Medical Tr of myoma??

Medl management of myoma?? There are many agents used for medical management of symptomatic myoma. The list of such drugs is long 1) NSAIDs-when Menorrhagia-related to myoma is the chief concern. However such myoma-related meno can be controlled  as well by  2) COC  or Progestins-if myoma-related symptoms are limited to  periods  only—by causing thinning of endo 3) LNG-IUS 4) Androgens-like Danazol / Gestrinone –not favored for their unacceptable side effects 5) Agonists as either Monthly basis 3.75 mg ( as IM or Sub cut)-/ Long acting 11.25mg  –on 3 monthly basis along with add back Ry -like COC(usually cyclically  Premarin for 25 days a month  along with MPA 10 mg × for 10 days per month)/ or continuous Premarin 0.625 & MPA 2.5 mg tablets to prevent primarily bone lisp(-in fact bone loss in Trabecular bone will be >6%  after 6 months of agonist Inj if no add back) is concurrently supplemented. As an add back Ry:-Tibolone / Raloxifene are also used occasionally but costlier –these are family of SERMs. 6) In research settings Antagonists have also been used with good success but frequency of Inj are unacceptable even in depot form 7) Mifepristone / Ulipristal:-SERMs... A word of caution:-No 6 & 7 has not been approved by any International / National Drug Regularly Authority. UPA.

3) Disadvantages of UPA? UPA has some adverse endometrial effects.  As

2) Not all women mandate medical Tr.  Not to prescribe whenever a myoma is visualized in USG or clinically become palpable? Why medical Tr? Each case have to be judged in its own way!-Not all myoma mandate Tr (medical /surgical) . The usual growth per annum is 0.5 cm per yr but some myoma can be faster growing as 3 cm/yr. Some will spont  regress of its own without medication. If a woman is aged and myoma hinders sonographic visualization of adenexae   then it become an indication for medl tr –so that USG can reduce the tumour to  certain extent-enabling gonads to visualize and asses properly.

S) Back to Basics :-Can we dream—it will be possible to predict the  therapeutic efficacy of medl agents prescribed for myoma e.g.  UPA/ Mifepristone/ or  Asoprisnil( newborn) ?:Selection of drug-as is often done  prior to ovulation induction?? Can we forecast /predict efficacy, as is done while choosing ( anticancer  drugs for Br Ca –type of Receptor and its sensitivity to the antineoplastic drugs and thereby avoiding prescribing costly drugs which is not going to exert any desirable effect.  Dynamics of action in the myomatous tumors cells? Are all the tumors  in a particular woman will show  same population of  progesterone receptors identically . Will a day come we can assess the drug sensitivity by FNAC of myoma à thereby selecting the most effective  drug.Hope for the best!!!

 -S) What is the present concept of etiology/pathogenesis of Myoma??   It is surprising to know that most of myoma is due to karyotypic defects!!! A many as 40% of myomatous casesà exhibit Karyotypic defects. In fact myomatous cells are  derived from progenitor myocyte -as such multiple tumors while harboring inside the same uterus can have independent  chromosomal make up and varying response to exogenous drugs. Quite logically, diff myomatous (in a same woman) -cells  can exhibit  diff response to diff hormones , facilaitiary growth factors or prohormones.

By and large most myomas exhibit defects in Chr No. 6,7,12 & 14 and rarely in X,1,3,10,13  and more we know about the what went wrong in a woman with that particular chromosome is a prophylaxis for dev myoma.

The idea to perform intermittent, rather than continuous, treatment courses were developed to address concerns including the safety of SPRMs UPA has with antiproliferative effects on fibroid cells.

http://fertstertforum.com/gallianod-ulipristal-acetate-uterine-fibroids/

What are the different receptors of progesterone?? Which type of receptor is commonly observed   in myomatous cells? - Out of the two known receptors of Progesterone (PR-A & PR-B) -- it is the A type that are more frequently seen densely (much more) than B at tumor cells.

S PRMs, also called as Anti progestins-as such pharmacological agent exert anti progesterone effects by exerting antagonistic effects on a receptors of progesterone-that is why such class of drugs are aptly termed as SELECTIVE.

  First drug to choose for medl management of myoma-where bleeding (Menorrhagia) is not the primary concern. Yes, Dr Daljit is possibly right. If meno is primary intention to treat then NSAID & COC should be considered first à or LNG IUS if there is no Cavitary distortion. Review of much literature on this topic which spanned in the entire day (05-05-17) led me to conclude like that. Though if U thinks of medl TR of myoma -first choice is still agonist, second choice will be mifepristone:-Mifepristone reduces the volume of myoma by 50%. People have used Mifepristone as 2.5 mg, 5, 10, even 50 mg for over 3 months continuously. But then again there are some associated medl disorders where Mifepristone can’t be used e.g. those who are on steroid Ry for some other diseases, on Aspirins, smokers, hepatic-renal parenchymal diseases.