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Alkhrait S, Al-Hendy A, Alkelani H, Karrison T, Laveaux OSM. Surgical myomectomy followed by oral Myfembree vs standard of care (SOUL trial): Study protocol for a randomized control trial. PLoS One 2024; 19:e0306053. [PMID: 38954680 PMCID: PMC11218990 DOI: 10.1371/journal.pone.0306053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 06/05/2024] [Indexed: 07/04/2024] Open
Abstract
BACKGROUND Uterine leiomyomas (often referred to as fibroids or myomas) are common benign, hormone-dependent tumors that grow in the uterus and occur in approximately 25% of reproductive age women, depending on selected population. Treatment recommendation is typically based on fibroid size, location, the patient's age, reproductive plans, and obstetrical history. Despite the range of treatment options available for uterine fibroids and their symptoms, including hysterectomy, myomectomy, endometrial ablation, endometrial uterine artery embolization, and magnetic resonance-guided focused-ultrasound surgery, myomectomy remains the gold standard treatment for patients who desire fertility-preserving surgery for their uterine fibroids. Myomectomy, while a prevalent surgical option for the removal of fibroids, carries known risks such as fibroid recurrence, symptom recurrence, and the subsequent need for reintervention. Despite ongoing research and advances in medical treatments for fibroids, there currently are no universally recommended therapeutic interventions proven to effectively delay the recurrence of fibroids or the return of symptoms following this procedure. This situation underscores a significant area of unmet medical need and highlights the importance of continued investigation into preventive strategies and long-term management options for patients undergoing fibroid removal with uterine preservation. We designed a study to assess the efficacy of the new FDA-approved GnRH antagonist, Myfembree in delaying the return of fibroids and their associated symptoms. METHODS A randomized, prospective, open-label clinical trial. The participants (n = 136) will be randomly distributed into two groups. The Control Group (Standard of care) will receive treatment with standard of care (SoC) after surgical myomectomy and the treatment group will receive Relugolix combination therapy (Myfembree®) after surgical myomectomy. The study protocol was approved by the University of Chicago's Institutional Review Board (IRB#22-0282), ensuring that all participants would provide written informed consent before their inclusion. DISCUSSION In this project, we propose the use of daily dosed Relugolix combination therapy (Relugolix with estradiol and norethindrone acetate), which is approved for uterine fibroids treatment, has the potential to delay the recurrence of fibroid symptoms, prolong the improved quality of life and delay need for re-intervention after uterine sparing surgery. TRIAL REGISTRATION The study protocol was approved by the Institutional Review Board of the University of Chicago on 9/16/2022 and was registered at ClinicalTrials.gov with number NCT05538689 on Sep 7, 2022. All subjects will provide informed consent to participate.
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Affiliation(s)
- Samar Alkhrait
- Department of Obstetrics and Gynecology, University of Chicago, Chicago, IL, United States of America
| | - Ayman Al-Hendy
- Department of Obstetrics and Gynecology, University of Chicago, Chicago, IL, United States of America
| | - Hiba Alkelani
- Department of Obstetrics and Gynecology, University of Chicago, Chicago, IL, United States of America
| | - Theodore Karrison
- Department of Public Health Sciences, University of Chicago, Chicago, IL, United States of America
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Mao C, Liu X, Guo SW. Meclizine improves endometrial repair and reduces simulated menstrual bleeding in mice with induced adenomyosis. Am J Obstet Gynecol 2024; 231:113.e1-113.e13. [PMID: 38367751 DOI: 10.1016/j.ajog.2024.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 01/31/2024] [Accepted: 02/11/2024] [Indexed: 02/19/2024]
Abstract
BACKGROUND Adenomyosis is one of the structural causes of abnormal uterine bleeding, which often presents as heavy menstrual bleeding. Mostly because of the poor understanding of its pathophysiology, medical management of adenomyosis-induced heavy menstrual bleeding is still a challenge. We have previously reported that glycolysis is crucial to endometrial repair following menstruation and that suppressed glycolysis can cause heavy menstrual bleeding. OBJECTIVE This study aimed to test the hypothesis that meclizine, a drug with an excellent safety profile, alleviates heavy menstrual bleeding in mice with induced adenomyosis using a simulated menstruation model. STUDY DESIGN Adenomyosis was induced in 36 female C57BL/6 mice using endometrial-myometrial interface disruption. Three months after induction, the mice were randomly divided into the following 3 groups: low-dose meclizine, high-dose meclizine, and controls. Treatment with meclizine or vehicle started shortly before the simulated menstruation procedure and ended before progesterone withdrawal. The amount of blood loss was quantified and uterine tissue was harvested for histologic evaluation of the grade of endometrial repair. We performed immunohistochemistry analysis of 4 proteins critically involved in glycolysis: Glut1 (glucose transporter 1), Hk2 (hexokinase 2), Pfkfb3 (6-phosphofructo-2-kinase/fructose-2,6-biphosphatase 3), and Pkm2 (pyruvate kinase M2). The extent of tissue fibrosis in both ectopic and eutopic endometria was evaluated using Masson trichrome staining. RESULTS In mice with induced adenomyosis, meclizine accelerated endometrial repair in a dose-dependent manner and reduced the amount of menstrual bleeding. Meclizine administration raised endometrial immunoexpression of Hk2 and Pfkfb3 but not of Glut1 or Pkm2. The extent of endometrial fibrosis was reduced following the meclizine administration. Remarkably, these favorable changes were accompanied by the suppression of lesional progression, as evidenced by the dose-dependent reduction in the extent of fibrosis (a surrogate for lesional progression). CONCLUSION These encouraging results, taken together, suggest that glycolysis may be a promising therapeutic target and that meclizine may hold therapeutic potential as a nonhormonal treatment for adenomyosis-induced heavy menstrual bleeding without exacerbating the disease.
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Affiliation(s)
- Chenyu Mao
- Department of General Gynecology, Obstetrics & Gynecology Hospital, Fudan University, Shanghai, China
| | - Xishi Liu
- Department of General Gynecology, Obstetrics & Gynecology Hospital, Fudan University, Shanghai, China
| | - Sun-Wei Guo
- Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Fudan University, Shanghai, China; Research Institute, Obstetrics & Gynecology Hospital, Fudan University, Shanghai, China.
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Pritts TL, Ogden M, Parker W, Ratcliffe J, Pritts EA. Intramural Leiomyomas and Fertility: A Systematic Review and Meta-Analysis. Obstet Gynecol 2024:00006250-990000000-01103. [PMID: 38935974 DOI: 10.1097/aog.0000000000005661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 05/09/2024] [Indexed: 06/29/2024]
Abstract
OBJECTIVE To evaluate fertility outcomes based on size and number of intramural leiomyomas and outcomes after removal. DATA SOURCES Online searches: MEDLINE, ClinicalTrials.gov, PubMed, Cochrane Library, and PROSPERO Library from 1994 to 2023. METHODS OF STUDY SELECTION A total of 5,143 studies were identified, with inclusion of 13 study groups. TABULATION, INTEGRATION AND RESULTS Outcomes for size and number of leiomyomas were reported with clinical pregnancy rates and ongoing pregnancy or live-birth rates. In data sets with maximum leiomyoma diameters of less than 6 cm for study inclusion, women with leiomyomas smaller than 3 cm had lower clinical pregnancy rates than women without leiomyomas, with an odds ratio (OR) of 0.53 (95% CI, 0.38-0.76) and, for ongoing pregnancy or live-birth rates, an OR of 0.59 (95% CI, 0.41-0.86). The ORs for clinical pregnancy rates in women with intermediately-sized leiomyomas (those between 3 cm and 6 cm) were lower than in women without leiomyomas, with an OR at 0.43 (95% CI, 0.29-0.63) and, for ongoing pregnancy or live-birth rates, an OR at 0.38 (95% CI, 0.24-0.59). In data sets without exclusion for women with larger-sized leiomyomas, clinical pregnancy rates were lower for those with leiomyomas smaller than 5 cm compared with those without leiomyomas, with an OR of 0.75 (95% CI, 0.58-0.96). Women with leiomyomas larger than 5 cm showed no differences in clinical pregnancy rate compared with women without leiomyomas, with an OR of 0.71 (95% CI, 0.32-1.58). Although women with a single leiomyoma in any location had no differences in outcomes, those with more than one leiomyoma had lower clinical pregnancy rates and ongoing pregnancy or live-birth rates, with an OR of 0.62 (95% CI, 0.44-0.86) and 0.57 (95% CI, 0.36-0.88), respectively. The clinical pregnancy rate for women undergoing myomectomy for intramural leiomyomas was no different than those with intramural leiomyomas in situ, with an OR of 1.10 (95% CI, 0.77-1.59). CONCLUSION Even small intramural leiomyomas are associated with lower fertility; removal does not confer benefit. Women with more than one leiomyoma in any location have reduced fertility.
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Affiliation(s)
- Taïna Laurore Pritts
- University of Wisconsin and the Wisconsin Fertility Institute, Madison, Wisconsin; and the University of California, San Diego, San Diego, and Advanced Fertility Associates Medical Group, Santa Rosa, California
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Kitahara Y, Hiraike O, Ishikawa H, Kugu K, Takai Y, Yoshino O, Ono M, Maekawa R, Ota I, Iwase A. A nationwide survey of diagnostic procedures for abnormal uterine bleeding in Japan. J Obstet Gynaecol Res 2024. [PMID: 38925169 DOI: 10.1111/jog.16014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 06/17/2024] [Indexed: 06/28/2024]
Abstract
AIM To clarify the diagnostic process of the causative disease of abnormal uterine bleeding (AUB) in Japan according to the International Federation of Gynecology and Obstetrics AUB diagnostic system. METHODS Patients diagnosed with AUB were included in a nationwide survey of AUB conducted during any 2-week period between December 2019 and January 2020. The second survey included information on patient background, AUB symptoms, examinations for diagnosing AUB, the order in which they were performed, and the causative diseases of AUB. RESULTS Correspondence analysis showed an association between hormonal testing, hysterosalpingography, and magnetic resonance imaging (MRI) in patients with amenorrhea, and heavy menstrual bleeding was strongly correlated with various examinations, such as coagulation tests, pelvic MRI, and endometrial cytology or biopsy. The results also indicated that each AUB causative disease can be diagnosed based on a specific examination profile. CONCLUSION We clarified the process of diagnosing the causative disease of AUB in our country and determined that it was mainly diagnosed by imaging and pathological examination in cases of structural disease. The high rate of AUB-E and the low rate of AUB-C are possibly associated with specific examination trends in Japan. The results of this study will be useful for the development of a standard protocol for AUB diagnosis in our country.
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Affiliation(s)
- Yoshikazu Kitahara
- Department of Obstetrics and Gynecology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Osamu Hiraike
- Department of Obstetrics and Gynecology, The University of Tokyo, Bunkyo-ku, Japan
| | - Hiroshi Ishikawa
- Department of Obstetrics and Gynecology, Reproductive Medicine, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Koji Kugu
- Department of Pharmaceutical Sciences (Narita Campus), International University of Health and Welfare (IUHW), Narita, Japan
| | - Yasushi Takai
- Department of Obstetrics and Gynecology, Saitama Medical Center, Saitama Medical University, Kawagoe, Japan
| | - Osamu Yoshino
- Department of Obstetrics and Gynecology, University of Yamanashi Hospital, Chuo, Japan
| | - Masanori Ono
- Department of Obstetrics and Gynecology, Tokyo Medical University, Shinjuku-ku, Japan
| | - Ryo Maekawa
- Department of Obstetrics and Gynecology, Yamaguchi University Hospital, Ube, Japan
| | - Ikuko Ota
- Department of Gynecology, Kurashiki Heisei Hospital, Kurashiki, Japan
| | - Akira Iwase
- Department of Obstetrics and Gynecology, Gunma University Graduate School of Medicine, Maebashi, Japan
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He Y, Wu M, Guo X, Ran F, Li H, Zhang D, Wang Y, Zeng J, Chen X, Zhai L, Li X, Lei T. Feasibility, safety and efficacy of high intensity focused ultrasound ablation as a preoperative treatment for challenging hysteroscopic myomectomy. Int J Hyperthermia 2024; 41:2365974. [PMID: 38880503 DOI: 10.1080/02656736.2024.2365974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 06/05/2024] [Indexed: 06/18/2024] Open
Abstract
PURPOSE To investigate the feasibility, safety and efficacy of high intensity focused ultrasound ablation (HIFU) as a preoperative treatment for challenging hysteroscopic myomectomies. MATERIALS AND METHODS A total of 75 patients diagnosed with types 0-III of uterine fibroids were enrolled. Based on the Size, Topography, Extension of the base, Penetration and lateral Wall position (STEPW) classification scoring system, 25 cases with a score ≥ 5 points were treated with HIFU followed by hysteroscopic myomectomy (HIFU + HM group), whereas 50 cases with a score < 5 points were treated with hysteroscopic myomectomy (HM group). RESULTS The median preoperative STEPW score was 7 in the HIFU + HM group and 2 in the HM group. The average non-perfused volume (NPV) ratio achieved in fibroids after HIFU was 86.87%. Patients in the HIFU + HM group underwent hysteroscopic myomectomy one to four days after HIFU, and downgrading was observed in 81.81% of fibroids. The operation time for patients in the HIFU + HM group was 73 min and the success rate of myomectomy in a single attempt was 60%. The volume of distention medium used during the operation was greater in the HIFU + HM group than in the HM group (15,500 ml vs. 7500 ml). No significant difference was observed between the two groups in terms of intraoperative blood loss, the incidence of intraoperative and postoperative complications, menstrual volume score, or uterine fibroid quality of life score. CONCLUSION HIFU can be utilized as a preoperative treatment for large submucosal fibroids prior to hysteroscopic myomectomy. HIFU offers a novel approach in the management of this subset of patients.
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Affiliation(s)
- Yuchun He
- Department of Gynecology and Obstetrics, Suining Municipal Hospital of Traditional Chinese Medicine, Suining, China
| | - Min Wu
- Department of Gynecology and Obstetrics, Suining Municipal Hospital of Traditional Chinese Medicine, Suining, China
| | - Xu Guo
- Department of Oncology, Suining Municipal Hospital of Traditional Chinese Medicine, Suining, China
| | - Feng Ran
- State Key Laboratory of Ultrasound in Medicine and Engineering, Chongqing Medical University, Chongqing, China
| | - Haiyan Li
- Department of Gynecology and Obstetrics, Suining Municipal Hospital of Traditional Chinese Medicine, Suining, China
| | - Daibi Zhang
- Department of Gynecology and Obstetrics, Suining Municipal Hospital of Traditional Chinese Medicine, Suining, China
| | - Yaqin Wang
- Department of Gynecology and Obstetrics, Suining Municipal Hospital of Traditional Chinese Medicine, Suining, China
| | - Jin Zeng
- Department of Gynecology and Obstetrics, Suining Municipal Hospital of Traditional Chinese Medicine, Suining, China
| | - Xuelian Chen
- Department of Oncology, Suining Municipal Hospital of Traditional Chinese Medicine, Suining, China
| | - Linghui Zhai
- Department of Gynecology and Obstetrics, Suining Municipal Hospital of Traditional Chinese Medicine, Suining, China
| | - Xiaohui Li
- Department of Gynecology and Obstetrics, Suining Municipal Hospital of Traditional Chinese Medicine, Suining, China
| | - Tingting Lei
- Department of Gynecology and Obstetrics, Suining Municipal Hospital of Traditional Chinese Medicine, Suining, China
- State Key Laboratory of Ultrasound in Medicine and Engineering, Chongqing Medical University, Chongqing, China
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Ekroos S, Karregat J, Toffol E, Castrén J, Arvas M, van den Hurk K. Menstrual blood loss is an independent determinant of hemoglobin and ferritin levels in premenopausal blood donors. Acta Obstet Gynecol Scand 2024. [PMID: 38856303 DOI: 10.1111/aogs.14890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 05/27/2024] [Accepted: 05/27/2024] [Indexed: 06/11/2024]
Abstract
INTRODUCTION To prevent blood donors from developing iron deficiency (ferritin <15 μg/L) and subsequent anemia (hemoglobin <120 g/L), blood services rely on information about known risk factors, including the donor's sex and age. For example, while Finnish women are able to donate whole blood with a minimum donation interval of 91 days, women in the 18 to 25-year-old age group are recommended to donate no more than once per year. Menstrual blood loss is not accounted for in blood donation interval recommendations, despite being a known risk factor of iron deficiency. We aim to investigate to what extent menstrual bleeding is associated with ferritin and hemoglobin levels in female blood donors, and quantify the association of other menstruation-related variables not currently accounted for by blood services (i.e., use of hormonal contraception, heavy menstrual bleeding) with iron deficiency or anemia. MATERIAL AND METHODS The study population consisted of 473 premenopausal and 491 postmenopausal Dutch whole blood donors. Exclusion criteria were current pregnancy, BMI ≥50, ferritin ≥200, pictorial blood assessment chart (PBAC) ≥400, and age <18 or ≥70 years. Menstrual blood loss was quantified using a PBAC, a semiquantitative method to evaluate the number of used menstrual products and the degree of staining. We identified predictors of log(ferritin)/hemoglobin and iron deficiency/anemia using Bayesian linear and logistic regression models and quantified the average percentage of variance in log(ferritin) and hemoglobin explained by the covariates. RESULTS Menstrual blood loss accounted for most of the explained variance in hemoglobin (8%) and second only to the number of days since last donation for ferritin (8%). Heavy menstrual bleeding (PBAC ≥150, OR = 3.56 [1.45-8.85], prevalence 13%) was associated with anemia, and use of levonorgestrel-releasing intrauterine device was negatively associated with iron deficiency (OR = 0.06 [0.01-0.44]). After statistical control for menstrual blood loss, age was not associated with iron status. CONCLUSIONS Menstrual blood loss and blood donation were the most important determinants of iron status in premenopausal women. Thus, results suggest that accounting for menstrual blood loss in donation interval guidelines may benefit blood donors.
