Factors associated with premature ovarian failure, early menopause and earlier onset of menopause in Japanese women

Operative management of pediatric ovarian tumors and the challenge of fertility-preservation: Results from the UK CCLG Surgeons Cancer Group Nationwide Study

BACKGROUND

Ovarian tumors in the pediatric age group are rare. A significant number of children with ovarian mass lesions present "out of hours "as surgical emergencies, and surgical management does not always involve a surgical oncologist. This multicenter study reports how the mode of clinical presentation may influence (i) operation (conventional open vs minimally invasive surgery (MIS)) and (ii) examines if young females presenting as surgical emergency(s) are more likely to undergo total oophorectomy or ovarian sparing surgery.

METHODS

Retrospective multicenter study amongst UK pediatric surgical oncology centers. Females <16 years with diagnosis of ovarian tumor from 2006 to 2016 were included. Functional/neonatal ovarian cysts were excluded.

RESULTS

Three hundred ten patients with ovarian tumors treated at 12 surgical oncology centers were identified. Mean age at surgery was 11 years [IQR 8-14]. Most common diagnosis were mature teratoma (57%, 177 cases), immature teratoma (10.9%, 34 cases) and cystadenoma (12%, 36 cases). Seventy percent (217) of cases were performed as open procedures. Thirty percent (94) of children underwent MIS. Tumors were significantly smaller in children who underwent MIS. Median tumor size in the laparoscopic group was 6 cm compared to 11 cm in the open group (p < 0.00001). Children who underwent MIS were significantly more likely to have ovary sparing surgery.

CONCLUSION

This UK nationwide study demonstrates that ovary-sparing surgery and minimally invasive surgery are still infrequently deployed by pediatric surgeons in the UK. Patients with smaller tumors were more likely to undergo MIS, and more frequently underwent ovary-sparing surgery. In view of the implications on fertility and hormonal health caused by unilateral oophorectomy, it is time to review this current practise and agree consensus guidelines to reduce rates of unnecessary oophorectomy.

LEVEL OF EVIDENCE STATEMENT

This is a level II evidence study. It is a retrospective multicentre collaborative study, which summarizes data from a national cohort of children.

Prevalence of the Use of Oral Contraceptives and Hormone Replacement Therapy in Japan: the Japan Nurses' Health Study

Background There have been few community-based epidemiological studies in which the prevalence of exogenous hormone use, including the use of oral contraceptives (OCs) and hormone replacement therapy (HRT), has been accurately assessed in Japan.Methods We have been conducting repeated surveys of participants in the Japan Nurses' Health Study (JNHS), as a nationwide prospective cohort study, since 2001. We determined the prevalence of exogenous hormone use at baseline and during a 10-year follow-up period. A total of 15,019 female nurses participated in the JNHS follow-up cohort. We determined the prevalence of OC use in 14,839 women <60 years of age at baseline and the prevalence of HRT use in 7,915 women, excluding premenopausal women, at the last time they answered a questionnaire. The duration of HRT use was estimated using the Kaplan-Meier method.Results Six percent of the participants used OCs. The proportion of HRT users who stopped HRT before the baseline survey, the proportion of women using HRT during the follow-up period, and the proportion of all of the participants who had used HRT were 3.2%, 10.6%, and 13.8%, respectively. The median duration of HRT use was 2 years.Conclusions The lifetime prevalences of exogenous hormone use during this prospective study conducted in Japanese nurses were 6.0% for OCs and 13.8% for HRT. The information obtained in this study will be useful for clarification of the association between exogenous estrogen exposure and estrogen-related diseases as future research.

Biological Impact of Unilateral Oophorectomy: Does the Number of Ovaries Really Matter?

Although unilateral oophorectomies are performed more often than bilateral ones in women of reproductive age, their clinical consequences have been less intensively investigated. Experimental models in animals have shown that compensatory mechanisms occur after a unilateral oophorectomy (UO). This review aims to summarize the available evidence on the biological effects of unilateral oophorectomy on women. Evaluated outcomes include age at onset of menopause, risk of cardiovascular and neurological disease, risk of mortality and fertility outcome after spontaneous conception or in vitro fertilization (IVF). Results were compared with findings reported after bilateral oophorectomy and/or ovarian excision and/or women with intact ovaries. An electronic database search was performed using PubMed and Scopus, followed by a manual search to identify controlled studies that compared women after UO with women with two intact ovaries. In particular, a systematic review of fertility outcomes after IVF was performed, and the data were summarized in a table. Women who underwent UO had a similar age at menopause and similar clinical pregnancy rate compared to women with two ovaries. However, decreased ovarian reserve affecting the quantity but not the quality of the ovarian pool after IVF was observed in the UO group. Furthermore, an increased risk of neurological disease and even an increased risk of mortality was observed in women with single ovary. These data need to be confirmed by further studies, and a plausible mechanism of action must be identified. At present, patients who undergo UO can be reassured with regard to their reproductive potential and their age at onset of menopause.

Ovarian tissue cryopreservation and transplantation to delay menopause: facts and fiction

Ovarian tissue cryopreservation and transplantation (OTCT) is increasingly being used in young cancer patients for fertility restoration and prevention of premature ovarian insufficiency (POI) and has recently been advocated as a method to delay menopause. This is accomplished by cryopreserving ovarian tissue that is excised laparoscopically in thin pieces at a young age. Cryopreserved tissue will be transplanted at menopause, when ovarian function is no longer present. Transplantation may need to be repeated several times to achieve long-term restoration of ovarian function. However, it is unknown whether ovarian grafts result in a normal steroid pulsatile secretion, similar to that present during reproductive years. In addition, it is not known whether the need to restore ovarian activity appears earlier in women who undergo OTCT to delay menopause, although indirect data suggest that this is likely to be true. Until today, no cohort or comparative studies evaluating OTCT as a potential alternative to hormone replacement therapy (HRT) have been published and, thus, there is no evidence to suggest that OTCT is superior to HRT in terms of both efficacy and safety. Given the availability of alternative, established treatments for managing menopausal symptoms, as well as the multiple unanswered questions regarding the method, it is imperative that, before OTCT is regarded as a mainstream technique for management of menopausal symptoms, further evaluation and clinical investigation are undertaken.

Trends of Premature and Early Menopause: a Comparative Study of the US National Health and Nutrition Examination Survey and the Korea National Health and Nutrition Examination Survey

BACKGROUND

While evidence shows a tendency toward delays in menopause worldwide, whether prevalence of premature (< 40 years) or early menopause (40-44 years) is also reduced in different ethnic groups is uncertain. The aim of this study was to explore birth cohort effect in the prevalence of premature and early menopause in United States (US) and Korea.

METHODS

This is a retrospective study using the National Health and Nutrition Examination Survey (NHANES, 1999-2014) and the Korea NHANES (KNHANES, 2007-2012). We analyzed prevalence of premature and early menopause in three ethnic groups of US and Korea. We restricted our analysis to women aged ≥ 45 years at the time of the survey born between 1920 and 1969. The data of both eligible 9,209 US women and 9,828 Korean was included in final analysis. We calculated odds ratios (OR) for each outcome adjusting for biological and socioeconomic factors, respectively.

RESULTS

Prevalence of premature menopause was 1.7% in US, 2.8% in Korean women. Early menopause occurred in 3.4% and 7.2% of US and Korean, respectively. In US women, prevalence of premature and early menopause did not change and did not differ across three ethnicities. Korean women showed highest and consistently decreasing prevalence (P < 0.001). When we adjusted for covariates, birth lower risk for premature menopause was evident in US Non-Hispanic black born in 1950s and in Korean born between 1940s and 1960s compared to those born in 1920s. In the analysis of early menopause, excluding premature menopause patients, lower risk of more recent generation (born in 1940s and later) was evident in Korean women.

CONCLUSION

The trend and birth cohort effect in occurrence of premature and early menopause among the US and Korea women are different. Prevalences of premature and early menopause decrease only in Korean.

Factors associated with age at natural menopause among elderly women in São Paulo, Brazil

OBJECTIVES

To analyze factors associated with age at natural menopause in elderly women who are part of the Health, Well-Being and Aging Study- which is a representative sample of elderly residents of the municipality of São Paulo, Brazil.

METHODS

Multivariate Cox proportional-hazards analysis using data from a total of 1,415 women with natural menopause. We included 163 women with hysterectomy, oophorectomy, and estrogen therapy as censored data.

