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Yuan X, Wong BWX, Randhawa NK, Win TPP, Chan YH, Ma L, Yong EL. Factors associated with deep infiltrating endometriosis, adenomyosis and ovarian endometrioma. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2023. [DOI: 10.47102/annals-acadmedsg.2022334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Abstract
Introduction: To compare epidemiological features and clinical presentations of deep infiltrating endometriosis with endometrioma and adenomyosis, as well as to identify risk factors for the respective histologically confirmed conditions.
Method: Patients undergoing index surgery at the National University Hospital, Singapore for endometriosis or adenomyosis over a 7-year period—from 2015 to 2021—were identified from hospital databases using the Table of Surgical Procedures coding. Social and epidemiological features of cases with histologically confirmed diagnoses of endometrioma only, adenomyosis only, and deep infiltrating endometriosis were compared. Significant variables from univariate analysis were entered into 3 binary multivariate logistic regression models to obtain independent risk factors for: deep infiltrating endometriosis versus endometrioma only, deep infiltrating endometriosis versus adenomyosis only, and adenomyosis only versus endometrioma only.
Results: A total of 258 patients were included with 59 ovarian endometrioma only, 47 adenomyosis only, and 152 deep infiltrating endometrioses. Compared to endometrioma only, deep infiltrating endometriosis was associated with higher rates of severe dysmenorrhoea (odds ratio [OR] 2.80, 95% confidence interval [CI] 1.02–7.70) and out-of-pocket private surgical care (OR 4.72, 95% CI 1.85–12.04). Compared to adenomyosis only, deep infiltrating endometriosis was associated with a higher fertility desire (OR 13.47, 95% CI 1.01–180.59) and a lower body mass index (OR 0.89, 95% CI 0.79–0.99). In contrast, heavy menstrual bleeding was the hallmark of adenomyosis, being less common in patients with endometriosis.
Conclusion: Deep infiltrating endometriosis is associated with severe dysmenorrhoea, pain related to urinary and gastrointestinal tracts, higher fertility desire and infertility rate. Patients with pain symptomatology and subfertility should be referred early to a tertiary centre with the capability to diagnose and manage deep infiltrating endometriosis.
Keywords: Adenomyosis, deep infiltrating endometriosis, obstetrics and gynaecology, ovarian endometrioma, public health
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Affiliation(s)
- Xi Yuan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Beverly WX Wong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Thu PP Win
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yiong Huak Chan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Li Ma
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Eu-Leong Yong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Ser HL, Au Yong SJ, Shafiee MN, Mokhtar NM, Ali RAR. Current Updates on the Role of Microbiome in Endometriosis: A Narrative Review. Microorganisms 2023; 11:360. [PMID: 36838325 PMCID: PMC9962481 DOI: 10.3390/microorganisms11020360] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/16/2023] [Accepted: 01/25/2023] [Indexed: 02/04/2023] Open
Abstract
Endometriosis affects approximately 6 to 10% of reproductive-age women globally. Despite much effort invested, the pathogenesis that promotes the development, as well as the progression of this chronic inflammatory disease, is poorly understood. The imbalance in the microbiome or dysbiosis has been implicated in a variety of human diseases, especially the gut microbiome. In the case of endometriosis, emerging evidence suggests that there may be urogenital-gastrointestinal crosstalk that leads to the development of endometriosis. Researchers may now exploit important information from microbiome studies to design endometriosis treatment strategies and disease biomarkers with the use of advanced molecular technologies and increased computational capacity. Future studies into the functional profile of the microbiome would greatly assist in the development of microbiome-based therapies to alleviate endometriosis symptoms and improve the quality of life of women suffering from endometriosis.
