Body Composition and Bone Mineral Density in Postmenopausal Women with Advanced Knee Osteoarthritis Undergoing Surgical Treatment

Objectives@#This study aimed to demonstrate the bone mineral density (BMD) and body composition in postmenopausal women with knee osteoarthritis (OA) who underwent surgical treatment, such as total knee arthroplasty, osteotomy, or meniscectomy. @*Methods@#A total of 254 women with OA aged 50 years who underwent surgical treatment were enrolled in this study. We evaluated obesity-related factors, muscle components, and BMD using dual-energy X-ray absorptiometry. @*Results@#No significant differences were noted in the BMD of the hip joint between the symptomatic side of the leg with knee OA and the contralateral side. However, when comparing the BMD of each component, the results indicated a significantly higher BMD in the obesity group based on body mass index (BMI). When defining sarcopenic obesity (SO) using various indicators of obesity (BMI, the estimated visceral adipose tissue area, android/gynoid ratio, and total body fat percentage), the prevalence of SO in the OA group who underwent surgical treatment ranged from 22.0% to 49.6%. @*Conclusions@#This study investigated obesity-related factors in patients with advanced knee OA who underwent surgery, revealing a high prevalence of overweight/obese individuals, the presence of SO, and a complex relationship between obesity, body composition, and bone density, highlighting the potential protective effects of weight-bearing on bone health while exploring the impact of sarcopenia on bone density differences in the context of OA. Depending on various definitions of obesity, diverse proportions of SO in patients with OA have been observed, and further detailed research is required to understand its impact on the condition.

Reproductive Life Span and Severe Hypoglycemia Risk in Postmenopausal Women with Type 2 Diabetes Mellitus

Background@#Estrogen promotes glucose homeostasis, enhances insulin sensitivity, and maintains counterregulatory responses in recurrent hypoglycemia in women of reproductive age. Postmenopausal women with type 2 diabetes mellitus (T2DM) might be more vulnerable to severe hypoglycemia (SH) events. However, the relationship between reproductive factors and SH occurrence in T2DM remains unelucidated. @*Methods@#This study included data on 181,263 women with postmenopausal T2DM who participated in a national health screening program from January 1 to December 31, 2009, obtained using the Korean National Health Insurance System database. Outcome data were obtained until December 31, 2018. Associations between reproductive factors and SH incidence were assessed using Cox proportional hazards models. @*Results@#During the mean follow-up of 7.9 years, 11,279 (6.22%) postmenopausal women with T2DM experienced SH episodes. A longer reproductive life span (RLS) (≥40 years) was associated with a lower SH risk compared to a shorter RLS (<30 years) (adjusted hazard ratio [HR], 0.74; 95% confidence interval [CI], 0.69 to 0.80; P for trend <0.001) after multivariable adjustment. SH risk decreased with every 5-year increment of RLS (with <30 years as a reference [adjusted HR, 0.91; 95% CI, 0.86 to 0.95; P=0.0001 for 30−34 years], [adjusted HR, 0.80; 95% CI, 0.76 to 0.84; P<0.001 for 35−39 years], [adjusted HR, 0.74; 95% CI, 0.68 to 0.81; P<0.001 for ≥40 years]). The use of hormone replacement therapy (HRT) was associated with a lower SH risk than HRT nonuse. @*Conclusion@#Extended exposure to endogenous ovarian hormone during lifetime may decrease the number of SH events in women with T2DM after menopause.

Efficient myometrial defect closure in a layer by layer fashion after robot-assisted laparoscopic adenomyomectomy: a novel technique