RESULTS

The median age of natural menopause was 50 years. In the multivariate Cox proportional hazards, smoking was associated with earlier age at natural menopause for the three cohorts (2000, 2006, and 2010). Current smokers had a 35% higher risk of earlier natural menopause (hazard ratio [HR] 1.35, 95% confidence interval [CI] 1.12, 1.62) and former smokers had a 27% higher risk of earlier natural menopause (HR 1.27, 95% CI 1.09, 1.50), in comparison with never-smokers. Women with 8 years or more of formal education had a 33% lower risk of earlier natural menopause (HR 0.67, 95% CI 0.50, 0.89) than women with no education, and women who were separated, widowed, or divorced had a 15% higher risk of earlier natural menopause (HR 1.15, 95% CI 1.00, 1.31) in comparison with married women. Marital status and parity were associated with later age at natural menopause only in 2006.

CONCLUSIONS

We found significant associations of age at natural menopause with reproductive and lifestyle factors similar to some studies of women from developed countries.

State of the Art in Fertility Preservation for Female Patients Prior to Oncologic Therapies

Quality of life improvement stands as one of the main goals of the medical sciences. Increasing cancer survival rates associated with better early detection and extended therapeutic options led to the specific modeling of patients’ choices, comprising aspects of reproductive life that correlated with the evolution of modern society, and requires better assessment. Of these, fertility preservation and ovarian function conservation for pre-menopause female oncologic patients pose a contemporary challenge due to procreation age advance in evolved societies and to the growing expectations regarding cancer treatment. Progress made in cell and tissue-freezing technologies brought hope and shed new light on the onco-fertility field. Additionally, crossing roads with general fertility and senescence studies proved highly beneficial due to the enlarged scope and better synergies and funding. We here strive to bring attention to this domain of care and to sensitize all medical specialties towards a more cohesive approach and to better communication among caregivers and patients.

Association of Parity and Breastfeeding With Risk of Early Natural Menopause

IMPORTANCE

Pregnancy and breastfeeding prevent ovulation and may slow the depletion of the ovarian follicle pool. These factors may lower the risk of early menopause, a condition associated with increased risk of cardiovascular disease and other adverse health outcomes.

OBJECTIVE

To examine the association of parity and breastfeeding with the risk of early menopause.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study within the Nurses' Health Study II cohort (1989-2015) included premenopausal participants who were aged 25 to 42 years at baseline. Response rates were 85% to 90% for each cycle, and follow-up continued until menopause, age 45 years, hysterectomy, oophorectomy, death, cancer diagnosis, loss to follow-up, or end of follow-up in May 2015. Hypotheses were formulated after data collection. Data analysis took place from February to July 2019.

EXPOSURES

Parity (ie, number of pregnancies lasting ≥6 months) was measured at baseline and every 2 years. History and duration of total and exclusive breastfeeding were assessed 3 times during follow-up. Menopause status and age were assessed every 2 years.

MAIN OUTCOMES AND MEASURES

Risk of natural menopause before age 45 years.

RESULTS

At baseline, 108 887 premenopausal women aged 25 to 42 years (mean [SD] age, 34.1 [4.6] years; 102 246 [93.9%] non-Hispanic white) were included in the study. In multivariable models, higher parity was associated with lower risk of early menopause. Hazard ratios were attenuated with adjustment for breastfeeding but remained significant. Compared with nulliparous women, those reporting 1, 2, 3, and 4 or more pregnancies lasting at least 6 months had hazard ratios for early menopause of 0.92 (95% CI, 0.79-1.06), 0.84 (95% CI, 0.73-0.96), 0.78 (95% CI, 0.67-0.92), and 0.81 (95% CI, 0.66-1.01), respectively (P for trend = .006). In multivariable models also adjusted for parity, hazard ratios for duration of exclusive breastfeeding of 1 to 6, 7 to 12, 13 to 18, and 19 or more months were 0.95 (95% CI, 0.85-1.07), 0.72 (95% CI, 0.62-0.83), 0.80 (95% CI, 0.66-0.97), and 0.89 (95% CI, 0.69-1.16), respectively, compared with less than 1 month of exclusive breastfeeding (P for trend = .001). Despite the significant test for trend, estimates were not observed to be lower as duration of exclusive breastfeeding increased. In a stratified analysis of parous women, risk of early menopause was lowest among those reporting exclusive breastfeeding for 7 to 12 months in each level of parity (women with 2 pregnancies and 7-12 months of breastfeeding: HR, 0.79; 95% CI, 0.66-0.96; ≥3 pregnancies and 7-12 months of breastfeeding: HR, 0.68; 95% CI, 0.52-0.88; 2 pregnancies and ≥13 months of breastfeeding: HR, 0.87; 95% CI, 0.66-1.15; ≥3 pregnancies and 13-18 months of breastfeeding: HR, 0.86; 95% CI, 0.66-1.13; and ≥3 pregnancies and ≥19 months of breastfeeding: HR, 0.98; 95% CI, 0.72-1.32).

CONCLUSIONS AND RELEVANCE

In this study, an inverse association of parity with risk of early menopause was observed. Breastfeeding was associated with significantly lower risk, even after accounting for parity. Breastfeeding at levels consistent with current recommendations may confer an additional benefit of lower risk of early menopause.

Reproductive factors and age at natural menopause: A systematic review and meta-analysis

OBJECTIVES

To systematically review the evidence on the association between age at natural menopause (NM) and reproductive factors such as age at menarche, parity and ever use of oral contraceptives.

STUDY DESIGN

A literature search was carried out in PubMed, Scielo, Scopus and LILACS databases, without restriction of publication year until July 6, 2017. We excluded clinical trials, case-control studies, case reports and studies using statistical methods other than Cox proportional hazard models to assess the factors associated with age at NM. Cross-sectional studies evaluating women aged <50 years were also excluded. Random-effects models were used to pool the estimates. We registered the systematic review in the International Prospective Register of Systematic Review (PROSPERO) in August 2018, CRD42018099105.

RESULTS

We identified 30 articles to include in the meta-analysis. We found that previous ever use of oral contraceptives (OC) (HR = 0.87, CI = 0.82, 0.93), age at menarche ≥13 years (HR = 0.90, CI = 0.84, 0.96), and having at least one live birth (HR = 0.79, CI = 0.74, 0.85) were associated with a later age of NM.

CONCLUSIONS

Despite differences in results between countries and study design, our findings suggest that previous use of OC, age at menarche ≥13 and having at least one live birth are associated with later menopause. The results suggest that these factors could be markers of later ovarian aging.

Importance of ovarian tissue cryopreservation in fertility preservation and anti-aging treatment

Various oncological and non-oncological diseases, as well as their treatments, can cause premature ovarian insufficiency and reduce a woman's reproductive potential. Fertility preservation is, therefore, becoming an emerging field of reproductive medicine allowing these patients to have their own biological children. The aim of this review is to analyze the importance of ovarian tissue cryopreservation as a fertility preservation method as well as its new role as a hormone replacement treatment. Although ovarian tissue cryopreservation is currently regarded as an experimental procedure, it is rapidly advancing and may become an established fertility preservation method in the near future. This method does not require ovarian stimulation or a subsequent delay in the initiation of cancer treatment. Furthermore, orthotopic ovarian tissue transplantation offers the unique opportunity of spontaneous conception. Due to the restoration of endocrine function following the procedure, ovarian tissue cryopreservation may also be used as tissue hormone replacement therapy in cases of premature ovarian insufficiency, to postpone menopause and prevent its troublesome symptoms and diseases. Even though the role of ovarian tissue cryopreservation as a new anti-aging treatment modality is quite promising, the safety and efficacy of this approach should be investigated in clinical settings.

Factors Associated With Management of Pediatric Ovarian Neoplasms

BACKGROUND

Available evidence supports ovary-sparing surgery for benign ovarian neoplasms; however, preoperative risk stratification of pediatric ovarian masses can be difficult. Our objective of this study was to characterize the surgical management of pediatric ovarian neoplasms across 10 children's hospitals and to identify factors that could potentially aid in the preoperative risk stratification of these lesions.

METHODS

A retrospective review of girls and women aged 2 to 21 years who underwent surgery for an ovarian neoplasm between 2010 and 2016 at 10 children's hospitals was performed. Multivariable logistic regression was used to examine the relationships between the preoperative cohort characteristics, procedure performed, and risk of malignancy.