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Affiliation(s)
- Sofie Ekroos
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Jan Karregat
- Donor Studies, Department of Donor Medicine Research, Sanquin Research, Amsterdam, the Netherlands
- Department of Public and Occupational Health, Amsterdam UMC, Amsterdam, the Netherlands
| | - Elena Toffol
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Johanna Castrén
- Finnish Red Cross, Blood Service (FRCBS), Research and Development, Helsinki, Finland
| | - Mikko Arvas
- Finnish Red Cross, Blood Service (FRCBS), Research and Development, Helsinki, Finland
| | - Katja van den Hurk
- Donor Studies, Department of Donor Medicine Research, Sanquin Research, Amsterdam, the Netherlands
- Department of Public and Occupational Health, Amsterdam UMC, Amsterdam, the Netherlands
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Favilli A, Mazzon I, Etrusco A, Dellino M, Laganà AS, Tinelli A, Chiantera V, Cicinelli E, Gerli S, Vitagliano A. The challenge of FIGO type 3 leiomyomas and infertility: Exploring therapeutic alternatives amidst limited scientific certainties. Int J Gynaecol Obstet 2024; 165:975-987. [PMID: 38009829 DOI: 10.1002/ijgo.15260] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 10/28/2023] [Accepted: 11/08/2023] [Indexed: 11/29/2023]
Abstract
Uterine leiomyomas (ULs) are non-cancerous tumors composed of smooth muscle cells that develop within the myometrium and represent the most prevalent pathological condition affecting the female genital tract. Despite the volume of available research, many aspects of ULs remain unresolved, making it a "paradoxical disease" where the increase in available scientific literature has not been matched by an increase in solid evidence for clinical management. Fertility stands at the top of the list of clinical issues where the role of ULs is still unclear. The leiomyoma subclassification system, released by the International Federaion of Gynecology and Obstetrics (FIGO) in 2008, introduced a new and more effective way of categorizing uterine fibroids. The aim was to go beyond the traditional classification "subserosal, intramural and submucosal", facilitating a detailed examination of individual ULs impact on the female reproductive system. The "type 3 UL" is a special type of myoma, characterized by its complete myometrial development while encroaching the endometrium. It is a unique "hybrid" between a submucous and an intramural UL, that may exert a detrimental "double hit" mechanism, which is of particular interest in patients wishing pregnancy. To date, no robust evidence is available regarding the management of type 3 ULs. The aim of this narrative review is to provide a comprehensive overview of the physiopathological mechanisms that type 3 UL may exert on fertility, and to present new perspectives that may help us to better understand both the need for and the methods of treating this unique type of fibroid.
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Affiliation(s)
- Alessandro Favilli
- Section of Obstetrics and Gynecology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
- Center of Perinatal and Reproductive Medicine, University of Perugia, Perugia, Italy
| | | | - Andrea Etrusco
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | - Miriam Dellino
- 1st Unit of Obstetrics and Gynecology, Department of Interdisciplinary Medicine (DIM), University of Bari, Bari, Italy
| | - Antonio Simone Laganà
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | - Andrea Tinelli
- Department of Obstetrics and Gynecology, CERICSAL (CEntro di RIcerca Clinico SALentino), Veris delli Ponti Hospital, Scorrano, Italy
| | - Vito Chiantera
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
- Unit of Gynecologic Oncology, National Cancer Institute - IRCCS - Fondazione "G. Pascale", Naples, Italy
| | - Ettore Cicinelli
- 1st Unit of Obstetrics and Gynecology, Department of Interdisciplinary Medicine (DIM), University of Bari, Bari, Italy
| | - Sandro Gerli
- Section of Obstetrics and Gynecology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
- Center of Perinatal and Reproductive Medicine, University of Perugia, Perugia, Italy
| | - Amerigo Vitagliano
- 1st Unit of Obstetrics and Gynecology, Department of Interdisciplinary Medicine (DIM), University of Bari, Bari, Italy
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Giannini A, Cuccu I, D'Auge TG, De Angelis E, Laganà AS, Chiantera V, Caserta D, Vitale SG, Muzii L, D'Oria O, Perniola G, Bogani G, Di Donato V. The great debate: Surgical outcomes of laparoscopic versus laparotomic myomectomy. A meta-analysis to critically evaluate current evidence and look over the horizon. Eur J Obstet Gynecol Reprod Biol 2024; 297:50-58. [PMID: 38581885 DOI: 10.1016/j.ejogrb.2024.03.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 03/28/2024] [Accepted: 03/31/2024] [Indexed: 04/08/2024]
Abstract
Myomectomy is one of the most common surgical procedure in the field of gynecology. However, the role of laparoscopic myomectomy is still debated for many factors, including surgical considerations, safety and fertility concerns, long-term outcomes, and cost-related issues. The aim of this study is to evaluate the surgical peri- and post-operative outcomes of laparoscopic and abdominal myomectomy. A systematic search for studies was performed up to June 2023 through MEDLINE, Pubmed, Embase. Studies reporting the comparison of surgical and obstetrical outcomes in laparoscopic versus laparotomic myomectomy were included for the following outcomes: time of surgery, estimated blood loss, decrease of postoperative hemoglobin, hospital stay, intra-operative complication rates, postoperative complications rates, postoperative analgesic use, postoperative pain at 24 h and pregnancy rate. The meta-analysis was performed using the Cochrane Review software. Fifty-six relevant articles were retrieved through the process of evidence acquisition. Eleven articles met inclusion criteria, for a total of 2,133 patients undergoing laparoscopic or laparotomic myomectomy. The estimated blood loss [standard mean differences (SMD) 0.72, IC 95 % 0.22 to 1.22], the hospital stays [SMD 3.12, IC 95 % 0.57 to 4.28], were significantly lower in laparoscopic than in open group. No statistically significant difference in intra-operative and post-operative complication rates, in pregnancy rate and others obstetrical outcomes between two surgical approaches were found. The findings of present metanalysis suggest that laparoscopic myomectomy offers multiple benefits, including reduced blood loss, shorter hospital stays, and less postoperative analgesic need, without a significant increase in complication rates and similar results in obstetrical outcomes when compared to abdominal myomectomy. However, the presence of few randomized studies on selected population may limit the generalizability of the findings to the entire population. Therefore, more well-designed studies or large population programdata to draw definitive conclusions are therefore warranted.
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Affiliation(s)
- Andrea Giannini
- Department of Medical and Surgical Sciences and Translational Medicine, PhD Course in "Translational Medicine and Oncology", Sapienza University, Viale dell'Università, 37, 00185 Rome, Italy; Gynecology Division, Department of Medical and Surgical Sciences and Translational Medicine, Sant'Andrea University Hospital, Sapienza University of Rome, Via di Grottarossa 1035, 00189 Rome, Italy; Unit of Gynecology, Sant'Andrea Hospital, Department of Surgical and Medical Sciences and Translational Medicine, Sapienza University of Rome, 00189 Rome, Italy
| | - Ilaria Cuccu
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico 155, 00161 Rome, Italy.
| | - Tullio Golia D'Auge
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico 155, 00161 Rome, Italy
| | - Emanuele De Angelis
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico 155, 00161 Rome, Italy
| | - Antonio Simone Laganà
- Unit of Obstetrics and Gynecology, "Paolo Giaccone" Hospital, Via Giordano Alfonso, 3, 90127 Palermo, Italy; Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Piazza delle Cliniche, 2, 90127 Palermo, Italy
| | - Vito Chiantera
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Piazza delle Cliniche, 2, 90127 Palermo, Italy; Unit of Gynecologic Oncology, National Cancer Institute - IRCCS - Fondazione "G. Pascale", Via Mariano Semmola, 53, 80131 Naples, Italy
| | - Donatella Caserta
- Gynecology Division, Department of Medical and Surgical Sciences and Translational Medicine, Sant'Andrea University Hospital, Sapienza University of Rome, Via di Grottarossa 1035, 00189 Rome, Italy
| | - Salvatore Giovanni Vitale
- Division of Gynecology and Obstetrics, Department of Surgical Sciences, University of Cagliari, Via Università 40, 09124 Cagliari, Italy
| | - Ludovico Muzii
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico 155, 00161 Rome, Italy
| | - Ottavia D'Oria
- Department of Medical and Surgical Sciences and Translational Medicine, PhD Course in "Translational Medicine and Oncology", Sapienza University, Viale dell'Università, 37, 00185 Rome, Italy; Department of Woman's and Child's Health, Obstetrics and Gynecological Unit, San Camillo-Forlanini Hospital, Circonvallazione Gianicolense, 87, 00152 Rome, Italy
| | - Giorgia Perniola
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico 155, 00161 Rome, Italy
| | - Giorgio Bogani
- Department of Gynaecologic Oncology, IRCCS National Cancer Institute, Via Giacomo Venezian 1, 20133 Milan, Italy
| | - Violante Di Donato
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico 155, 00161 Rome, Italy
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Dreisler E, Frandsen CS, Ulrich L. Perimenopausal abnormal uterine bleeding. Maturitas 2024; 184:107944. [PMID: 38412750 DOI: 10.1016/j.maturitas.2024.107944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 12/01/2023] [Accepted: 02/12/2024] [Indexed: 02/29/2024]
Abstract
Abnormal uterine bleeding is a frequent symptom in the perimenopause. Causes are numerous, ranging from physiological reactions due to decreasing/unstable ovarian function to premalignant and malignant conditions. Benign findings such as endometrial polyps and myomas increase with age, leading to more abnormal uterine bleeding in the perimenopause. Cervical and vaginal causes of abnormal uterine bleeding should be excluded by speculum examination. Sexually transmitted diseases or pregnancy should be ruled out. Measurement of haemoglobin and iron levels, human chorion gonadotropin and thyroid hormones are relevant in selected cases. Transvaginal ultrasound is an ideal first step for the evaluation of perimenopausal abnormal uterine bleeding. Saline or gel contrast sonohysterography improves the diagnostic accuracy. Based on the ultrasound findings, invasive procedures such as endometrial biopsy or hysteroscopy can be planned. Once premalignant and malignant causes are excluded, the necessity for treatment can be evaluated in collaboration with the patient. Heavy menstrual bleeding causing anaemia will need immediate treatment. In less severe cases and in intermenstrual bleeding, expectant management can be considered. Hormonal treatment, such as oral progestogens, combined oral contraceptives or insertion of the levonorgestrel intrauterine system, may be a possibility if anovulatory bleeding is interfering with quality of life. The amount of bleeding can be reduced both by antifibrinolytic and non-steroidal anti-inflammatory drugs, progestogens and the levonorgestrel intrauterine system. Focal intrauterine lesions such as endometrial polyps or submucous myomas may require operative hysteroscopic procedures. Endometrial ablation or endometrial resection are good choices in selected cases, but some women will need a hysterectomy to treat their abnormal uterine bleeding in perimenopause.
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Affiliation(s)
- Eva Dreisler
- Department of Gynaecology, University of Copenhagen, Rigshospitalet, Blegdamsvej 3, DK-2200 Copenhagen O, Denmark.
| | - Christian Seerup Frandsen
- Department of Gynaecology, University of Copenhagen, Rigshospitalet, Blegdamsvej 3, DK-2200 Copenhagen O, Denmark
| | - Lian Ulrich
- Department of Gynaecology, University of Copenhagen, Rigshospitalet, Blegdamsvej 3, DK-2200 Copenhagen O, Denmark
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10
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Habiba M, Guo SW, Benagiano G. Adenomyosis and Abnormal Uterine Bleeding: Review of the Evidence. Biomolecules 2024; 14:616. [PMID: 38927019 PMCID: PMC11201750 DOI: 10.3390/biom14060616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 05/15/2024] [Accepted: 05/20/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND Thomas Cullen described bleeding abnormalities and dysmenorrhea as the "expected" presentations of adenomyomas. Adenomyosis is included within the FIGO classification of structural causes of abnormal uterine bleeding (AUB). Nevertheless, this long-standing association has been questioned by some authors who reported a high incidence of adenomyosis in uteri removed for indications other than AUB or dysmenorrhea. Here, we examine evidence for the link between adenomyosis and AUB. METHODS A comprehensive Medline literature review of all publications to October 2023. RESULTS Sixty-three articles were identified and included in the review. Despite a large body of studies, the available literature does not provide conclusive evidence of a link between adenomyosis and AUB. This is because of unsuitable study design, or poor characterization of the study population or of the inclusion or exclusion criteria. Additional challenges arise because of the lack of agreed criteria for diagnosing adenomyosis and the often absence of detailed assessment of menstrual blood loss. Adenomyosis often coexists with other conditions that have also been linked to similar symptoms, and many cases of adenomyosis are asymptomatic. CONCLUSION Most of the existing literature and studies that addressed treatment outcome of adenomyosis started from the premise that a link between the condition and AUB had been proven. Yet, published information shows that aspects such a relationship is still uncertain. Further research is needed to address the relation between AUB and adenomyosis burden (or subtypes), distribution, and concomitant pathology.
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Affiliation(s)
- Marwan Habiba
- Department of Health Sciences, University of Leicester, Leicester LE1 7RH, UK
- Women and Perinatal Services, Leicester Royal Infirmary, Leicester LE1 5WW, UK
| | - Sun-Wei Guo
- Research Institute, Shanghai Obstetrics and Gynecology Hospital, Fudan University, Shanghai 200011, China;
| | - Giuseppe Benagiano
- Faculty of Medicine and Surgery, “Sapienza” University of Rome, 00161 Rome, Italy;
- Geneva Foundation for Medical Education and Research, 1202 Geneva, Switzerland
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11
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Hansen-Lindner L, Schmid-Lossberg J, Toub D. Transcervical Fibroid Ablation (TFA): Update on Pregnancy Outcomes. J Clin Med 2024; 13:2892. [PMID: 38792434 PMCID: PMC11122290 DOI: 10.3390/jcm13102892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Revised: 05/06/2024] [Accepted: 05/12/2024] [Indexed: 05/26/2024] Open
Abstract
Background/Objectives: Transcervical fibroid ablation (TFA) is an incisionless method to treat symptomatic uterine fibroids. While safety regarding future pregnancy remains to be established, TFA does not preclude the possibility of pregnancy, and a previous 36-patient case series of post-TFA pregnancies reported normal outcomes. That prior series did not include postmarket cases in the United States, as the Sonata® System was initially cleared and used in Europe. This is a substantive update of known pregnancies with the Sonata System since June 2011, and includes pregnancies in Europe, Mexico, and the US. Methods: TFA was carried out under both clinical trial and postmarket use to treat symptomatic uterine fibroids. All post-TFA pregnancies reported by physicians with their patient's consent were included. Results: 89 pregnancies and 55 deliveries have occurred among 72 women treated with the Sonata System. This includes 8 women who conceived more than once after TFA. Completed pregnancies (n = 62 women) include 19 vaginal deliveries, 35 Cesarean sections, 5 therapeutic abortions, 1 ectopic pregnancy, and 1 delivery by an unknown route. Ten pregnancies are ongoing. Mean birthweight was 3276.7 ± 587.3 g. Ten women experienced 18 first-trimester spontaneous abortions (SAbs), with 10 of the 18 SAbs (55.6%) occurring between two patients with a history of recurrent abortion. The SAb rate was 22.8%, inclusive of these two patients, and 10.1% if they were excluded as outliers. There were no instances of uterine rupture, placenta accreta spectrum, or stillbirth. Conclusions: This case series, the largest to date for any hyperthermic ablation modality, suggests that TFA with the Sonata System could be a feasible, safe treatment option regarding eventual pregnancy in women with symptomatic uterine fibroids.
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Affiliation(s)
| | | | - David Toub
- Medical Affairs, Gynesonics, Redwood City, CA 94063, USA
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12
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Balen AH, Tamblyn J, Skorupskaite K, Munro MG. A comprehensive review of the new FIGO classification of ovulatory disorders. Hum Reprod Update 2024; 30:355-382. [PMID: 38412452 DOI: 10.1093/humupd/dmae003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 01/23/2024] [Indexed: 02/29/2024] Open
Abstract
BACKGROUND The World Health Organization (WHO) system for the classification of disorders of ovulation was produced 50 years ago and, by international consensus, has been updated by the International Federation of Gynecology and Obstetrics (FIGO). OBJECTIVE AND RATIONALE This review outlines in detail each component of the FIGO HyPO-P (hypothalamic, pituitary, ovarian, PCOS) classification with a concise description of each cause, and thereby provides a systematic method for diagnosis and management. SEARCH METHODS We searched the published articles in the PubMed database in the English-language literature until October 2022, containing the keywords ovulatory disorders; ovulatory dysfunction; anovulation, and each subheading in the FIGO HyPO-P classification. We did not include abstracts or conference proceedings because the data are usually difficult to assess. OUTCOMES We present the most comprehensive review of all disorders of ovulation, published systematically according to the logical FIGO classification. WIDER IMPLICATIONS Improving the diagnosis of an individual's ovulatory dysfunction will significantly impact clinical practice by enabling healthcare practitioners to make a precise diagnosis and plan appropriate management.
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Affiliation(s)
- Adam H Balen
- Leeds Centre for Reproductive Medicine, The University of Leeds, Leeds, UK
| | - Jennifer Tamblyn
- Leeds Centre for Reproductive Medicine, The University of Leeds, Leeds, UK
| | | | - Malcolm G Munro
- Department of Obstetrics and Gynecology, The University of California, Los Angeles, Los Angeles, CA, USA
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13
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Huijs DPC, Derickx AJM, Beelen P, Leemans JC, van Kuijk SMJ, Bongers MY, Geomini PMAJ. A 52-mg levonorgestrel-releasing intrauterine system vs bipolar radiofrequency nonresectoscopic endometrial ablation in women with heavy menstrual bleeding: long-term follow-up of a multicenter randomized controlled trial. Am J Obstet Gynecol 2024; 230:542.e1-542.e10. [PMID: 38280433 DOI: 10.1016/j.ajog.2024.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 01/16/2024] [Accepted: 01/21/2024] [Indexed: 01/29/2024]
Abstract
BACKGROUND The symptom of heavy menstrual bleeding has a substantial impact on professional, physical, and social functioning. In 2021, results from a randomized controlled trial comparing a 52-mg levonorgestrel-releasing intrauterine system and radiofrequency nonresectoscopic endometrial ablation as treatments for women with heavy menstrual bleeding were published. Both treatment strategies were equally effective in treating heavy menstrual bleeding during 2-year follow-up. However, long-term results are also relevant for both patients and healthcare providers. OBJECTIVE This study aimed to assess long-term differences in reintervention risk and menstrual blood loss in women with the symptom of heavy menstrual bleeding treated according to a strategy starting with a 52-mg levonorgestrel-releasing intrauterine system or radiofrequency nonresectoscopic endometrial ablation. STUDY DESIGN This study was a long-term follow-up study of a multicenter randomized controlled trial (MIRA trial), in which women were allocated to either a 52-mg levonorgestrel-releasing intrauterine device (n=132) or radiofrequency nonresectoscopic endometrial ablation (n=138). Women from the original trial were contacted to fill out 6 questionnaires. The primary outcome was the reintervention rate after allocated treatment. Secondary outcomes included surgical reintervention rate, menstrual bleeding measured by the Pictorial Blood Loss Assessment Chart, (disease-specific) quality of life, sexual function, and patient satisfaction. RESULTS From the 270 women who were randomized in the original trial, 196 (52-mg levonorgestrel-releasing intrauterine system group: n=94; radiofrequency nonresectoscopic endometrial ablation group: n=102) participated in this long-term follow-up study. Mean follow-up duration was 7.4 years (range, 6-9 years). The cumulative reintervention rate (including both medical and surgical reinterventions) was 40.0% (34/85) in the 52-mg levonorgestrel-releasing intrauterine system group and 28.7% (27/94) in the radiofrequency nonresectoscopic endometrial ablation group (relative risk, 1.39; 95% confidence interval, 0.92-2.10). The cumulative rate of surgical reinterventions only was significantly higher among patients with a treatment strategy starting with a 52-mg levonorgestrel-releasing intrauterine system compared with radiofrequency nonresectoscopic endometrial ablation (35.3% [30/85] vs 19.1% [18/94]; relative risk, 1.84; 95% confidence interval, 1.11-3.10). However, the hysterectomy rate was similar (11.8% [10/94] in the 52-mg levonorgestrel-releasing intrauterine system group and 18.1% [17/102] in the radiofrequency nonresectoscopic endometrial ablation group; relative risk, 0.65; 95% confidence interval, 0.32-1.34). Most reinterventions occurred during the first 24 months of follow-up. A total of 171 Pictorial Blood Loss Assessment Chart scores showed a median bleeding score of 0.0. No clinically relevant differences were found regarding quality of life, sexual function, and patient satisfaction. CONCLUSION The overall risk of reintervention after long-term follow-up was not different between women treated according to a treatment strategy starting with a 52-mg levonorgestrel-releasing intrauterine system and those treated using a strategy starting with radiofrequency nonresectoscopic endometrial ablation. However, women allocated to a treatment strategy starting with a 52-mg levonorgestrel-releasing intrauterine system had a higher risk of surgical reintervention, which was driven by an increase in subsequent endometrial ablation. Both treatment strategies were effective in lowering menstrual blood loss over the long term. The results of this long-term follow-up study can support physicians in optimizing the counseling of women with heavy menstrual bleeding, thus promoting informed decision-making regarding choice of treatment.
