Therapeutic roles of platelet-rich plasma to restore female reproductive and endocrine dysfunction

Millions of women worldwide are infertile due to gynecological disorders, including premature ovarian insufficiency, polycystic ovary syndrome, Asherman syndrome, endometrial atrophy, and fallopian tube obstruction. These conditions frequently lead to infertility and have a substantial impact on the quality of life of the affected couples, primarily because of their psychological implications and high financial costs. Recently, using platelets to stimulate cell proliferation and tissue differentiation has emerged as a promising approach in regenerative medicine. Platelet-rich plasma (PRP) shows considerable potential for promoting endometrial hypertrophy and follicle development, making it a promising therapeutic option for tissue repair or replacement. This review provides an overview of the recent advancements and underlying mechanisms of PRP therapy for various female reproductive diseases and presents new therapeutic options for addressing female infertility.

Integrated Care for Persons With Persistent Gynecologic Conditions

Persons with persistent gynecologic conditions frequently cope with complex biopsychosocial challenges and benefit from integrated behavioral health evaluation and treatment within gynecologic practices. Integrated care refers to the provision of behavioral health services within a health care setting which contributes to improved patient, provider, and practice outcomes, however, has not been commonly provided in traditional gynecologic practices. Several models of integrated behavioral health are reviewed. Each model holds specific applications in primary and specialty gynecology settings and may enhance the gynecologic patient experience. This article reviews current research supporting integrated care and describes implementation, funding, and evaluation to improve patient outcomes.

Patient navigation in women's health care for maternal health and noncancerous gynecologic conditions: a scoping review

PURPOSE

This study investigated the scope of patient navigation studies on women's health care for maternal health and noncancerous gynecologic conditions and aimed to report the characteristics of the identified patient navigation programs.

METHODS

A scoping review was conducted following Arksey and O'Malley's framework. Five electronic databases were searched for relevant studies published in English: PubMed, Embase, Cochrane Library, CINAHL, and PsycInfo. There were no restrictions on the publication date and the search was completed in July 2023.

RESULTS

This scoping review included 14 studies, which collectively examined seven patient navigation programs. All selected studies were related to maternal health issues (e.g., perinatal health problems and contraception for birth spacing). Close to two-thirds of the patient navigation services were provided by women (n=9, 64.3%) and half by lay navigators (n=7, 50.0%). The majority incorporated the use of mobile health technologies (n=11, 78.6%). All of the patient navigation programs included in the review coordinated the necessary clinical and social support services to improve women's access to care.

CONCLUSION

Patient navigation appears to be in its nascent phase in the field of maternal health. The results of this study suggest that the implementation of patient navigation services could potentially improve access to care for socially disadvantaged women and families. Furthermore, providing patient navigation services that are specifically tailored to meet women's needs could improve the quality of maternity care.

Acute Pelvic Pain: Role of Imaging in the Diagnosis and Management

Acute pelvic pain is defined as a new symptom that has been present for less than 3 months. It is a common symptom seen in 15%-24% of women and is the indication for 20% of laparoscopies and 2%-10% of outpatient gynecologic visits. The pregnancy status and correlation of the physical symptoms with clinical findings are important. Ultrasound is the imaging modality of choice, not only to diagnose gynecological causes, but also bowel or urinary tract related causes of pelvic pain. When an ultrasound scan is inconclusive, a computed tomography scan is the preferred means of additional imaging and is particularly useful in gastrointestinal and urogenital causes of pelvic pain. Gynecological causes of acute pelvic pain include uterine, tubal, or ovarian pathology; non-gynecological causes include bowel diseases, such as appendicitis and diverticulitis; urogenital causes such as ureteral, bladder stones, and urinary tract infection as well as vascular causes. Ultrasound imaging alone may provide a definitive diagnosis in underlying conditions that require prompt medical or surgical intervention in gynecological conditions, such as ovarian torsion, ectopic pregnancy, and non-gynecological condition, such as in acute appendicitis.

Regeneration and anti-inflammatory effects of stem cells and their extracellular vesicles in gynecological diseases

There are many gynecological diseases, among which breast cancer (BC), cervical cancer (CC), endometriosis (EMs), and polycystic ovary syndrome (PCOS) are common and difficult to cure. Stem cells (SCs) are a focus of regenerative medicine. They are commonly used to treat organ damage and difficult diseases because of their potential for self-renewal and multidirectional differentiation. SCs are also commonly used for difficult-to-treat gynecological diseases because of their strong directional differentiation ability with unlimited possibilities, their tendency to adhere to the diseased tissue site, and their use as carriers for drug delivery. SCs can produce exosomes in a paracrine manner. Exosomes can be produced in large quantities and have the advantage of easy storage. Their safety and efficacy are superior to those of SCs, which have considerable potential in gynecological treatment, such as inhibiting endometrial senescence, promoting vascular reconstruction, and improving anti-inflammatory and immune functions. In this paper, we review the mechanisms of the regenerative and anti-inflammatory capacity of SCs and exosomes in incurable gynecological diseases and the current progress in their application in genetic engineering to provide a foundation for further research.

