Does dienogest influence the inflammatory response of endometriotic cells? A systematic review

OBJECTIVE AND DESIGN

A systematic review of all literature was done to assess the ability of the progestin dienogest (DNG) to influence the inflammatory response of endometriotic cells.

MAIN OUTCOME MEASURES

In vitro and in vivo studies report an influence of DNG on the inflammatory response in eutopic or ectopic endometrial tissue (animal or human).

RESULTS

After strict inclusion criteria were satisfied, 15 studies were identified that reported a DNG influence on the inflammatory response in endometrial tissue. These studies identified a modulation of prostaglandin (PG) production and metabolism (PGE2, PGE2 synthase, cyclo-oxygenase-2 and microsomal PGE synthase-1), pro-inflammatory cytokine and chemokine production [interleukin (IL)-1β, IL-6, IL-8, tumor necrosis factor-α, monocyte chemoattractant protein-1 and stromal cell-derived factor-1], growth factor biosynthesis (vascular endothelial growth factor and nerve growth factor) and signaling kinases, responsible for the control of inflammation. Evidence supports a progesterone receptor-mediated inhibition of the inflammatory response in PR-expressing epithelial cells. It also indicated that DNG inhibited the inflammatory response in stromal cells, however, whether this was via a PR-mediated mechanism is not clear.

CONCLUSIONS

DNG has a significant effect on the inflammatory microenvironment of endometriotic lesions that may contribute to its clinical efficacy. A better understanding of the specific anti-inflammatory activity of DNG and whether this contributes to its clinical efficacy can help develop treatments that focus on the inhibition of inflammation while minimizing hormonal modulation.

Use of contraception by women with induced abortion in Italy

AIM

Aim of the present study was to investigate type of contraception, if any, used by women with induced abortion.

METHODS

Retrospective analysis on the medical records of 1782 women with induced abortion performed at the University Hospital of Modena (Italy) between 2009 and 2011.

RESULTS

Some kind of contraception was used by 81.1% of women with induced abortion. At time of conception most of these women (39%) had used withdrawal, 19% natural methods, 15.2% condom, 7% hormonal contraception (95% estrogen plus progestin for any route) and 0.4% copper-IUD. None was using implants or levonorgestrel-IUD. Figures of past use of hormonal contraception were much higher than those present at the time of the unwanted pregnancy (50.3% vs. 7%; P<0.0001). A higher prevalence of condom use (19.7% vs. 10.9%; P<0.0001), and a lower prevalence of natural methods (14.5% vs. 21.6%; P<0.001) were found in single vs. married women. Use of no contraception was more prevalent among low vs. highly educated women with induced abortion (22.2% vs. 14.2%; P<0.02), but was not related to marital status. Prevalence of use of the different contraceptives is different from the one described in the general population, suggesting differences in contraceptive efficacy among the different methods.

CONCLUSION

Women with induced abortion infrequently use long term or hormonal contraception. In half of the cases the latter has been used at least once in life, but then it has been abandoned. Appropriate education and contraceptive counselling, personalization and follow-up may reduce induced abortion.

Modification of body composition and metabolism during oral contraceptives containing non-androgenic progestins in association with estradiol or ethinyl estradiol

AIM

To observe the influence on metabolism and body composition of two oral contraceptives containing non-androgenic progestins in association with estradiol or ethinyl estradiol (EE).

STUDY DESIGN

Women on hormonal contraception with estradiol valerate (E2V)/dienogest (DNG) in a quadriphasic regimen (n = 16) or 30 μg EE/2 mg chlormadinone acetate (CMA) (n = 16) in a monophasic regimen were evaluated at the third cycle for modifications in lipoproteins, apoproteins and homeostatic model assessment for insulin resistance (HOMA-IR), and at the sixth cycle for body composition and the markers of bone turnover osteocalcin and C-telopeptide X.

RESULTS

During E2V/DNG lipoprotein, apoproteins and HOMA-IR remained stable. During EE/CMA, total-cholesterol (p = 0.003), high-density lipoprotein (HDL)-cholesterol (p = 0.001), triglycerides (p = 0.003) Apoprotein-A1 (Apo-A1; p = 0.001) and Apo B (p = 0.04) increased, low-density lipoprotein/HDL (p = 0.039) decreased and total-cholesterol/HDL and Apoprotein-B/Apo-A1 ratio did not vary. HOMA-IR slightly increased from 1.33 ± 0.87 to 1.95 ± 0.88 (p = 0.005). There was a reduction of markers of bone metabolism in both groups with no modification of body composition.