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Affiliation(s)
- Daniëlle P C Huijs
- Department of Obstetrics and Gynecology, Máxima Medical Center, Veldhoven, The Netherlands; GROW School for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands.
| | - Arianne J M Derickx
- Department of Obstetrics and Gynecology, Máxima Medical Center, Veldhoven, The Netherlands
| | - Pleun Beelen
- Department of Obstetrics and Gynecology, Máxima Medical Center, Veldhoven, The Netherlands
| | - Jaklien C Leemans
- Department of Obstetrics and Gynecology, Máxima Medical Center, Veldhoven, The Netherlands
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Marlies Y Bongers
- Department of Obstetrics and Gynecology, Máxima Medical Center, Veldhoven, The Netherlands; GROW School for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
| | - Peggy M A J Geomini
- Department of Obstetrics and Gynecology, Máxima Medical Center, Veldhoven, The Netherlands
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14
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Xholli A, Scovazzi U, Londero AP, Paudice M, Vacca I, Schiaffino MG, Kratochwila C, Cavalli E, Perugi I, Cagnacci A. Clinical and ultrasonographic characteristics of pregnancy-related enhanced myometrial vascularity: prospective cohort study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:672-682. [PMID: 37984401 DOI: 10.1002/uog.27537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 11/04/2023] [Accepted: 11/07/2023] [Indexed: 11/22/2023]
Abstract
OBJECTIVE To assess the ultrasonographic, epidemiological, clinical and evolutive characteristics of enhanced myometrial vascularity (EMV) following a first-trimester termination of pregnancy (TOP) or management of non-viable pregnancy. METHODS This prospective study included women who underwent follow-up ultrasound examination 5-6 weeks after a first-trimester TOP or after management of a first-trimester non-viable pregnancy at the University Hospital Polyclinic San Martino of Genoa between March 2021 and March 2022. EMV was characterized using two- and three-dimensional ultrasound and Virtual Organ Computer-aided Analysis. Ultrasonographic diagnosis of EMV was made when an unusual, tortuous myometrial vessel structure, with high-velocity blood flow, protruding towards the endometrium was observed, while an abnormal junctional zone, absent endometrial midline and heterogeneous endometrium supported the diagnosis. Patients with EMV underwent expectant management with planned ultrasonographic follow-up every 2 weeks until resolution. RESULTS During the study period, 305 women underwent TOP, of whom 132 attended the initial follow-up 5-6 weeks later, at which 52 were diagnosed with EMV. Ninety-six women were managed for a non-viable pregnancy, of whom 32 presented for follow-up, at which six had a diagnosis of EMV. Thus, overall, 164 of 401 women were included in the study and EMV was identified in 58 (35%) of these. The prevalence of EMV 5-6 weeks after a TOP was therefore between 52/305 (17%) and 52/132 (39%), and that after management of a non-viable pregnancy was between 6/96 (6%) and 6/32 (19%). Bleeding/pelvic pain was present in half (29/58) of the women with EMV, and serum human chorionic gonadotropin was detectable in 29% (17/58) at the first follow-up examination. At ultrasound assessment, all cases with EMV presented abundant tortuous myometrial vessels with high-velocity flow projecting from the myometrium towards the endometrium, along with non-uniform heterogeneous endometrium in 97% of cases, which often (67% of these) contained cystic areas, absence of the endometrial midline in 98% of cases and an abnormal junctional zone in 97% of cases (64% interrupted, 33% irregular). Most (67%) women with EMV were parous and 90% of them had undergone TOP rather than management for a non-viable pregnancy. Medical management of the TOP or non-viable pregnancy was more frequent in women with than those without EMV (93% vs 77%, P = 0.023). Multiple regression analysis showed the risk of EMV to be increased following TOP vs non-viable pregnancy (odds ratio (OR), 3.67 (95% CI, 1.16-11.56), P = 0.026) and in parous compared with nulliparous women (OR, 2.95 (95% CI, 1.45-6.01), P = 0.002). All women with EMV underwent expectant management. Eleven women did not return for subsequent follow-up examinations and did not present to our outpatient or emergency facilities, so were lost to further follow-up. Spontaneous resolution of the lesion was observed within 7-16 weeks after the procedure in 96% (45/47) of the remaining cases. Two women chose to undergo surgery for pelvic discomfort, and histology showed the presence of neovessels mixed with retained chorionic villi. CONCLUSIONS EMV is a transient and common finding 5-6 weeks following first-trimester TOP or management of non-viable pregnancy. TOP and being parous are risk factors for EMV. Expectant management of EMV is appropriate, because, in almost all cases, this resolves spontaneously, without complications, within 2-4 months. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- A Xholli
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - U Scovazzi
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Neurology, Rehabilitation, Ophthalmology, Genetics, Maternal and Infant Health (DINOGMI), Genoa, Italy
| | - A P Londero
- Department of Neurology, Rehabilitation, Ophthalmology, Genetics, Maternal and Infant Health (DINOGMI), Genoa, Italy
| | - M Paudice
- Department of Pathology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- University of Genoa, Genoa, Italy
| | - I Vacca
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Neurology, Rehabilitation, Ophthalmology, Genetics, Maternal and Infant Health (DINOGMI), Genoa, Italy
| | - M G Schiaffino
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Neurology, Rehabilitation, Ophthalmology, Genetics, Maternal and Infant Health (DINOGMI), Genoa, Italy
| | - C Kratochwila
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Neurology, Rehabilitation, Ophthalmology, Genetics, Maternal and Infant Health (DINOGMI), Genoa, Italy
| | - E Cavalli
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Neurology, Rehabilitation, Ophthalmology, Genetics, Maternal and Infant Health (DINOGMI), Genoa, Italy
| | - I Perugi
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Neurology, Rehabilitation, Ophthalmology, Genetics, Maternal and Infant Health (DINOGMI), Genoa, Italy
| | - A Cagnacci
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Neurology, Rehabilitation, Ophthalmology, Genetics, Maternal and Infant Health (DINOGMI), Genoa, Italy
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15
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Maharana N, Behera MR, Mitra S, Singh S. Challenges in Diagnosis and Management of Recurrent Uterine Arteriovenous Malformation: A Case Report. Cureus 2024; 16:e59665. [PMID: 38836161 PMCID: PMC11148843 DOI: 10.7759/cureus.59665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2024] [Indexed: 06/06/2024] Open
Abstract
Uterine arteriovenous malformation (AVM) is a potentially life-threatening condition. The vast majority of cases are acquired. Uterine artery embolization (UAE) is currently the treatment of choice for symptomatic women desiring future childbearing. However, there is no consensus on the number of UAE procedures that can be performed on an individual woman. We report a case of recurrent uterine AVM and discuss the challenges in diagnosis and management. A 35-year-old multiparous woman presented with heavy menstrual bleeding (HMB). She had been diagnosed with uterine AVM six years ago and had undergone two previous UAE procedures. Her abdominal examination revealed a healthy Pfannensteil scar. Bimanual examination revealed a normal-sized uterus that was firm, mobile, and fornices were free. Her haemoglobin was 10.2 g/dl. Greyscale two-dimensional ultrasound revealed a normal-sized uterus with multiple hypoechoic lesions in the myometrium. Colour Doppler ultrasound showed intense vascularity with multidirectional flow in the myometrium, suggestive of uterine AVM. In view of previous failed UAE procedures, she opted for a hysterectomy. A total abdominal hysterectomy with a bilateral salpingectomy was performed. Blood loss during the procedure was greater than average, and she was transfused with a unit of packed cells. Her post-operative course was uneventful. Histopathology confirmed the diagnosis of a uterine AVM. To conclude, the UAE is considered the treatment of choice for symptomatic women with uterine AVM desiring future childbearing. In cases of failure of UAE procedures, hysterectomy is therapeutic but may be associated with more than average blood loss.
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Affiliation(s)
- Nibedita Maharana
- Obstetrics and Gynecology, All India Institute of Medical Sciences, Bhubaneswar, Bhubaneswar, IND
| | - Manas R Behera
- Obstetrics and Gynecology, All India Institute of Medical Sciences, Bhubaneswar, Bhubaneswar, IND
| | - Suvradeep Mitra
- Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, Chandigarh, IND
| | - Sweta Singh
- Obstetrics and Gynecology, All India Institute of Medical Sciences, Bhubaneswar, Bhubaneswar, IND
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16
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Brooks N, Irving SA, Kauffman TL, Vesco KK, Slaughter M, Smith N, Tepper NK, Olson CK, Weintraub ES, Naleway AL. Abnormal uterine bleeding diagnoses and care following COVID-19 vaccination. Am J Obstet Gynecol 2024; 230:540.e1-540.e13. [PMID: 38219855 DOI: 10.1016/j.ajog.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 01/03/2024] [Accepted: 01/05/2024] [Indexed: 01/16/2024]
Abstract
BACKGROUND There is evidence suggesting that COVID-19 vaccination may be associated with small, transitory effects on uterine bleeding, possibly including menstrual timing, flow, and duration, in some individuals. However, changes in health care seeking, diagnosis, and workup for abnormal uterine bleeding in the COVID-19 vaccine era are less clear. OBJECTIVE This study aimed to assess the impact of COVID-19 vaccination on incident abnormal uterine bleeding diagnosis and diagnostic evaluation in a large integrated health system. STUDY DESIGN Using segmented regression, we assessed whether the availability of COVID-19 vaccines was associated with changes in monthly, population-based rates of incident abnormal uterine bleeding diagnoses relative to the prepandemic period in health system members aged 16 to 44 years who were not menopausal. We also compared clinical and demographic characteristics of patients diagnosed with incident abnormal uterine bleeding between December 2020 and October 13, 2021 by vaccination status (never vaccinated, vaccinated in the 60 days before diagnosis, vaccinated >60 days before diagnosis). Furthermore, we conducted detailed chart review of patients diagnosed with abnormal uterine bleeding within 1 to 60 days of COVID-19 vaccination in the same time period. RESULTS In monthly populations ranging from 79,000 to 85,000 female health system members, incidence of abnormal uterine bleeding diagnosis per 100,000 person-days ranged from 8.97 to 19.19. There was no significant change in the level or trend in the incidence of abnormal uterine bleeding diagnoses between the prepandemic (January 2019-January 2020) and post-COVID-19 vaccine (December 2020-December 2021) periods. A comparison of clinical characteristics of 2717 abnormal uterine bleeding cases by vaccination status suggested that abnormal bleeding among recently vaccinated patients was similar or less severe than abnormal bleeding among patients who had never been vaccinated or those vaccinated >60 days before. There were also significant differences in age and race of patients with incident abnormal uterine bleeding diagnoses by vaccination status (Ps<.02). Never-vaccinated patients were the youngest and those vaccinated >60 days before were the oldest. The proportion of patients who were Black/African American was highest among never-vaccinated patients, and the proportion of Asian patients was higher among vaccinated patients. Chart review of 114 confirmed postvaccination abnormal uterine bleeding cases diagnosed from December 2020 through October 13, 2021 found that the most common symptoms reported were changes in timing, duration, and volume of bleeding. Approximately one-third of cases received no diagnostic workup; 57% had no etiology for the bleeding documented in the electronic health record. In 12% of cases, the patient mentioned or asked about a possible link between their bleeding and their recent COVID-19 vaccine. CONCLUSION The availability of COVID-19 vaccination was not associated with a change in incidence of medically attended abnormal uterine bleeding in our population of over 79,000 female patients of reproductive age. In addition, among 2717 patients with abnormal uterine bleeding diagnoses in the period following COVID-19 vaccine availability, receipt of the vaccine was not associated with greater bleeding severity.
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Affiliation(s)
- Neon Brooks
- Kaiser Permanente Center for Health Research, Portland, OR.
| | | | - Tia L Kauffman
- Kaiser Permanente Center for Health Research, Portland, OR
| | - Kimberly K Vesco
- Kaiser Permanente Center for Health Research, Portland, OR; Department of Obstetrics and Gynecology, Kaiser Permanente Northwest, Portland, OR
| | | | - Ning Smith
- Kaiser Permanente Center for Health Research, Portland, OR
| | - Naomi K Tepper
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - Christine K Olson
- Immunization Safety Office, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - Eric S Weintraub
- Immunization Safety Office, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA
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17
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Memi E, Pavli P, Papagianni M, Vrachnis N, Mastorakos G. Diagnostic and therapeutic use of oral micronized progesterone in endocrinology. Rev Endocr Metab Disord 2024:10.1007/s11154-024-09882-0. [PMID: 38652231 DOI: 10.1007/s11154-024-09882-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/04/2024] [Indexed: 04/25/2024]
Abstract
Progesterone is a natural steroid hormone, while progestins are synthetic molecules. In the female reproductive system, progesterone contributes to the control of luteinizing hormone and follicle-stimulating hormone secretion and their pulsatility, via its receptors on the kisspeptin, neurokinin B, and dynorphin neurons in the hypothalamus. Progesterone together with estradiol controls the cyclic changes of proliferation and decidualization of the endometrium; exerts anti-mitogenic actions on endometrial epithelial cells; regulates normal menstrual bleeding; contributes to fertilization and pregnancy maintenance; participates in the onset of labor. In addition, it exerts numerous effects on other endocrine systems. Micronized progesterone (MP) is natural progesterone with increased bioavailability, due to its pharmacotechnical micronized structure, which makes it an attractive diagnostic and therapeutic tool. This critical literature review aims to summarize and put forward the potential diagnostic and therapeutic uses of MP in the field of endocrinology. During reproductive life, MP is used for diagnostic purposes in the evaluation of primary or secondary amenorrhea as a challenge test. Moreover, it can be prescribed to women presenting with amenorrhea or oligomenorrhea for induction of withdrawal bleeding, in order to time blood-sampling for diagnostic purposes in early follicular phase. Therapeutically, MP, alone or combined with estrogens, is a useful tool in various endocrine disorders including primary amenorrhea, abnormal uterine bleeding due to disordered ovulation, luteal phase deficiency, premenstrual syndrome, polycystic ovary syndrome, secondary amenorrhea [functional hypothalamic amenorrhea, premature ovarian insufficiency], perimenopause and menopause. When administrated per os, acting as a neurosteroid directly or through its metabolites, it exerts beneficial effects on brain function such as alleviation of symptoms of anxiety and depression, asw well as of sleep problems, while it improves working memory in peri- and menopausal women. Micronized progesterone preserves full potential of progesterone activity, without presenting many of the side-effects of progestins. Although it has been associated with more frequent drowsiness and dizziness, it can be well tolerated with nocturnal administration. Because of its better safety profile, especially with regard to metabolic ailments, breast cancer risk and veno-thromboembolism risk, MP is the preferred option for individuals with an increased risk of cardiovascular and metabolic diseases and of all-cause mortality.
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Affiliation(s)
- Eleni Memi
- Unit of Endocrinology, Diabetes mellitus, and Metabolism, Aretaieion Hospital, School of Medicine, National and Kapodistrian University of Athens, Vas. Sophias Av. 76, 11528, Athens, Greece
| | - Polina Pavli
- Unit of Endocrinology, Diabetes mellitus, and Metabolism, Aretaieion Hospital, School of Medicine, National and Kapodistrian University of Athens, Vas. Sophias Av. 76, 11528, Athens, Greece
| | - Maria Papagianni
- Department of Nutrition and Dietetics, School of Physical Education, Sport Science and Dietetics, University of Thessaly, 42100, Trikala, Greece
- Endocrine Unit, 3rd Department of Pediatrics, Hippokration Hospital of Thessaloniki, Aristotle University of Thessaloniki, 54642, Thessaloniki, Greece
| | - Nikolaos Vrachnis
- Third Department of Obstetrics and Gynecology, Attikon General Hospital, School of Medicine, National and Kapodistrian University of Athens, Rimini Str. 1, 12462, Chaidari, Athens, Greece
- St George's NHS Foundation Trust Teaching Hospitals, St George's University of London, London, UK
| | - George Mastorakos
- Unit of Endocrinology, Diabetes mellitus, and Metabolism, Aretaieion Hospital, School of Medicine, National and Kapodistrian University of Athens, Vas. Sophias Av. 76, 11528, Athens, Greece.
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18
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Pan H, Chen M, Bai W, Li B, Zhao X, Zhang M, Zhang D, Li Y, Wang H, Geng H, Kong W, Yin C, Han L, Lan J, Zhao T. Large-scale uterine myoma MRI dataset covering all FIGO types with pixel-level annotations. Sci Data 2024; 11:410. [PMID: 38649693 PMCID: PMC11035617 DOI: 10.1038/s41597-024-03170-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 03/21/2024] [Indexed: 04/25/2024] Open
Abstract
Uterine myomas are the most common pelvic tumors in women, which can lead to abnormal uterine bleeding, abdominal pain, pelvic compression symptoms, infertility, or adverse pregnancy. In this article, we provide a dataset named uterine myoma MRI dataset (UMD), which can be used for clinical research on uterine myoma imaging. The UMD is the largest publicly available uterine MRI dataset to date including 300 cases of uterine myoma T2-weighted imaging (T2WI) sagittal patient images and their corresponding annotation files. The UMD covers 9 types of uterine myomas classified by the International Federation of Obstetrics and Gynecology (FIGO), which were annotated and reviewed by 11 experienced doctors to ensure the authority of the annotated data. The UMD is helpful for uterine myomas classification and uterine 3D reconstruction tasks, which has important implications for clinical research on uterine myomas.
