The Effect of Gynecologic Oncologist Availability on Ovarian Cancer Mortality

AIM

To determine the association between the distribution of gynecologic oncologist (GO) and population-based ovarian cancer death rates.

MATERIALS AND METHODS

Data on ovarian cancer incidence and mortality in the United States (U.S.) was supplemented with U.S. census data, and analyzed in relation to practicing GOs. GO locations were geocoded to link association between county variables and GO availability. Logistic regression was used to measure areas of high and low ovarian cancer mortality, adjusting for contextual variables.

RESULTS

Practicing GOs were unevenly distributed in the United States, with the greatest numbers in metropolitan areas. Ovarian cancer incidence and death rates increased as distance to a practicing GO increased. A relatively small number (153) of counties within 24 miles of a GO had high ovarian cancer death rates compared to 577 counties located 50 or more miles away with high ovarian cancer death rates. Counties located 50 or more miles away from a GO practice had an almost 60% greater odds of high ovarian cancer mortality compared to those with closer practicing GOs (OR 1.59, 95% CI 1.18-2.15).

CONCLUSION

The distribution of GOs across the United States appears to be significantly associated with ovarian cancer mortality. Efforts that facilitate outreach of GOs to certain populations may increase geographic access. Future studies examining other factors associated with lack of GO access (e.g. insurance and other socioeconomic factors) at the individual level will assist with further defining barriers to quality ovarian cancer care in the United States.

Gynecologic oncologists involvement on ovarian cancer standard of care receipt and survival

AIM: To examine the influence of gynecologic oncologists (GO) in the United States on surgical/chemotherapeutic standard of care (SOC), and how this translates into improved survival among women with ovarian cancer (OC).

METHODS: Surveillance, Epidemiology, and End Result (SEER)-Medicare data were used to identify 11688 OC patients (1992-2006). Only Medicare recipients with an initial surgical procedure code (n = 6714) were included. Physician specialty was identified by linking SEER-Medicare to the American Medical Association Masterfile. SOC was defined by a panel of GOs. Multivariate logistic regression was used to determine predictors of receiving surgical/chemotherapeutic SOC and proportional hazards modeling to estimate the effect of SOC treatment and physician specialty on survival.

RESULTS: About 34% received surgery from a GO and 25% received the overall SOC. One-third of women had a GO involved sometime during their care. Women receiving surgery from a GO vs non-GO had 2.35 times the odds of receiving the surgical SOC and 1.25 times the odds of receiving chemotherapeutic SOC (P < 0.01). Risk of mortality was greater among women not receiving surgical SOC compared to those who did [hazard ratio = 1.22 (95%CI: 1.12-1.33), P < 0.01], and also was higher among women seen by non-GOs vs GOs (for surgical treatment) after adjusting for covariates. Median survival time was 14 mo longer for women receiving combined SOC.

CONCLUSION: A survival advantage associated with receiving surgical SOC and overall treatment by a GO is supported. Persistent survival differences, particularly among those not receiving the SOC, require further investigation.

Free radicals generation in an in vitro fertilization setting and how to minimize them

Several studies report an increase in both male and female factors in infertility worldwide. In recent years there has been a tremendous increase in couples seeking assisted reproductive technology (ART) procedures in order to have children. However, the success rates of these procedures still remain very low. One of the major contributing factors to the low success rate in ART has been the damage caused by free radicals to the gametes and the developing embryo. The manipulation of gametes and embryos in an in vitro environment when performing assisted reproductive techniques carries the risk of exposure of these cells to supraphysiological levels of free radicals; namely, reactive oxygen species (ROS) and reactive nitrogen species. Oxidative stress can originate from the early steps of ART involving the oocyte, sperm and embryo, as well as in the endometrial environment later on following embryo transfer. The common sources of free radicals in an in vitro fertilization setting include the developing embryo, spermatozoa and leukocytes, semen centrifugation, oxygen partial pressure, light, culture media and cryopreservation/thawing. These free radicals are measured using different techniques, such as the cytochrome C reduction method and chemiluminescence-based techniques. Different efforts are being employed to minimize the excess generation of free radicals in the ART setting, with the aim of improving the success rate, and antioxidant supplementation has emerged as one of the viable routes. Moreover, it is very important to inform ART personnel about the sources of ROS in the laboratory so that they can stop the use of procedures that are deleterious and start to use safer procedures.