Objective@#In this video, we present our novel technique for myometrial defect closure following robot-assisted laparoscopic adenomyomectomy. @*Methods@#A narrated video demonstration of our technique. Our patient was a 47-year-old single woman with severe dysmenorrhea, who did not respond to medical therapy and wished to preserve her uterus. Surgery was performed after thorough counseling and obtaining informed consent from the patient (Institutional Review Board number: KC17OESI0238; approval date: March 19, 2018). After removal of the adenomyotic tissue during surgical intervention, the myometrial defect was closed in three steps. First, the defect between the anterior and posterior innermost myometrial layers was closed using a 2-0 Stratafix suture, CT-1 (circle taper) needle (Ethicon, Somerville, NJ, USA). Next, the two sides were approximated using a 2-0 PDS® (polydioxanone) Suture (Ethicon, Somerville, NJ, USA) and V-34 (TAPERCUT®) surgical needle (Ethicon, Somerville, NJ, USA). Finally, the serosa was sutured in a baseball fashion using a 2-0 PDS suture, slim half-circle [SH] needle (Ethicon, Somerville, NJ, USA). @*Results@#The patient had no postoperative complications, and her pain was greatly improved. The CA125 level decreased from 434 U/mL to 45.99 U/mL, and the transvaginal ultrasound showed a reduction in posterior myometrial thickness from 5.61 cm to 2.69 cm. @*Conclusion@#This technique maintained the integrity of the endometrial cavity, posterior myometrial thickness, and uterine layer alignment. We believe that it is a feasible technique and may be a solution for adenomyosis in patients seeking for fertility preservation.

The comparison of bilateral bone mineral density in postmenopausal women

Objectives@#The aim of this study is to determine whether there is a difference between right and left femur bone mineral density (BMD) in postmenopausal women. @*Methods@#We performed a retrospective chart review of postmenopausal women who underwent bone mineral density (BMD) measurement from 2010 to 2019 at a single center using dual-energy X-ray absorptiometry (DXA). Data, including BMD and T-scores of bilateral hip and lumbar spine, was gathered for all postmenopausal women above the age of 50 years. The continuous variables were expressed as means with standard deviation for normal distribution and analyzed with a two-sample t-test. Multiple regression analysis was used to test the effect of underlying medical conditions on T-score of bilateral hips. For all analyses, a p-value of ＜0.05 was considered significant. @*Results@#346 patients were included in the study with a mean age at imaging of 62 + 9.7 years and body mass index (BMI) of 23.4 + 6.1 kg/m2 . There were no significant differences between right and left femoral BMDs in all patients. There were significant differences in BMD of both total femurs in women in their 60s and women with normal BMD. There was no difference in both femur BMDs between those taking hormone therapy and those not taking hormone therapy. In patients undergoing osteoporosis treatment, there was a difference in the BMD of both femur neck. Calcium and vitamin D intake were not associated with differences between both femur BMD. We found a significant correlation between the BMD measures at lumbar spine and both femur (p ＜ 0.01). @*Conclusion@#There were no significant differences between right and left femoral BMDs in postmenopausal women. Therefore, BMD may be measured at either hip. The correlation of bone density between lumbar spine and femur neck is shown to be statistically meaningful. Based on the knowledge of the correlation coefficients between lumbar spine and femur neck, it seems possible to predict the BMD result of one location through the measurement of another.

Vitamin D and the Immune System in Menopause: A Review

Menopause is a normal phenomenon in a woman’s life cycle involving multiple health-related issues that contribute to physical instability. Changes in the immune system in postmenopausal women are caused by estrogen deprivation along with age. Increased proinflammatory serum marker levels, cytokine responses in body cells, decreased CD4 T and B lymphocyte levels, and natural killer cell cytotoxic activity are also observed during postmenopause. Moreover, vitamin D, in addition to its classical effects on calcium homeostasis and bone density, plays an important role. Current evidence indicates that vitamin D regulates innate and adaptive immune responses; however, vitamin D deficiency is linked to increased autoimmune activity and infection susceptibility. This review provides an overview of the consequences of immune alterations as an outcome of aging in postmenopausal women and the benefit of vitamin D supplementation.

Updates on Therapeutic Alternatives for Genitourinary Syndrome of Menopause: Hormonal and Non-Hormonal Managements

Postmenopausal atrophic vaginitis, along with vasomotor symptoms and sleep disorders, is one of the most troublesome symptoms of menopause. However, many women do not manage this symptom properly due to insufficient knowledge of the symptoms or sexual embarrassment. With appropriate treatment, many postmenopausal women can experience relief from discomforts, including burning sensation or dryness of the vagina and dyspareunia. Topical lubricants and moisturizers, systemic and local estrogens, testosterones, intravaginal dehydroepiandrosterones (DHEAs), selective estrogen receptor modulators, and energy-based therapies are possible treatment modalities. Systemic and local estrogen therapies effectively treat genitourinary syndrome of menopause (GSM), but they are contraindicated in patients with breast cancer, for whom lubricants and moisturizers must be considered as the primary treatment. Intravaginal DHEA and ospemifene can be recommended for moderate to severe GSM; however, there is insufficient data on the use of intravaginal DHEA or ospemifene in patients with breast cancer, and further studies are needed. Energy-based devices such as vaginal laser therapy reportedly alleviate GSM symptoms; however, the U.S. Food and Drug Administration warning has recently been issued because of complications such as chronic pain and burning sensations of the vagina. To summarize, clinicians should provide appropriate individualized treatment options depending on women’s past history, symptom severity, and chief complaints.