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Affiliation(s)
- Haixia Pan
- College of Software, Beihang University, Beijing, 100191, China.
| | - Minghuang Chen
- Department of Obstetrics and Gynecology, Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, China
| | - Wenpei Bai
- Department of Obstetrics and Gynecology, Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, China.
| | - Bin Li
- Department of MRI/Emergency and Critical Care Medical Center, Beijing Shijitan Hospital, Capital Medical University/Peking University, Ninth Clinical Medical College, Beijing, 100038, China.
| | - Xiaoran Zhao
- College of Software, Beihang University, Beijing, 100191, China
| | - Meng Zhang
- College of Software, Beihang University, Beijing, 100191, China
| | - Dongdong Zhang
- College of Software, Beihang University, Beijing, 100191, China
| | - Yanan Li
- College of Software, Beihang University, Beijing, 100191, China
| | - Hongqiang Wang
- College of Software, Beihang University, Beijing, 100191, China
| | - Haotian Geng
- College of Software, Beihang University, Beijing, 100191, China
| | - Weiya Kong
- Department of Obstetrics and Gynecology, Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, China
| | - Cong Yin
- Department of Obstetrics and Gynecology, Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, China
| | - Linfeng Han
- College of Software, Beihang University, Beijing, 100191, China
| | - Jiahua Lan
- College of Software, Beihang University, Beijing, 100191, China
| | - Tian Zhao
- College of Software, Beihang University, Beijing, 100191, China
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19
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Tian Y, Bai B, Wang L, Zhou Z, Tang J. Contributing factors related to abnormal uterine bleeding in perimenopausal women: a case-control study. JOURNAL OF HEALTH, POPULATION, AND NUTRITION 2024; 43:52. [PMID: 38637861 PMCID: PMC11025148 DOI: 10.1186/s41043-024-00540-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 03/19/2024] [Indexed: 04/20/2024]
Abstract
Abnormal uterine bleeding (AUB) during the menopausal transition results in reproductive endocrine disorders and both physiological and pathological changes, substantially impacting women's health. This study aimed to investigate the factors influencing AUB in perimenopausal women. Between April 2021 and June 2022, 120 perimenopausal women with AUB in the menopausal transition, diagnosed and treated at the Gynaecology Department of Kunming Tongren Hospital, were included in the case group. Concurrently, women undergoing routine health examinations at the same hospital were randomly selected as the control group. Univariate and multivariate logistic regression analyses identified factors related to AUB. The univariate analysis revealed significant associations (P < 0.05) between AUB and several factors, including age, body mass index (BMI), age at menarche, gravidity, and intrauterine device (IUD) placement in perimenopausal women. The multivariate regression analysis indicated that the independent risk factors for AUB include benign endometrial lesions (odds ratio [OR] 5.243, 95% confidence interval [CI] 3.082-9.458, P < 0.001), endometrial thickness ≥ 10 mm (OR 1.573, 95% CI 0.984-3.287, P < 0.001), age ≥ 50 years (OR 2.045, 95% CI 1.035-4.762, P = 0.001), BMI ≥ 25 kg/m2 (OR 2.436, 95% CI 1.43-4.86, P = 0.002), and IUD placement (OR 2.458, 95% CI 1.253-4.406, P < 0.001). Abnormal uterine bleeding during the menopausal transition is associated with several factors, including age, BMI, and IUD placement, highlighting the importance of early screening for these risk factors in the diagnosis and treatment of AUB.
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Affiliation(s)
- Yuan Tian
- Department of Obstetrics and Gynecology, Clinical Skill Experiment Center of Haiyuan College, Kunming Medical University, Kunming, China
| | - Bin Bai
- Department of Critical Medicine, The Third People's Hospital of Kunming, Kunming, China
| | - Li Wang
- Department of Gynaecology, Kunming Tongren Hospital, Kunming, China
| | - Zongchang Zhou
- Department of Obstetrics and Gynecology, Department of Obstetrics and Gynecology, Shuifu People's Hospital, 150 Meters West of the Intersection of Shanghai Road and Ping'an Road, Gaotan New District, Shuifu City, Zhaotong City, 657800, Yunnan Province, China.
| | - Jiahui Tang
- Department of Obstetrics and Gynecology, Department of Obstetrics and Gynecology, Shuifu People's Hospital, 150 Meters West of the Intersection of Shanghai Road and Ping'an Road, Gaotan New District, Shuifu City, Zhaotong City, 657800, Yunnan Province, China.
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20
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Exacoustos C, Ticconi C, Colombi I, Iorio GG, Vaquero E, Selntigia A, Chiaramonte B, Soreca G, Rizzo G. Type and Location of Adenomyosis in Women with Recurrent Pregnancy Loss: A Transvaginal Ultrasonographic Assessment. Reprod Sci 2024:10.1007/s43032-024-01541-8. [PMID: 38619796 DOI: 10.1007/s43032-024-01541-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 04/02/2024] [Indexed: 04/16/2024]
Abstract
The current knowledge on adenomyosis as a risk factor for RPL is very scant. Overall 120 women were included in this retrospective observational study. They were divided in three groups each of which consisted of 40 subjects: Group 1: women with RPL who were diagnosed to have adenomyosis on transvaginal ultrasound (TVS); Group 2: patients with RPL without ultrasonographic findings of adenomyosis; Group 3: patients with ultrasound diagnosis of adenomyosis without RPL and at least one live birth pregnancy. The copresence of endometriosis was also investigated. Among women with RPL, patients with adenomyosis (Group 1) had higher number of pregnancy losses (p = 0.03) and lower age at first pregnancy loss (p = 0.03) than women without adenomyosis (Group 2). Moreover, they had more frequently primary RPL (p = 0.008). Adenomyosis of the inner myometrium was found more frequently (p = 0.04) in patients of Group 1 than in patients of Group 3 in which adenomyosis was mainly in the outer myometrium (p= 0.02). No differences were found in the severity of adenomyosis between these two groups of women. TVS findings for endometriosis were observed more frequently in women with adenomyosis without RPL (Group 3) than in the other two groups of patients. Adenomyosis can be a factor involved in RPL. Differences in adenomyosis localization are associated with different risks for RPL. Patients with RPL should be investigated for the presence of adenomyosis and also for the type and localization of the disease in the different myometrial layers.
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Affiliation(s)
- Caterina Exacoustos
- Department of Surgical Sciences, Obstetrics and Gynecological Unit, University of Rome 'Tor Vergata', Rome, Italy
| | - Carlo Ticconi
- Department of Surgical Sciences, Obstetrics and Gynecological Unit, University of Rome 'Tor Vergata', Rome, Italy.
| | - Irene Colombi
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic University of Siena, Siena, Italy
| | - Giuseppe Gabriele Iorio
- Department of Neuroscience, Reproductive Science and Odontostomatology, University of Naples 'Federico II', Naples, Italy
| | - Elena Vaquero
- Department of Biomedicine and Prevention, Obstetrics and Gynecological Unit, University of Rome 'Tor Vergata', Rome, Italy
| | - Aikaterini Selntigia
- Department of Surgical Sciences, Obstetrics and Gynecological Unit, University of Rome 'Tor Vergata', Rome, Italy
| | - Barbara Chiaramonte
- Department of Biomedicine and Prevention, Obstetrics and Gynecological Unit, University of Rome 'Tor Vergata', Rome, Italy
| | - Giorgia Soreca
- Department of Surgical Sciences, Obstetrics and Gynecological Unit, University of Rome 'Tor Vergata', Rome, Italy
| | - Giuseppe Rizzo
- Department of Biomedicine and Prevention, Obstetrics and Gynecological Unit, University of Rome 'Tor Vergata', Rome, Italy
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21
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Zhao Y, Liao Y, Xu G, Wang Y. Endometrial microbiota alteration in female patients with endometrial polyps based on 16S rRNA gene sequencing analysis. Front Cell Infect Microbiol 2024; 14:1351329. [PMID: 38655283 PMCID: PMC11035718 DOI: 10.3389/fcimb.2024.1351329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 03/11/2024] [Indexed: 04/26/2024] Open
Abstract
Introduction The potential role of the endometrial microbiota in the pathogenesis of endometrial polyps (EPs) warrants further investigation, given the current landscape of limited and inconclusive research findings. We aimed to explore the microecological characteristics of the uterine cavity in patients with EPs and investigate the potential of endometrial microbiota species as novel biomarkers for identifying EPs. Methods Endometrial samples were collected from 225 patients who underwent hysteroscopies, of whom 167 had EPs, whereas 58 had non- hyperproliferative endometrium status. The endometrial microbiota was assessed using 16S rRNA gene sequencing. We characterized the endometrial microbiota and identified microbial biomarkers for predicting EPs. Results The endometrial microbial diversity and composition were significantly different between the EP and control groups. Predictive functional analyses of the endometrial microbiota demonstrated significant alterations in pathways involved in sphingolipid metabolism, steroid hormone biosynthesis, and apoptosis between the two groups. Moreover, a classification model based on endometrial microbial ASV-based biomarkers along with the presence of abnormal uterine bleeding symptoms achieved powerful classification potential in identifying EPs in both the discovery and validation cohorts. Conclusion Our study indicates a potential association between altered endometrial microbiota and EPs. Endometrial microbiota-based biomarkers may prove valuable for the diagnosis of EPs. Clinical trial registration Chinese Clinical Trial Registry (ChiCTR2100052746).
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Affiliation(s)
- Yu Zhao
- Department of Ambulatory Surgery, Women’s Hospital School of Medicine Zhejiang University, Hangzhou, China
- Zhejiang Provincial Clinical Research Center for Obstetrics and Gynecology, Hangzhou, China
| | - Yun Liao
- Department of Ambulatory Surgery, Women’s Hospital School of Medicine Zhejiang University, Hangzhou, China
- Zhejiang Provincial Clinical Research Center for Obstetrics and Gynecology, Hangzhou, China
- Zhejiang Provincial Key Laboratory of Precision Diagnosis and Therapy for Major Gynecological Diseases, Women’s Hospital School of Medicine Zhejiang University, Hangzhou, China
| | - Gufeng Xu
- Department of Ambulatory Surgery, Women’s Hospital School of Medicine Zhejiang University, Hangzhou, China
- Zhejiang Provincial Clinical Research Center for Obstetrics and Gynecology, Hangzhou, China
| | - Yue Wang
- Department of Ambulatory Surgery, Women’s Hospital School of Medicine Zhejiang University, Hangzhou, China
- Zhejiang Provincial Clinical Research Center for Obstetrics and Gynecology, Hangzhou, China
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22
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Sparić R, Andrić L, Guler O, Malvasi A, Babović I, Hatirnaz S, Dellino M, Tinelli A. Cesarean Myomectomy: Reflections on Clinical and Surgical Controversies between a New Trans-Decidual Technique vs. Traditional Method. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:609. [PMID: 38674255 PMCID: PMC11052397 DOI: 10.3390/medicina60040609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 04/04/2024] [Accepted: 04/06/2024] [Indexed: 04/28/2024]
Abstract
Up to 70-80% of women of reproductive age may be affected with the most common uterine tumors, known as fibroids or myomas. These benign tumors are the second most prevalent cause of surgery among premenopausal women. Predictions show that the occurrence of myomas in pregnancy will increase, and that the risk of having myomas during pregnancy increases with advanced maternal age. Although most women with fibroids do not experience any symptoms during pregnancy, up to 30% of women experience problems during pregnancy, childbirth, and the puerperium. The viability of myoma excision during cesarean surgery (CS) is a contentious issue raised by the rising incidence of myomas in pregnancy and CS rates. A new surgical procedure for removing fibroids using a trans-endometrial approach, which involves making an incision through the decidua itself, has put into doubt the long-standing practice of cesarean myomectomy (CM) with a trans-serosal approach. Some authors have recently advocated for this last approach, highlighting its advantages and potential uses in real-world situations. The purpose of this paper is to critique the present approach to cesarean myomectomy by analyzing the clinical and surgical distinctions between the two approaches and providing illustrations of the CM methods.
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Affiliation(s)
- Radmila Sparić
- Faculty of Medicine, University of Belgrade, Dr Subotića 8, 11000 Belgrade, Serbia;
- Clinic for Gynecology and Obstetrics, University Clinical Centre of Serbia, Dr Koste Todorovića 26, 11000 Belgrade, Serbia;
| | - Luka Andrić
- Clinic for Gynecology and Obstetrics, University Clinical Centre of Serbia, Dr Koste Todorovića 26, 11000 Belgrade, Serbia;
| | - Oguz Guler
- Department of Obstetrics and Gynecology, Private Asya Hospital, Yenimahalle mh. 537, St. No.5 Gaziosmanpasa, 34250 Istanbul, Turkey;
| | - Antonio Malvasi
- Department of Interdisciplinary Medicine (DIM), University of Bari, Aldo Moro, 70100 Bari, Italy; (A.M.); (M.D.)
| | - Ivana Babović
- Faculty of Medicine, University of Belgrade, Dr Subotića 8, 11000 Belgrade, Serbia;
- Clinic for Gynecology and Obstetrics, University Clinical Centre of Serbia, Dr Koste Todorovića 26, 11000 Belgrade, Serbia;
| | - Safak Hatirnaz
- Mediliv Medical Center, Kale, Mevlevihane Cd. No.11, 55100 Samsun, Turkey;
| | - Miriam Dellino
- Department of Interdisciplinary Medicine (DIM), University of Bari, Aldo Moro, 70100 Bari, Italy; (A.M.); (M.D.)
| | - Andrea Tinelli
- Department of Obstetrics and Gynecology, CERICSAL (CEntro di RIcerca Clinico SALentino), “Veris delli Ponti Hospital”, Via Giuseppina Delli Ponti, 73020 Scorrano, Italy;
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23
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Dorji N, Dorjey Y, Tshering S, Pradhan B, Chhetri M, Bhujel D. Rate and risk factors of inadequate endometrial tissues after endometrial sampling among Bhutanese women at the national referral hospital of Bhutan: a cross-sectional study. BMC Womens Health 2024; 24:214. [PMID: 38566186 PMCID: PMC10988946 DOI: 10.1186/s12905-024-03047-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 03/25/2024] [Indexed: 04/04/2024] Open
Abstract
INTRODUCTION Women presenting with abnormal uterine bleeding needs careful and thorough assessment including ultrasound examination of endometrium and histopathological assessment of the endometrial tissues. The objective of this cross-sectional study was to determine the rate and the factors associated with inadequate endometrial tissues after endometrial sampling using MedGyn® pipette among Bhutanese women at the colposcopy clinic, Jigme Dorji Wangchuck National Referral Hospital (JDWNRH), Bhutan. METHODS This cross-sectional study was conducted at the colposcopy clinic, JDWNRH, Thimphu between October, 2021 and March, 2022. Women included in this study underwent endometrial sampling using MedGyn® pipette without anesthesia as an office procedure. Data were collected using an interviewer-administered questionnaire and results extracted into a structured pro forma. The histopathology reports were extracted from the Department of Pathology and Laboratory Medicine, JDWNRH using the unique Bhutanese citizenship identity card number of the study participants. RESULTS Inadequate endometrial tissues were noted in 27% (33 out of 122 cases). Among 89 patients with an adequate endometrial tissue, histologic results were normal in 30 (33.7%), benign pathology in 22 (24.7%), atrophy in 10 (8.2%), and hyperplasia in 27 (30.3%). In a univariate analysis, menopausal state (OR 1.6, 95% CI 0.708-3.765), overweight and obese (OR 1.6 95% CI 0.640-3.945), unemployed (OR 1.7, 95% CI 0.674-1.140), nulliparous (OR 1.7, 95% CI 0.183-15.816), primipara (OR 5.1, 95% CI 0.635-40.905) and use of hormonal contraception (OR 2.1, 95% CI 0.449-10.049) were associated with increased risk of inadequate endometrial tissues. On multivariate regression analysis, nulliparity (OR 1.1, 95% CI 0.101-12.061), overweight and obesity (OR 1.4, 95% CI 0.490-3.917), use of hormonal contraceptives (OR 2.2, 95% CI 0.347-13.889), and junior surgeons (OR 1.1, 95%CI 0.463-2.443) were found to be associated with inadequate endometrial tissues. However, the above associations were not statistically significant (p > 0.05). CONCLUSION The rate of inadequate endometrial tissue following endometrial sampling using MedGyn® pipette was 27.0%. Factors associated with an increased risk of inadequate endometrial tissue after endometrial sampling were menopausal state, overweight and obese, unemployed, nulliparous, primipara and use of hormonal contraception.
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Affiliation(s)
- Namkha Dorji
- Department of Obstetrics and Gynaecology, Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan.
| | - Yeshey Dorjey
- Department of Obstetrics and Gynaecology, Phuntsholing General Hospital, Chukha, Bhutan
| | - Sangay Tshering
- Department of Obstetrics and Gynaecology, Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan
| | - Birendra Pradhan
- Department of Pathology and Laboratory Medicine, Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan
| | - Meera Chhetri
- Colposcopy Clinic, Gyaltsuen Jetsun Pema Mother and Child Hospital, Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan
| | - Damanti Bhujel
- Colposcopy Clinic, Gyaltsuen Jetsun Pema Mother and Child Hospital, Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan
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24
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Tang Q, Chen X. Curative effect of motherwort combined with ethinylestradiol-cyproterone acetate on dysfunctional uterine bleeding. Expert Rev Hematol 2024; 17:165-171. [PMID: 38613836 DOI: 10.1080/17474086.2024.2343878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 02/13/2024] [Indexed: 04/15/2024]
Abstract
OBJECTIVE This study aimed to investigate the curative effect of motherwort combined with ethinylestradiol-cyproterone acetate (EE/CPA) on dysfunctional uterine bleeding (DUB). METHODS Atotal of 68 patients with DUB were divided into a single medication group (treated with EE/CPA) and a combination medication group(treated with motherwort and EE/CPA). The clinical efficacy, uterine hemodynamic parameters, sex hormone levels, coagulation index levels, blood routine test levels, and adverse reactions of patients were evaluated. RESULTS After three months of treatment, total treatment response rate of the combination medication group was significantly higher than that of the single medication group. Decreased uterine volume, endometrial thickness and resistance index (RI), increased pulsatility index(PI), average flow rate, and uterine artery blood flow, as well asreduced follicle-stimulating hormone (FSH), luteinizing hormone (LH),estradiol (E2), progesterone (P), activated partial thromboplastin time (aPTT), prothrombin time (PT), fibrinogen (FIB), thrombin time(TT), platelet count (PLT), red blood cell (RBC), and hemoglobin (Hb)levels were witnessed in patients of the two groups. In thecombination medication group, there exhibited reduced uterine volume, endometrial thickness and RI, elevated PI, average flow rate, and uterine artery blood flow, reduced P, E2, FSH, LH, aPTT, PT, FIB, TT,PLT, RBC, and Hb levels in comparison to the single medication group. CONCLUSION The combination of motherwort and EE/CPA is clinically effective in the treatment of DUB.
