Hiérarchisation des stratégies thérapeutiques pour ménométrorragies avec ou sans désir de grossesse

[Treatment of adenomyosis (excluding pregnancy project)]

In this review we aimed to update the possibilities of adenomyosis treatment in women excluding those with a desire for pregnancy. Adenomyosis is defined as the presence of endometrial tissue within the myometrium and frequently underestimated. Over the last decades, its pathophysiology has been better known. The diagnosis is essentially based on clinical symptoms like menorrhagia and dysmenorrhea. Transvaginal ultrasound and magnetic resonance imaging are the main tools of the radiologic diagnosis. However, the definitive diagnosis is histological. The most effective treatment remains hysterectomy; however it is expensive, radical and at risk of morbidity compared with medical or surgical conservative management. The literature has reported several series of patients undergoing various treatments, thus allowing different therapeutic options. The levonorgestrel-releasing intrauterine device showed its efficacy alone or in combination with hysteroscopic treatment. Oral progestins, GnRH agonists are useful at short term or in preoperative condition. Some conservative treatments like focused ultrasound therapies or uterus-sparing operative treatment stay under evaluation and seems to be effective. Embolization has been the subject of several studies and must be outlined. Furthermore, several molecules, such as modulators of progesterone receptors and the aromatase inhibitors have been recently studied and are perhaps future treatments.

Cardiac, obstetric, and fetal outcomes during pregnancy after biological or mechanical aortic valve replacement

BACKGROUND

The aim of this study was to assess pregnancy-related cardiac, maternal, and fetal outcomes in women who underwent aortic valve replacement (AVR).

METHODS

From 1978-2011, 67 women < 40 years of age underwent 74 isolated AVRs (52 mechanical prostheses and 22 bioprostheses). All patients were prospectively followed at our dedicated valve clinic. Patients with Turner syndrome, previous hysterectomy, or tubal ligation were excluded. Cardiovascular, obstetric, and fetal outcomes were gathered from medical records and telephone interviews.

RESULTS

A total of 27 pregnancies were reported in 14 patients (bioprosthetic AVR, n = 20; mechanical AVR, n = 7). In the bioprosthetic AVR group, the following adverse events occurred: hospitalizations for syncope (n = 2), prosthetic valve deterioration after pregnancy necessitating reintervention 6 months postpartum (n = 1), miscarriages (n = 9), and preterm birth (n = 1). In the mechanical AVR group, the following adverse events occurred: embolic myocardial infarctions with a decrease in systolic function (n = 2; 1 pregnancy was terminated and 1 was completed), miscarriage (n = 1), postpartum bleeding (n = 1), urgent cesarean section for placental abruption (n = 1), and preterm birth (n = 1).

CONCLUSIONS

Findings from this study suggest that pregnancies in women with mechanical AVRs are associated with a higher risk of cardiac and obstetric adverse events. Thus, from this limited cohort, it appears that pregnancies in women with bioprostheses are safer than those in patients with mechanical AVRs.

[Myomas management, alternatives to hysterectomy and myomectomy: what can we propose?]

Second generation endometrial ablation techniques must be used preferably as they present less complications than first generation techniques. An efficient contraception is highly recommended after thermal ablation. Myolysis techniques are still investigational, focused ultrasound myolysis MR or ultrasound-guided is accessible to approximately 10% of uterine myomas with 70% of long-term symptom relief. Outcomes of laparoscopic uterine artery occlusion are similar to those of uterine artery embolization but with less long-term durability.

[Superficial hysteroscopic resection for polypoid endometrium: preliminary results of an innovative approach for women of childbearing age]

OBJECTIVE

To evaluate the reproductive safety and long-term efficacy of hysteroscopic superficial endometrial resection for polypoid endometrium in symptomatic patients (menorrhagia, dysmenorrhea and unexplained infertility).

PATIENTS AND METHODS

The present retrospective descriptive case series study included 44 patients of reproductive age who underwent superficial hysteroscopic endometrial resection between January 1st, 2004 and December 31, 2009. Reproductive outcome, and the patients' perceptions of menstrual symptoms after the surgical intervention were collected from the clinical notes and a semi-structured telephone interview.

RESULTS

Of the patients presenting abnormal uterine bleeding, 59% reported long-term improvement of this symptom; of those with dysmenorrhea, 52% reported long-term relief. Among 26 infertile women who wanted to become pregnant immediately after the procedure, 58% succeeded (n=15), with a live-born rate of 38%. The pregnancy rate in primary and secondary infertility cases was respectively 53% (n=8/15) and 64% (n=7/11).

CONCLUSION

Superficial endometrial resection is an alternative for treating polypoid endometrium when it is associated with menorrhagia, dysmenorrhea and infertility. It treats menstrual symptoms successfully, with no adverse impact on fertility.

Misconceptions about the side effects of combined oral contraceptive pills

OBJECTIVE

Although combined oral contraceptive pills (COCPs) are one of the most commonly used methods of contraception in western countries, they are taken by only a minority of sexually active women in Turkey. The purpose of this research has been to define women's specific misconceptions with regard to the side effects of COCPs.

METHODS

This descriptive and cross-sectional research was conducted on 418 reproductive aged women who agreed to participate. Data were collected through face-to-face interviews with a questionnaire which assessed socio-demographic characteristics and women's beliefs about the side effects of COCPs.

RESULTS

It is observed that 45.2% believed that the pills cause weight gain. Another 7.9% of the cases held the belief that COCPs cause cancer. A group of 13.4% of the subjects thought that COCPs lead to infertility, 28.7% believed that they cause headache, 41.1% believed that they cause acne and/or an increase in body hair, and 11.7% were afraid that they cause a decrease in libido.

CONCLUSION

The present study has shown that misconceptions about the side effects of COCPs were considerably prevalent among this cohort group of Turkish women. Healthcare professionals have the potential of playing an important role in dispersing these misconceptions.

Current and future medical treatments for menometrorrhagia during the premenopause

Excessive menstrual bleeding reflects aberrant angiogenesis, generally due to submucosal myomas and endometrial polyps, although it is also frequently observed with long-term progestin-only contraception, impaired haemostasis and hormonal disorders. Surgery (hysterectomy, endometrial ablation) is used too frequently. Uterine artery embolisation is also an option for myomas. Medical treatments include combined oral contraception, progestins and levonorgestrel-releasing Intrauterine System. Gonadotropin-releasing hormone agonists provide significant improvements in bleeding for myomas, but also decrease estrogen secretion (e.g. hot flushes, decreased bone mass). Progestins, although used widely, remain poorly effective as they promote myoma cell growth. Recently, Selective Progesterone Receptor Modulators (SPRMs) have been shown to induce amenorrhea whilst maintaining endogenous estrogen secretion. Phase II studies have also demonstrated decreased fibroid size in SPRM-treated women. Although the mechanism of amenorrhea observed after SPRM treatment is still poorly understood, they may control uterine bleeding via a direct effect on endometrial blood vessels. Suppression of bleeding in women with uterine fibroids receiving SPRMs is associated with moderate reductions in uterine artery blood flow, without major changes in angiogenic factors and extracellular matrix composition; a clear difference to modifications observed with progestins. These data suggest major progress in the treatment of excessive menstrual bleeding.