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Affiliation(s)
- Hooi-Leng Ser
- Department of Biological Sciences, School of Medical and Life Sciences, Sunway University, Bandar Sunway 47500, Malaysia
| | - Siu-Jung Au Yong
- Department of Biological Sciences, School of Medical and Life Sciences, Sunway University, Bandar Sunway 47500, Malaysia
| | - Mohamad Nasir Shafiee
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Universiti Kebangsan Malaysia, Cheras 56000, Malaysia
| | - Norfilza Mohd Mokhtar
- Department of Physiology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur 56000, Malaysia
| | - Raja Affendi Raja Ali
- School of Medical and Life Sciences, Sunway University, Bandar Sunway 47500, Malaysia
- Gut Research Group, Faculty of Medicine, Universiti Kebangsan Malaysia, Cheras 56000, Malaysia
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Du Y, Hu C, Ye C, Wu R. Risk factors for coexisting deep endometriosis for patients with recurrent ovarian endometrioma. Front Surg 2022; 9:963686. [PMID: 36406381 PMCID: PMC9666391 DOI: 10.3389/fsurg.2022.963686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 10/13/2022] [Indexed: 11/05/2022] Open
Abstract
Aim The aim of this study was to assess the risk factors for coexisting deep endometriosis (DE) in patients with recurrent ovarian endometrioma (OE). Methods We retrospectively reviewed 151 recurrent OE patients who had been diagnosed of OE but not DE at the time of their first surgery and then received a second surgery for recurrent endometriosis with or without DE. Their clinical characteristics at the time of the first and second surgeries were collected. Univariate and multivariate logistic regression analyses were conducted to identify potential risk factors for coexisting DE in patients with recurrent OE. Results Among the 151 recurrent OE patients, 46 were diagnosed of DE during the recurrent surgery and included in the DE group, while the remaining 105 patients were included in the non-DE group. In univariate analysis, there were significant differences in terms of uterine retroversion during the primary surgery and the follow-up time after the primary surgery between the DE and non-DE groups. The multivariate analysis also showed that both uterine retroversion and the follow-up time (≥5 years) were associated with the coexistence of DE during the recurrent surgery. The odds ratio (OR) for uterine retroversion was 3.72 [95% confidence interval (CI) 1.62–8.53], and the OR for follow-up time (≥5 years) was 5.03 (95% CI 2.29–11.02). Conclusions Our study suggested that for recurrent OE patients, uterine retroversion during the first surgery and a follow-up time of at least 5 years are risk factors for the coexistence of DE in recurrent surgery, early prevention and full preparation before the recurrent surgery should be emphasized in these conditions.
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Xing L, Liu YN, Yao H, Wang T, Xie F, Luo S, Luo P, Tang S. An Efficient UPLC-MS/MS Method Established to Detect Relugolix Concentration in Rat Plasma. Front Pharmacol 2022; 13:874973. [PMID: 35784757 PMCID: PMC9243301 DOI: 10.3389/fphar.2022.874973] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 05/17/2022] [Indexed: 12/18/2022] Open
Abstract
Relugolix, a gonadotropin-releasing hormone (GnRH) receptor antagonist, has been well studied in the treatment of endometriosis symptomatic. It is mainly metabolized by the CYP3A subfamily of P450 enzymes, while minorly metabolized by CYP2C8. Daidzein in different dose groups exhibited a certain induction on the mRNA expression level of CYP3A4 and resulted in the potent induction of CYP3A4. However, it is still unknown whether daidzein and relugolix interact. We developed an effective ultra-performance liquid chromatography tandem mass spectrometry (UPLC-MS/MS) method to study the effect of daidzein on the pharmacokinetics of relugolix in rats after oral administration of 12 mg/kg relugolix in a single or mixed of 50 mg/kg daidzein. The results showed that the method had respectable linearity (r2 > 0.999) on the scale of 0.7–1000 ng/mL. The intra-day precision was between 3.0% and 8.4% in this assay, and the inter-day was between 4.0% and 11.7%. The intra-day accuracy was from -4.3% to 6.1%, and the inter-day was 2.9% to 12.1%. Another three key indicators, including the stability, the recovery rate of extraction and the new technique’s matrix effect, were perfectly in accord with the test verification rule in the biological medium by the United States Food and Drug Administration. Meanwhile, treatment with daidzein led to a decrease in Cmax and AUC0–t of relugolix by about 15.56% and 21.36%, respectively. Although there was no statistical difference in pharmacokinetic parameters, it reflected the induction trend of daidzein on relugolix metabolism for food-drug interaction. It would provide reference and improvement value for subsequent experiments.
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Affiliation(s)
- Liying Xing
- The First People’s Hospital of Jiashan, Jiaxing, China
| | - Ya-nan Liu
- The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Hongye Yao
- The First People’s Hospital of Jiashan, Jiaxing, China
| | - Tingting Wang
- The First People’s Hospital of Jiashan, Jiaxing, China
| | - Fuchen Xie
- The People’s Hospital of Lishui, Lishui, China
| | - Shunbin Luo
- The People’s Hospital of Lishui, Lishui, China
| | - Pingping Luo
- The People’s Hospital of Lishui, Lishui, China
- *Correspondence: Pingping Luo, ; Shengling Tang,
| | - Shengling Tang
- The People’s Hospital of Lishui, Lishui, China
- *Correspondence: Pingping Luo, ; Shengling Tang,
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Dai Y, Li MH, Liu YJ, Liu B, Wu YS, Lang JH, Zhang ZY, Leng JH. Thoracic endometriosis presented as catamental hemoptysis: a case series of a rare disease. Curr Med Res Opin 2021; 37:685-691. [PMID: 33538197 DOI: 10.1080/03007995.2021.1885363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Thoracic endometriosis syndrome (TES) is a rare disease in which a functioning endometrial tissue is observed in the pleura, lung, parenchyma, airways, and/or diaphragm. The optimal management of this disease remains a matter of debate. We aimed to report TES cases and their effective hormonal treatment and management. METHODS In this retrospective study, women presented as catamenial hemoptysis (CH) diagnosed with thoracic endometriosis were included. The main outcome of measure was cessation or recurrence of the clinical manifestations of thoracic endometriosis. RESULTS The mean onset age of the 14 patients was 30.21 ± 5.40 years. CH was characteristic symptom of these patients. All patients underwent chest computed tomography (CT) scan during menstruation and 2 or 3 weeks after menstruation, which showed the obvious shrinking or disappearance of the lesions. All of the patients were given Gonadotropin releasing hormone agonists (GnRHa) for 3 to 6 months, eleven of them were administered with combined oral contraceptives (COC) cyclically after GnRHa. The median follow-up duration was 24 months. Hemoptysis recurrence was observed in one patient. CONCLUSIONS CH is a rare clinical entity of thoracic endometriosis, the change of CT images during and after menstruation or the response to GnRHa were helpful for accurate diagnosis. Hormonal treatment with GnRHa followed by COCs cyclically could be employed for efficient management of thoracic endometriosis.