[Pelvic exam in gynecology and obstetrics: Guidelines for clinical practice]

OBJECTIVE

To provide guidelines for the pelvic clinical exam in gynecology and obstetrics.

MATERIAL AND METHODS

A multidisciplinary experts consensus committee of 45 experts was formed, including representatives of patients' associations and users of the health system. The entire guidelines process was conducted independently of any funding. The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized.

METHODS

The committee studied 40 questions within 4 fields for symptomatic or asymptomatic women (emergency conditions, gynecological consultation, gynecological diseases, obstetrics, and pregnancy). Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology.

RESULTS

The experts' synthesis work and the application of the GRADE method resulted in 27 recommendations. Among the formalized recommendations, 17 present a strong agreement, 7 a weak agreement and 3 an expert consensus agreement. Thirteen questions resulted in an absence of recommendation due to lack of evidence in the literature.

CONCLUSIONS

The need to perform clinical examination in gynecological and obstetrics patients was specified in 27 pre-defined situations based on scientific evidence. More research is required to investigate the benefit in other cases.

A population-based analysis of the impact of the COVID-19 pandemic on common abdominal and gynecological emergency department visits

BACKGROUND

Reduced use of the emergency department during the COVID-19 pandemic may result in increased disease acuity when patients do seek health care services. We sought to evaluate emergency department visits for common abdominal and gynecologic conditions before and at the beginning of the pandemic to determine whether changes in emergency department attendance had serious consequences for patients.

METHODS

We conducted a population-based analysis using administrative data to evaluate the weekly rate of emergency department visits pre-COVID-19 (Jan. 1-Mar. 10, 2020) and during the beginning of the COVID-19 pandemic (Mar. 11-June 30, 2020), compared with a historical control period (Jan. 1-July 1, 2019). All residents of Ontario, Canada, presenting to the emergency department with appendicitis, cholecystitis, ectopic pregnancy or miscarriage were included. We evaluated weekly incidence rate ratios (IRRs) of emergency department visits, management strategies and clinical outcomes.

RESULTS

Across all study periods, 39 691 emergency department visits met inclusion criteria (40.2 % appendicitis, 32.1% miscarriage, 21.3% cholecystitis, 6.4% ectopic pregnancy). Baseline characteristics of patients presenting to the emergency department did not vary across study periods. After an initial reduction in emergency department visits, presentations for cholecystitis and ectopic pregnancy quickly returned to expected levels. However, presentations for appendicitis and miscarriage showed sustained reductions (IRR 0.61-0.80), with 1087 and 984 fewer visits, respectively, after the start of the pandemic, relative to 2019. Management strategies, complications and mortality rates were similar across study periods for all conditions.

INTERPRETATION

Although our study showed evidence of emergency department avoidance in Ontario during the first wave of the COVID-19 pandemic, no adverse consequences were evident. Emergency care and outcomes for patients were similar before and during the pandemic.

Nutrition in Gynecological Diseases: Current Perspectives

Diet and nutrition are fundamental in maintaining the general health of populations, including women’s health. Health status can be affected by nutrient deficiency and vice versa. Gene–nutrient interactions are important contributors to health management and disease prevention. Nutrition can alter gene expression, as well as the susceptibility to diseases, including cancer, through several mechanisms. Gynecological diseases in general are diseases involving the female reproductive system and include benign and malignant tumors, infections, and endocrine diseases. Benign diseases such as uterine fibroids and endometriosis are common, with a negative impact on women’s quality of life, while malignant tumors are among the most common cause of death in the recent years. In this comprehensive review article, a bibliographic search was performed for retrieving information about nutrients and how their deficiencies can be associated with gynecological diseases, namely polycystic ovary syndrome, infertility, uterine fibroids, endometriosis, dysmenorrhea, and infections, as well as cervical, endometrial, and ovarian cancers. Moreover, we discussed the potential beneficial impact of promising natural compounds and dietary supplements on alleviating these significant diseases.