RESULTS

Among 819 girls and women undergoing surgery for an ovarian neoplasm, malignant lesions were identified in 11%. The overall oophorectomy rate for benign disease was 33% (range: 15%-49%) across institutions. Oophorectomy for benign lesions was independently associated with provider specialty (P = .002: adult gynecologist, 45%; pediatric surgeon, 32%; pediatric gynecologist, 18%), premenarchal status (P = .02), preoperative suspicion for malignancy (P < .0001), larger lesion size (P < .0001), and presence of solid components (P < .0001). Preoperative findings independently associated with malignancy included increasing size (P < .0001), solid components (P = .003), and age (P < .0001).

CONCLUSIONS

The rate of oophorectomy for benign ovarian disease remains high within the pediatric population. Identification of factors associated with the choice of procedure and the risk of malignancy may allow for improved preoperative risk stratification and fewer unnecessary oophorectomies. These results have been used to develop and validate a multidisciplinary preoperative risk stratification algorithm that is currently being studied prospectively across 10 institutions.

Age at natural menopause in Koreans: secular trends and influences thereon

OBJECTIVES

Age at natural menopause (ANM) has become an important health issue in older women. We explored secular trends in ANM in Korea during the past decade, and defined factors predicting ANM.

METHODS

A total of 12,761 naturally menopausal women were selected from the 2001 to 2014 data of the Korea National Health and Nutrition Examination Survey, stages II to VI. The participants were divided into four groups based on 5-year ANM categories: <45, 45 to 49, 50 to 54, and ≥55 years. To identify factors associated with ANM, the regression analysis was used.

RESULTS

Both the mean (SE) and median (SE) ANM were 49.30 (0.07) years. The cumulative proportion of women experiencing menopause before the age of 40, 45, 50, and 55 years was 3.6%, 11.8%, 46.0%, and 90.3%, respectively. The mean (SE) ANM in women born in 1929 or earlier, and between 1930 to 1934, 1935 to 1939, 1940 to 1944, and 1945 to 1949, was 47.9 (0.3), 48.1 (0.2), 48.8 (0.2), 50.1 (0.2), and 50.5 (0.1) years, respectively (P < 0.001). Residence in a rural area (odds ratio [OR] 1.82), low weight status (OR 1.61), a history of or current smoking, a low educational level, being without a partner, and participating in at least moderate physical activity (OR 1.47, 1.33, 1.32, and 1.26, respectively) were more likely to result in an early ANM. Women with prior childbirth were less likely to experience early menopause (OR 0.34). In contrast, late menopause was associated with obesity and being overweight (OR 1.63 and 1.27).

CONCLUSIONS

We found that the mean ANM exhibited upward secular trends. Socioeconomic status and lifestyle factors were the principal independent factors affecting ANM.

Ovary-sparing surgery for benign pediatric ovarian masses

PURPOSE OF REVIEW

This review highlights progress in the management of pediatric ovarian neoplasms. Recent research has identified disparities in the management of patients with benign ovarian neoplasms based on a variety of factors. However, the long-term effects of unilateral oophorectomy have prompted an emphasis on ovary-sparing surgery (OSS) for benign masses. One of the challenges still facing providers is the preoperative differentiation between benign and malignant masses.

RECENT FINDINGS

Recent studies highlight the variability in practice patterns surrounding the management of benign ovarian neoplasms. Progress continues to be made in identifying reliable factors that can be used to inform preoperative risk stratification of patients who present with ovarian neoplasms. These factors include imaging characteristics, symptoms and tumor markers. In addition, the safety of OSS with regard to recurrence and upstaging in appropriate settings continues to be demonstrated.

SUMMARY

This review highlights the importance of multidisciplinary collaboration in the treatment of ovarian neoplasms given the varied surgical approach by specialty. Multiple retrospective studies have identified factors that can be used for preoperative risk stratification and selection of patients for OSS. Prospective studies evaluating the accuracy of these factors for preoperative risk stratification are needed.

Contralateral ovarian endometrioma recurrence after unilateral salpingo-oophorectomy

Background

The recurrence rate after unilateral salpingo-oophorectomy (USO) for unilateral endometrioma has not been reported. We evaluated the rate of and risk factors for endometrioma recurrence after USO.

Methods

In this retrospective observational study, we enrolled 110 women (age, 35–45 years) who underwent laparoscopic USO (n = 50) or cystectomy (n = 60) for unilateral ovarian endometrioma from January 2010 through December 2012. We compared patients’ characteristics between patients who underwent USO and those who underwent cystectomy. We also compared patients with and without an endometrioma recurrence after USO using univariate and multivariate stepwise logistic regression models to identify recurrence risk factors. Endometrioma recurrence was defined as an ovarian cyst (> 2 cm) with features typical of an endometrioma identified by postoperative transvaginal sonography.

Results

Endometrioma recurred in 8 (16%) patients after USO (mean follow-up, 46.0 ± 12.9 months [range, 15–73]). The post-USO cumulative recurrence rates at 12, 24, 36, and 60 months were 8.0, 10.2, 12.7, and 24.7%, respectively (Kaplan-Meier analysis). In logistic regression analysis, a contralateral side adhesion score ≥ 4 was an independent risk factor for endometrioma recurrence after USO (odds ratio, 19.48, 95% confidence interval, 1.59–237.72). The post-USO cumulative recurrence rates at 12, 24, 36, and 57 months were 19.5, 24.1, 31.0, and 54.0%, respectively, in cases with contralateral side adhesion scores ≥4, and 0.0, 0.0, 0.0, and 5.9%, respectively, in cases with scores < 4 (log-rank test, P = 0.0023).

Conclusions

To our knowledge, this is the first report on the recurrence rate and risk factors associated with recurrence after USO. Endometrioma recurrence rates were 24.7% during the first 5 years after USO. The post-USO recurrence rate increased significantly in cases with contralateral side adhesions. Our findings could improve the planning of USO and patient selection for postoperative hormonal therapy.

Association of gene polymorphisms in the anti-Müllerian hormone signalling pathway with ovarian function: a systematic review and meta-analysis

This systematic review evaluated whether single nucleotide polymorphisms of AMH and AMHRII genes are associated with ovarian function. A literature search of PubMed and Embase was complemented by hand searches in the reference lists. Eight studies involving 3155 participants were included in a meta-analysis and 10 studies included for description. For AMH c.146T>G polymorphism, no significant difference in serum anti-Müllerian hormone (AMH) levels was found between participants with different genotypes (weighted mean difference [WMD] 0.42, 95% confidence interval [CI] -0.16 to 0.99). Subgroup analyses showed similar results for the European region and in healthy and infertile populations. Regarding AMHRII -482 A>G, there was no significant difference in serum AMH levels between participants with A/A genotype and G/A or G/G genotype carriers (WMD -0.04, 95% CI -0.31 to 0.23). In subgroup analysis, an interesting trend was confirmed in healthy women and polycystic ovary syndrome (PCOS) patients (WMD -0.36, 95% CI -0.63 to -0.09, P = 0.009; WMD 0.46, 95% CI 0.15 to 0.77, P = 0.004). The review suggests that AMH c.146T>G is not associated with AMH levels, while AMHRII -482 A>G may be related to AMH levels in PCOS and healthy subgroups. However, the impact of polymorphisms in the AMH signalling pathway on ovarian function still requires further investigation.

Laparoscopic unilateral oophorectomy for ovarian tissue cryopreservation in children

BACKGROUND/PURPOSE

Many survivors of childhood cancer will experience premature gonadal insufficiency or infertility as a consequence of their medical treatments. Ovarian tissue cryopreservation (OTC) remains an experimental means of fertility preservation with few reports focused on the surgical technique and postoperative outcomes for OTC in children.

METHODS

This is a single institution, retrospective review of OTC cases from January 2011 to December 2017. Children were eligible for OTC if they had a greater than 80% risk of premature ovarian insufficiency or infertility owing to their anticipated gonadotoxic medical treatment.

RESULTS

OTC was performed in 64 patients. Median age was 12 years old (range: 5 months-23 years). Nearly half (48%) of the patients were premenarchal. Laparoscopic unilateral oophorectomy was performed in 84% of patients. There were no surgical complications. In 76% of patients, OTC was performed in conjunction with an ancillary procedure. The majority (96%) of patients were discharged within 24 hours. Median time from operation to medical therapy was six days, with no unanticipated treatments delays attributable to OTC.

CONCLUSIONS

Laparoscopic unilateral oophorectomy for OTC can be performed safely, in combination with other ancillary procedures, as an outpatient procedure without delaying medical therapy for children facing a fertility-threatening diagnosis or treatment.

LEVEL OF EVIDENCE

IV.