Efficient myometrial defect closure in a layer by layer fashion after robot-assisted laparoscopic adenomyomectomy: a novel technique

Objective@#In this video, we present our novel technique for myometrial defect closure following robot-assisted laparoscopic adenomyomectomy. @*Methods@#A narrated video demonstration of our technique. Our patient was a 47-year-old single woman with severe dysmenorrhea, who did not respond to medical therapy and wished to preserve her uterus. Surgery was performed after thorough counseling and obtaining informed consent from the patient (Institutional Review Board number: KC17OESI0238; approval date: March 19, 2018). After removal of the adenomyotic tissue during surgical intervention, the myometrial defect was closed in three steps. First, the defect between the anterior and posterior innermost myometrial layers was closed using a 2-0 Stratafix suture, CT-1 (circle taper) needle (Ethicon, Somerville, NJ, USA). Next, the two sides were approximated using a 2-0 PDS® (polydioxanone) Suture (Ethicon, Somerville, NJ, USA) and V-34 (TAPERCUT®) surgical needle (Ethicon, Somerville, NJ, USA). Finally, the serosa was sutured in a baseball fashion using a 2-0 PDS suture, slim half-circle [SH] needle (Ethicon, Somerville, NJ, USA). @*Results@#The patient had no postoperative complications, and her pain was greatly improved. The CA125 level decreased from 434 U/mL to 45.99 U/mL, and the transvaginal ultrasound showed a reduction in posterior myometrial thickness from 5.61 cm to 2.69 cm. @*Conclusion@#This technique maintained the integrity of the endometrial cavity, posterior myometrial thickness, and uterine layer alignment. We believe that it is a feasible technique and may be a solution for adenomyosis in patients seeking for fertility preservation.

Updates on Therapeutic Alternatives for Genitourinary Syndrome of Menopause: Hormonal and Non-Hormonal Managements

Postmenopausal atrophic vaginitis, along with vasomotor symptoms and sleep disorders, is one of the most troublesome symptoms of menopause. However, many women do not manage this symptom properly due to insufficient knowledge of the symptoms or sexual embarrassment. With appropriate treatment, many postmenopausal women can experience relief from discomforts, including burning sensation or dryness of the vagina and dyspareunia. Topical lubricants and moisturizers, systemic and local estrogens, testosterones, intravaginal dehydroepiandrosterones (DHEAs), selective estrogen receptor modulators, and energy-based therapies are possible treatment modalities. Systemic and local estrogen therapies effectively treat genitourinary syndrome of menopause (GSM), but they are contraindicated in patients with breast cancer, for whom lubricants and moisturizers must be considered as the primary treatment. Intravaginal DHEA and ospemifene can be recommended for moderate to severe GSM; however, there is insufficient data on the use of intravaginal DHEA or ospemifene in patients with breast cancer, and further studies are needed. Energy-based devices such as vaginal laser therapy reportedly alleviate GSM symptoms; however, the U.S. Food and Drug Administration warning has recently been issued because of complications such as chronic pain and burning sensations of the vagina. To summarize, clinicians should provide appropriate individualized treatment options depending on women’s past history, symptom severity, and chief complaints.