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Affiliation(s)
- Qiaoyun Tang
- Department of Gynaecology, Zhejiang Province WuYi County First People's Hospital, Jinhua, China
| | - Xueyuan Chen
- Department of Gynaecology and Obstetrics, Traditional Chinese Medical Hospital of Yongkang, Yongkang, China
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25
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David DA, Rodrigues ÂR, Amaral J, Geraldes F. Submucous leiomyoma: an uncommon cause of heavy menstrual bleeding in early adolescence. BMJ Case Rep 2024; 17:e258426. [PMID: 38538101 PMCID: PMC10982701 DOI: 10.1136/bcr-2023-258426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024] Open
Abstract
Uterine leiomyomas are rare in the paediatric population. This report describes a rare case of a submucous leiomyoma in an adolescent girl. The patient presented with a history of abnormal and painful period which was refractory to medical treatment. Sonographic findings revealed a uterine mass that protruded through the cervix until the upper third of the vagina. A hysteroscopic resection was performed, and a pathological examination confirmed a leiomyoma. 12 months after surgery, there were no signs of recurrence. Conservative sparing-fertility management, such as hysteroscopic resection, is the best option with a type 0 submucosal fibroid, especially in adolescents and young women.
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Affiliation(s)
- Daniela Agostinho David
- Department of Gynecology, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
| | - Ângela Reis Rodrigues
- Department of Gynecology, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
| | - João Amaral
- Department of Pathology, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
| | - Fernanda Geraldes
- Department of Gynecology, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
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26
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Moratalla-Bartolomé E, Lázaro-de-la-Fuente J, López-Carrasco I, Cabezas-López E, Carugno J, Sancho-Sauco J, Pelayo-Delgado I. Surgical impact of bilateral transient occlusion of uterine and utero-ovarian arteries during laparoscopic myomectomy. Sci Rep 2024; 14:7044. [PMID: 38528094 PMCID: PMC10963736 DOI: 10.1038/s41598-024-57720-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 03/21/2024] [Indexed: 03/27/2024] Open
Abstract
The objective of this article is to compare the amount of intraoperative blood loss during laparoscopic myomectomy when performing bilateral transient clamping of the uterine and utero-ovarian arteries versus no intervention. It´s a randomized controlled prospective study carried out in the Department of Obstetrics and Gynecology Ramón y Cajal University Hospital and HM Montepríncipe-Sanchinarro University Hospital, Madrid, Spain, in women with fibroid uterus undergoing laparoscopic myomectomy. Eighty women diagnosed with symptomatic fibroid uterus were randomly assigned to undergo laparoscopic myomectomy without additional intervention (Group A) or temporary clamping of bilateral uterine and utero-ovarian arteries prior to laparoscopic myomectomy (Group B). Estimated blood loss, operating time, length of hospital stay, and postoperative hemoglobin values were compared in both groups. The number of fibroids removed was similar in both groups (p = 0.77). Estimated blood loss was lower in the group of patients with prior occlusion of uterine arteries (p = 0.025) without increasing operating time (p = 0.17) nor length of stay (p = 0.17). No patient had either intra or postoperative complications. Only two patients (2.5%) required blood transfusion after surgery. We conclude that temporary clamping of bilateral uterine arteries prior to laparoscopic myomectomy is a safe intervention that reduces blood loss without increasing operative time.
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Affiliation(s)
- Enrique Moratalla-Bartolomé
- Department of Obstetrics and Gynecology, Ramón y Cajal University Hospital, 3428034, Madrid, Spain
- Department of Obstetrics and Gynecology, HM Montepríncipe-Sanchinarro University Hospital, 3428050, Madrid, Spain
| | | | - Irene López-Carrasco
- Department of Obstetrics and Gynecology, HM Montepríncipe-Sanchinarro University Hospital, 3428050, Madrid, Spain
| | - Elena Cabezas-López
- Department of Obstetrics and Gynecology, Ramón y Cajal University Hospital, 3428034, Madrid, Spain
- Department of Obstetrics and Gynecology, HM Montepríncipe-Sanchinarro University Hospital, 3428050, Madrid, Spain
| | - Jose Carugno
- Minimally Invasive Gynecology Division, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Miami, Florida, USA
| | - Javier Sancho-Sauco
- Department of Obstetrics and Gynecology, Ramón y Cajal University Hospital, 3428034, Madrid, Spain
- Department of Obstetrics and Gynecology, HM Montepríncipe-Sanchinarro University Hospital, 3428050, Madrid, Spain
| | - Irene Pelayo-Delgado
- Department of Obstetrics and Gynecology, Ramón y Cajal University Hospital, Alcalá de Henares University, 3428034, Madrid, Spain.
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27
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Pleasant V. Gynecologic Care of Black Breast Cancer Survivors. CURRENT BREAST CANCER REPORTS 2024; 16:84-97. [PMID: 38725438 PMCID: PMC11081127 DOI: 10.1007/s12609-024-00527-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2024] [Indexed: 05/12/2024]
Abstract
Purpose of Review Black patients suffer from breast cancer-related racial health disparities, which could have implications on their gynecologic care. This review explores considerations in the gynecologic care of Black breast cancer survivors. Recent Findings Black people have a higher risk of leiomyoma and endometrial cancer, which could confound bleeding patterns such as in the setting of tamoxifen use. As Black people are more likely to have early-onset breast cancer, this may have implications on long-term bone and heart health. Black patients may be more likely to have menopausal symptoms at baseline and as a result of breast cancer treatment. Furthermore, Black patients are less likely to utilize assisted reproductive technology and genetic testing services. Summary It is important for healthcare providers to be well-versed in the intersections of breast cancer and gynecologic care. Black breast cancer survivors may have unique considerations for which practitioners should be knowledgeable.
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Affiliation(s)
- Versha Pleasant
- University of Michigan Hospital, Mott Children & Women’s Hospital, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
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Tinelli A, Panese G, Licchelli M, Morciano A, Pecorella G, Gambioli R. The impact of epigallocatechin gallate, vitamin D, and D-chiro-inositol on early surgical outcomes of laparoscopic myomectomy: a pilot study. Arch Gynecol Obstet 2024; 309:1021-1026. [PMID: 38183422 DOI: 10.1007/s00404-023-07324-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 11/26/2023] [Indexed: 01/08/2024]
Abstract
PURPOSE A prospective investigation to assess the impact of 3 months of treatment with epigallocatechin gallate (EGCG), vitamin D and D-chiro-inositol (DCI) in the treatment of uterine fibroids (UF) with laparoscopic myomectomy as evidenced by surgical outcomes and effect on liver function. METHODS Non-pregnant or lactating women aged between 30 and 40 years were scheduled for laparoscopic myomectomy to treat symptoms or looking to conceive. After enrollment, patients were assigned to either (1) intervention group, assuming a total of 300 mg EGCG, 50 μg vitamin D, and 50 mg DCI divided in 2 pills per day for 3 months, or (2) control group, including untreated women scheduled to undergo laparoscopic myomectomy after 3 months. RESULTS 91 patients completed the study. The comparison of the surgical outcomes between the intervention (n = 44) and the control (n = 47) groups revealed that the treatment significantly reduces the duration of surgery (41.93 ± 7.56 min vs 56.32 ± 10.63 min, p < 0.001). Moreover, the treatment also reduced blood loss during surgery (149.09 ± 25.40 mL vs 168.41 ± 21.34 mL, p < 0.001), resulting in treated patients having higher Hb levels at discharge 11.27 ± 0.82 mL vs 10.56 ± 0.82 mL, p < 0.01). The surgery induced an increase in AST and in total bilirubin regardless of the assigned group, and the treatment induced no change in liver function. CONCLUSIONS Our data suggest that EGCG plus vitamin D, and DCI could represent a safe option for women with UF scheduled for laparoscopic myomectomy, improving surgical outcomes without affecting liver functionality.
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Affiliation(s)
- Andrea Tinelli
- Department of Obstetrics and Gynecology, CERICSAL (CEntro di RIcerca Clinico SALentino), "Veris delli Ponti Hospital", Via Giuseppina Delli Ponti, 73020, Scorrano, Lecce, Italy.
| | - Gaetano Panese
- Department of Obstetrics and Gynecology, CERICSAL (CEntro di RIcerca Clinico SALentino), "Veris delli Ponti Hospital", Via Giuseppina Delli Ponti, 73020, Scorrano, Lecce, Italy
| | - Martina Licchelli
- Department of Obstetrics and Gynecology, CERICSAL (CEntro di RIcerca Clinico SALentino), "Veris delli Ponti Hospital", Via Giuseppina Delli Ponti, 73020, Scorrano, Lecce, Italy
| | - Andrea Morciano
- Department of Gynaecology and Obstetrics, Pia Fondazione "Card. G. Panico", Tricase, Lecce, Italy
| | - Giovanni Pecorella
- Department of Obstetrics, Gynecology and Reproductive Medicine, Saarland University, 66421, Homburg, Saarland, Germany
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Vitale SG, Saponara S, Sicilia G, Klarić M, Sorrentino F, D'Alterio MN, Nappi L, Angioni S. Hysteroscopic diode laser myolysis: from a case series to literature review of incisionless myolysis techniques for managing heavy menstrual bleeding in premenopausal women. Arch Gynecol Obstet 2024; 309:949-959. [PMID: 37831177 PMCID: PMC10866768 DOI: 10.1007/s00404-023-07218-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 09/02/2023] [Indexed: 10/14/2023]
Abstract
PURPOSE This case series examined the safety and effectiveness of hysteroscopic myolysis using laser-induced interstitial thermo-therapy (LITT) for treating heavy menstrual bleeding (HMB) in premenopausal women with FIGO type 1 or 2 uterine fibroids, not planning for future fertility. Additionally, a comprehensive review of innovative, minimally invasive, incisionless myolysis techniques was conducted. METHODS Women with HMB, sonographically diagnosed with a single FIGO type 1 or 2 fibroid, underwent hysteroscopic myolysis using the Leonardo® diode laser. Effectiveness was assessed via transvaginal ultrasound measurement of myoma size, volume and vascularization pre and post-procedure. Moreover, we also evaluated any improvements in symptoms using the Pictorial Blood Loss Assessment Chart (PBAC score) scores. RESULTS The procedure resulted in significant HMB reductions and noticeable fibroid size, volume, and vascularization decrease in all three patients, with no reported complications. The literature review revealed both advantages and limitations of the minimally invasive, incisionless myolysis techniques. CONCLUSIONS Hysteroscopic laser myolysis is a safe and effective therapeutic intervention for patients experiencing HMB, diagnosed with FIGO type 1 or 2 fibroids, and not planning for future fertility. The procedure resulted in significant reductions in menstrual blood loss and fibroid size. Despite the promising results, it is essential to note the limitations of this report, including its case series design, a small number of patients, and a short follow-up period. Further research is necessary to confirm these results.
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Affiliation(s)
- Salvatore Giovanni Vitale
- Division of Gynecology and Obstetrics, Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
| | - Stefania Saponara
- Division of Gynecology and Obstetrics, Department of Surgical Sciences, University of Cagliari, Cagliari, Italy.
| | - Gilda Sicilia
- Division of Gynecology and Obstetrics, Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
| | - Marko Klarić
- Clinical Hospital Center of Rijeka, Department of Obstetrics and Gynaecology, Rijeka, Croatia
| | - Felice Sorrentino
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynaecology, University of Foggia, Foggia, Italy
| | - Maurizio Nicola D'Alterio
- Division of Gynecology and Obstetrics, Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
| | - Luigi Nappi
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynaecology, University of Foggia, Foggia, Italy
| | - Stefano Angioni
- Division of Gynecology and Obstetrics, Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
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Mikkelsen TF, Vera-Rodriguez M, Greggains G, Fedorcsák P, Hald K. Effect of endometrial biopsy method on ribonucleic acid quality and gene expression analysis in patients with leiomyoma. F S Rep 2024; 5:72-79. [PMID: 38524201 PMCID: PMC10958711 DOI: 10.1016/j.xfre.2023.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 11/02/2023] [Accepted: 11/09/2023] [Indexed: 03/26/2024] Open
Abstract
Objective To compare ribonucleic acid (RNA) quantity and purity in tissue collected with different endometrial sampling methods to establish the optimal tool for use in endometrial gene expression studies. Design Observational study. Setting University hospital. Patients Fourteen patients with submucosal leiomyomas. Interventions Unguided biopsies were obtained using a low-pressure suction device before hysteroscopy from 14 patients with submucosal leiomyomas followed by guided biopsy with a resectoscope loop. Fifty-seven samples were collected: 25 obtained using a suction device and 32 with a loop. Main Outcome Measures Total biopsy weight, RNA purity, and RNA yield for each collection method. After complementary deoxyribonucleic acid synthesis, HOXA10 expression was measured by quantitative polymerase chain reaction in the endometrium overlying and remote from the leiomyoma, as similar expression throughout the cavity was a prerequisite for the use of unguided biopsy method. Results The median weight of the samples was significantly larger when obtained with the low-pressure suction device than with the resectoscope loop (153 vs. 20 mg). The RNA yield was similar (suction curette, 1,625 ng/mg; resectoscope loop, 1,779 ng/mg). The A260-to-A280 ratio was satisfactory for 94.7 % of the samples, with no difference between the groups. The endometrial expression of HOXA10 was similar in areas overlying the leiomyoma compared with that in remote endometrial sites (2-ΔCt = 0.0224 vs. 0.0225). Conclusions Low-pressure endometrial suction devices provide tissue samples with acceptable RNA purity and quantity for gene expression studies. The expression of HOXA10 did not differ between endometrial sampling sites even in the presence of leiomyomas.
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Affiliation(s)
- Thea Falkenberg Mikkelsen
- Department of Gynecology, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Maria Vera-Rodriguez
- Department of Reproductive Medicine, Oslo University Hospital, Oslo, Norway
- Department of Microbiology, Oslo University Hospital, Oslo, Norway
| | - Gareth Greggains
- Department of Reproductive Medicine, Oslo University Hospital, Oslo, Norway
- Department of Microbiology, Oslo University Hospital, Oslo, Norway
| | - Péter Fedorcsák
- Department of Reproductive Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Kirsten Hald
- Department of Gynecology, Oslo University Hospital, Oslo, Norway
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Laganà AS, Romano A, Vanhie A, Bafort C, Götte M, Aaltonen LA, Mas A, De Bruyn C, Van den Bosch T, Coosemans A, Guerriero S, Haimovich S, Tanos V, Bongers M, Barra F, Al-Hendy A, Chiantera V, Leone Roberti Maggiore U. Management of Uterine Fibroids and Sarcomas: The Palermo Position Paper. Gynecol Obstet Invest 2024; 89:73-86. [PMID: 38382486 DOI: 10.1159/000537730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 01/19/2024] [Indexed: 02/23/2024]
Abstract
BACKGROUND Uterine fibroids are benign monoclonal tumors originating from the smooth muscle cells of the myometrium, constituting the most prevalent pathology within the female genital tract. Uterine sarcomas, although rare, still represent a diagnostic challenge and should be managed in centers with adequate expertise in gynecological oncology. OBJECTIVES This article is aimed to summarize and discuss cutting-edge elements about the diagnosis and management of uterine fibroids and sarcomas. METHODS This paper is a report of the lectures presented in an expert meeting about uterine fibroids and sarcomas held in Palermo in February 2023. OUTCOME Overall, the combination of novel molecular pathways may help combine biomarkers and expert ultrasound for the differential diagnosis of uterine fibroids and sarcomas. On the one hand, molecular and cellular maps of uterine fibroids and matched myometrium may enhance our understanding of tumor development compared to histologic analysis and whole tissue transcriptomics, and support the development of minimally invasive treatment strategies; on the other hand, ultrasound imaging allows in most of the cases a proper mapping the fibroids and to differentiate between benign and malignant lesions, which need appropriate management. CONCLUSIONS AND OUTLOOK The choice of uterine fibroid management, including pharmacological approaches, surgical treatment, or other strategies, such as high-intensity focused ultrasound (HIFU), should be carefully considered, taking into account the characteristics of the patient and reproductive prognosis.
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Affiliation(s)
- Antonio Simone Laganà
- Unit of Obstetrics and Gynecology, "Paolo Giaccone" Hospital, Palermo, Italy
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | - Andrea Romano
- Department of Obstetrics and Gynecology, GROW-School for Oncology and Reproduction, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Arne Vanhie
- Department of Obstetrics and Gynaecology, Leuven University Fertility Center, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration - Woman and Child, KU Leuven, Leuven, Belgium
| | - Celine Bafort
- Department of Obstetrics and Gynaecology, Leuven University Fertility Center, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration - Woman and Child, KU Leuven, Leuven, Belgium
| | - Martin Götte
- Department of Gynecology and Obstetrics, Münster University Hospital, Munster, Germany
| | - Lauri A Aaltonen
- Department of Medical and Clinical Genetics, University of Helsinki, Helsinki, Finland
- Applied Tumor Genomics Research Program, Research Programs Unit, University of Helsinki, Helsinki, Finland
- iCAN Digital Precision Cancer Medicine Flagship, University of Helsinki, Helsinki, Finland
| | - Aymara Mas
- Carlos Simon Foundation - INCLIVA Health Research Institute, Valencia, Spain
| | - Christine De Bruyn
- Department of Development and Regeneration - Woman and Child, KU Leuven, Leuven, Belgium
- Department Obstetrics and Gynaecology, University Hospital Antwerp, Edegem, Belgium
| | - Thierry Van den Bosch
- Department of Development and Regeneration - Woman and Child, KU Leuven, Leuven, Belgium
- Department of Obstetrics and Gynecology, University Hospital Leuven, Leuven, Belgium
| | - An Coosemans
- Department of Oncology, Laboratory of Tumor Immunology and Immunotherapy, Leuven Cancer Institute, KU Leuven, Leuven, Belgium
| | - Stefano Guerriero
- Centro Integrato di Procreazione Medicalmente Assistita (PMA) e Diagnostica Ostetrico-Ginecologica, Azienda Ospedaliero Universitaria-Policlinico Duilio Casula, Monserrato, Italy
- Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
| | - Sergio Haimovich
- Department of Obstetrics and Gynecology, Laniado University Hospital, Netanya, Israel
- Adelson School of Medicine, Ariel University, Ariel, Israel
| | - Vasilios Tanos
- Department of Obstetrics and Gynecology, Aretaeio Hospital, Nicosia, Cyprus
- Department of Basic and Clinical Sciences, University of Nicosia Medical School, Nicosia, Cyprus
| | - Marlies Bongers
- Department of Obstetrics and Gynecology, GROW-School for Oncology and Reproduction, Maastricht University Medical Centre, Maastricht, The Netherlands
- Department of Obstetrics and Gynecology, Máxima Medical Centre, Veldhoven, The Netherlands
| | - Fabio Barra
- Unit of Obstetrics and Gynecology, P.O. "Ospedale del Tigullio" - ASL4, Metropolitan Area of Genoa, Genoa, Italy
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Ayman Al-Hendy
- Department of Obstetrics and Gynecology, University of Chicago, Chicago, USA
- Department of Surgery, University of Illinois at Chicago, Chicago, USA
| | - Vito Chiantera
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
- Unit of Gynecologic Oncology, National Cancer Institute - IRCCS - Fondazione "G. Pascale", Naples, Italy
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Battegay M, Khaled S, Reitz L, Balaya V, Von Theobald P, Boukerrou M, Tran PL. [Prevalence of menorrhagia among women in Reunion Island]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2024:S2468-7189(24)00041-2. [PMID: 38342237 DOI: 10.1016/j.gofs.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 01/12/2024] [Accepted: 02/05/2024] [Indexed: 02/13/2024]
Abstract
OBJECTIVES To estimate the prevalence of menorrhagia in women in Reunion Island using the Higham score, to evaluate self-reporting as an alternative diagnostic method, and to study women's level of knowledge about menorrhagia and its impact on their quality of life. METHODS This was a descriptive, cross-sectional observational study involving 185 adult women with menstrual periods living in Reunion Island. Women volunteered to answer an online self-questionnaire proposed by healthcare professionals from January to May 2023 in Reunion Island. They completed a general information questionnaire, the Higham score, a menorrhagia knowledge questionnaire and a menstrual quality of life questionnaire. RESULTS The prevalence of menorrhagia in the sample was 48.1% using the Higham score and 46.5% using self-report. Women's level of knowledge about menorrhagia is still insufficient, given the significant impact on quality of life during menstruation among those suffering from this symptom. CONCLUSION The prevalence of menorrhagia in our sample of women on Reunion Island is high. Measures need to be taken to break the taboos surrounding menstruation, promote menstrual education and foster a better understanding by women of menstrual pathologies, particularly menorrhagia. Early detection of this symptom would enable faster treatment and avoid complications and adverse effects on quality of life.