Ovarian masses in the child and adolescent: An American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee systematic review

BACKGROUND

The treatment of ovarian masses in pediatric patients should balance appropriate surgical management with the preservation of future reproductive capability. Preoperative estimation of malignant potential is essential to planning an optimal surgical strategy.

METHODS

The American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee drafted three consensus-based questions regarding the evaluation and treatment of ovarian masses in pediatric patients. A search of PubMed, the Cochrane Library, and Web of Science was performed and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed to identify articles for review.

RESULTS

Preoperative tumor markers, ultrasound malignancy indices, and the presence or absence of the ovarian crescent sign on imaging can help estimate malignant potential prior to surgical resection. Frozen section also plays a role in operative strategy. Surgical staging is useful for directing chemotherapy and for prognostication. Both unilateral oophorectomy and cystectomy have been used successfully for germ cell and borderline ovarian tumors, although cystectomy may be associated with higher rates of local recurrence.

CONCLUSIONS

Malignant potential of ovarian masses can be estimated preoperatively, and fertility-sparing techniques may be appropriate depending on the type of tumor. This review provides recommendations based on a critical evaluation of recent literature.

TYPE OF STUDY

Systematic review of level 1-4 studies.

LEVEL OF EVIDENCE

Level 1-4 (mainly 3-4).

A Preoperative Scoring System for Adnexal Mass in Children and Adolescents to Preserve Their Future Fertility

STUDY OBJECTIVE

To develop a predictive score for ovarian malignancy to avoid unnecessary adnexectomy in cases of adnexal mass in pediatric and adolescent girls.

DESIGN

A population-based retrospective study on girls who underwent surgery for an ovarian mass with normal levels of human chorionic gonadotrophin and alpha fetoprotein between 1996 and 2016.

SETTING

Rennes University Hospital, Rennes, France.

PARTICIPANTS

Eighty-one patients who received surgery for ovarian tumor.

MAIN OUTCOME MEASURES

The main outcome measure was the rate of malignant and borderline tumor. A preoperative scoring system was constructed after multivariate analysis.

RESULTS

The rate of malignant ovarian tumor was 6/81 (7%), borderline tumor was 7/81 (9%) (ie, outcome measure: 16%), and benign tumor was 84%. In a univariate analysis, the characteristics significantly associated with malignancy were early puberty, palpable mass, size and content of the tumor, and positive epithelial tumor markers (carcinoma antigen 125, carcinoembryonic antigen, and carcinoma antigen 19-9). The predictive malignancy score was on the basis of 2 variables obtained after multivariate analysis: tumor size and cystic content. The score defined 3 groups at risk for malignancy: low risk, middle-risk, and high-risk. The sensitivity for detecting malignancy was 1.3% (95% confidence interval [CI], 0.1-18.4), 26.2% (95% CI, 11.6-49.0), and 53.1% (95% CI, 29.1-75.8), respectively.

CONCLUSION

We set up a simple predictive score of malignancy on the basis of objective criteria to help decision-making on whether or not ovarian-sparing surgery is feasible in case of children and adolescents with ovarian tumors and normal human chorionic gonadotrophin and alpha fetoprotein levels while ensuring oncologic safety.

Cryostorage and retransplantation of ovarian tissue as an infertility treatment

While still considered an experimental procedure in most countries, ovarian tissue cryopreservation and transplantation has been increasingly applied worldwide to restore fertility in patients with malignant and non-malignant pathologies with risk of premature ovarian insufficiency. It has yielded more than 130 live births up to now and almost all transplanted patients recovered their ovarian function. This study summarizes ovarian tissue cryopreservation and transplantation indications, procedures, their efficacy and main results and proposes different strategies to improve this strategy. Although the main focus of this study is on ovarian tissue cryopreservation and transplantation as a strategy to restore fertility, we believe that it is also important to discuss other applications for this approach.

Reduced live-birth rates after IVF/ICSI in women with previous unilateral oophorectomy: results of a multicentre cohort study

STUDY QUESTION

Is there a reduced live-birth rate (LBR) after IVF/ICSI treatment in women with a previous unilateral oophorectomy (UO)?

SUMMARY ANSWER

A significantly reduced LBR after IVF/ICSI was found in women with previous UO when compared with women with intact ovaries in this large multicentre cohort, both crudely and after adjustment for age, BMI, fertility centre and calendar period and regardless of whether the analysis was based on transfer of embryos in the fresh cycle only or on cumulative results including transfers using frozen-thawed embryos.

WHAT IS KNOWN ALREADY

Similar pregnancy rates after IVF/ICSI have been previously reported in case-control studies and small cohort studies of women with previous UO versus women without ovarian surgery. In all previous studies multiple embryos were transferred. No study has previously evaluated LBR in a large cohort of women with a history of UO.

STUDY DESIGN, SIZE, DURATION

This research was a multicentre cohort study, including five reproductive medicine centres in Sweden: Carl von Linné Clinic (A), Karolinska University Hospital (B), Uppsala University Hospital (C), Linköping University Hospital (D) and Örebro University Hospital (E). The women underwent IVF/ICSI between January 1999 and November 2015. Single embryo transfer (SET) was performed in approximately 70% of all treatments, without any significant difference between UO exposed women versus controls (68% versus 71%), respectively (P = 0.32), and a maximum of two embryos were transferred in the remaining cases. The dataset included all consecutive treatments and fresh and frozen-thawed cycles.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The exposed cohort included 154 women with UO who underwent 301 IVF/ICSI cycles and the unexposed control cohort consisted of 22 693 women who underwent 41 545 IVF/ICSI cycles. Overall, at the five centres (A-E), the exposed cohort underwent 151, 34, 35, 41 and 40 treatments, respectively, and they were compared with controls of the same centre (18 484, 8371, 5575, 4670 and 4445, respectively). The primary outcome was LBR, which was analysed per started cycle, per ovum pick-up (OPU) and per embryo transfer (ET). Secondary outcomes included the numbers of oocytes retrieved and supernumerary embryos obtained, the Ovarian Sensitivity Index (OSI), embryo quality scores and cumulative pregnancy rates. We used a Generalized Estimating Equation (GEE) model for statistical analysis in order to account for repeated treatments.

MAIN RESULTS AND THE ROLE OF CHANCE

The exposed (UO) and control women's groups were comparable with regard to age and performance of IVF or ICSI. Significant differences in LBR, both crude and age-adjusted, were observed between the UO and control groups: LBR per started cycle (18.6% versus 25.4%, P = 0.007 and P = 0.014, respectively), LBR/OPU (20.3% versus 27.1%, P = 0.012 and P = 0.015, respectively) and LBR/ET (23.0% versus 29.7%, P = 0.022 and P = 0.025, respectively). The differences in LBR remained significant after inclusion of both fresh and frozen-thawed transfers (both crude and age-adjusted data): LBR/OPU (26.1% versus 34.4%, P = 0.005 and P = 0.006, respectively) and LBR/ET (28.3% versus 37.1%, P = 0.006 and P = 0.006, respectively). The crude cancellation rate was significantly higher among women with a history of UO than in controls (18.9% versus 14.5%, P = 0.034 and age-adjusted, P = 0.178). In a multivariate GEE model, the cumulative odds ratios for LBR (fresh and frozen-thawed)/OPU (OR 0.70, 95% CI 0.52-0.94, P = 0.016) and LBR (fresh and frozen-thawed)/ET (OR 0.68, 95% CI 0.51-0.92, P = 0.012) were approximately 30% lower in the group of women with UO when adjusted for age, BMI, reproductive centre, calendar period and number of embryos transferred when appropriate. The OSI was significantly lower in women with a history of UO than in controls (3.6 versus 6.0) and the difference was significant for both crude and age-adjusted data (P = <0.001 for both). Significantly fewer oocytes were retrieved in treatments of women with UO than in controls (7.2 versus 9.9, P = <0.001, respectively).

LIMITATIONS, REASONS FOR CAUTION

Due to the nature of the topic, this is a retrospective analysis, with all its inherent limitations. Furthermore, the cause for UO was not possible to obtain in all cases. A diagnosis of endometriosis was also more common in the UO group, i.e. a selection bias in terms of poorer patient characteristics in the UO group cannot be completely ruled out. However, adjustment for all known confounders did not affect the general results.

WIDER IMPLICATIONS OF THE FINDINGS

To date, this is the largest cohort investigated and the first study indicating an association of achieving reduced live birth after IVF/ICSI in women with previous UO. These findings are novel and contradict the earlier notion that IVF/ICSI treatment is not affected, or is only marginally affected by previous UO.

STUDY FUNDING/COMPETING INTEREST(S)

None.