Organoids of the female reproductive tract

Healthy functioning of the female reproductive tract (FRT) depends on balanced and dynamic regulation by hormones during the menstrual cycle, pregnancy and childbirth. The mucosal epithelial lining of different regions of the FRT-ovaries, fallopian tubes, uterus, cervix and vagina-facilitates the selective transport of gametes and successful transfer of the zygote to the uterus where it implants and pregnancy takes place. It also prevents pathogen entry. Recent developments in three-dimensional (3D) organoid systems from the FRT now provide crucial experimental models that recapitulate the cellular heterogeneity and physiological, anatomical and functional properties of the organ in vitro. In this review, we summarise the state of the art on organoids generated from different regions of the FRT. We discuss the potential applications of these powerful in vitro models to study normal physiology, fertility, infections, diseases, drug discovery and personalised medicine.

Exosomes as Biomarkers for Female Reproductive Diseases Diagnosis and Therapy

Cell-cell communication is an essential mechanism for the maintenance and development of various organs, including the female reproductive system. Today, it is well-known that the function of the female reproductive system and successful pregnancy are related to appropriate follicular growth, oogenesis, implantation, embryo development, and proper fertilization, dependent on the main regulators of cellular crosstalk, exosomes. During exosome synthesis, selective packaging of different factors into these vesicles happens within the originating cells. Therefore, exosomes contain both genetic and proteomic data that could be applied as biomarkers or therapeutic targets in pregnancy-associated disorders or placental functions. In this context, the present review aims to compile information about the potential exosomes with key molecular cargos that are dysregulated in female reproductive diseases which lead to infertility, including polycystic ovary syndrome (PCOS), premature ovarian failure (POF), Asherman syndrome, endometriosis, endometrial cancer, cervical cancer, ovarian cancer, and preeclampsia, as well as signaling pathways related to the regulation of the reproductive system and pregnancy outcome during these pathological conditions. This review might help us realize the etiology of reproductive dysfunction and improve the early diagnosis and treatment of the related complications.

A Diagnostic Approach to Conditions that Mimic Sexual Abuse

Primary care providers are often the first point of contact when there are concerns of child sexual abuse. The history is the key factor in making the diagnosis as most children who have experienced child sexual abuse do not have an abnormal anogenital examination. When anogenital symptoms precipitate concerns for sexual abuse, especially in the absence of a history of sexual abuse, it is important to be aware of conditions that mimic sexual abuse. Being familiar with such conditions allows the provider to determine appropriate management, differentiate an anatomical variant or medical condition from abuse, and provide reassurance to the patient and family. Unnecessarily reporting these cases can have detrimental effects on the patient and family. If any doubt arises, patients can be referred for further evaluation by an expert in child abuse. This article presents many common medical conditions that can mimic sexual abuse, with a focus on history, examination findings, and management. [Pediatr Ann. 2020;49(8):e334-e340.].

The management of gynecological complications in long-term survivors after allogeneic hematopoietic cell transplantation-a single-center real-life experience

In everyday gynecological practice, there is an unmet need to manage survivors after allogeneic hematopoietic cell transplantation (allo-HCT). The major gynecological complications include premature ovarian insufficiency (POI), chronic graft-versus-host disease (cGVHD) of the anogenital zone (cGVHDgyn), and secondary neoplasms. Aiming to assess a real-life scale of problems associated with HCT, we performed a detailed analysis of a consecutive series of females after allo-HCT who were referred for a routine gynecological evaluation. The study includes 38 females after allo-HCT in whom gynecological examination with cervical smear and USG were performed, followed by colposcopy according to NCCN guidelines. NIH scoring system was used to classify a grade of cGVHDgyn. The incidence of cGVHD was 71% whereas GVHDgyn was 29%, including 5 patients with score 3 at the time of diagnosis. The other manifestations (frequently noted) included the skin, mucosa, eyes, and liver. Menopause was diagnosed in 93% females, and in 81% of them, POI criteria were fulfilled. Ovarian function resumed in 2 cases. The rate of abnormal cytology was 26%: 4 ASCUS, 1 AGUS, 1 LSIL, 3 HSIL/ASC-H, and one cytological suspicion of cervical cancer. GVHDgyn was documented in 10 patients, and 6 of them had abnormal cervical cytology. Early topical estrogen therapy led to a significant reduction in vaginal dryness (p < 0.05), dyspareunia (p < 0.05), and less frequent cGVHDgyn (p < 0.05). GVHDgyn develops in about 30% of long-term allo-HCT survivors. Topical estrogens and hormonal replacement therapy alleviate symptoms and prevent the occurrence of severe consequences of menopause.