CONCLUSIONS

Administration of E2V/DNG does not influence lipid and glucose metabolism, while mixed effect are exerted by EE/CMA. Both preparations reduce bone metabolism without influencing short-term effect on body composition.

Multinational, multicentre, randomised, open-label study evaluating the impact of a 91-day extended regimen combined oral contraceptive, compared with two 28-day traditional combined oral contraceptives, on haemostatic parameters in healthy women

OBJECTIVES

To evaluate the impact of a 91-day extended regimen combined oral contraceptive (150 μg levonorgestrel [LNG]/30 μg ethinylestradiol [EE] for 84 days, followed by 10 μg EE for seven days [Treatment 1]) compared with two traditional 21/7 regimens (21 days 150 μg LNG/30 μg EE [Treatment 2] or 150 μg desogestrel [DSG]/30 μg EE [Treatment 3], both with seven days' hormone free), on several coagulation factors and thrombin formation markers.

METHODS

Randomised, open-label, parallel-group comparative study involving healthy women (18-40 years). The primary endpoint was change from baseline in prothrombin fragment 1 + 2 (F1 + 2) levels over six months.

RESULTS

A total of 187 subjects were included in the primary analysis. In all groups, mean F1 + 2 values were elevated after six months of treatment. Changes were comparable between Treatments 1 and 2 (least squares mean change: 170 pmol/L and 158 pmol/L, respectively) but noticeably larger after Treatment 3 (least squares mean change: 592 pmol/L). The haemostatic effects of Treatment 1 were comparable to those of Treatment 2 and noninferior to those of Treatment 3 (lower limit of 95% confidence interval [- 18.3 pmol/L] > - 130 pmol/L).

CONCLUSIONS

The LNG/EE regimens had similar effects on F1 + 2. Noninferiority was demonstrated between extended regimen LNG/EE and DSG/EE.

Tetracycline accumulates in Iberis sempervirens L. through apoplastic transport inducing oxidative stress and growth inhibition

Environmental antibiotic contamination is due mainly to improper and illegal disposal of these molecules that, yet pharmacologically active, are excreted by humans and animals. These compounds contaminate soil, water and plants. Many studies have reported the bioaccumulation of antibiotics in plants and their negative effects on photosynthesis, cell growth and oxidative balance. Therefore, the principal objective of this paper was the study of antibiotic accumulation sites in plants and its uptake modality. Iberis sempervirens L., grown in soil and in agar in the presence or absence of tetracycline, were used as a model system. Using confocal and transmission electron microscopy, we demonstrated that tetracycline was absorbed and propagated in plants through apoplastic transport and also accumulated in intercellular spaces. Tetracycline was rarely detected inside cells (in cytoplasm and mitochondria where, coherent to its pharmacological activity, it probably affected ribosomes), except in stomata. Moreover, we verified and clarified further the phytotoxic effects of tetracycline on plants. We observed that the antibiotic induced a large reduction in plant growth and development and inhibition of photosynthetic activity. As tetracycline may lead to oxidative stress in plants, plant cells tried to balance this disequilibrium by increasing the amount and activity of some endogenous enzyme antioxidant agents (superoxide dismutase 1 and catalase) and levels of antiradical secondary metabolites.

Age-specific reference values for serum FSH and estradiol levels throughout the reproductive period

High serum day 3 FSH levels are associated with poor ovarian reserve and reduced fertility, but the interpretation of FSH values according to age is still not univocal. The purpose of this study was to determine age-dependent reference values in women with regular menstrual cycles and FSH as a guide for specialists. The study was performed at the Department of Mother-Infant of a University-based tertiary care centre. One-hundred ninety-two healthy normal menstruating women were recruited for the study. All patients attended the department on menstrual cycle day 3 for a blood sample for FSH and estradiol determination. A linear relationship between FSH or estradiol serum levels and age was observed. The FSH level increased by 0.11 IU for every year of age (1 IU for every 9 years of age). The values of FSH and estradiol corresponding to the 5th, 25th, 50th, 75th, 95th centiles for any specific age have been calculated. Serum FSH levels need to be interpreted according to age-dependent reference values. Serum FSH levels on 95th centile for any age may represent a warning sign for reduced ovarian reserve.