TRIAL REGISTRATION NUMBER

Not applicable.

Menstrual Cycle Characteristics in Adolescence and Early Adulthood Are Associated With Risk of Early Natural Menopause

CONTEXT

Early natural menopause (i.e., before age 45 years) is associated with increased risk of adverse outcomes. Associations of earlier menopause with younger age at menarche and short and/or regular cycle length are suggested, but study findings are inconsistent and few address early menopause risk.

OBJECTIVE

To evaluate the relationship between menstrual cycle characteristics in early life with incident early natural menopause.

DESIGN

The prospective Nurses' Health Study 2 (1989 to 2011).

SETTING AND PARTICIPANTS

Women ages 25 to 42 years and premenopausal in 1989 (N = 108,811).

MAIN OUTCOME MEASURE(S)

Risk of early natural menopause not due to surgery, radiation, or chemotherapy (n = 2794) was evaluated with Cox proportional hazards models. Anti-Müllerian hormone (AMH) levels were considered in a nested case-control sample (n = 820).

RESULTS

In adjusted models, risk was associated with earlier age at menarche (P for trend = 0.05), shorter (P for trend < 0.0001), and more-regular cycles (P for < 0.0001). The hazard ratio (HR) for women with age at menarche ≤9 (vs. 12) years was 1.28 (95% CI, 0.99 to 1.67). Women reporting usual menstrual cycle lengths <25 days at ages 18 to 22 years had substantially higher risk of early menopause (HR, 1.70; 95% CI, 1.47 to 1.96) than women with 26- to 31-day cycles, whereas women with ≥40 day cycles had lower risk (HR, 0.44; 95% CI, 0.34 to 0.58). Women with irregular cycle length had lower risk compared with women with regular cycles (HR, 0.51; 95% CI, 0.43 to 0.60). Associations with AMH concentrations among the nested case-control subset were consistent with these findings.

CONCLUSION

Results from this large prospective study of early menopause suggest an influence of accelerated oocyte depletion on risk and may help clarify the etiology of early menopause.

Cryopreservation and transplantation of ovarian tissue: results from one center in the USA

Purpose

To report the results of cryopreserved ovary tissue transplantation for leukemia and other cancers, in a single US center.

Methods

One hundred eight females between age 6 and (median age 24) 35 were referred for possible ovary tissue cryopreservation over a 20-year period, with either slow freeze or vitrification. Thus far 13 patients returned up to 18 years later to have their tissue transplanted back.

Results

All 13 patients had return of ovarian function 5 months post transplant with regular menstrual cycling. AMH rose to very high levels as the FSH declined to normal. Four months later, the AMH again declined to very low levels. Nonetheless, the grafts remained functional for up to 5 years or longer. Ten of the 13 (77%) became spontaneously pregnant at least once, resulting in 13 healthy babies. A total of 24 healthy babies have been born 11 from fresh transplanted ovarian tissue and 13 from cryopreserved transplanted ovarian tissue.

Conclusions

(1) Ovary tissue cryopreservation is a robust method for preserving a woman’s fertility. (2) Cortical tissue pressure may be a key regulator of primordial follicle arrest, recruitment, and ovarian longevity. (3) This is the only such series yet reported in the USA.

Hormone therapy use in the Canadian Longitudinal Study on Aging: a cross-sectional analysis

OBJECTIVE

The aim of the study was to assess the prevalence and factors associated with hormone therapy (HT) use among Canadian women.

METHODS

Baseline data from the Tracking cohort of the Canadian Longitudinal Study on Aging (CLSA) was used for this analysis. The main outcome was HT use among women aged 45-85 years, defined as current, past, and never users. Multinomial logistic regression models were used to examine the differences between current, past, and never HT users in terms of sociodemographic, health behavior, and health-related variables.

RESULTS

Overall, 9.5% of the sample reported current use of HT, whereas 21.9% reported past use. The main factors associated with a lower likelihood of current HT use were older age (>80 y), nonwhite ethnic background, current employment, regular smoking, obesity, and breast cancer. By contrast, alcohol consumption, and the presence of allergies or mood disorders were positively associated with current HT use.

CONCLUSIONS

These findings provide a recent national picture of HT use in Canada that may be used to inform opportunities for improved physician-patient communication regarding menopause management.

In-utero cigarette smoke exposure and the risk of earlier menopause

OBJECTIVE

Cigarette smoking is a risk factor for earlier menopause. Animal studies show that in-utero smoke exposure is toxic to developing ovaries. Our aim was to evaluate whether in-utero smoke exposed women reach menopause earlier compared with nonexposed women.

METHODS

This is a cohort study within the Avon Longitudinal Study of Parents and Children. Participants included in this study were followed from 1991/1992 until 2010. Participant characteristics for the current analysis were obtained from obstetric records and from annual follow-up questionnaires. When not available, age at natural menopause was estimated by age at filling in the questionnaire minus 1 year. Cox proportional hazards modeling was used to estimate hazard ratios of menopause for in-utero exposed and nonexposed women.

RESULTS

There were 695/2,852 postmenopausal women, of whom 466 had natural menopause, 117 had hormonal therapy, and 112 had surgical menopause. Age at natural menopause was 50.6 ± 3.7 years. Of all participants, 20.2% (577/2,852) were exposed to smoke in-utero. Participants who were in-utero exposed but were not smokers did not have higher hazards of menopause (adjusted hazard ratio [HR] 0.92, 95% CI 0.72-1.18), whereas participants who were ever smokers (current or previous) and were in-utero exposed (adjusted HR 1.41, 95% CI 1.01-1.95) or were ever smokers but not exposed (adjusted HR 1.24, 95% CI 1.00-1.53) did have higher hazards of earlier menopause.

CONCLUSIONS

In-utero smoke exposure was not associated with earlier menopause, but the effect of in-utero smoke exposure was modified by the smoking habits of the participants themselves increasing the risk for smokers who were in-utero exposed.

The relation of age at menarche with age at natural menopause: a population study of 336 788 women in Norway

STUDY QUESTION

Is age at menarche associated with age at menopause or with duration of the reproductive period (interval between menarche and menopause)?

SUMMARY ANSWER

The association of age at menarche with age at menopause was weak and non-linear, and the duration of the reproductive period decreased by increasing age at menarche.

WHAT IS KNOWN ALREADY

It remains uncertain whether age at menarche is associated with age at menopause. Some studies report that women with early menarche also have early menopause. Other studies report that women with early menarche have late menopause, or they report no association. The duration of the reproductive period may be an indicator of the cumulative endogenous exposure to estrogens and progestogens during life course and is associated with risk of breast cancer and endometrial cancer.

STUDY DESIGN, SIZE, DURATION

A retrospective cohort study of 336 788 women, aged 48-71 years, in the BreastScreen Norway during the years 2006-2014 was performed.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Information about age at menarche and menopausal status was obtained by self-administered questionnaires. We used time to event approaches to estimate the associations.

MAIN RESULTS AND THE ROLE OF CHANCE

Median age at menopause was 51 years in most menarche groups. Women with menarche at age 16 years or age ≥ 17 years had menopause 1 year later [median: 52 years, interquartile range (IQR): 49-54 years] than women with menarche at age 13 years (median: 51 years, IQR: 49-54 years, reference) (crude hazard ratio (HR) = 0.95; 95% CI: 0.93-0.97 and 0.95; 95% CI: 0.92-0.99, Pnon-linearity < 0.001). The reproductive period decreased with increasing age at menarche (Pnon-linearity < 0.001), and women with menarche at age ≤ 9 years had 9 years longer median reproductive period than women with menarche at age ≥ 17 years (median: 43 versus 34 years). Adjustment for year of birth did not change the HR estimates notably.

LARGE SCALE DATA

Not applicable.

LIMITATIONS, REASONS FOR CAUTION

Information about age at menarche and age at menopause was based on self-reports. Particularly for age at menarche, the long time interval between the event and data collection may have caused imprecise reporting.

WIDER IMPLICATIONS OF THE FINDINGS

Our study suggests that age at menarche is a strong indicator for the duration of women's reproductive period. Our findings should encourage studies of the independent role of duration of the reproductive period on the risk of breast cancer and endometrial cancer, since these cancers have been associated with exposure to estrogens and progestogens.

STUDY FUNDING/COMPETING INTEREST(S)

The present study was funded by the Norwegian Cancer Society [Grant number 6863294-2015]. The authors declare no conflicts of interest.