Genital Ulcers: Differential Diagnosis and Management

Genital ulcers may be located on the vagina, penis, and anorectal or perineal areas and may be infectious or noninfectious. Herpes simplex virus is the most common cause of genital ulcers in the United States. A diagnosis of genital herpes simplex virus infection is made through physical examination and observation of genital lesions. The 2015 Centers for Disease Control and Prevention sexually transmitted disease guidelines provide strategies for the management of patients with genital ulcer disease. Specific testing includes a polymerase chain reaction test for herpes simplex virus; syphilis serology and darkfield microscopy or a direct fluorescent antibody test for Treponema pallidum; and/or culture for Haemophilus ducreyi in settings where chancroid is highly prevalent. Rarely, cases of Epstein-Barr virus may present with genital ulcers. Syphilis and chancroid cause genital ulcers and are mandatory reportable diseases to the local health department. In some cases, no pathogen is identified. It is important to consider noninfectious etiologies such as sexual trauma, psoriasis, Behçet syndrome, and fixed drug eruptions. Genital ulcers are symptomatic by definition, and the U.S. Preventive Services Task Force recommends screening for syphilis infection for those at risk, early screening for syphilis infection in all pregnant women, and against routine serologic screening for genital herpes simplex virus infection in asymptomatic adolescents and adults, including those who are pregnant.

Effectiveness of topical and ablative therapies in treatment of anogenital warts: a systematic review and network meta-analysis

OBJECTIVE

To generate estimates of comparative clinical effectiveness for interventions used in the treatment of anogenital warts (AGWs) through the systematic review, appraisal and synthesis of data from randomised controlled trials (RCTs).

DESIGN

Systematic review and network meta-analysis of RCTs. Search strategies were developed for MEDLINE, Embase, the Cochrane Library and the Web of Science. For electronic databases, searches were run from inception to March 2018. The systematic review was carried out following the general principles recommended in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.

PARTICIPANTS

People aged ≥16 years with clinically diagnosed AGWs (irrespective of biopsy confirmation).

INTERVENTIONS

Topical and ablative treatments recommended by the British Association for Sexual Health and HIV for the treatment of AGWs, either as monotherapy or in combination versus each other.

OUTCOME MEASURES

Complete clearance of AGWs at the end of treatment and at other scheduled visits, and rate of recurrence.

RESULTS

Thirty-seven RCTs met inclusion criteria. Twenty studies were assessed as being at unclear risk of bias, with the remaining studies categorised as high risk of bias. Network meta-analysis indicates that, of the treatment options compared, carbon dioxide laser therapy is the most effective treatment for achieving complete clearance of AGWs at the end of treatment. Of patient-applied topical treatments, podophyllotoxin 0.5% solution was found to be the most effective at achieving complete clearance, and was associated with a statistically significant difference compared with imiquimod 5% cream and polyphenon E 10% ointment (p<0.05). Few data were available on recurrence of AGWs after complete clearance. Of the interventions evaluated, surgical excision was the most effective at minimising risk of recurrence.

CONCLUSION

Of the studies assessed, as a collective, the quality of the evidence is low. Few studies are available that evaluate treatment options versus each other.

TRIAL REGISTRATION NUMBER

CRD42013005457.

Genital Psoriasis: Impact on Quality of Life and Treatment Options

Psoriasis involving the genital skin occurs in up to two-thirds of psoriasis patients but is often overlooked by physicians. Furthermore, psoriasis objective and subjective severity indexes for common plaque psoriasis often neglect the impact this small area of psoriasis can have on a patient. It can have a significant impact on patients' psychosocial function due to intrusive physical symptoms such as genital itch and pain, and a detrimental impact on sexual health and impaired relationships. The mainstay of treatment is topical therapy. In patients with genital psoriasis refractory to traditional topical treatment, biologic treatments may greatly improve patient outcomes.

Position statement for the diagnosis and management of anogenital warts

BACKGROUND

Anogenital warts (AGW) can cause economic burden on healthcare systems and are associated with emotional, psychological and physical issues.

OBJECTIVE

To provide guidance to physicians on the diagnosis and management of AGW.

METHODS

Fourteen global experts on AGW developed guidance on the diagnosis and management of AGW in an effort to unify international recommendations. Guidance was developed based on published international and national AGW guidelines and an evaluation of relevant literature published up to August 2016. Authors provided expert opinion based on their clinical experiences.