Effects of the insulin sensitizer pioglitazone on menstrual irregularity, insulin resistance and hyperandrogenism in young women with polycystic ovary syndrome

BACKGROUND

Polycystic ovary syndrome (PCOS) is the most common endocrine cause of menstrual irregularities, hirsutism and acne. Women with PCOS present elevated plasma insulin levels, both fasting and after a glucose load, as an indirect evidence of insulin resistance. PCOS women may also present hypertension, low levels of HDL cholesterol, hypertriglyceridemia, visceral obesity and a higher level of CRP and fibrinogen that can predict an atherosclerotic risk.

METHODS

This study was carried out on 15 young women with PCOS selected according to the 2003 diagnostic criteria of The Rotterdam Consensus Statement and 15 Control women. PCOS women were treated with pioglitazone 30 mg/day and at the beginning and after 6 months of treatment were evaluated: menstrual cycle trend, hirsutism and acne, total cholesterolemia and HDL, triglyceridemia, fibrinogenemia, C-reactive protein, oral glucose tolerance test, glycated hemoglobin, FSH, LH, 17OH-progesterone, 17β-estradiol, free and total testosterone, SHBG, DHEA-S, Δ4-androstenedione and adiponectin.

RESULTS AND DISCUSSION

Treatment with pioglitazone improves the irregularities of menses and hirsutism. Six months of treatment modify other parameters linked with a higher risk of type 2 diabetes mellitus and cardiovascular diseases: adiponectin increased with reduction of insulin resistance while fibrinogen and CRP levels decreased.

Simple enucleation versus standard partial nephrectomy for clinical T1 renal masses: perioperative outcomes based on a matched-pair comparison of 396 patients (RECORd project)

OBJECTIVES

To compare simple enucleation (SE) and standard partial nephrectomy (SPN) in terms of surgical results in a multicenter dataset (RECORd Project).

MATERIALS AND METHODS

patients treated with nephron sparing surgery (NSS) for clinical T1 renal tumors between January 2009 and January 2011 were evaluated. Overall, 198 patients who underwent SE were retrospectively matched to 198 patients who underwent SPN. The SPN and SE groups were compared regarding intraoperative, early post-operative and pathologic outcome variables. Multivariable analysis was applied to analyze predictors of positive surgical margin (PSM) status.

RESULTS

SE was associated with similar WIT (18 vs 17.8 min), lower intraoperative blood loss (177 vs 221 cc, p = 0.02) and shorter operative time (121 vs 147 min; p < 0.0001). Surgical approach (laparoscopic vs. open), tumor size and type of indication (elective/relative vs absolute) were associated with WIT >20 min. The incidence of PSM was significantly lower in patients treated with SE (1.4% vs 6.9%; p = 0.02). At multivariable analysis, PSM was related to the surgical technique, with a 4.7-fold increased risk of PSM for SPN compared to SE. The incidence of overall, medical and surgical complications was similar between SE and SPN.

CONCLUSIONS

Type of NSS technique (SE vs SPN) adopted has a negligible impact on WIT and postoperative morbidity but SE seems protective against PSM occurrence.

Reference values in ovarian response to controlled ovarian stimulation throughout the reproductive period

Abstract The age-related decline in ovarian response to gonadotropins has been well known since the beginning of ovarian stimulation in IVF cycles and has been considered secondary to the age-related decline in ovarian reserve. The objective of this study was to establish reference values and to construct nomograms of ovarian response for any specific age to gonadotropins in IVF/ICSI cycles. We analyzed our database containing information on IVF cycles. According to inclusion and exclusion criteria, a total of 703 patients were selected. Among inclusion criteria, there were regular menstrual cycle, treatment with a long GnRH agonist protocol and starting follicle-stimulating hormone (FSH) dose of at least 200 IU per day. To estimate the reference values of ovarian response, the CG-LMS method was used. A linear decline in the parameters of ovarian response with age was observed: the median number of oocytes decreases approximately by one every three years, and the median number of follicles >16 mm by one every eight years. The number of oocytes and growing follicles corresponding to the 5th, 25th, 50th, 75th and 95th centiles has been calculated. This study confirmed the well known negative relationship between ovarian response to FSH and female ageing and permitted the construction of nomograms of ovarian response.

Intensity of menstrual pain and estimated angle of uterine flexion

OBJECTIVE

To assess the impact of ultrasound-estimated uterus position on the intensity of pelvic pain.

DESIGN

Descriptive analytical study.

SETTING

Tertiary university gynecology unit.

POPULATION

181 consecutive patients with pelvic pain.

METHODS

Each woman underwent physical examination, transvaginal sonography and filled self-administered questionnaires on pain using a 10-cm visual analog scale (VAS).