Robot-assisted surgery in gynecology

The development of robotic technology has facilitated the application of minimally invasive techniques for complex gynecologic surgery. Robot-assisted gynecologic surgery has grown exponentially since receiving Food and Drug Administration approval for use in gynecologic surgery in 2005. Robotic surgery has several major advantages, including three-dimensional visual magnification, articulation beyond normal manipulation, and the filtering of the operator's hand tremors. Therefore, robotic surgery is suitable for microsurgery, and it could be an alternative option for laparotomy. Robotic surgery has advantages, especially for suture-intensive operations such as myomectomy. Patients who underwent robot-assisted laparoscopic myomectomy had significantly decreased estimated blood loss, complication rates, and length of hospital stay. The advantages of robotic surgery help to overcome the limitations of laparoscopy, especially for complicated procedures in deep infiltrating endometriosis. Although extensive radical operations for deep infiltrating endometriosis of the bowel and urinary tract, such as segmental resections of the bladder, ureters, and bowel, were performed by laparotomy in the past, they are now performed more easily and more effectively using robotic techniques. In a recent systematic review and meta-analysis, robotic and laparoscopic sacrocolpopexy resulted in similar clinical outcomes, but robotic surgery was associated with a longer operation time and higher costs. Robotic and conventional laparoscopic hysterectomy show equivalent surgical and clinical outcomes. Compared to laparotomy, robotic gynecologic cancer surgery results in improved clinical outcomes and comparable oncologic outcomes. If robotic surgery is tailored in terms of patient selection, surgeon ability, and equipment availability, it could be a feasible option for highly advanced minimally invasive surgery.

Position Statement on the Use of Bone Turnover Markers for Osteoporosis Treatment

Current evidences continue to support the clinical application of bone turnover markers (BTMs) in the management of postmenopausal osteoporosis. The limitations of bone mineral density measured by dual energy X-ray absorptiomet especially emphasize the beneficial roles of BTMs, such as serum C-terminal telopeptide of type I collagen and serum procollagen type I N-propeptide, as monitoring tools to assess the responses to treatment. Therefore, the proper application and assessment of BTM in clinical practice is very important. However, their use in Korea is still insufficient. Therefore, the BTM committee has set up by the Korean Society for Bone and Mineral Research have been constituted and provided a position statement which will suggest on the clinical application of BTM for the management of postmenopausal osteoporosis in Korea.

Use of Bone Turnover Markers in Clinical Practice for the Management of Osteoporosis in Korea: From the Survey on the Prescription Pattern of Bone Turnover Markers

BACKGROUND: There has been interest in the clinical potential of bone turnover markers (BTMs) as tools both for assessing fracture risk and for monitoring treatment. However, the practical use of BTMs has been limited by their biological variability and difficulties in the interpretation of results. We investigated the current situation of application of BTMs by clinicians in Korea for the management of osteoporosis through a survey asking the patterns of BTMs prescription in clinical practice.METHODS: The survey was conducted online using the “google survey” by the BTM committee authorized by the Korean Society for Bone and Mineral Research.RESULTS: Total 108 clinicians responded the survey. Most of the respondents prescribed BTMs (80.6%) when they prescribed anti-osteoporotic medications (AOMs). The most frequently prescribed bone resorption and formation markers were serum C-terminal telopeptide of type I collagen (90.7%) and osteocalcin (65.1%), respectively. BTMs were mostly prescribed before starting AOMs (90.8%) and used for the purpose of evaluating treatment response (74.4%). Treatment response and compliance to AOMs were evaluated according to the change of absolute value of BTMs (55.1%). The respondents complained difficulties in the interpretation of BTMs (33.3%), the choice of proper BTMs (17.2%), and the proper sample preparation and handling (13.8%).CONCLUSIONS: In Korea, most of clinicians recognized the benefit of BTMs in the management of osteoporosis. However, there are limitations in the broad use of these markers in clinical practice. Therefore, a clear recommendation for BTM in Korea enhances their use in clinical practice.

Clinical Application of Bone Turnover Markers in Osteoporosis in Korea

Bone turnover markers (BTMs) have important role in the management of osteoporosis. Recently the clinical application of BTMs has achieved significant progress and measurement of BTMs give us better understanding of pathogenesis of osteoporosis. However, the use of BTMs is still insufficient in Korea. We summarized the available methods and standard interval of the BTMs in Korea. Also we reviewed published literatures on pre-analytical variability in the measurement of BTMs and provided recommendations for standardized sample handling and patient preparation for reducing those pre-analytical variabilities. The clinical application of BTMs in patients with chronic kidney disease who have a higher fracture risk than the general population is summarized.