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Affiliation(s)
- Mélanie Battegay
- Université de la Réunion, UFR santé, 40, avenue de Soweto - Terre-Sainte, BP 373, 97455 Saint-Pierre cedex, Réunion
| | - Samy Khaled
- Service de gynécologie-obstétrique, centre hospitalier universitaire Sud-Réunion, BP 350, 97448 Saint-Pierre cedex, Réunion
| | - Laurianne Reitz
- Service de gynécologie-obstétrique, centre hospitalier universitaire Nord-Réunion, allée des topazes, 97400 Saint-Denis, Réunion
| | - Vincent Balaya
- Service de gynécologie-obstétrique, centre hospitalier universitaire Nord-Réunion, allée des topazes, 97400 Saint-Denis, Réunion
| | - Peter Von Theobald
- Service de gynécologie-obstétrique, centre hospitalier universitaire Nord-Réunion, allée des topazes, 97400 Saint-Denis, Réunion
| | - Malik Boukerrou
- Université de la Réunion, UFR santé, 40, avenue de Soweto - Terre-Sainte, BP 373, 97455 Saint-Pierre cedex, Réunion; Service de gynécologie-obstétrique, centre hospitalier universitaire Sud-Réunion, BP 350, 97448 Saint-Pierre cedex, Réunion; Centre d'études périnatales de l'océan Indien (UR 7388), université de la Réunion, Saint-Pierre, France
| | - Phuong Lien Tran
- Université de la Réunion, UFR santé, 40, avenue de Soweto - Terre-Sainte, BP 373, 97455 Saint-Pierre cedex, Réunion; Service de gynécologie-obstétrique, centre hospitalier universitaire Sud-Réunion, BP 350, 97448 Saint-Pierre cedex, Réunion; Inserm, CIC 1410, Reunion University Hospital, 97448 Saint-Pierre, France.
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Etrusco A, Buzzaccarini G, Laganà AS, Chiantera V, Vitale SG, Angioni S, D’Alterio MN, Nappi L, Sorrentino F, Vitagliano A, Difonzo T, Riemma G, Mereu L, Favilli A, Peitsidis P, D’Amato A. Use of Diode Laser in Hysteroscopy for the Management of Intrauterine Pathology: A Systematic Review. Diagnostics (Basel) 2024; 14:327. [PMID: 38337843 PMCID: PMC10855490 DOI: 10.3390/diagnostics14030327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/20/2024] [Accepted: 01/31/2024] [Indexed: 02/12/2024] Open
Abstract
Background: Hysteroscopy currently represents the gold standard for the diagnosis and treatment of intrauterine pathologies. Recent technological progress has enabled the integration of diagnostic and operative time, leading to the "see and treat" approach. Diode laser technology is emerging as one of the most innovative and intriguing techniques in this context. Methods: A comprehensive search of the literature was carried out on the main databases. Only original studies reporting the treatment of intrauterine pathologies using diode laser were deemed eligible for inclusion in this systematic review (PROSPERO ID: CRD42023485452). Results: Eight studies were included in the qualitative analysis for a total of 474 patients undergoing laser hysteroscopic surgery. Eighty-three patients had female genital tract abnormalities, 63 had submucosal leiomyomas, 327 had endometrial polyps, and one patient had a scar pregnancy. Except for leiomyomas, whose technique already included two surgical times at the beginning, only seven patients required a second surgical step. Cumulative rates of intraoperative and postoperative complications of 2.7% and 0.6%, respectively, were reported. Conclusions: Diode laser through "see and treat" hysteroscopy appears to be a safe and effective method. However, additional studies with larger sample sizes and improved designs are needed to consolidate the evidence currently available in the literature.
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Affiliation(s)
- Andrea Etrusco
- Unit of Obstetrics and Gynecology, “Paolo Giaccone” Hospital, 90127 Palermo, Italy;
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90127 Palermo, Italy;
| | - Giovanni Buzzaccarini
- Department of Obstetrics and Gynecology, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, 20132 Milan, Italy;
| | - Antonio Simone Laganà
- Unit of Obstetrics and Gynecology, “Paolo Giaccone” Hospital, 90127 Palermo, Italy;
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90127 Palermo, Italy;
| | - Vito Chiantera
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90127 Palermo, Italy;
- Unit of Gynecologic Oncology, National Cancer Institute IRCCS Fondazione “G. Pascale”, 80131 Naples, Italy
| | - Salvatore Giovanni Vitale
- Division of Gynecology and Obstetrics, Department of Surgical Sciences, University of Cagliari, 09124 Cagliari, Italy; (S.G.V.); (S.A.); (M.N.D.)
| | - Stefano Angioni
- Division of Gynecology and Obstetrics, Department of Surgical Sciences, University of Cagliari, 09124 Cagliari, Italy; (S.G.V.); (S.A.); (M.N.D.)
| | - Maurizio Nicola D’Alterio
- Division of Gynecology and Obstetrics, Department of Surgical Sciences, University of Cagliari, 09124 Cagliari, Italy; (S.G.V.); (S.A.); (M.N.D.)
| | - Luigi Nappi
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynecology, University of Foggia, 71121 Foggia, Italy; (L.N.); (F.S.)
| | - Felice Sorrentino
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynecology, University of Foggia, 71121 Foggia, Italy; (L.N.); (F.S.)
| | - Amerigo Vitagliano
- Department of Interdisciplinary Medicine (DIM), Unit of Obstetrics and Gynecology, University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy; (A.V.); (T.D.); (A.D.)
| | - Tommaso Difonzo
- Department of Interdisciplinary Medicine (DIM), Unit of Obstetrics and Gynecology, University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy; (A.V.); (T.D.); (A.D.)
| | - Gaetano Riemma
- Department of Woman, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy;
| | - Liliana Mereu
- Unit of Obstetrics and Gynecology, Department of General Surgery and Medical-Surgical Specialism, University of Catania, P.O. “G. Rodolico”, Via Santa Sofia, 78, 95123 Catania, Italy;
| | - Alessandro Favilli
- Section of Obstetrics and Gynecology, Department of Medicine and Surgery, University of Perugia, 06135 Perugia, Italy;
| | - Panagiotis Peitsidis
- Department of Obstetrics and Gynecology, Helena Venizelou Hospital, 11521 Athens, Greece;
| | - Antonio D’Amato
- Department of Interdisciplinary Medicine (DIM), Unit of Obstetrics and Gynecology, University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy; (A.V.); (T.D.); (A.D.)
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Ito H, Nakai M, Yunaiyama D, Shirota N, Kobayashi T, Yasutomi M, Kikuchi T, Kinoshita Y, Takara Y, Tanaka T, Saguchi T, Saito K. Efficacy of uterine artery embolization (UAE) for uterine fibroids according to FIGO classification: a single-center experience. Jpn J Radiol 2024; 42:174-181. [PMID: 37815695 DOI: 10.1007/s11604-023-01492-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 09/13/2023] [Indexed: 10/11/2023]
Abstract
OBJECTIVE This study aims to retrospectively evaluate the outcomes of uterine artery embolization (UAE) for uterine fibroids (UFs), specifically submucosal UFs, according to the International Federation of Gynecology and Obstetrics (FIGO) classification of UFs. MATERIALS AND METHODS Forty-two patients with symptomatic UFs underwent UAE with Embosphere® between July 2016 and November 2021. MRI was performed before, at 3 and 6 months after the UAE. At each examination, the volume of UF was measured, and the percentage volume reduction rate (VRR) was calculated. The technical success rate (TSR), symptom improvement rate (SIR), regrowth rate (RR) after 6 months, and adverse events (AEs) were examined; VRR was compared between patients with submucosal UFs (FIGO types 0-2, group A), those with submucosal contacts (FIGO type 3, group B), and those without submucosal UFs (FIGO types 4-7, group C). Statistical analysis was performed on the difference in VRR between groups A, B, and C at 3 and 6 months after UAE. The relationship with hormone levels before UAE and VRR was evaluated. RESULTS Thirty-seven of the 42 patients were evaluated. Overall, VRR was 37.0% at 3 months and 52.1% at 6 months; TSR, SIR, and RR were 100%, 95.2%, and 5.4%, respectively; VRR at 6 months was 80.7% for group A (n = 7), 57.8% for group B (n = 13), and 37.1% for group C (n = 17). Significant differences were found between A and C (p < 0.001) and B and C (p = 0.023). Hormone levels before UAE had no effect on VRR. There was no significant AEs other than grade 3 pulmonary embolism in one patient. CONCLUSION UAE was effective for submucosal FIGO types 0-3. UAE was especially useful as an option for FIGO type 3 with a low protrusion rate that is difficult to treat with transcervical resection.
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Affiliation(s)
- Hiroe Ito
- Department of Obstetrics and Gynecology, Tokyo Medical University, 6-7-1, Nishishinjuku, Shinjuku-Ku, Tokyo, Japan
| | - Motoki Nakai
- Department of Radiology, Tokyo Medical University, 6-7-1, Nishishinjuku, Shinjuku-Ku, Tokyo, Japan.
| | - Daisuke Yunaiyama
- Department of Radiology, Tokyo Medical University, 6-7-1, Nishishinjuku, Shinjuku-Ku, Tokyo, Japan
| | - Natsuhiko Shirota
- Department of Radiology, Tokyo Medical University, 6-7-1, Nishishinjuku, Shinjuku-Ku, Tokyo, Japan
| | - Takehiro Kobayashi
- Department of Radiology, Tokyo Medical University, 6-7-1, Nishishinjuku, Shinjuku-Ku, Tokyo, Japan
| | - Mika Yasutomi
- Department of Radiology, Tokyo Medical University, 6-7-1, Nishishinjuku, Shinjuku-Ku, Tokyo, Japan
| | - Takayuki Kikuchi
- Department of Obstetrics and Gynecology, Tokyo Medical University, 6-7-1, Nishishinjuku, Shinjuku-Ku, Tokyo, Japan
| | - Yuta Kinoshita
- Department of Obstetrics and Gynecology, Tokyo Medical University, 6-7-1, Nishishinjuku, Shinjuku-Ku, Tokyo, Japan
| | - Yuki Takara
- Department of Radiology, Tokyo Medical University, 6-7-1, Nishishinjuku, Shinjuku-Ku, Tokyo, Japan
| | - Taro Tanaka
- Department of Radiology, Tokyo Medical University, 6-7-1, Nishishinjuku, Shinjuku-Ku, Tokyo, Japan
| | - Toru Saguchi
- Department of Radiology, Tokyo Medical University, 6-7-1, Nishishinjuku, Shinjuku-Ku, Tokyo, Japan
| | - Kazuhiro Saito
- Department of Radiology, Tokyo Medical University, 6-7-1, Nishishinjuku, Shinjuku-Ku, Tokyo, Japan
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Motan T, Cockwell H, Elliott J, Antaki R. Guideline No. 446: Hysteroscopic Surgery in Fertility Therapy. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2024; 46:102400. [PMID: 38320665 DOI: 10.1016/j.jogc.2024.102400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
OBJECTIVE To evaluate the indications, benefits, and risks of hysteroscopy in the management of patients with infertility and provide guidance to gynaecologists who manage common conditions in these patients. TARGET POPULATION Patients with infertility (inability to conceive after 12 months of unprotected intercourse) undergoing investigation and treatment. BENEFITS, HARMS, AND COSTS Hysteroscopic surgery can be used to diagnose the etiology of infertility and improve fertility treatment outcomes. All surgery has risks and associated complications. Hysteroscopic surgery may not always improve fertility outcomes. All procedures have costs, which are borne either by the patient or their health insurance provider. EVIDENCE We searched English-language articles from January 2010 to May 2021 in PubMed/MEDLINE, Embase, Science Direct, Scopus, and Cochrane Library (see Appendix B for MeSH search terms). VALIDATION METHODS The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional recommendations). INTENDED AUDIENCE Gynaecologists who manage common conditions in patients with infertility. TWEETABLE ABSTRACT When offering hysteroscopic surgery to patients with infertility, ensure it improves the live birth rate. SUMMARY STATEMENTS RECOMMENDATIONS.
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Motan T, Cockwell H, Elliott J, Antaki R. Directive clinique n o446 : Chirurgie hystéroscopique dans les traitements de fertilité. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2024; 46:102399. [PMID: 38325735 DOI: 10.1016/j.jogc.2024.102399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
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Abul R, Selcuki NFT, Karadeniz O, Bahat PY. A comparison of the effects of oral dydrogesterone and levonorgestrel-releasing intrauterine device on quality of life and sexual function in patients with abnormal uterine bleeding. Arch Gynecol Obstet 2024; 309:715-719. [PMID: 38150038 DOI: 10.1007/s00404-023-07315-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 11/22/2023] [Indexed: 12/28/2023]
Abstract
OBJECTIVE The purpose of this study is to compare the effects of cyclic oral dydrogesterone treatment and levonorgestrel-releasing intrauterine device (LNG_IUD) on quality of life (QoL) and sexual function in patients diagnosed with abnormal uterine bleeding (AUB). STUDY DESIGN The study was conducted at the University of Health Sciences Turkey Health Istanbul Kanuni Sultan Süleyman Training and Research Hospital, on 171 sexually active patients, aged 18-45, who were under a minimum of 6 months of treatment for AUB. 85 patients were treated with oral cyclic dydrogesterone, and 86 patients received LNG-IUD. Following a minimum of 6 months of treatment, these patients were recruited to the study and were asked to complete a 36-Item Short Form Survey (SF-36) and the Female Sexual Function Index (FSFI). RESULTS When the FSFI scores of the patients were compared, it was observed that the total FSFI score was significantly higher in the cyclic dydrogesterone group (p < 0.05). Likewise, it was observed that sexual desire, arousal, and lubrication domains were significantly higher in the cyclic dydrogesterone group (p < 0.05). No significant differences were found between the treatment groups in 7 out of the 8 dimensions of SF-36. The energy/vitality dimension was found to be significantly higher in the cyclic dydrogesterone group. CONCLUSION Total FSFI score, as well as sexual desire, arousal, and lubrication scores, were significantly higher in the cyclic dydrogesterone group compared to the LNG-IUD group indicating that cyclic dydrogesterone has a more positive impact on sexual function when compared to LNG-IUD.
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Affiliation(s)
- Ruken Abul
- Department of Obstetrics and Gynaecology, University of Health Sciences Turkey, Istanbul Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey
| | - Nura Fitnat Topbas Selcuki
- Department of Obstetrics and Gynaecology, University of Health Sciences Turkey, Istanbul Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Ozan Karadeniz
- Department of Gynaecology and Obstetrics, Arnavutkoy State Hospital, Eski Edirne Street, No: 3, Arnavutkoy Centre, 34275, Istanbul, Turkey.
| | - Pınar Yalçın Bahat
- Department of Obstetrics and Gynaecology, University of Health Sciences Turkey, Istanbul Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey
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James AH, James PD. What do we know about why women bleed and what do we not know? J Thromb Haemost 2024; 22:315-322. [PMID: 37709147 DOI: 10.1016/j.jtha.2023.08.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 08/07/2023] [Accepted: 08/31/2023] [Indexed: 09/16/2023]
Abstract
Women or people with a uterus are vulnerable to both normal and abnormal bleeding. During the reproductive years, the uterus is prepared physiologically to accept an embryo and support its growth and development during pregnancy, or in the absence of implantation of an embryo, recycle through the process of menstruation and accept an embryo a month or so later. If fertilization takes place and an embryo or embryos implant in the uterus, the fetal trophoblast, or outer cell layer of the embryo, invades and dilates the maternal spiral arteries and forms the placenta. No matter when in gestation a pregnancy ends, at the conclusion of pregnancy, the placenta should separate from the wall of the uterus and be expelled. Abnormal bleeding occurs during pregnancy or after delivery when the normal uteroplacental interface has not been established or is interrupted; during miscarriage; during ectopic pregnancy; during premature separation of the placenta; or during postpartum hemorrhage. Heavy menstrual bleeding, a subset of abnormal menstrual bleeding, can be quantitatively defined as >80 mL of blood loss per cycle. Unlike postpartum hemorrhage, heavy menstrual bleeding is significantly associated with an underlying bleeding disorder. While there is other reproductive tract bleeding in women, notably bleeding at the time of ovulation or with a life-threatening ruptured ectopic pregnancy, the unique bleeding that women experience is predominantly uterine in origin. Many of the unique aspects of uterine hemostasis, however, remain unknown.
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Affiliation(s)
- Andra H James
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, Durham, USA; Division of Hematology, Department of Medicine, Duke University Medical Center, Durham, Durham, USA.
| | - Paula D James
- Departments of Medicine and Pathology & Molecular Medicine, Queen's University, Kingston, Ontario, Canada
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Sherifi SK, Odahowski CL, López Castillo H. Uterine leiomyomata claim rate estimates and demographic characteristics by county. Florida, 2010-2019. Women Health 2024; 64:75-89. [PMID: 38154484 DOI: 10.1080/03630242.2023.2296524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 12/13/2023] [Indexed: 12/30/2023]
Abstract
To describe the demographic characteristics and estimate the uterine leiomyomata claim rates (ULCRs) by women 18 years and older in Florida, we conducted a cross-sectional analysis of the 2010-2019 administrative claims for uterine leiomyomata and associated study variables (age, race, ethnicity, county of residence, anatomic site, length of stay, and additional diagnoses). ULCR ratios were estimated by race and ethnicity, using ULCR for non-Hispanic White women as the reference group. We identified 232,475 claims, most of which were among non-Hispanic White women in their forties. The overall ULCR estimate [95 percent CI] was 284.8 [284.21, 285.39] per 100,000 women 18 years and older, with a small, nonsignificant trend to increase over time (R2 = .310; p = .094). Black, Hispanic, and other women of color presented with higher ULCR ratios (4.84, 1.87, and 1.58, respectively). Urban counties had significantly higher ULCRs than suburban and rural counties. While non-Hispanic White women had the highest frequency of ULCRs, women of color-especially Black women-presented with significantly higher ULCR ratios. The epidemiologic profile of uterine leiomyomata in terms of age, race, ethnicity, and geographic location points to unmet healthcare needs among specific demographic and geographic groups of women in Florida.