Burden of gynaecological cancers in developing countries

Approximately 1:4 of all cancers in women in developing countries (excluding non-melanoma skin cancer) is a gynaecological cancer. The gynaecological cancer burden in developing countries is huge primarily due to the high incidence and mortality of cervical cancer. Cervical cancer accounts for over 60% of the gynaecological cancer burden in developing countries despite being preventable by current technologies. This is due to the absence of effective nationally organized screening programmes in most developing countries. Institution of such programmes, therefore, has the potential to dramatically reduce gynaecological cancer burden in these countries. Subsidized human papilloma virus (HPV) vaccine and HPV typing as well as cheap screening techniques such as visual inspection aided with acetic acid hold the key to effective prevention of cervical cancer in these countries. This is because a significant proportion of patients in developing countries are unable to access and avail themselves of the few available preventive, diagnostic and treatment services because of poverty. Although, advocacy and the political will to invest in the development of human resources and healthcare infrastructure appear critical to gynaecological cancer control and reducing the burden of disease in many developing countries, the proposition assumes that resources are truly available for this investment. This may not be true. Many developing countries rely on foreign aids for developmental programmes and these aids have dwindled significantly with the current global economic meltdown.

Mirabegron, a novel, non-antimuscarinic drug for the overactive bladder: An up-to-dated review

Mirabegron opened a new era in the treatment of overactive bladder (OAB). For the first time physicians dealing with OAB have an effective alternative to the pharmacological mainstay of the therapy for this disorder, the antimuscarinic drugs. This first-in-class, potent β3-adrenoceptors agonist has recently received approval by regulatory authorities in Japan, United States and Europe, based on the favourable efficacy-tolerability profile demonstrated in multiple randomized, multinational, controlled trials, both short and long-term. There is substantial consistency through the studies in reporting the cardiovascular safety of treatment with mirabegron. The main advantage of mirabegron is the placebo-like incidence of classic adverse effects caused by antimuscarinics, dry mouth and constipation, that is expected to improve long-term adherence of patients to treatment. Mirabegron can be used in patients with contraindications to antimuscarinics and in those who discontinued previous antimuscarinic therapy. Herein, we reviewed the published literature on mirabegron, focusing on the rationale of β3-agonism for OAB treatment and on the preclinical and clinical evidence of efficacy and safety available on this new pharmacological principle.

Urinary incontinence following obstetric fistula repair

Prolonged and/or obstructed labour is the most common cause of genital tract fistula world-wide, in particular, sub-Saharan Africa and parts of Asia where emergency obstetric services are unavailable or suboptimal to afford timely delivery of the baby. This results in pressure necrosis by the fetal presenting part at the level of the obstruction in the maternal pelvis. Other reasons for obstetric fistula include trauma from vaginal deliveries (spontaneous or instrumental) and iatrogenic from cesarean section/hysterectomy. The majority of women develop the fistula during their first labour and most babies are stillborn. Women with a fistula suffer from leakage of urine and/or faeces from the vagina and surgery is the treatment for an established fistula. Long-term complications of fistulas include recurrent fistula, urinary incontinence, reproductive dysfunction, sexual dysfunction, mental health dysfunction, social isolation and orthopaedic complications such as footdrop. Ongoing urinary symptoms are not uncommon after successful fistula closure. There are various reasons for residual urinary incontinence following obstetric fistula repair including urinary stress incontinence, overactive bladder, mixed urinary incontinence and voiding dysfunction. Urinary incontinence after fistula repair requires careful evaluation prior to further surgery, as in some diagnoses, continence surgery is unlikely to treat and may worsen the condition. Initial results from educational and physiotherapy programs demonstrated a positive impact on post-fistula incontinence.

