Evolving patient evaluation and therapies for uterine fibroids

“As a result, heterogeneity can be seen among patients, such as race, age and associated health condition,” said Singh, who spoke on the future of individualized evaluation and therapies at the 2021 Fibroid Summit, sponsored by The Fibroid Foundation and The Campion Fund. “Each fibroid pathology is also different, even in the same patient.”

In addition, patient experiences vary for symptoms, impact of disease, and response to therapy.

“Therefore, we cannot ‘paint’ every patient with uterine fibroids with the same brush,” Singh told Contemporary OB/GYN. “Each patient deserves a personalized assessment and plan that is right for them.”

Despite this noble goal, clinicians have not been able to identify the factors that help determine the right treatment for the right patient, based on the variations above, according to Singh.

“Often our approach is to use the same medical, surgical or interventional modalities, without having fibroid-specific details or patient factors that may impact outcomes,” he said. “The location of the fibroids -- in the cavity versus in the myometrium -- is usually the main finding we use to guide therapy.”

Goals of each individual patient should be considered. “Is the goal to manage a specific symptom or to try to get pregnant?” Singh said. “And what are their expectations and lived experience? It is so important to acknowledge this aspect of the patient journey.”

The three most common presentations to manage are heavy menstrual bleeding/anemia, fibroid size, and pelvic pain/pressure symptoms.

“For some patients, the main issue is their heavy menstrual bleeding,” Singh said. “Conversely, it may be that the patient has lots of fibroids, but it is that 1 or 2 cm fibroid on the inside of the uterine lining causing all of the problems? Perhaps it is bulk symptoms, for which shrinking the fibroid might make a difference.”

Just like for many other diseases, including cancers, Singh believes there eventually will be detailed genetic, imaging and biomarker information about UFs to help guide therapy. “We already know that certain genetic mutations are found more in fibroids,” he said. “It is also likely that different fibroid presentations, such as size, number and characteristics, are programmed differently. Using that knowledge may help lead us to different approaches.”

Singh’s research group is exploring imaging via shearwave elastography to help understanding fibroid characteristics that might predict treatment response.

“A second research project is looking at using 3D modeling and printing to help surgeons plan complex cases in the operating room,” said Singh, who also serves as the director of the American Association of Gynecologic Laparoscopists (AAGL) Fellowship in minimally invasive gynecology at the University of Ottawa.

Currently, hormonal interventions are the mainstay medical therapies for UFs and chiefly to manage symptoms. “But there is a huge need for alternative therapies that approach the problem differently,” Singh said. “Vitamin D and green tea extract are examples of alternative potential options for management, but are still under study.”

Singh is hopeful that one day clinicians will be able to identify those women who are at highest risk of developing UFs earlier in life and that there are reliable interventions to prevent the disease from starting or progressing.

“Prevention should be a goal alongside current symptom management research,” he said.

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Disclosures

Singh serves on the advisory board of Myovant, AbbVie, Bayer, Merck and Hologic. He is also a research investigator for AbbVie, Allergan and Bayer. In addition, Singh is a continuing medical education (CME) developer for AbbVie, Allergan, Hologic and Bayer.