MAIN OUTCOME MEASURES

Visual analog scale score of menstrual pain, intermenstrual pain and dyspareunia was related to uterine version (ante- or retroversion) and the angle of uterine flexion (actual angle between cervix and uterine body) evaluated by transvaginal sonography.

RESULTS

Estimated uterine version was not associated with the intensity of any type of pain. The estimated angle of flexion was higher in retroverted than in anteverted uteri (182.3° ± 50.3° vs. 142.3° ± 24.2°, p < 0.0001). Intensity of menstrual pain was lowest with flexion between 150° and 210° (4.9 ± 3.1) (p = 0.002), intermediate with flexion <150° (6.3 ± 2.8) and highest with flexion ≥210° (7.9 ± 2.3). Severe menstrual pain was more prevalent with flexion ≥210° (77.7%) than between 150° and 210° (31.4%; p = 0.0008) or <150° (45.2%; p = 0.005). The intensity of intermenstrual pain and dyspareunia were not associated with the angle of flexion. In multiple regression analysis, the angle of flexion was independently related only to the intensity of menstrual pain (r = 0.272; p = 0.002).

CONCLUSIONS

In women with pelvic pain, ultrasound-estimated uterine flexion represents an independent risk for intense menstrual pain.

Middle and long-term outcomes of dual kidney transplant: a multicenter experience

INTRODUCTION

Dual kidney transplantation (DKTx) to reduce the disparity between demand and supply of organs was evaluated in two Italian centers (Bari and Novara).

MATERIALS AND METHODS

Between October 2000 and October 2011, we performed 97 DKT (26 ipsilateral/71 bilateral) following routine biopsy of all kidneys obtained from expanded criteria donors by Remuzzi-Karpinsky scores. The reference group was 379 single grafts from donors older than 60 years single kidney transplantation ([SKT] × > 60).

RESULTS

Good postoperative renal function was observed in 56 DKTx (57.7%); whereas acute tubular necrosis requiring dialysis was observed in 41 (42.3%) patients. After a mean follow-up of 60 months, DKTx graft survivals were 96%, 93%, and 90% and patient survivals, 96%, 91%, and 91% at 1, 3, and 5 years, respectively. Complications in expanded criteria donor kidney transplantations included a high rate of cytomegalovirus (CMV) disease especially dual kidney cases. DKTx represented the only independent risk factor for CMV disease upon multivariate analysis (odds ratio [OR] 2.33, 95% confidence interval [CI] 1.28-4.2; P = .006). We did not observe any significant difference in graft or patient survival between DKTx and SKTx > 60 years.

CONCLUSIONS

We observed good outcomes up to 5 years after transplantation in terms of graft and patient survival despite the use of inferior grafts. Comparing DKTx and SKT > 60, we noted that the mean Karpinski score for SKTx was significantly better than DKTx, although patient and graft survivals were similar. This trend confirms that the use of a biopsy to allocate expanded criteria donor kidneys may be too protective; therefore, the criteria to select DKTx require further refinement.

Ischemic Charcot foot: different disease with different treatment?

AIM

Aim of the study was to describe the presence of peripheral arterial disease in combination with Charcot neuroarthropathy in diabetic patients, and to evaluate the role of revascularization supporting surgical and orthopedic treatment.

METHODS

We retrospectively collected and analyzed data of all diabetic patients affected by Charcot neuroarthropathy in combination with critical limb ischemia, which arrived to our care for the presence of foot lesions and underwent endovascular revascularization, followed by surgical and orthopedic treatment between January 2010 and January 2012. The primary end point was to assess the limb salvage rate. The secondary end point was to evaluate the healing time of the lesions.

RESULTS

Ten diabetic patients (10 men; mean age 69.1±8.5 years), affected by ischemic Charcot neuroarthropathy underwent endovascular revascularization, surgical debridement and orthopedic correction. The limb salvage rate was 90%, avoiding major amputation in 9 patients. In one patient (10%) the infection could not be controlled and below-the-knee amputation was carried out. The required time to heal the lesion was in mean 197.4±22.4 days, after revascularization, surgical and orthopedic treatment.

CONCLUSION

Patients with Charcot foot deformity can be affected by critical limb ischemia and revascularization therapy is necessary, to support surgical and orthopedic treatment, avoiding amputation and leading to limb and foot salvage.