Robot-assisted surgery in gynecology

The development of robotic technology has facilitated the application of minimally invasive techniques for complex gynecologic surgery. Robot-assisted gynecologic surgery has grown exponentially since receiving Food and Drug Administration approval for use in gynecologic surgery in 2005. Robotic surgery has several major advantages, including three-dimensional visual magnification, articulation beyond normal manipulation, and the filtering of the operator's hand tremors. Therefore, robotic surgery is suitable for microsurgery, and it could be an alternative option for laparotomy. Robotic surgery has advantages, especially for suture-intensive operations such as myomectomy. Patients who underwent robot-assisted laparoscopic myomectomy had significantly decreased estimated blood loss, complication rates, and length of hospital stay. The advantages of robotic surgery help to overcome the limitations of laparoscopy, especially for complicated procedures in deep infiltrating endometriosis. Although extensive radical operations for deep infiltrating endometriosis of the bowel and urinary tract, such as segmental resections of the bladder, ureters, and bowel, were performed by laparotomy in the past, they are now performed more easily and more effectively using robotic techniques. In a recent systematic review and meta-analysis, robotic and laparoscopic sacrocolpopexy resulted in similar clinical outcomes, but robotic surgery was associated with a longer operation time and higher costs. Robotic and conventional laparoscopic hysterectomy show equivalent surgical and clinical outcomes. Compared to laparotomy, robotic gynecologic cancer surgery results in improved clinical outcomes and comparable oncologic outcomes. If robotic surgery is tailored in terms of patient selection, surgeon ability, and equipment availability, it could be a feasible option for highly advanced minimally invasive surgery.

Clinical evaluation and management of endometriosis: guideline for Korean patients from Korean Society of Endometriosis

Endometriosis is one of the most common diseases in reproductive ages, and it affects patients' quality of life and fertility. However, few Korean guidelines are available for the evaluation and management of endometriosis. Korean Society of Endometriosis reviewed various literatures and trials, and to provide seventy-one evidence-based recommendations. This review presents guidelines for the diagnosis and management of endometriosis with emphasis on: it's role in infertility, treatment of recurrence, asymptomatic women, endometriosis in adolescents and menopausal women, and possible association of endometriosis with cancer.

The expression of Müllerian inhibiting substance/anti-Müllerian hormone type II receptor in myoma and adenomyosis

OBJECTIVE: We compared the expression levels of Müllerian inhibiting substance (MIS)/anti-Müllerian hormone type II receptor (AMHRII) in uterine myoma and adenomyosis to evaluate the possibility of using MIS/anti-Müllerian hormone (AMH) as a biological regulator or therapeutic agent in patients with uterine leiomyoma and adenomyosis. METHODS: We studied normal uterine myometrium, leiomyoma, endometrial tissue, and adenomyosis from 57 patients who underwent hysterectomy for uterine leiomyoma (22 cases) or adenomyosis (28 cases) and myomectomy for uterine myoma (7 cases). Immunohistochemical staining was used to confirm the MIS/AMHRII protein expression level in each tissue. Reverse transcription-polymerase chain reaction was performed to quantify MIS/AMHRII mRNA expression. RESULTS: The MIS/AMHRII protein was more strongly expressed in uterine myoma (frequency of MIS/AMHRII expressing cells: 51.95%±13.96%) and adenomyosis (64.65%±4.85%) tissues than that in the normal uterine myometrium (3.15%±1.69%) and endometrium (31.10%±7.19%). In the quantitative analysis of MIS/AMHRII mRNA expression, MIS/AMHRII mRNA expression levels in uterine myoma (mean density: 4.51±0.26) and adenomyosis (6.84±0.20) tissues were higher than that in normal uterine myometrial tissue (0.08±0.09) and endometrial tissue (1.63±0.06). CONCLUSION: This study demonstrated that MIS/AMHRII was highly and strongly expressed on uterine myoma and adenomyosis. Our data suggest that MIS/AMH may be evaluated as a biological modulator or therapeutic agent on MIS/AMHRII expressing uterine myoma and adenomyosis.

Successfully removed uterine angioleiomyoma by robot-assisted laparoscopic myomectomy

Angioleiomyoma is a rare type of leiomyoma variant and there are a few cases reported to date. Herein, we present a case of angioleiomyoma in a 36-year-old woman with lower abdominal pain, initially diagnosed by degenerated uterine leiomyoma. The transvaginal ultrasonogram showed an ovoid-shaped heterogeneously hyperechoic lesion in left cornual site of uterus and pelvic magnetic resonance image showed an about 5.1 cm sized heterogenous T2 intermediate high mass with poor enhancement. The patient underwent a robot-assisted laparoscopic myomectomy, and final histopathologic diagnosis revealed uterine angioleiomyoma. This case is the first case of angioleiomyoma resected by robotic surgery. The patient is on follow up for over 1 year and shows no evidence of recurrence until now.