Loss of PUMA protects the ovarian reserve during DNA-damaging chemotherapy and preserves fertility

Female gametes are stored in the ovary in structures called primordial follicles, the supply of which is non-renewable. It is well established that DNA-damaging cancer treatments can deplete the ovarian reserve of primordial follicles, causing premature ovarian failure and infertility. The precise mechanisms underlying this chemotherapy-driven follicle loss are unclear, and this has limited the development of targeted ovarian-protective agents. To address this fundamental knowledge gap, we used gene deletion mouse models to examine the role of the DNA damage-induced pro-apoptotic protein, PUMA, and its transcriptional activator TAp63, in primordial follicle depletion caused by treatment with cyclophosphamide or cisplatin. Cyclophosphamide caused almost complete destruction of the primordial follicle pool in adult wild-type (WT) mice, and a significant destructive effect was also observed for cisplatin. In striking contrast, Puma-/- mice retained 100% of their primordial follicles following either genotoxic treatment. Furthermore, elimination of PUMA alone completely preserved fertility in cyclophosphamide-treated mice, indicating that oocytes rescued from DNA damage-induced death can repair themselves sufficiently to support reproductive function and offspring health. Primordial follicles were also protected in TAp63-/- mice following cisplatin treatment, but not cyclophosphamide, suggesting mechanistic differences in the induction of apoptosis and depletion of the ovarian reserve in response to these different chemotherapies. These studies identify PUMA as a crucial effector of apoptosis responsible for depletion of primordial follicles following exposure to cyclophosphamide or cisplatin, and this indicates that inhibition of PUMA may be an effective ovarian-protective strategy during cancer treatment in women.

Age at natural menopause and associated factors in adult women: Findings from the China Kadoorie Biobank study in Zhejiang rural area

Objectives

To investigate the factors associated with age at natural menopause in a large population of Chinese adult women.

Methods

This cross-sectional study was part of the baseline survey of China Kadoorie Biobank in Zhejiang Province. A total of 17,076 postmenopausal women were included in the present study. Relevant data of socio-demographic, lifestyle, dietary and reproductive characteristics were collected. Multinomial logistic regression models were used to examine the associated factors of age at natural menopause with adjusted odds ratios (ORs) and their 95% confidence intervals (CIs) were reported.

Results

The mean age at natural menopause was 48.94 years, with 3.40% of the women experienced premature menopause and 6.75% early menopause. Younger age, higher education, consumption of meat (1–3 days per week) and increased parity were associated with late menopause. Current smoking, underweight, higher physical activity, consumption of sea food (1–3 days per week), fresh eggs (≥4 days per week), fresh fruits (≥1 day per week), taking vitamins, experiencing severe food shortage, earlier age at menarche and older age at first birth were associated with earlier age at natural menopause.

Conclusions

These results suggest that certain factors involved with socio-demographic, lifestyle, dietary and reproductive characteristics are related to the age at natural menopause in Chinese women.

Cigarette Smoking and Risk of Early Natural Menopause

Menopause before 45 years of age affects roughly 5%-10% of women and is associated with a higher risk of adverse health conditions. Although smoking may increase the risk of early menopause, evidence is inconsistent, and data regarding smoking amount, duration, cessation, associated risks, and patterns over time are scant. We analyzed data of 116,429 nurses from the Nurses' Health Study II from 1989 through 2011 and used Cox proportional hazards models to estimate hazard ratios adjusted for confounders. Compared with never-smokers, current smokers (hazard ratio (HR) = 1.90, 95% confidence interval (CI): 1.71, 2.11) and former smokers (HR = 1.10, 95% CI: 1.00, 1.21) showed an increased risk of early menopause. Increased risks were observed among women who reported current smoking for 11-15 pack-years (HR = 1.72, 95% CI: 1.36, 2.18), 16-20 pack-years (HR = 1.72, 95% CI: 1.38, 2.14), and more than 20 pack-years (HR = 2.42, 95% CI: 2.11, 2.77). Elevated risk was observed in former smokers who reported 11-15 pack-years (HR = 1.29, 95% CI: 1.07, 1.55), 16-20 pack-years (HR = 1.42, 95% CI: 1.13, 1.79), or more than 20 pack-years (HR = 1.54, 95% CI: 1.23, 1.93). Women who smoked 10 or fewer cigarettes/day but quit by age 25 had comparable risk to never-smokers (HR = 1.03, 95% CI: 0.91, 1.17). A dose-response relationship between smoking and early natural menopause risk, as well as reduced risk among quitters, may provide insights into the mechanisms of cigarette smoking in reproductive health.

Body mass index and age at natural menopause: an international pooled analysis of 11 prospective studies

Current evidence on the association between body mass index (BMI) and age at menopause remains unclear. We investigated the relationship between BMI and age at menopause using data from 11 prospective studies. A total of 24,196 women who experienced menopause after recruitment was included. Baseline BMI was categorised according to the WHO criteria. Age at menopause, confirmed by natural cessation of menses for ≥ 12 months, was categorised as < 45 years (early menopause), 45-49, 50-51 (reference category), 52-53, 54-55, and ≥ 56 years (late age at menopause). We used multinomial logistic regression models to estimate multivariable relative risk ratios (RRRs) and 95% confidence intervals (CI) for the associations between BMI and age at menopause. The mean (standard deviation) age at menopause was 51.4 (3.3) years, with 2.5% of the women having early and 8.1% late menopause. Compared with those with normal BMI (18.5-24.9 kg/m²), underweight women were at a higher risk of early menopause (RRR 2.15, 95% CI 1.50-3.06), while overweight (1.52, 1.31-1.77) and obese women (1.54, 1.18-2.01) were at increased risk of late menopause. Overweight and obesity were also significantly associated with around 20% increased risk of menopause at ages 52-53 and 54-55 years. We observed no association between underweight and late menopause. The risk of early menopause was higher among obese women albeit not significant (1.23, 0.89-1.71). Underweight women had over twice the risk of experiencing early menopause, while overweight and obese women had over 50% higher risk of experiencing late menopause.

Using quality improvement methodology to improve ovarian salvage for benign ovarian masses

PURPOSE

Most ovarian masses in children are benign and potentially amenable to ovarian salvage surgery (OSS). Despite the common use of OSS among pediatric and adolescent gynecologists (PAG) in recognition of reproductive and hormonal health advantages, this technique is not commonly performed by pediatric surgeons. The aim of this quality improvement (QI) initiative was to improve our institutional rate of OSS for benign ovarian masses.

METHODS

Baseline data were obtained retrospectively from surgical procedures performed for benign ovarian masses between January 2012 and February 2016. Designed interventions to improve the rate of OSS included the development of an ovarian mass algorithm, standardization of radiologic templates, multidisciplinary analyses of ovarian procedures, and implementation of a training model for performing OSS. Procedures performed for benign ovarian masses from March 2016 to February 2017 comprised the process stage.

RESULTS

Our institutional baseline OSS rate was 28.8%. After implementation of the institutional algorithm, a single oophorectomy was performed for a benign mass, increasing the OSS rate to 96%. There have been no missed ovarian malignancies.

CONCLUSIONS

Utilizing preoperative risk assessment, QI methodology and multidisciplinary collaboration resulted in improved OSS rates for benign ovarian masses with no evidence of missed ovarian malignancies.

LEVEL OF EVIDENCE

Level II. This is a prospective comparative study, with comparison to a retrospective cohort. This is a quality improvement initiative without randomization.

Premature Ovarian Insufficiency: Phenotypic Characterization Within Different Etiologies

CONTEXT

Premature ovarian insufficiency (POI) is highly heterogeneous, both in phenotype and etiology. They are not yet clearly stated and correlated.

OBJECTIVE

To characterize clinical presentations of a large, well-phenotyped cohort of women with POI, and correlate phenotypes with etiologies to draw a comprehensive clinical picture of POI.

DESIGN, PATIENTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES

In this retrospective study, a total of 955 Chinese women with overt POI between 2006 and 2015 were systemically evaluated and analyzed. The phenotypic features, including menstrual characteristics, hormone profiles, ovarian ultrasonography/biopsy, pregnancy/family history, and genetic/autoimmune/iatrogenic etiologies were assessed and further compared within different subgroups.