New developments of the effect of melatonin on reproduction

In the past decades, a lot of advances in understanding the biochemistry and physiology of the pineal gland have been made. There is evidence that it interacts with many endocrine as well as non-endocrine tissues to influence their metabolic activity modulating many organs and functions. Melatonin is secreted by the pineal gland in the brain and plays an important role in regulating the neuroendocrine system. This hormone is one of the major role players in the regulation of the circadian sleep-wake cycle. It is normally released from the pineal gland during the night in response to environmental changes in light. Studies have shown that melatonin plays a role in the regulation of many reproductive processes such as puberty, gonadal function, and pregnancy. Beside these, melatonin has been shown to be able to directly neutralize a number of free radicals and reactive oxygen and nitrogen species. The main objective of this review is to provide comprehensive information about the new developments in melatonin research regarding its role in reproduction. A review of international scientific literature was done and a question-and-answer format was used in an attempt to convey comprehensive information in a simple manner. This review discusses evidence currently available relating to the effect of melatonin on reproductive processes. It deliberates the mechanism of action of melatonin, its effect on puberty, testicular and ova function, pregnancy, and oxidative stress. A growing body of scientific evidence is suggesting that melatonin plays an important role in reproductive function. It is therefore imperative to highlight the beneficial effects of this hormone in improving the reproductive processes.

Cancer stem cells and early stage basal-like breast cancer

Ductal carcinoma in situ (DCIS) is a category of early stage, non-invasive breast tumor defined by the intraductal proliferation of malignant breast epithelial cells. DCIS is a heterogeneous disease composed of multiple molecular subtypes including luminal, HER2 and basal-like types, which are characterized by immunohistochemical analyses and gene expression profiling. Following surgical and radiation therapies, patients with luminal-type, estrogen receptor-positive DCIS breast tumors can benefit from adjuvant endocrine-based treatment. However, there are no available targeted therapies for patients with basal-like DCIS (BL-DCIS) tumors due to their frequent lack of endocrine receptors and HER2 amplification, rendering them potentially susceptible to recurrence. Moreover, multiple lines of evidence suggest that DCIS is a non-obligate precursor of invasive breast carcinoma. This raises the possibility that targeting precursor BL-DCIS is a promising strategy to prevent BL-DCIS patients from the development of invasive basal-like breast cancer. An accumulating body of evidence demonstrates the existence of cancer stem-like cells (CSCs) in BL-DCIS, which potentially determine the features of BL-DCIS and their ability to progress into invasive cancer. This review encompasses the current knowledge in regard to the characteristics of BL-DCIS, identification of CSCs, and their biological properties in BL-DCIS. We summarize recently discovered relevant molecular signaling alterations that promote the generation of CSCs in BL-DCIS and the progression of BL-DCIS to invasive breast cancer, as well as the influence of the tissue microenvironment on CSCs and the invasive transition. Finally, we discuss the translational implications of these findings for the prognosis and prevention of BL-DCIS relapse and progression.

Impact of pelvic radiotherapy on the female genital tract and fertility preservation measures

Radiotherapy to the pelvis can have a major and deleterious impact on the female genital tract. Despite significant advances in the technical delivery of radical pelvic radiotherapy there remains no way to avoid delivering substantial radiation doses to the ovaries and uterus for patients undergoing treatment for gynaecological cancers. Due to improved cure rates from radical chemo-radiotherapy and social trends toward delayed childbirth many women treated for cervical cancer with radical chemo-radiotherapy will wish to attempt to preserve their fertility. Whilst there are now established and emerging techniques for preserving ovarian function and ovarian tissue, there remains the difficulty of the irradiated uterus which, even if pregnancy can be achieved, results in an increased risk for pregnancy-related complications. Future developments may offer women in this difficult situation more and improved options for fertility preservation.