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Affiliation(s)
- Saarah K Sherifi
- Department of Health Sciences, College of Health Professions and Sciences, University of Central Florida, Orlando, Florida, USA
| | - Cassie L Odahowski
- Department of Health Sciences, College of Health Professions and Sciences, University of Central Florida, Orlando, Florida, USA
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA
| | - Humberto López Castillo
- Department of Health Sciences, College of Health Professions and Sciences, University of Central Florida, Orlando, Florida, USA
- Department of Population Health Sciences, College of Medicine, University of Central Florida, Orlando, Florida, USA
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Cianci S, Gulino FA, Palmara V, La Verde M, Ronsini C, Romeo P, Occhipinti S, Incognito GG, Capozzi VA, Restaino S, Vizzielli G, Palumbo M. Exploring Surgical Strategies for Uterine Fibroid Treatment: A Comprehensive Review of Literature on Open and Minimally Invasive Approaches. MEDICINA (KAUNAS, LITHUANIA) 2023; 60:64. [PMID: 38256325 PMCID: PMC10820219 DOI: 10.3390/medicina60010064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Revised: 12/19/2023] [Accepted: 12/27/2023] [Indexed: 01/24/2024]
Abstract
Background and Objectives: Uterine myomas represent one of the most prevalent pathologies affecting the female population. These benign neoplasms originate from the smooth muscular cells of the uterus, and they can be either single or multiple. Often associated with debilitating symptoms such as pelvic heaviness, pain, constipation, and urinary dysfunctions, the surgical management of myomectomy exhibits considerable variability. This diversity in approaches is influenced by factors such as the number and size of myomas, the patient's age, and overall clinical conditions. This study aims to elucidate and compare the advantages and disadvantages of different surgical approaches, specifically endoscopic procedures versus open surgery, providing valuable insights for clinical decision making. Materials and Methods: A comprehensive bibliographic search spanning from 2013 to 2023 was systematically conducted across databases including Medline, Embase, the Cochrane Database of Systematic Reviews, and ClinicalTrials.gov. The search utilized keywords such as "myomectomy laparoscopic and open", "myomectomy open and minimally invasive", "myomectomy open and laparoscopic", and "myomectomy open vs. laparoscopic." The research methodology, along with predetermined inclusion and exclusion criteria, was established prior to the search, ensuring a systematic and rigorous approach. Subsequently, data analysis was carried out. Results: Following the study selection process, 25 articles met the eligibility criteria for inclusion in this analysis. The average numbers of myomas were 3.7 (ranging from 1 to 13.7) and 5.4 (ranging from 1 to 13.5) for the minimally invasive surgery and open surgery groups, respectively. In terms of myoma size, the total averages across studies were 7 cm (ranging from 4.8 to 14) for the minimally invasive group and 8 cm (ranging from 3.9 to 11.2) for the open surgery group. The average pregnancy and delivery rates were 29.7% (ranging from 1.8 to 100) for the minimally invasive group and 28.5% (ranging from 1.8 to 100) for the open surgery group. Regarding complications, the average rate was 14.2% (ranging from 0 to 50) for the endoscopic group and 22.3% (ranging from 0 to 60.3) for the laparotomic group. Conclusions: In conclusion, a critical factor influencing the choice of surgical approach is primarily the size and quantity of fibroids. The mini-laparotomic approach emerges as a viable alternative to endoscopy, demonstrating favorable surgical outcomes and aesthetic results. Interestingly, the type of surgical procedure appears to have no significant impact on the pregnancy rate.
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Affiliation(s)
- Stefano Cianci
- Unit of Gynecology and Obstetrics, Department of Human Pathology of Adult and Childhood “G. Barresi”, University of Messina, 98122 Messina, Italy; (F.A.G.); (V.P.); (P.R.)
| | - Ferdinando Antonio Gulino
- Unit of Gynecology and Obstetrics, Department of Human Pathology of Adult and Childhood “G. Barresi”, University of Messina, 98122 Messina, Italy; (F.A.G.); (V.P.); (P.R.)
| | - Vittorio Palmara
- Unit of Gynecology and Obstetrics, Department of Human Pathology of Adult and Childhood “G. Barresi”, University of Messina, 98122 Messina, Italy; (F.A.G.); (V.P.); (P.R.)
| | - Marco La Verde
- Department of Woman, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (M.L.V.); (C.R.)
| | - Carlo Ronsini
- Department of Woman, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (M.L.V.); (C.R.)
| | - Paola Romeo
- Unit of Gynecology and Obstetrics, Department of Human Pathology of Adult and Childhood “G. Barresi”, University of Messina, 98122 Messina, Italy; (F.A.G.); (V.P.); (P.R.)
| | - Sara Occhipinti
- Department of General Surgery and Medical Surgical Specialties, University of Catania, 95124 Catania, Italy; (S.O.); (G.G.I.); (M.P.)
| | - Giosuè Giordano Incognito
- Department of General Surgery and Medical Surgical Specialties, University of Catania, 95124 Catania, Italy; (S.O.); (G.G.I.); (M.P.)
| | - Vito Andrea Capozzi
- Department of Obstetrics and Gynecology, University of Parma, 43125 Parma, Italy;
| | - Stefano Restaino
- Clinic of Obstetrics and Gynecology, “Santa Maria della Misericordia” University Hospital, Azienda Sanitaria Universitaria Friuli Centrale, 33100 Udine, Italy; (S.R.); (G.V.)
| | - Giuseppe Vizzielli
- Clinic of Obstetrics and Gynecology, “Santa Maria della Misericordia” University Hospital, Azienda Sanitaria Universitaria Friuli Centrale, 33100 Udine, Italy; (S.R.); (G.V.)
- Department of Medicine, University of Udine, 33100 Udine, Italy
| | - Marco Palumbo
- Department of General Surgery and Medical Surgical Specialties, University of Catania, 95124 Catania, Italy; (S.O.); (G.G.I.); (M.P.)
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Zouzoulas D, Tsolakidis D, Pavlidi OI, Pappas PD, Theodoridis T, Pados G, Pervana S, Pazarli E, Grimbizis G. Rate of Leiomyosarcomas during Surgery for Uterine Fibroids: 8-Year Experience of a Single Center. J Clin Med 2023; 12:7555. [PMID: 38137623 PMCID: PMC10743724 DOI: 10.3390/jcm12247555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 12/04/2023] [Accepted: 12/06/2023] [Indexed: 12/24/2023] Open
Abstract
The aim of this study is to investigate the prevalence of occult malignant mesenchymal tumors in patients operated on for uterine fibroids in relation to the surgical approach and type of operation. A retrospective review of all patients that underwent surgery for uterine fibroids (January 2011-December 2018) at the 1st Department of Obstetrics & Gynecology at "Papageorgiou" Hospital. The surgical approach and clinicopathological characteristics were analyzed. A total of 803 patients were operated on: 603 (75.1%) with laparotomy, 187 (23.3%) laparoscopically, and 13 (1.6%) vaginally. Furthermore, 423 (52.7%) patients underwent hysterectomy and 380 (47.3%) myomectomies. Laparoscopy and myomectomy were offered to younger patients with fewer smaller uterine fibroids and were associated with statistically significant shorter hospitalization. The pathological reports revealed: 690 (86%) benign leiomyomas, 32 (4%) cellular leiomyomas, 29 (3.6%) degenerated leiomyomas, 22 (2.7%) adenomyomas, 18 (2.2%) atypical-bizarre leiomyomas, 1 (0.1%) STUMP, 5 (0.65%) endometrial stromal sarcomas, and 6 (0.75%) cases of leiomyosarcomas (LMS). All LMS were preoperatively characterized as suspicious and underwent abdominal hysterectomy. Morcellation was offered in two cases of atypical leiomyomas, with no morcellation-associated complication. Laparoscopy as a valuable surgical approach for young patients with fewer in number and smaller in size fibroids is associated with shorter hospitalization. The risk of unintended morcellation of LMS seems to be very low and can be reduced with careful preoperative work-up but not eliminated.
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Affiliation(s)
- Dimitrios Zouzoulas
- 1st Department of Obstetrics & Gynecology, “Papageorgiou” Hospital, Aristotle University of Thessaloniki, 56403 Thessaloniki, Greece (O.I.P.); (P.D.P.); (T.T.); (G.P.); (G.G.)
| | - Dimitrios Tsolakidis
- 1st Department of Obstetrics & Gynecology, “Papageorgiou” Hospital, Aristotle University of Thessaloniki, 56403 Thessaloniki, Greece (O.I.P.); (P.D.P.); (T.T.); (G.P.); (G.G.)
| | - Olga I. Pavlidi
- 1st Department of Obstetrics & Gynecology, “Papageorgiou” Hospital, Aristotle University of Thessaloniki, 56403 Thessaloniki, Greece (O.I.P.); (P.D.P.); (T.T.); (G.P.); (G.G.)
| | - Panagiotis D. Pappas
- 1st Department of Obstetrics & Gynecology, “Papageorgiou” Hospital, Aristotle University of Thessaloniki, 56403 Thessaloniki, Greece (O.I.P.); (P.D.P.); (T.T.); (G.P.); (G.G.)
| | - Theodoros Theodoridis
- 1st Department of Obstetrics & Gynecology, “Papageorgiou” Hospital, Aristotle University of Thessaloniki, 56403 Thessaloniki, Greece (O.I.P.); (P.D.P.); (T.T.); (G.P.); (G.G.)
| | - George Pados
- 1st Department of Obstetrics & Gynecology, “Papageorgiou” Hospital, Aristotle University of Thessaloniki, 56403 Thessaloniki, Greece (O.I.P.); (P.D.P.); (T.T.); (G.P.); (G.G.)
| | - Stavroula Pervana
- Anatomical Pathology Laboratory, “Papageorgiou” Hospital, 56403 Thessaloniki, Greece
| | - Elsa Pazarli
- Anatomical Pathology Laboratory, “Papageorgiou” Hospital, 56403 Thessaloniki, Greece
| | - Grigoris Grimbizis
- 1st Department of Obstetrics & Gynecology, “Papageorgiou” Hospital, Aristotle University of Thessaloniki, 56403 Thessaloniki, Greece (O.I.P.); (P.D.P.); (T.T.); (G.P.); (G.G.)
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Borella F, Mancarella M, Preti M, Mariani L, Stura I, Sciarrone A, Bertschy G, Leuzzi B, Piovano E, Valabrega G, Turinetto M, Pino I, Castellano I, Bertero L, Cassoni P, Cosma S, Franchi D, Benedetto C. Uterine smooth muscle tumors: a multicenter, retrospective, comparative study of clinical and ultrasound features. Int J Gynecol Cancer 2023:ijgc-2023-004880. [PMID: 38054268 DOI: 10.1136/ijgc-2023-004880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023] Open
Abstract
OBJECTIVE To evaluate a wide range of clinical and ultrasound characteristics of different uterine smooth muscle tumors to identify features capable of discriminating between these types. METHODS This was a retrospective, multicenter study that included 285 patients diagnosed with uterine smooth muscle tumors (50 leiomyosarcomas, 35 smooth muscle tumors of uncertain malignant potential, and 200 leiomyomas). The patients were divided into three groups based on the histological type of their tumors, and the groups were compared according to the variables collected. RESULTS Leiomyosarcomas were more common in older and post-menopausal women. Compared with leiomyomas, smooth muscle tumors of uncertain malignant potential and leiomyosarcomas had similar ultrasound features such as absence of normal myometrium, multilocular appearance, hyper-echogenicity in case of uniform echogenicity, absence of posterior shadows, echogenic areas, and hyperechoic rim. Leiomyosarcomas were larger, had more cystic areas, and were associated with a higher prevalence of pelvic free fluid. Smooth muscle tumors of uncertain malignant potential were characterized by a higher frequency of International Federation of Gynecology and Obstetrics (FIGO) type 6-7, the absence of internal shadows, and, in the case of cystic area, the presence of a regular internal wall. Tumor outline varied among the three histological types. A color score of 1 was typical of leiomyoma, a color score 2 was mainly observed in leiomyomas and smooth muscle tumors of uncertain malignant potential, a color score 3 did not differ among the tumors, while a color of score 4 was related to leiomyosarcomas. When combining color scores 3 and 4, leiomyosarcomas and smooth muscle tumors of uncertain malignant potential showed a high percentage of both circumferential and intra-lesional vascularization. A cooked appearance was not statistically different among the tumors. CONCLUSIONS Based on our findings, specific ultrasonographic features as well as age and menopausal status are associated with different uterine smooth muscle tumor types. Integration of these data can help the pre-operative assessment of these lesions for proper management.
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Affiliation(s)
- Fulvio Borella
- Division of Gynecology and Obstetrics 1, Department of Surgical Sciences, City of Health and Science University Hospital, University of Turin, Turin, Italy
| | - Matteo Mancarella
- Azienda Ospedaliera Ordine Mauriziano di Torino, Torino, Piemonte, Italy
| | - Mario Preti
- Division of Gynecology and Obstetrics 1, Department of Surgical Sciences, City of Health and Science University Hospital, University of Turin, Turin, Italy
| | - Luca Mariani
- Azienda Ospedaliera Ordine Mauriziano di Torino, Torino, Piemonte, Italy
| | - Ilaria Stura
- Department of Public Health and Pediatric Sciences, University of Turin, Torino, Piemonte, Italy
| | | | - Gianluca Bertschy
- Division of Gynecology and Obstetrics 1, Department of Surgical Sciences, City of Health and Science University Hospital, University of Turin, Turin, Italy
| | - Beatrice Leuzzi
- Division of Gynecology and Obstetrics 1, Department of Surgical Sciences, City of Health and Science University Hospital, University of Turin, Turin, Italy
| | - Elisa Piovano
- Division of Gynecology and Obstetrics 2, Department of Surgical Sciences, City of Health and Science University Hospital, University of Turin, Turin, Italy
| | | | | | - Ida Pino
- Preventive Gynecology Unit, Istituto Europeo di Oncologia, Milan, Italy
| | - Isabella Castellano
- Pathology Unit, Department of Medical Sciences, City of Health and Science University Hospital, University of Turin, Turin, Italy
| | - Luca Bertero
- Pathology Unit, Department of Medical Sciences, City of Health and Science University Hospital, University of Turin, Turin, Italy
| | - Paola Cassoni
- Pathology Unit, Department of Medical Sciences, City of Health and Science University Hospital, University of Turin, Turin, Italy
| | - Stefano Cosma
- Division of Gynecology and Obstetrics 1, Department of Surgical Sciences, City of Health and Science University Hospital, University of Turin, Turin, Italy
| | - Dorella Franchi
- Preventive Gynecology Unit, Istituto Europeo di Oncologia, Milan, Italy
| | - Chiara Benedetto
- Division of Gynecology and Obstetrics 1, Department of Surgical Sciences, City of Health and Science University Hospital, University of Turin, Turin, Italy
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Michos G, Dagklis T, Papanikolaou E, Tsakiridis I, Oikonomou K, Mamopoulos AM, Kalogiannidis IA, Athanasiadis A. Uterine Leiomyomas and Infertility: A Comparison of National and International Guidelines. Cureus 2023; 15:e50992. [PMID: 38259363 PMCID: PMC10802214 DOI: 10.7759/cureus.50992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2023] [Indexed: 01/24/2024] Open
Abstract
Uterine leiomyomas are the most common benign tumors of the female genital track, causing various symptoms and problems, including a possible impact on fertility. The relationship between fibroids and infertility has long been a debate among gynecologists. Management of fibroids in women with otherwise unexplained infertility worldwide lacks standardized, evidence-based guidelines. Therefore, a review of guidelines from the Royal Australian and New Zealand College of Obstetricians and Gynecologists, the American College of Obstetricians and Gynecologists, the Society of Obstetricians and Gynecologists of Canada, the Collège National des Gynécologues et Obstétriciens Français, and the American Society of Reproductive Medicine was conducted. There is agreement among all guidelines that the effect of fibroids on fertility is related to their position in the uterus and the alteration of the endometrial cavity. However, whether surgical intervention (laparotomy, laparoscopy, or hysteroscopy) is required varies among committees. More specifically, for submucous myomas, all guidelines agree that surgical intervention is needed. On the other hand, regarding intramural myomas, there is no consensus on what the approach may be. Novel treatments such as uterine artery embolization (UAE) and magnetic resonance-guided focused ultrasound surgery (MRgFUS) should only be used in clinical trial settings. Nevertheless, all guidelines agree that medical management of fibroids further delays efforts to conceive and has no role as a stand-alone treatment of fibroids; though, the use of GnRH analogues preoperatively can be useful to improve anemia and/or reduce fibroid volume. There is a need for updated international protocols to be introduced, in order to help clinicians dealing with fibroids and infertility to better suggest the optimal treatment.
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Affiliation(s)
- Georgios Michos
- 3rd Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki, Thessaloniki, GRC
| | - Themistoklis Dagklis
- 3rd Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki, Thessaloniki, GRC
| | - Evangelos Papanikolaou
- 3rd Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki, Thessaloniki, GRC
| | - Ioannis Tsakiridis
- 3rd Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki, Thessaloniki, GRC
| | - Kyriakos Oikonomou
- 3rd Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki, Thessaloniki, GRC
| | - Apostolos M Mamopoulos
- 3rd Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki, Thessaloniki, GRC
| | - Ioannis A Kalogiannidis
- 3rd Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki, Thessaloniki, GRC
| | - Apostolos Athanasiadis
- 3rd Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki, Thessaloniki, GRC
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Hill S, Shetty MK. Abnormal Uterine Bleeding in Reproductive Age Women: Role of Imaging in the Diagnosis and Management. Semin Ultrasound CT MR 2023; 44:511-518. [PMID: 37832698 DOI: 10.1053/j.sult.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
Abstract
Abnormal uterine bleeding (AUB) is defined by the International Federation of Gynecology and Obstetrics as bleeding from the uterine corpus that is abnormal in regularity, volume, frequency, or duration and occurs in the absence of pregnancy. AUB is a common condition that affects about a third of women in their lifetime. Abnormal bleeding in duration, quantity, or timing consists of 2 categories, predictable cyclical heavy menstrual bleeding (HMB) and irregular non-cyclical intermenstrual bleeding (IMB). The most common causes of HMB include fibroids and adenomyosis and IMB is commonly caused by ovulatory dysfunction such as in polycystic ovaries, endometrial polyp, or an IUD. A pelvic ultrasound is the initial and often only imaging modality needed in the imaging evaluation of abnormal uterine bleeding and can accurately identify the common causes of abnormal uterine bleeding in the reproductive age group.
