuprorelin group at 16 weeks compared to the progestogen lynestrenol group (MD -15.93 mm, 95% CI -18.02 to -13.84 mm, 46 women). There was no RCT evaluating the effect of DMPA on uterine fibroids. Authors' conclusions Progestogen-releasing intrauterine systems appear to reduce menstrual blood loss in premenopausal women with uterine fibroids. Oral progestogens did not reduce fibroid size or fibroid- related symptoms. However, there was a methodological limitation and the one included study with data had a small sample size. This evidence is insufficient to support the use of progestogens or progestogenreleasing intrauterine systems in treating premenopausal women with uterine fibroids.Ussanee S Sangkomkamhang , Pisake Lumbiganon , Malinee Laopaiboon , Ben Willem J Mo

Barriers and Facilitators to Implementing Immediate Postpartum Contraceptive Implant Programs: A Formative Implementation Research

Jen Sothornwit,1 Pisake Lumbiganon,1 Kesinee Saranrittichai,2 Ussanee Sangkomkamhang,3 Thanyarat Singhdaeng,4 Nampet Jampathong5 1Department of Obstetrics and Gynaecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand; 2Department of Health Behavior and Health Promotion, Faculty of Public Health, Khon Kaen University, Khon Kaen, Thailand; 3Department of Obstetrics and Gynecology, Khon Kaen Hospital, Khon Kaen, Thailand; 4Department of Obstetrics and Gynecology, Nam Phong Hospital, Khon Kaen, Thailand; 5Cochrane Thailand, Faculty of Medicine, Khon Kaen University, Khon Kaen, ThailandCorrespondence: Jen Sothornwit, Department of Obstetrics and Gynaecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand, Email [email protected]: This study sought to identify the factors that act as barriers and facilitators to developing and implementing Immediate postpartum (IPP) insertion of contraceptive implants service according to the Consolidated Framework for Implementation Research (CFIR).Methods: We conducted in-depth interviews and focus group discussions to explore IPP contraceptive implantation programs implemented in community, regional, and university hospitals in Thailand. The CFIR was used to guide the data collection and analyses.Results: All CFIR domains were found to have an impact on planning and implementation. Out of 38 constructs, nine were identified as either barriers or facilitators, and four were determined to be both. Barriers included an insufficient training budget, lack of policy to support non-teenagers, disconnect among organizations, and lack of knowledge on the part of the clients. Facilitators included the relative advantage of implants over other contraceptive methods, reimbursement policy, laws that promote teenage autonomy, setting IPP implants as a key performance indicator (KPI), identifying project champions, and educating clients through antenatal counseling or multimedia intervention.Conclusion: Barriers and facilitators to the successful implementation of an IPP contraceptive implant program were identified. In order to successfully implement this service, modifiable barriers should be overcome and facilitators should be strengthened. Strategies tailored to the local context should be developed to ensure the sustainability of the program. Educating clients is crucial and need both hospital- and community interventions.Keywords: contraceptive implants, implementation science, influencing factors, long-acting reversible contraception, postpartum contraceptio