Amniocentesis: A contemporary review

Amniocentesis is an essential tool in obstetrics. Invasive testing remains the only modality for diagnostic genetic testing and the only way to provide comprehensive testing for chromosomal abnormalities. Despite increasing use of cell free fetal deoxyribonucleic acid (DNA) testing, amniocentesis should still be offered to all women who desire more complete and accurate genetic testing. Counseling patients on the limitations of screening tests is of the upmost importance and amniocentesis should continue to be recommended to confirm positive results from cell free fetal DNA testing or in the case of failed cell free fetal DNA test. As cell free fetal DNA screening has not adequately been studied in multiple gestations, its use is not recommended in this population and invasive testing should be offered. Amniocentesis is also very useful in providing additional information in settings other than genetic testing the second and third trimester. If intraamniotic infection is suspected, but the clinical findings are not enough to guide management, amniocentesis can provide testing that can both immediately clarify the picture (interleukin-6, gram stain, glucose levels) and finally confirm the presence of infection (culture). It can also be used to detect the presence of intrauterine viral infections. Additionally, amniocentesis may be used to test for markers of fetal lung maturity. The American Congress of Obstetricians and Gynecologists recommends that amniocentesis for this indication not be used in cases where late preterm delivery is indicated. It may be useful in guiding decision-making, however, when late preterm delivery is indicated, but when exact timing is unclear. Regardless of the indication, amniocentesis appears to be a relatively low risk procedure with minimal risk to the patient. Additional randomized controlled trials are not likely, as they are not feasible to due extremely high number of participants that would be needed to detect a difference in loss rates. Based on current literature, however, the risk of pregnancy loss from second trimester amniocentesis is low in both singleton and twin gestations. We counsel patients that technique has changed since the original studies in the 1970s and feel comfortable quoting a loss rate of 1/500-1/1000 based on contemporary data.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in epithelial ovarian cancer: State of the art

Advanced stage epithelial ovarian cancer (EOC) is difficult to treat with low overall cure rates. A new strategy combining maximal cytoreductive surgery (CRS) with intra-operative hyperthermic intraperitoneal chemotherapy (HIPEC) has been proposed to treat advanced stage EOC in the primary setting. Numerous small, heterogeneous studies have been conducted exploring outcomes in patients with predominantly advanced, recurrent or refractory disease treated with CRS + HIPEC. Although morbidity rates approaching 35% have been reported, oncologic outcomes are promising. Incorporation of HIPEC for the treatment of primary EOC has continued to gain interest. Several prospective phase 2 clinical trials were recently completed evaluating the impact of CRS + HIPEC in the primary setting. This article will briefly discuss the benefits of optimal surgical cytoreduction and the theoretical basis of intraperitoneal chemotherapy in patients with advanced stage EOC, and will then review existing literature describing oncologic outcomes in EOC patients treated with HIPEC in the primary setting.

Preeclampsia - What is to blame? The placenta, maternal cardiovascular system or both?

Preeclampsia (PE) is a pregnancy-specific syndrome, complicating 2%-8% of pregnancies. PE is a major cause of maternal mortality throughout the world with 60000 maternal deaths attributed to hypertensive disorders of pregnancy. PE also results in fetal morbidity due to prematurity and fetal growth restriction. The precise aetiology of PE remains an enigma with multiple theories including a combination of environmental, immunological and genetic factors. The conventional and leading hypotheses for the initial insult in PE is inadequate trophoblast invasion which is thought to result in incomplete remodelling of uterine spiral arteries leading to placental ischaemia, hypoxia and thus oxidative stress. The significant heterogeneity observed in pre-eclampsia cannot be solely explained by the placental model alone. Herein we critically evaluate the clinical (risk factors, placental blood flow and biomarkers) and pathological (genetic, molecular, histological) correlates for PE. Furthermore, we discuss the role played by the (dysfunctional) maternal cardiovascular system in the aetiology of PE. We review the evidence that demonstrates a role for both the placenta and the cardiovascular system in early- and late-onset PE and highlight some of the key differences between these two distinct disease entities.