RESULTS

Among 955 women with POI, 85.97% presented with secondary amenorrhea (SA) and 14.03% with primary amenorrhea (PA). PA represented the most severe ovarian dysfunction and more chromosomal aberrations than SA. The decline of ovarian function in patients with SA progressed quickly. They had shortened reproductive periods (approximately 10 years) and developed amenorrhea within 1 to 2 years after menstrual irregularity. The ovaries were invisible or small, and the presence of follicles (28.43%) was correlated with other good reproductive indicators. Familial patients (12.25%) manifested better ovarian status and fewer chromosomal aberrations than sporadic patients. The etiologies consisted of genetic (13.15%), autoimmune (12.04%), and iatrogenic (7.29%), approximately 68% remaining idiopathic. There were significant differences among different etiologies, with the genetic group representing the most severe phenotype.

CONCLUSION

Our results regarding distinct phenotypic characteristics and association with different etiologies further confirmed the high heterogeneity of POI. Additional longitudinal clinical studies and pathogenesis research are warranted.

Variability in surgical management of benign ovarian neoplasms in children

BACKGROUND/PURPOSE

Although most pediatric ovarian neoplasms are benign and may be treated with ovary-sparing surgery (OSS), consensus is lacking on the optimal surgical approach. We aimed to determine the proportion of pediatric benign ovarian neoplasms managed with OSS and to assess variability in management across hospitals and specialties.

METHODS

Using the Pediatric Health Information System, we studied patients aged 6-21 years treated in 2006-2014 for a benign ovarian neoplasm with oophorectomy or OSS. Inter-hospital variability and predictors of the type of surgery were determined using logistic mixed effects models with random hospital effects.

RESULTS

Of 1164 patients with benign ovarian neoplasms, 646 underwent oophorectomy, and 518 underwent OSS. Across hospitals, there was significant variability in the proportion of OSS (range: 21.7-76.6%). In multivariable analysis, patients managed by pediatric surgeons (vs. pediatric and adolescent gynecologists) (OR: 0.27, 95%CI: 0.17-0.43, p<0.001), younger patients (OR: 0.94 per year, 95%CI: 0.90-0.98, p=0.007), and those admitted through the emergency department (OR: 0.76, 95%CI: 0.58-0.99, p=0.04) were less likely to undergo OSS. Inter-hospital variability remained significant after adjusting for relevant patient and hospital characteristics (p<0.001).

CONCLUSIONS

Significant variability exists in management of benign ovarian neoplasms across hospitals and specialties. Collaborative efforts between treating specialists may improve implementation of evidence-based guidelines for OSS.

TYPE OF STUDY

retrospective study LEVEL OF EVIDENCE: III.

Intrinsic fertility of human oocytes

OBJECTIVE

To study the intrinsic fertility of the human oocyte.

DESIGN

A large retrospective study of natural cycle single embryo transfer (ET) IVF cycles.

SETTING

Private IVF clinic, university, and private hospital.

PATIENT(S)

Patients were enrolled consecutively over an 8-year period in a single ET natural cycle protocol.

INTERVENTION(S)

A total of 13,949 oocyte retrievals with natural IVF single ET. Software package R (version 3.2.5) was used for statistical calculations.

MAIN OUTCOME MEASURE(S)

Live baby rate per oocyte according to age.

RESULT(S)

A total of 14,185 natural cycle oocytes resulted in 1,913 live babies from single ET. The number of oocytes required to make one live baby in this large series varied with the age of the female partner. For those under 35, the live baby born per oocyte was 26%. For over age 42 it decreased to 1%. These results fit very robustly with a logistic function curve, which is at first steady (horizontal), followed by a linear decline after age 35 with a 10% loss every year until age 43, and then a flattening out (horizontal) by age 44.

CONCLUSION(S)

The intrinsic fertility per oocyte in natural cycle is far greater than reported in hyperstimulated cycles, varying robustly from 26% to 4% with age from <35 to 42 years. The curve is relatively flat until age 34, and then declines rapidly 10% per year thereafter.

Environmental pollutants, a possible etiology for premature ovarian insufficiency: a narrative review of animal and human data

BACKGROUND

Because only 25% of cases of premature ovarian insufficiency (POI) have a known etiology, the aim of this review was to summarize the associations and mechanisms of the impact of the environment on this pathology. Eligible studies were selected from an electronic literature search from the PUBMED database from January 2000 to February 2016 and associated references in published studies. Search terms included ovary, follicle, oocyte, endocrine disruptor, environmental exposure, occupational exposure, environmental contaminant, pesticide, polyaromatic hydrocarbon, polychlorinated biphenyl PCB, phenol, bisphenol, flame retardant, phthalate, dioxin, phytoestrogen, tobacco, smoke, cigarette, cosmetic, xenobiotic. The literature search was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We have included the human and animal studies corresponding to the terms and published in English. We have excluded articles that included results that did not concern ovarian pathology and those focused on ovarian cancer, polycystic ovary syndrome, endometriosis or precocious puberty. We have also excluded genetic, auto-immune or iatrogenic causes from our analysis. Finally, we have excluded animal data that does not concern mammals and studies based on results from in vitro culture. Data have been grouped according to the studied pollutants in order to synthetize their impact on follicular development and follicular atresia and the molecular pathways involved. Ninety-seven studies appeared to be eligible and were included in the present study, even though few directly address POI. Phthalates, bisphenol A, pesticides and tobacco were the most reported substances having a negative impact on ovarian function with an increased follicular depletion leading to an earlier age of menopause onset. These effects were found when exposure occured at different times throughout the lifetime from the prenatal to the adult period, possibly due to different mechanisms. The main mechanism seemed to be an increase in atresia of pre-antral follicles.

CONCLUSION

Environmental pollutants are probably a cause of POI. Health officials and the general public must be aware of this environmental effect in order to implement individual and global preventive actions.

Early menarche, nulliparity and the risk for premature and early natural menopause

STUDY QUESTION

Are parity and the timing of menarche associated with premature and early natural menopause?

SUMMARY ANSWER

Early menarche (≤11 years) is a risk factor for both premature menopause (final menstrual period, FMP <40 years) and early menopause (FMP 40-44 years), a risk that is amplified for nulliparous women.

WHAT IS KNOWN ALREADY

Women with either premature or early menopause face an increased risk of chronic conditions in later life and of early death. Findings from some studies suggest that early menarche and nulliparity are associated with early menopause, however overall the evidence is mixed. Much of the evidence for a direct relationship is hampered by a lack of comparability across studies, failure to adjust for confounding factors and inadequate statistical power.

STUDY DESIGN, SIZE, DURATION

This pooled study comprises 51 450 postmenopausal women from nine observational studies in the UK, Scandinavia, Australia and Japan that contribute to the International collaboration for a Life course Approach to reproductive health and Chronic disease Events (InterLACE).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Age at menarche (categorized as ≤11, 12, 13, 14 and 15 or more years) and parity (categorized as no children, one child and two or more children) were exposures of interest. Age at FMP was confirmed by at least 12 months of cessation of menses where this was not the result of an intervention (such as surgical menopause due to bilateral oophorectomy or hysterectomy) and categorized as premature menopause (FMP before age 40), early menopause (FMP 40-44 years), 45-49 years, 50-51 years, 52-53 years and 54 or more years. We used multivariate multinomial logistic regression models to estimate relative risk ratio (RRR) and 95% CI for associations between menarche, parity and age at FMP adjusting for within-study correlation.

MAIN RESULTS AND THE ROLE OF CHANCE

The median age at FMP was 50 years (interquartile range 48-53 years), with 2% of the women experiencing premature menopause and 7.6% early menopause. Women with early menarche (≤11 years, compared with 12-13 years) were at higher risk of premature menopause (RRR 1.80, 95% CI 1.53-2.12) and early menopause (1.31, 1.19-1.44). Nulliparity was associated with increased risk of premature menopause (2.26, 1.84-2.77) and early menopause (1.32, 1.09-1.59). Women having early menarche and nulliparity were at over 5-fold increased risk of premature menopause (5.64, 4.04-7.87) and 2-fold increased risk of early menopause (2.16, 1.48-3.15) compared with women who had menarche at ≥12 years and two or more children.

LIMITATIONS, REASONS FOR CAUTION

Most of the studies (except the birth cohorts) relied on retrospectively reported age at menarche, which may have led to some degree of recall bias.

WIDER IMPLICATIONS OF THE FINDINGS

Our findings support early monitoring of women with early menarche, especially those who have no children, for preventive health interventions aimed at mitigating the risk of adverse health outcomes associated with early menopause.

STUDY FUNDING/COMPETING INTEREST(S)

InterLACE project is funded by the Australian National Health and Medical Research Council project grant (APP1027196). G.D.M. is supported by Australian Research Council Future Fellowship (FT120100812). There are no competing interests.