Effects of physical exercise on the female reproductive system

The excess in physical activity could be closely linked to considerable negative consequences on the whole body. These dysfunctions called as "female athlete triad"' by the American College of Sports Medicine (ACSM) include amenorrhea, osteoporosis and disorder eating. The female athlete triad poses serious health risks, both on the short and on the long term, to the overall well-being of affected individuals. Sustained low energy availability can impair health, causing many medical complications within skeletal, endocrine, cardiovascular, reproductive and central nervous system. On the contrary, several studies have shown, that physical activity improves cardiovascular risk factors, hormonal profile and reproductive function. These improvements include a decrease in abdominal fat, blood glucose, blood lipids and insulin resistance, as well as improvements in menstrual cyclicity, ovulation and fertility, decreases in testosterone levels and Free Androgen Index (FAI) and increases in sex hormone binding globulin (SHBG). Other studies reported that physical activity improved self-esteem, depression and anxiety. Thus, the aim of this review is to elucidate the effect of physical exercise on female reproductive system and viceversa the impact of hormonal status on physical activity and metabolism. In addition this review supports the idea that physical exercise is a helpful tool for the management of obesity, prevention of cardiovascular, metabolic diseases and female reproductive organs related diseases (e.g. breast cancer). When the excess in physical activity leads up to the female athlete triad, it is imperative to treat each component of the triad by employing both pharmacological and non pharmacological treatments.

Management of localized and locally advanced renal tumors. A contemporary review of current treatment options

About 70% of patients with renal cell carcinoma present with localized or locally advanced disease at primary diagnosis. Whereas these patients are potentially curable by surgical treatment alone, a further 20% to 30% of patients are diagnosed with primary metastatic disease. Although over the past years medical treatment for metastatic patients has nearly completely changed from immunotherapy to effective treatment with targeted agents, metastatic disease still represents a disease status which is not curable. Also in patients with metastatic disease, surgical treatment of the primary tumor plays an important role, since local tumor related complications can be avoided or minimized by surgery. Furthermore, also improvement of overall survival has been proven for surgery in metastatic patients when combined with cytokine treatment. Hence, surgical combined with systemic treatment as a multi-modal, adjuvant, and neo-adjuvant treatment is also required in patients with advanced or metastatic disease. A growing number of elderly and comorbid patients are currently diagnosed with small renal masses, which has led to increased attention paid to alternative ablative treatment modalities as well as active surveillance strategies, which are applied in order to avoid unnecessary overtreatment in these patients. Since surgical treatment also might enhance the risk of chronic kidney disease with consecutive cardiac disorders as well as reduced overall survival, ablative techniques and active surveillance are increasingly applied. In this review article we focus on current surgical and none-surgical treatment options for the management of patients with localized, locally advanced, and metastatic renal cell carcinoma.

Prevalence of Dio2(T92A) polymorphism and its association with thyroid autoimmunity

The 3,5,3'-L-triiodothyronine (T₃) partly derives by the deiodination of the prohormone 3,5,3',5'-L-tetraiodothyronine (T₄) by the type 2 iodothyronine deiodinase (D2). The single-nucleotide polymorphism in the D2 gene at position 92 (Dio(2T92A)), generates an enzyme with a reduced T₄ to T₃ conversion velocity. Because thyroid hormones can modulate the immune response, we hypothesized a pathophysiological role for Dio(2T92A) polymorphism in autoimmunity. The objective of this study was to investigate the Dio(2T92A) polymorphism in relation to thyroid autoimmunity (TA). We compared the prevalence of Dio(2T92A) polymorphism and serum thyroid hormone levels in healthy subjects and subjects with TA. A total of 110 subjects with TA and 106 controls were genotypized for Dio(2T92A) polymorphism. Free T₃ (FT₃), free T₄ (FT₄) and TSH were measured and compared with the Dio(2T92A) polymorphism. Dio(292T/A), Dio(292A/A), and Dio(292T/T) healthy subjects were 40.9%, 46.4%, and 12.7%, respectively. These prevalences were similar to those of some European countries whilst significantly different from that of Brazil. In the two groups of healthy subjects and TA subjects, Dio(2T92A) polymorphism had a similar distribution with non-significant differences. Similarly, no significant differences were observed in the serum concentration of FT₃, FT₄, and TSH between subjects with different Dio(2T92A) polymorphism. The FT₄/FT₃, and TSH/FT₃ ratios were higher in Dio(292T/T) than in Dio(292T/A) and Dio(292A/A) subjects in both TA and healthy groups, but these differences were not significant. In conclusion, the distribution of Dio(2T92A) polymorphism may reflect geographical and ethnic differences, and it is not associated with TA.