Apoptosis and endometrial receptivity: Relationship with in vitro fertilization treatment outcome

Apoptosis is an important process in the reconstruction of endometrium within the menstrual cycle. The balance between cell proliferation and apoptosis regulates the periodic repair and shedding of endometrial cells and leads to the menstruation or prepare the mucosal layer of endometrium for the implantation of the embryo. Many factors with pro- and antiapoptotic action, such as B cell lymphoma/leukemia-2 and inhibitors apoptosis proteins families, caspases, tumor necrosis factor receptors, phosphatase and tensin homolog, proliferator-activated receptor gamma, microRNAs and others are differently expressed in the endometrial tissue at phases of menstrual cycle. Receptivity of the endometrium at the period of “window of implantation” is associated with the significant increase of apoptosis in endometrium to allow the embryo to be successfully implanted. The impairment of apoptosis regulation in the endometrium at this period often is observed in infertile women with endometriosis, tubal factor, polycystic ovary syndrome, etc.. In many cases the impairment of apoptosis regulation in the endometrium is the main cause of in vitro fertilization (IVF) treatment failure in these patients. As of today, the exact mechanisms and factors mediating the apoptotic process in normal endometrium and in infertile women are not fully understood. Herein, the literature data concerning the endometrial apoptosis regulation in general, and in light of the influence of apoptosis upon IVF treatment outcome are reviewed. The possibility to use some parameters of endometrial apoptosis for prediction of the successful pregnancy achievement in women participating in IVF protocols also is discussed.

Hepatitis B and pregnancy: An update review article

Chronic hepatitis B, as a global health problem, is a disease that begins in the prenatal period and its complications gradually become clear later in life. About 5% of women worldwide are carriers of chronic hepatitis B virus (HBV). The most common method of transmission of HBV around the world is from mother to infant. This article aims to review the unique challenges of hepatitis B in pregnancy. Data for this review were collected from our previous studies and experiences plus various data banks, such as PubMed, EMBASE, ISI Web of science, Scopus, Google Scholar and Iranian databases. A comprehensive search was performed using the combinations of the keywords to review relevant literature and higher education journals. All published data up to February 2014 have been included in this review. This article addresses several interesting aspects. First, hepatitis B in pregnancy can vary regarding prevalence, virus behavior, prenatal transmission and outcome of the pregnancy. Second, the women of reproductive age with chronic HBV remain a major source for continued spread of the virus. Finally, pregnant women need screening in prenatal care to enable early intervention when necessary.

Risks and guidelines for the consumption of alcohol during pregnancy

Daily average intake of alcohol during pregnancy has consistently been associated with short term adverse outcomes such as miscarriage, preterm birth and intrauterine growth restriction, a large variety of malformations, as well as long term adverse outcomes such as foetal alcohol syndrome, mental retardation and general impairment of cognitive functions including intelligence, attention, learning abilities as well as social and behavioural functions. Weekly average consumption and alcohol binge drinking (usually defined as ≥ 5 drinks on a single occasion) independently of high daily average intake has not been consistently associated with short and long term adverse outcomes. Health authorities in most countries recommend that pregnant women completely abstain from alcohol. Even so, many health professionals including doctors, midwives and nurses do not provide information to pregnant women in accordance with the official recommendations, although a large proportion of women of child bearing age and pregnant women drink alcohol, especially before recognition of pregnancy. The discrepancy between guidelines and the information practice of health personnel is likely to continue to exist because guidelines of abstinence are not clearly evidence-based and not in line with current focus on autonomy and informed choice for patients, and because guidelines do not consider the everyday clinical communication situation.

Anesthetic management of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy procedures