RESULTS

A checklist for a patient's initial consultation is provided to help physicians when diagnosing AGW to get the relevant information from the patient in order to manage and treat the AGW effectively. A number of frequently asked questions are also provided to aid physicians when communicating with patients about AGW. Treatment of AGW should be individualized and selected based on the number, size, morphology, location, and keratinization of warts, and whether they are new or recurrent. Different techniques can be used to treat AGW including ablation, immunotherapy and other topical therapies. Combinations of these techniques are thought to be more effective at reducing AGW recurrence than monotherapy. A simplified algorithm was created suggesting patients with 1-5 warts should be treated with ablation followed by immunotherapy. Patients with >5 warts should use immunotherapy for 2 months followed by ablation and a second 2-month course of immunotherapy. Guidance for daily practice situations and the subsequent action that can be taken, as well as an algorithm for treatment of large warts, were also created.

CONCLUSION

The guidance provided will help physicians with the diagnosis and management of AGW in order to improve the health and quality of life of patients with AGW.

[The application of "regulate sanjiao acupuncture" in the treatment of gynecological diseases]

To explore the clinical efficacy of "regulate sanjiao (triple warmer) acupuncture" in the treatment of gynecological diseases. To discuss the pathogenesis of sanjiao and gynecological diseases, and to briefly analyze the theory of "regulate sanjiao acupuncture", the method of selecting acupoints and operating methods. In order to use the "regulate sanjiao" as the rule, Baihui (GV 20), Danzhong (CV 17), Zhongwan (CV 12), Tianshu (ST 25), Qihai (CV 6), Guanyuan (CV 4), Zhongji (CV 3), Zigong (EX-CA 1), Xuehai (SP 10), Sanyinjiao (SP 6), Baliao were selected as the main acupoints to cooperate with syndrome differentiation for the treatment of gynecological diseases, such as infertility, perimenopausal syndrome. "Regulate sanjiao acupuncture" is effective in the treatment of infertility and perimenopausal syndrome, which is worthy of clinical promotion and application.

Identification and management of adolescent gynecologic emergencies in the emergency department

In the emergency department, gynecologic complaints are common presentations for adolescent girls, who may present with abdominal pain, pelvic pain, vaginal discharge, and vaginal bleeding. The differential diagnosis for these presentations is broad, and further complicated by psychosocial factors, confidentiality concerns, and the need to recognize abuse and sexual assault. This issue provides recommendations for the evaluation and management of obstetric and gynecologic emergencies including infectious, anatomic, and endocrine etiologies. Offering adolescents evidence-based guidance and treatment for sexually transmitted infection and avoiding unwanted pregnancy can help to mitigate the high-risk behavior that can affect their wellness and future fertility.

Diagnosing and managing common genital emergencies in pediatric girls

The presentation of genital injuries and emergencies in pediatric girls can sometimes be misleading. A traumatic injury with excessive bleeding may be a straddle injury that requires only conservative management, while a penetrating injury may have no recognizable signs or symptoms but require extensive surgery. This issue reviews the most common traumatic genital injuries in girls presenting to the emergency department, including straddle injuries, hematomas, and impalement injuries. Nontraumatic emergencies, including hematocolpos and urethral prolapse, are also discussed. Evidence-based recommendations are presented for identifying and managing these common genital injuries and emergencies in pediatric girls.

Non-contraceptive benefits of intrauterine levonorgestrel administration: why not?

Levonorgestrel intrauterine systems (LNG-IUS) represent a modern therapy for an array of preexisting gynecological conditions, though they were first marketed in Finland in 1990. However, there are countries in which their use is extremely limited by social and cultural factors. This manuscript describes the possible reasons for this misuse, taking in consideration the clinical noncontraceptive benefits of intrauterine levonorgestrel in routinary practice. Medical diseases in which LNG-IUS represent a treatment include abnormal uterine bleeding, iron-deficiency anemia, endometrial hyperplasia, uterine fibroids, adenomyosis, endometriosis, and coagulopathies. The advantage of reducing the need for more radical treatments such as surgery or hysterectomy is well demonstrated, with remarkable benefits for patients. However, in many countries, surgery is still used as a first-line treatment and there is a need to define who could benefit from a less invasive option. It seems clear that such a reduced use of LNG-IUS depends on factors that imply both patients and practitioners, and that the role of counseling is becoming a key component in the decision-making process to reach the ultimate goal of compliance.

A Pediatrician's Take on a Few Common Infant Urologic and Gynecologic Issues

Urologic and gynecologic issues are common in a pediatric primary care office. This article focuses on the evaluation and management of a few common diagnoses in infants and young children: fetal hydronephrosis, labial adhesions, physiologic phimosis, and hydrocele. This article can help pediatricians decide when these common issues can be managed in the primary care office and when they need subspecialty guidance. [Pediatr Ann. 2017;46(11):e397-e399.].