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Frankfurter D, Kliman H. Progress on the Endometrium. Obstet Gynecol Clin North Am 2023; 50:677-694. [PMID: 37914487 DOI: 10.1016/j.ogc.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
The endometrium is a dynamic tissue that facilitates mammalian internal reproduction and thus, the ability to deliver live born progeny that are more easily protected from predators. This tissue is unique in its ability to undergo cyclic regeneration and destruction in the absence of pregnancy. Ovarian steroids guide endometrial proliferation and maturation promoting its receptivity and selectivity with regards to blastocyst implantation. It is decidualization, terminal stromal maturation, that prevents the trophoblast from breeching containment of the uterus and allows for endometrial sloughing should pregnancy not occur. Endometrial pathology is highly variable and therefore a wide array of diagnostic measures are required for its interrogation. There remains no single test that can distinguish between all potential issues and it is critical that appropriate and evidence-based endometrial assessment is carried out. Emerging data on developmental markers, inflammatory mediators, and bacterial profiling offer hope that conditions including endometriosis, cancer, infertility, and implantation failure will be more easily and less invasively diagnosed. This will allow for a more timely and targeted approach to intervention. Accordingly, assessing novel measures requires an evidence-based approach prior to their mass utilization.
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Affiliation(s)
- David Frankfurter
- Yale Meidcal School, Department of Obstetrics, Gynecology and Reproductive Sciences, Yale Fertility Center, 200 West Campus Drive, 2nd Floor, Orange, CT 06477, USA.
| | - Harvey Kliman
- Yale University School of Medicine, Kliman Laboratories, Reproductive and Placental Research Unit, Department of Obstetrics, Gynecology and Reproductive Sciences, 310 Cedar Street, FMB 225, New Haven, CT 06510, USA. https://twitter.com/placentatalk
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Grubman J, Mora V, Nguyen M, Ladwig N, Chen LM, Jacoby V. Impact of abnormal uterine bleeding care in premenopausal patients prior to endometrial malignancy diagnosis. Gynecol Oncol Rep 2023; 50:101292. [PMID: 37868015 PMCID: PMC10587729 DOI: 10.1016/j.gore.2023.101292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 10/05/2023] [Accepted: 10/07/2023] [Indexed: 10/24/2023] Open
Abstract
Background Literature evaluating the management of abnormal uterine bleeding in premenopausal patients prior to endometrial malignancy diagnosis is lacking. Objective To evaluate predictors and consequences of inadequate evaluation and management of abnormal uterine bleeding and time to endometrial sampling in premenopausal patients prior to endometrial malignancy diagnosis.Study Design.This was a retrospective cohort study of premenopausal individuals with endometrioid endometrial cancer or atypical hyperplasia at a single institution from 2015 to 2020.. Complete noninvasive management encompassed pelvic exam, ultrasound, and progestin treatment before or in conjunction with the endometrial sampling of diagnosis. Multivariable logistic and ordinal odds models were used to evaluate predictors and outcomes. Results 152 subjects were included, 80.3 % with cancer and 19.7 % with atypical hyperplasia. The majority of patients had anovulatory bleeding, obesityand recent health care. Only 20.4 % had complete nonvinvasive management, and only 12.5 % had complete noninvasive management or endometrial sampling within 2 months of presentation with abnormal bleeding. Class III obesity reduced the likelihood of complete assessment and increased time to sampling, while age 45 and up and parity reduced time to sampling. Most patients had partial workup but no progestin treatment and long intervals before endometrial sampling after presentation to a provider with abnormal bleeding. Incomplete workup correlated to worse cancer grade and stage. Conclusion Despite high clinical risk and health care contact, most patients had insufficient gynecologic management preceding a diagnosis of endometrial malignancy. Inadequate care correlated to worse oncologic outcomes and demonstrates missed opportunities for early detection and prevention of endometrial cancer.
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Affiliation(s)
- Jessica Grubman
- Division of Obstetrics, Gynecology, and Gynecologic Subspecialties, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Vanessa Mora
- University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - May Nguyen
- University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - Nicholas Ladwig
- Division of Surgical Pathology, Department of Pathology and Laboratory Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Lee-may Chen
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Vanessa Jacoby
- Division of Obstetrics, Gynecology, and Gynecologic Subspecialties, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, CA, USA
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Ferrando CA, Lintel MK, Bradley LD. Comparing endometrial biopsy results with hysteroscopic pathology in women presenting with abnormal and postmenopausal uterine bleeding. J Gynecol Obstet Hum Reprod 2023; 52:102685. [PMID: 37871649 DOI: 10.1016/j.jogoh.2023.102685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 08/30/2023] [Accepted: 10/20/2023] [Indexed: 10/25/2023]
Abstract
OBJECTIVE To compare pathology results after office-based blind endometrial biopsy and pathology results from hysteroscopy in women presenting with abnormal uterine bleeding (AUB). METHODS A retrospective cohort study of biologic women presenting with AUB at a tertiary care referral care center. Patients were included if they underwent evaluation with blind endometrial biopsy performed in the office followed by hysteroscopy within one year. Hysteroscopic findings and pathology were correlated with index endometrial biopsy findings. RESULTS 689 patients met inclusion criteria. The mean age and BMI were 49 (±10) years and 31 (±8) kg/m2. The median duration of bleeding leading up to presentation was of 3.5 (1.5-9) months. Of the patients who had operative hysteroscopic pathology demonstrating endometrial polyp, 30.6 % (81) had a polyp detected on office endometrial biopsy. Of the patients who had hysteroscopic pathology demonstrating intracavitary fibroids, 0 % (0) were detected on endometrial biopsy. Of the patients who had hyperplasia without atypia on hysteroscopy, 28.6 % (4) were detected or suspected on endometrial biopsy. Of the patients who had hyperplasia with atypia on hysteroscopy, 5.9 % (1) were detected or suspected on endometrial biopsy. There were 12 cases of confirmed or suspected malignancy on hysteroscopy, of which 8.3 % (1) were detected on endometrial biopsy. CONCLUSION Concordance between focal findings on office hysteroscopy and endometrial biopsy is low. Endometrial biopsy when malignancy is suspected has been shown to be of benefit, but in the setting of suspected benign focal pathology, blind assessment of the endometrial cavity for definitive diagnosis should be abandoned. In women with symptomatic uterine bleeding, hysteroscopic visualization is associated with increased sensitivity in identifying intrauterine pathology.
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Affiliation(s)
- Cecile A Ferrando
- Obstetrics, Gynecology & Women's Health Institute; Cleveland Clinic, Cleveland, OH 44195, United States.
| | - M Kate Lintel
- Obstetrics, Gynecology & Women's Health Institute; Cleveland Clinic, Cleveland, OH 44195, United States
| | - Linda D Bradley
- Obstetrics, Gynecology & Women's Health Institute; Cleveland Clinic, Cleveland, OH 44195, United States
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van der Meulen JF, Bongers MY, van der Zee LG, Leemans JC, Duijnhoven RG, de Leeuw RA, Overdijk LE, Radder CM, van der Voet LF, Smeets NAC, van Vliet HAAM, Hehenkamp WJK, Manger AP, Lim AC, Peters LW, Horree N, Briët JM, van der Steeg JW, Coppus SFPJ, Kok HS. Procedural sedation and analgesia versus general anesthesia for hysteroscopic myomectomy (PROSECCO trial): A multicenter randomized controlled trial. PLoS Med 2023; 20:e1004323. [PMID: 38153958 PMCID: PMC10754450 DOI: 10.1371/journal.pmed.1004323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 11/15/2023] [Indexed: 12/30/2023] Open
Abstract
BACKGROUND Hysteroscopic resection is the first-choice treatment for symptomatic type 0 and 1 fibroids. Traditionally, this was performed under general anesthesia. Over the last decade, surgical procedures are increasingly being performed in an outpatient setting under procedural sedation and analgesia. However, studies evaluating safety and effectiveness of hysteroscopic myomectomy under procedural sedation are lacking. This study aims to investigate whether hysteroscopic myomectomy under procedural sedation and analgesia with propofol is noninferior to hysteroscopic myomectomy under general anesthesia. METHODS AND FINDINGS This was a multicenter, randomized controlled noninferiority trial conducted in 14 university and teaching hospitals in the Netherlands between 2016 and 2021. Inclusion criteria were age ≥18 years, maximum number of 3 type 0 or 1 fibroids, maximum fibroid diameter 3.5 cm, American Society of Anesthesiologists class 1 or 2, and having sufficient knowledge of the Dutch or English language. Women with clotting disorders or with severe anemia (Hb < 5.0 mmol/L) were excluded. Women were randomized using block randomization with variable block sizes of 2, 4, and 6, between hysteroscopic myomectomy under procedural sedation and analgesia (PSA) with propofol or under general anesthesia (GA). Primary outcome was the percentage of complete resections, assessed on transvaginal ultrasonography 6 weeks postoperatively by a sonographer blinded for the treatment arm and surgical outcome. Secondary outcomes were the surgeon's judgment of completeness of procedure, menstrual blood loss, uterine fibroid related and general quality of life, pain, recovery, hospitalization, complications, and surgical reinterventions. Follow-up period was 1 year. The risk difference between both treatment arms was estimated, and a Farrington-Manning test was used to determine the p-value for noninferiority (noninferiority margin 7.5% of incomplete resections). Data were analyzed according to the intention-to-treat principle, including a per-protocol analysis for the primary outcome. A total of 209 women participated in the study and underwent hysteroscopic myomectomy with PSA (n = 106) or GA (n = 103). Mean age was 45.1 [SD 6.4] years in the PSA group versus 45.0 [7.7] years in the GA group. For 98/106 women in the PSA group and 89/103 women in the GA group, data were available for analysis of the primary outcome. Hysteroscopic resection was complete in 86/98 women (87.8%) in the PSA group and 79/89 women (88.8%) in the GA group (risk difference -1.01%; 95% confidence interval (CI) -10.36 to 8.34; noninferiority, P = 0.09). No serious anesthesiologic complications occurred, and conversion from PSA to GA was not required. During the follow-up period, 15 serious adverse events occurred (overnight admissions). All were unrelated to the intervention studied. Main limitations were the choice of primary outcome and the fact that our study proved to be underpowered. CONCLUSIONS Noninferiority of PSA for completeness of resection was not shown, though there were no significant differences in clinical outcomes and quality of life. In this study, hysteroscopic myomectomy for type 0 and 1 fibroids with PSA compared to GA was safe and led to shorter hospitalization. These results can be used for counseling patients by gynecologists and anesthesiologists. Based on these findings, we suggest that hysteroscopic myomectomies can be performed under PSA in an outpatient setting. TRIAL REGISTRATION The study was registered prospectively in the Dutch Trial Register (NTR 5357; registration date: 11 August 2015; Date of initial participant enrollment: 18 February 2016).
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Affiliation(s)
- Julia F. van der Meulen
- Department of Obstetrics & Gynecology, Máxima Medical Centre, Veldhoven, the Netherlands
- Grow school for oncology and reproduction, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Marlies Y. Bongers
- Department of Obstetrics & Gynecology, Máxima Medical Centre, Veldhoven, the Netherlands
- Grow school for oncology and reproduction, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Lisa G. van der Zee
- Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - Jaklien C. Leemans
- Department of Obstetrics & Gynecology, Máxima Medical Centre, Veldhoven, the Netherlands
| | - Ruben G. Duijnhoven
- Department of Obstetrics & Gynecology, Amsterdam University Medical Centre, Amsterdam, the Netherlands
- Clinical Trials Unit, Netherlands Society for Obstetrics and Gynecology, Amsterdam, the Netherlands
| | - Robert A. de Leeuw
- Department of Obstetrics & Gynecology, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | | | - Celine M. Radder
- Department of Obstetrics & Gynecology, OLVG, Amsterdam, the Netherlands
| | - Lucet F. van der Voet
- Department of Obstetrics & Gynecology, Deventer Ziekenhuis, Deventer, the Netherlands
| | - Nicol A. C. Smeets
- Department of Obstetrics & Gynecology, Zuyderland Medical Centre, Heerlen, the Netherlands
| | - Huib A. A. M. van Vliet
- Department of Obstetrics & Gynecology, Catharina Ziekenhuis, Eindhoven, the Netherlands
- Department of human structure and repair, Ghent University, Gent, Belgium
| | - Wouter J. K. Hehenkamp
- Department of Obstetrics & Gynecology, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - Arentje P. Manger
- Department of Obstetrics & Gynecology, Diakonessenhuis, Utrecht, the Netherlands
| | - Arianne C. Lim
- Department of Obstetrics & Gynecology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | | | - Nicole Horree
- Department of Obstetrics & Gynecology, Flevoziekenhuis, Almere, the Netherlands
| | - Justine M. Briët
- Department of Obstetrics & Gynecology, Ziekenhuisgroep Twente, Almelo, the Netherlands
| | - Jan Willem van der Steeg
- Department of Obstetrics & Gynecology, Jeroen Bosch Ziekenhuis, ‘s-Hertogenbosch, the Netherlands
| | - Sjors F. P. J. Coppus
- Department of Obstetrics & Gynecology, Máxima Medical Centre, Veldhoven, the Netherlands
- Department of Obstetrics & Gynecology, University Medical Centre St Radboud, Nijmegen, the Netherlands
| | - Helen S. Kok
- Department of Obstetrics & Gynecology, Alrijne Ziekenhuis, Leiden, the Netherlands
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Topcu EG, McClenahan P, Pule K, Khattak H, Karsli SE, Cukelj M, Ubom AE, Algurjia E, Ozpinar K, Perez YR, Bunu R, Sanabria LS, Portilla FJR, Pumpure E, Roy P, Fogarty P. FIGO best practice guidance in surgical consent. Int J Gynaecol Obstet 2023; 163:795-812. [PMID: 37807812 DOI: 10.1002/ijgo.15174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
Obtaining medical consent preoperatively is one of the key steps in preparing for surgery, and is an important step in informed decision making with the patient. According to good medical practice guidelines, doctors are required to have the knowledge and skills to treat patients as well as inform them, respect their wishes, and establish trust between themselves and their patients. Valid consent includes elements of competence, disclosure, understanding, and voluntariness. Documentation of these elements is also very important. The International Federation of Gynecology and Obstetrics (FIGO) Education Communication and Advocacy Consortium (ECAC) has realized that the quality of consent varies considerably across the world and has developed simple guidelines regarding consent and procedure-specific checklists for the most common obstetric and gynecological procedures.
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Affiliation(s)
- E Goknur Topcu
- Department of Obstetrics and Gynecology, Istanbul Health and Technology University, Istanbul, Turkey
| | - Phil McClenahan
- Department of Obstetrics and Gynecology, Nepean Hospital, Kingswood, New South Wales, Australia
| | - Koketso Pule
- Department of Obstetrics and Gynecology, Wits University, Johannesburg, South Africa
| | - Hajra Khattak
- Department of Obstetrics and Gynecology, UCL EGA Institute for Women's Health, London, UK
| | - S Eda Karsli
- Department of Obstetrics and Gynecology, Ankara Bilkent City Hospital, Ankara, Turkey
| | - Marijo Cukelj
- Department of Obstetrics and Gynecology, Sestre Milosrdnice University Hospital Center, Zagreb, Croatia
| | - Akaninyene E Ubom
- Department of Obstetrics and Gynecology, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Osun State, Nigeria
| | - Esraa Algurjia
- Department of Obstetrics and Gynecology, Al-Elwya Maternity Hospital, Baghdad, Iraq
| | - Kubra Ozpinar
- Department of Obstetrics and Gynecology, Gulhane Training and Research Hospital, Ankara, Turkey
| | - Yotin Ramon Perez
- Department of Obstetrics and Gynecology, Hospital Central de las Fuerzas, Santo Domingo, Dominican Republic
| | - Rashid Bunu
- Department of Obstetrics and Gynecology, Kenyatta National Hospital, Nairobi, Kenya
| | - Leopoldo S Sanabria
- Department of Obstetrics and Gynecology, Unidad Medica de Alta Especialidad, Mexico City, Mexico
| | - Francisco J R Portilla
- Department of Obstetrics and Gynecology, Instituto Nacional de Perinatologia, Mexico City, Mexico
| | - Elizabete Pumpure
- Department of Obstetrics and Gynecology, Riga East Clinical University, Riga, Latvia
| | - Priyankur Roy
- Department of Obstetrics and Gynecology, Roy's Clinic, Siliguri, West Bengal, India
| | - Paul Fogarty
- International Federation of Gynecology and Obstetrics (FIGO), London, UK
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Chera-Aree P, Tanpong S, Thanaboonyawat I, Laokirkkiat P. Clomiphene citrate plus letrozole versus clomiphene citrate alone for ovulation induction in infertile women with ovulatory dysfunction: a randomized controlled trial. BMC Womens Health 2023; 23:602. [PMID: 37964246 PMCID: PMC10647029 DOI: 10.1186/s12905-023-02773-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 11/07/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND The aim of this study was to compare the efficacy of the combination of clomiphene citrate (CC) and letrozole to that of CC alone in inducing ovulation in infertile women with ovulatory dysfunction. METHODS A randomized controlled trial was conducted at a single academic medical center between November 2020 and December 2021. Anovulatory infertility females, aged 18 to 40, were evenly distributed by a computer-generated block of four into two treatment groups. A "combination group" received a daily dose of CC (50 mg) and letrozole (2.5 mg), while a "CC-alone group" received a daily dose of CC alone (50 mg). The study medications were administered on days 3 through 7 of menstrual cycle. The primary outcome was the ovulation rate, defined by serum progesterone levels exceeding 3 ng/mL at the mid-luteal phase. The secondary outcomes were ovulation induction cycle characteristics, endometrial thickness, conception rate, and adverse events. RESULTS One hundred women (50 per group) were enrolled in the study. The mean age was not significantly different in both groups: 31.8 years in the combination group and 32.4 years in the CC-alone groups (P = 0.54). The prevalence of polycystic ovary syndrome in the combination and CC-alone groups was 48% and 44%, respectively (P = 0.841). According to intention-to-treat analysis, the ovulation rates were 78% and 70% in the combination and CC-alone groups, respectively (P > 0.05). There was no significant difference in the mean endometrial thickness or the number of dominant follicles of the groups. No serious adverse events were observed in either group. CONCLUSIONS Our study found no significant difference between the combination of CC and letrozole and CC alone in inducing ovulation in infertile women with ovulatory dysfunction in one cycle. The small number of live births precluded any meaningful statistical analysis. Further studies are needed to validate and extend our findings beyond the scope of the current study. TRIAL REGISTRATION The study was registered at https://www.thaiclinicaltrials.org with the following number: TCTR20201108004 and was approved on 08/11/2020.
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Affiliation(s)
- Pattraporn Chera-Aree
- Infertility and Reproductive Biology Unit, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand.
| | - Sirikul Tanpong
- Infertility and Reproductive Biology Unit, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Isarin Thanaboonyawat
- Infertility and Reproductive Biology Unit, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Pitak Laokirkkiat
- Infertility and Reproductive Biology Unit, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand
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