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy procedure are performed with increasing frequency to treat patients with diffused peritoneal carcinomatosis. These procedures have showed to increase life expectancy in what was previously considered a “terminal condition”. Anyway patients face major and life threatening derangements of their hemodynamic, respiratory and metabolic physiologic balance during the surgery and in the immediate postoperative period. Despite the need of an advanced organ monitoring and support all these derangements seem to be mild and short-lived when timely addressed, at least in the majority of patients. Intensive care physicians are involved in providing surveillance and organ support till the patient is effectively weaned after the operation. Moreover, the anesthesiologist as perioperative physician is involved in pain control, metabolic and nutritional support of this cohort of patients. This task can be challenging considering that part of the patients are already on a long list of pain control medication after previous surgery or chemotherapy. A malnourished state is common too and it is secondary to difficult feeding, wasting syndrome from the tumor and massive ascites. The last issue the anesthesiologists need to be aware of is the impact over the quality of life (QoL) of this procedure. The patient’s underlying pathology is unlikely to be definitively cured so no treatment is an acceptable choice. The possibility to withhold the treatments must be part of the consultation process like the discussion about the QoL in the immediate, as well as in the long-term, after the operation. Careful monitoring and treatment of every aspect that can impact the QoL must be taken and the efforts to be poured into an effective preservation of the QoL must be doubled when compared with a patient scheduled for major abdominal surgery.

Human papilloma virus vaccination: Review article and an update

Human papilloma virus (HPV) is sexually transmitted and associated with uterine cervix, vaginal, and vulvar cancers in females, oropharyngeal and anal cancer in both genders, and penile cancer in males. Moreover, genital warts are benign tumors which are HPV-related and can occur in both genders. This is a review of HPV structure, HPV infection transmission, the global impact of HPV and its associated diseases, HPV vaccines and their efficacy and safety, public acceptance of HPV vaccines, the obstacles for its acceptance and strategies to address the barriers. Cervarix (a bivalent vaccine with protection against HPV types 16 and 18) and Gardasil (a quadrivalent vaccine with protection against HPV types 6, 11, 16 and 18) are 2 recommended vaccines. The longest follow up of 9.4 years has shown efficacy and protection of the vaccine against HPV types 16 and 18. The adverse effects have been minimal and the vaccine is considered safe. Numerous studies are conducted to follow the vaccinated individuals to better understand the effect of HPV vaccine on incidence of HPV-related cancers and precancerous lesions.

Pathobiological role of MUC16 mucin (CA125) in ovarian cancer: Much more than a tumor biomarker

MUC16 (CA125) has remained the mainstay for ovarian cancer assessment and management since the early 1980’s. With the exception of HE4, it is the only reliable serum biomarker for ovarian cancer. MUC16 belongs to a family of high-molecular weight glycoproteins known as mucins. The mucin family is comprised of large secreted transmembrane proteins that includes MUC1, MUC4 and MUC16. These mucins are often overexpressed in a variety of malignancies. MUC1 and MUC4 have been shown to contribute to breast and pancreatic tumorigenesis. Recent studies have uncovered unique biological functions for MUC16 that go beyond its role as a biomarker for ovarian cancer. Here, we provide an overview of the literature to highlight the importance of MUC16 in ovarian cancer tumorigenesis. We focus on the growing literature describing the role of MUC16 in proliferation, migration, metastasis, tumorigenesis and drug resistance. Accumulating experimental evidence suggest that the C-terminal domain of MUC16 is critical to mediate theses effects. The importance of MUC16 in the pathogenesis of ovarian cancer emphasizes the need to fully understand the signaling capabilities of MUC16 C-terminal domain to develop more efficient strategies for the successful treatment of ovarian cancer.

Pioneering drugs for overactive bladder and detrusor overactivity: Ongoing research and future directions

The ongoing research on pioneering drug candidates for the overactive bladder (OAB) aimed to overcome the limitations of currently licensed pharmacotherapies, such as antimuscarinics, β3-adrenergic agents, and botulinum neurotoxin, has been reviewed performing a systematic literature review and web search. The review covers the exploratory agents alternative to available medications for OAB and that may ultimately prove to be therapeutically useful in the future management of OAB patients based on preclinical and early clinical data. It emerges that many alternative pharmacological strategies have been discovered or are under investigation in disease-oriented studies. Several potential therapeutics are known for years but still find obstacles to pass the clinical stages of development, while other completely novel compounds, targeting new pharmacological targets, have been recently discovered and show potential to translate into clinical therapeutic agents for idiopathic and neurogenic OAB syndrome. The global scenario of investigational drugs for OAB gives promise for the development of innovative therapeutics that may ultimately prove effective as first, combined or second-line treatments within a realistic timescale of ten years.