Chapter 13 Human Ovarian Tissue Vitrification

Ovarian freezing and transplantation has garnered increasing interest as a potential way of preserving fertility in cancer patients as well as for women who just wish to delay childbearing. This chapter spells out our techniques of ovarian cortex vitrification and results for frozen compared to fresh ovarian cortex transplantation (in one single series from one center for the sake of consistency), as well as potentially provides insight into the mechanism behind ovarian follicle recruitment. This represents an effort to simplify and popularize an approach that has yielded favorable results (all cases recovered ovulation and 75% had successful spontaneous pregnancy) in one single, disciplined study. It should be clear that this is a review for the more general reader of our original scientific papers published in Reproductive BioMedicine Online, New England Journal of Medicine, Fertility and Sterility, Human Reproduction, Molecular Human Reproduction, and Journal of Assisted Reproduction and Genetics (JARG).

Ovarian tissue cryopreservation and transplantation: scientific implications

After fresh or frozen ovary transplantation, FSH levels return to normal, and menstrual cycles resume by 150 days, coincident with anti-Müllerian hormone rising to higher than normal levels. AMH then returns to well below normal levels by 240 days, remaining as such for many years with nonetheless normal ovulation and fertility. To date, 20 babies have been born in our program from 11 fresh and 13 cryopreserved ovary transplant recipients with a live baby rate of over 70 % (11 babies from fresh and 9 from frozen). Globally, over 70 live births have been reported for both fresh and frozen ovary transplants with an approximate 30 % live birth rate. Given the rapid rise of AMH after the fall of FSH, with a subsequent AMH decrease with retention of ovarian function, it is tempting to speculate the existence of a shared mechanism controlling primordial follicle recruitment, fetal oocyte meiotic arrest, and recruitment in the adult ovary. With the massive recruitment of primordial follicles observed after human ovarian cortical tissue transplantation, which subsides to an extremely low recruitment rate, we will discuss how this phenomenon suggests a unifying theory implicating ovarian cortical tissue rigidity in the regulation of both fetal oocyte arrest and recruitment of follicles in the adult ovary. As the paper by Winkler-Crepaz et al. in this issue demonstrates, our in vivo results are consistent with the in vitro demonstration that primordial follicles in the fetal cortex are "locked" in development, resulting in meiotic arrest, which spares the oocytes from being rapidly lost all at once (Winkler-Crepaz et al., J Assist Reprod Genet, 1). Winkler-Crepaz et al. demonstrate that follicle loss after ovarian cortex transplantation is unlikely due to ischemic apoptosis, but rather from a "burst" of primordial follicle recruitment. In vivo, primordial follicles are normally resistant to further development or activation to prevent oocyte depletion. The dense fibrous ovarian cortex, through as yet unresolved mechanisms, arrests the further continuation of meiosis and also prevents a sudden depletion of all resting follicles in the adult ovary. Intrinsic tissue pressure is released after cortical tissue transplantation, temporarily resulting in a rapid follicle depletion. These results are consistent with the observation that once the ovarian reserve is reduced in the graft, the rate of recruitment diminishes and the ovarian tissue exhibits a relatively long duration of function.

Perimenopause and Menopause Are Associated With High Frequency Headache in Women With Migraine: Results of the American Migraine Prevalence and Prevention Study

OBJECTIVES

To examine the relationship of headache frequency to the stages of the menopausal transition in mid-life women with migraine.

BACKGROUND

Past studies suggest that the perimenopause is associated with an increased prevalence of migraine, particularly in those with a history of premenstrual syndrome. The effect of the menopausal transition on the frequency of headache attacks in women with migraine has not been explored.

METHODS

This was a cross-sectional observational study. Using data from the 2006 American Migraine, Prevalence and Prevention study survey, women meeting modified ICHD-3 beta criteria for migraine between the ages of 35-65 years were included in analyses. Women who had never menstruated or were pregnant, breastfeeding, or using exogenous sex hormones were excluded. The 2006 survey was selected because it included detailed questions on the menstrual cycle. The stages of the menopausal transition were defined based upon the self-reported cycle length and/or duration of amenorrhea. The primary outcome, high vs low headache frequency, was defined using a cut score of ≥10 headache days per month. Binary logistic regression models were used to assess the influence of menopausal stage on headache frequency category using premenopause as the reference group. Adjustments for stage of menopausal transition and sociodemographics (eg, age and income) were included in the first model, while the second model included sociodemographics, depression, body mass index, preventative medications, and medication overuse.

RESULTS

The study sample included 3664 women at a mean age of 46 years. Among women who were premenopausal, 8.0% (99/1242) were in the high frequency headache group in comparison with 12.2% (154/1266) of perimenopausal and 12.0% (131/1095) of postmenopausal women. Compared with premenopausal women, the adjusted odds of being in the high frequency headache group was 1.62 (95% CI = 1.23, 2.12) for perimenopausal and 1.76 (95% CI = 1.23, 2.52) for postmenopausal women (Model 1). In model 2, high frequency headache was only increased in perimenopausal women with an OR of 1.42 (95% CI = 1.03, 1.94).

CONCLUSIONS

The risk of high frequency headache is increased in women during the perimenopause compared to premenopause in the fully adjusted model. The fact that the increased risk of high frequency headache was not statistically significant for menopause in the fully adjusted models suggests that different mechanisms might account for the increased risk for this stage of the menopausal transition. Recognition of the increased risk of high frequency headache during the menopausal transition suggests a need for optimized preventive treatment of migraine during this time of women's life.

The Bologna criteria for poor ovarian response: a contemporary critical appraisal

Postponement of child bearing and maternal age at first pregnancy are on the rise, contributing considerably to an increase in age-related infertility and the demand for assisted reproductive technologies (ART) treatment. This brings to the infertility clinics many women with low ovarian reserve and poor ovarian response (POR) to conventional stimulation. The Bologna criteria were released to standardize the definition of POR and pave the way for the formulation of evidence-based, efficient modalities of treatment for women undergoing IVF-ET. More than four years have passed since the introduction of these criteria and the debate is still ongoing whether a revision is due. Women with POR comprise several sub-groups with diverse baseline distinctiveness, a major issue that has fueled the discussion. Although antral follicle count (AFC) and anti-Müllerian hormone (AMH), are considered good predictors of ovarian reserve, their threshold values are still not universally standardized. Different definitions for sonographic AFC and diverse assays for AMH are held responsible for this delay in standardization. Adding established risk factors to the criteria will lead to more reliable and reproducible definition of a POR, especially in young women. The original criteria did not address the issue of oocyte quality, and the addition of risk factors may yield specific associations with quality vs. quantity. Patient’s age is the best available criterion, although limited, to predict live-birth and presumably oocyte quality. High scale studies to validate these criteria are still missing while recent evidence raises concern regarding over diagnosis.

Relationship between some indicators of reproductive history, body fatness and the menopausal transition in Hungarian women

BACKGROUND

This paper analyzed the relationship between some indicators of reproductive history and body fatness in relation to the timing of the menopause transition in Hungarian women using survival analysis after controlling for birth cohort.

METHODS

Data on menstruation and reproductive history were collected during the personal interviews in a sample of 1932 women (aged 35+ years). Menarcheal age, the length of menstrual cycles and menstrual bleedings, regularity of menstrual cycles, number of gestations, lactation, the ever use of contraceptives, menopausal status and age at menopause were used as indicators of reproductive history. The body fat fraction was estimated by bioelectrical impedance analysis. Body fatness was also estimated by dividing women into obese and non-obese categories (considering body mass index and waist-to-hip ratio). Survival analyses were used to analyze the relationship between the indicators of reproductive history and body fatness during the menopausal transition.

RESULTS

Only the menarcheal age among the investigated reproductive life characteristics showed secular changes in the studied decades in Hungary; the mean age at menarche decreased by approximately 2.5 months per decade from the 1920s until the 1970s. Ever use of hormonal contraceptives, a relatively long cycle length in the perimenopausal transition and higher parity were all related with lower risk of early menopause. Later menarcheal age, normal length of menstrual cycle or bleeding in the climacterium, irregular bleeding pattern and postmenopausal status were associated with a higher amount of body fatness, while never use of contraceptives, regular menstruation, postmenopausal status and relatively early menopause were associated with a higher risk of abdominal obesity.

CONCLUSION

This report confirms that age of menarche is not significantly predictive of age at menopause but prior use of oral contraceptives, longer mean cycle length and smaller number of gestations all are. In addition, age of menarche, irregular bleeding pattern before the climacterium, length of menstrual cycles and bleedings during the climacterium and postmenopausal status were associated with obesity during the climacterium.