Association between Body Weight Changes and Menstrual Irregularity: The Korea National Health and Nutrition Examination Survey 2010 to 2012

BACKGROUND: Menstrual irregularity is an indicator of endocrine disorders and reproductive health status. It is associated with various diseases and medical conditions, including obesity and underweight. We aimed to assess the association between body weight changes and menstrual irregularity in Korean women. METHODS: A total of 4,621 women 19 to 54 years of age who participated in the 2010 to 2012 Korea National Health and Nutrition Examination Survey were included in this study. Self-reported questionnaires were used to collect medical information assessing menstrual health status and body weight changes. Odds ratios (ORs) and 95% confidence interval (CI) were calculated to evaluate the association between body weight changes and menstrual irregularity. RESULTS: Significantly higher ORs (95% CI) were observed in the association between menstrual irregularity and both weight loss (OR, 1.74; 95% CI, 1.22 to 2.48) and weight gain (OR, 1.45; 95% CI, 1.13 to 1.86) after adjusting for age, body mass index, current smoking, heavy alcohol drinking, regular exercise, calorie intake, education, income, metabolic syndrome, age of menarche, parity, and stress perception. Of note, significant associations were only observed in subjects with obesity and abdominal obesity, but not in non-obese or non-abdominally obese subjects. U-shaped patterns were demonstrated in both obese and abdominally obese subjects, indicating that greater changes in body weight are associated with higher odds of menstrual irregularity. CONCLUSION: We found a U-shaped pattern of association between body weight changes and menstrual irregularity among obese women in the general Korean population. This result indicates that not only proper weight management but also changes in body weight may influence the regulation of the menstrual cycle.

Robot-Assisted Laparoscopic Adenomyomectomy for Patients Who Want to Preserve Fertility

An adenomyomectomy is a conservative-surgical option for preserving fertility. Conventional laparoscopic adenomyomectomies present difficulties in adenomyoma removal and suturing of the remaining myometrium. Robot-assisted laparoscopic surgery could overcome the limitations of conventional laparoscopic surgery. Four patients with severe secondary dysmenorrhea and pelvic pain visited Seoul St. Mary's Hospital and were diagnosed with adenomyosis by pelvic ultrasonography and pelvic magnetic resonance imaging (MRI). The four patients were unmarried, nulliparous women, who desired a fertility-preserving treatment. We performed robot-assisted laparoscopic adenomyomectomies. The dysmenorrhea and pelvic pain of the patients nearly disappeared after surgery. No residual adenomyosis was observed on the follow-up pelvic MRI. A robot-assisted laparoscopic adenomyomectomy was feasible, and could be a minimally invasive surgical option for fertility-sparing treatment in patients with adenomyosis.

The Recent Review of the Genitourinary Syndrome of Menopause

The genitourinary syndrome of menopause (GSM) is a new term that describes various menopausal symptoms and signs including not only genital symptoms (dryness, burning, and irritation), and sexual symptoms (lack of lubrication, discomfort or pain, and impaired function, but also urinary symptoms (urgency, dysuria, and recurrent urinary tract infections). The terms vulvovaginal atrophy and atrophic vaginitis, which were generally used until recently, had a limitation because they did not cover the full spectrum of symptoms and did not imply that the symptoms are related to a decreased estrogen level in menopause. Since the GSM may have a profound negative impact on the quality of life of postmenopausal women, women should be made aware of these problems and treated with an appropriate effective therapy. Thus, in this review we introduce new terminology and discuss the importance of comprehension of GSM and the necessity of active treatment of this syndrome in postmenopausal women.

Three cases of complications after high-intensity focused ultrasound treatment in unmarried women

High-intensity focused ultrasound (HIFU) has been regarded as a non-surgical, minimally invasive therapeutic option for patients who prioritize uterus-conservation. Although many studies have shown that HIFU therapy is a safe and effective treatment of uterine fibroid, not all fibroids are suitable for HIFU due to risks of serious complications. We experienced three cases of complications after the HIFU ablation for huge uterine fibroids, including two cases of rapid myoma enlargement and one case of heavy vaginal bleeding.