High prevalence of post-partum depression in women with coeliac disease

AIM: To explore the prevalence of post-partum depression (PPD) in coeliac disease (CD).

METHODS: We performed a case-control study evaluating the prevalence of PPD in CD patients on gluten-free diet (GFD) compared to that of healthy subjects experiencing a recent delivery. All participants were interviewed about menstrual features, modality and outcome of delivery and were evaluated for PPD by Edinburgh Postnatal Depression Scale (EPDS).

RESULTS: The study included 70 CD patients on GFD (group A) and 70 controls (group B). PPD was present in 47.1% of CD women and in 14.3% of controls (P < 0.01; OR = 3.3). Mean EPDS score was higher in CD compared to the controls (mean score: group A 9.9 ± 5.9; group B 6.7 ± 3.7; P < 0.01). A significant association was observed between PPD and menstrual disorders in CD (69.7% vs 18.9%; P < 0.001; OR = 3.6).

CONCLUSION: PPD is frequent in CD women on GFD, particularly in those with previous menstrual disorders. We suggest screening for PPD in CD for early detection and treatment of this condition.

MicroRNAs: New players in endometriosis

Endometriosis is an estrogen-dependent inflammatory disorder that limits the quality of life of affected women. This pathology affects 10% of reproductive-age women, although the prevalence in those patients experiencing pain, infertility or both is as high as 35%-50%. Endometriosis is characterized by endometrial-like tissue outside the uterus, primarily on the pelvic peritoneum, ovaries and the pouch of Douglas. Despite extensive research endeavours, a unifying theory regarding the exact etiopathogenic mechanism of this high prevalent and incapacitating condition is still lacking, although it has been suggested that epigenetics could be involved. MicroRNAs (miRNAs), one of the epigenetic players, are small non-coding RNAs that can act as post-transcriptional regulators of gene expression, reducing the expression of their target mRNAs either inhibiting its translation or promoting its degradation. MiRNA expression profiles are specific of tissue and cell type. Abnormal miRNA expression has been described in different pathological conditions, such as a myriad of oncological, cardiovascular and inflammatory diseases and gynecological pathologies. In endometriosis, miRNA expression patterns of eutopic endometrium from patients and control women and from different endometriotic lesions have been described. These small non-coding molecules have become attractive candidates as novel biomarkers for an early non-invasive diagnosis of the disease, which could suppose a valuable benefit to the patients in terms of improvement of prognosis and reduction of the ratio of recurrence. In this systematic review we will focus on the role of miRNAs in the pathophisiology of endometriosis.

Care of survivors of gynecologic cancers

The number of cancer survivors is increasing and most healthcare providers will manage patients who have completed therapy for malignancy at some point. The care of survivors of gynecologic malignancies may seem daunting in a busy general gynecology practice. This paper intends to review the literature and suggest management of these women for the general gynecologist.

Hypothyroidism during pregnancy: Controversy over screening and intervention

Thyroid hormones are critical for foetal neurological development and maternal health. Maternal hypothyroidism during pregnancy is associated with adverse impact on health of the mother as well as the progeny. Reduced thyroid hormone levels predispose the child to develop mental retardation and cognitive delay in early life. In the mother, hypothyroidism during pregnancy is associated with spontaneous abortion, placental abruption, preterm delivery and hypertensive disorders. Therefore, screening and therapeutic intervention is justified to prevent foetal as well as maternal co-morbidities. In view of impact of such a large-scale screening and intervention program on limited healthcare resources, it is debatable if a targeted rather than universal screening program will result in comparable outcomes. In addition, there is an ongoing debate regarding best evidence-based practice for the management of isolated hypothyroxinaemia, subclinical hypothyroidism and euthyroid women with autoimmune hypothyroidism. We have carried out a review of the literature; firstly, to determine whether universal screening for asymptomatic women in early pregnancy would be cost-effective. Secondly, we have retrospectively reviewed the literature to analyse the evidence regarding the impact of therapeutic intervention in women with subclinical hypothyroidism.