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Affiliation(s)
- Yi Dai
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
| | - Meng-Hui Li
- Department of Obstetrics and Gynecology, Beijing Chaoyang Hospital, Affiliated to Capital University of Medical Science, Beijing, China
| | - Yong-Jian Liu
- Department of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
| | - Bing Liu
- Peking Union Medical College Hospital, Beijing, China
| | - Yu-Shi Wu
- Peking Union Medical College Hospital, Beijing, China
| | - Jing-He Lang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
| | - Zhen-Yu Zhang
- Department of Obstetrics and Gynecology, Beijing Chaoyang Hospital, Affiliated to Capital University of Medical Science, Beijing, China
| | - Jin-Hua Leng
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
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Yahya A, Mustapha A, Kolawole A, Oguntayo A, Bello N, Aliyu H, Adewuyi S. Giant ovarian endometrioma: A case report. JOURNAL OF WEST AFRICAN COLLEGE OF SURGEONS 2021; 11:41-44. [PMID: 36188060 PMCID: PMC9516747 DOI: 10.4103/jwas.jwas_40_21] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 04/13/2022] [Indexed: 11/30/2022]
Abstract
Ovarian endometrioma is quite common among women of reproductive age but rarely exceed 6 cm in diameter. Ovarian endometrioma exceeding 10 cm in dimension, often referred to as giant endometrioma, is rare and can pose a diagnostic dilemma to clinicians. We present a 33-year-old single nullipara referred to our facility with a 3-year history of recurrent abdominal pain, abdominal swelling, and difficulty in breathing. The challenges in making diagnosis of a huge ovarian endometrioma are highlighted and the literature on huge ovarian endometrioma reviewed.
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Chen S, Gu Z, Zhang W, Jia S, Wu Y, Zheng P, Dai Y, Leng J. Microbiome of the lower genital tract in Chinese women with endometriosis by 16s-rRNA sequencing technique: a pilot study. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1440. [PMID: 33313185 PMCID: PMC7723586 DOI: 10.21037/atm-20-1309] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background Endometriosis is a benign, chronic, gynecological disease which affect the women in reproductive age. The dysfunction of immune system is associated with endometriosis and the diversity of microbiota in genital tract. According to previous studies, microbiota significantly contributes to multi-systemic function, but the evidence of relationship between microbiota and endometriosis remains insufficient. Methods There are 68 participants were included in this study and 134 samples obtained from the cervical canal, posterior fornix and uterine cavity were analyzed by 16s-rRNA sequencing. The raw data was filtered, analyzed, and visualized, and bio-information methods were used to identify the characteristics of microbiota. Results Two different locations near the cervix, cervical canal, and posterior fornix, exhibited no differences in alpha diversity. The microbiota profile of adenomyosis with endometriosis patients is different from control group through PCoA. Among the different disease groups, five microbiotas were distinctive in the genus level, and Atopobium presented with the greatest significance in adenomyoisis-endometriosis patients. The LeFSe analysis failed to identify the special biomarkers, while several characteristic functions were identified through PICRUSt. Conclusions Lactobacillus is the predominant genus in the female lower genital tract, and Atopobium is higher in patients with endometriosis combined with adenomyosis. Several different functions of microbiota were explored, some of them are found to be associated with endometriosis or adenomyosis, other functions are needed to be further verified. These findings may provide a new concept of microbiota/immune system/endometriosis system.
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Affiliation(s)
- Sikai Chen
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science/Peking Union Medical College, Beijing, China.,Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing, China
| | - Zhiyue Gu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science/Peking Union Medical College, Beijing, China
| | - Wen Zhang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science/Peking Union Medical College, Beijing, China.,Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Shuangzheng Jia
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science/Peking Union Medical College, Beijing, China.,Department of Gynecologic Oncology, Cancer Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yushi Wu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science/Peking Union Medical College, Beijing, China
| | - Ping Zheng
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science/Peking Union Medical College, Beijing, China.,Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Yi Dai
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science/Peking Union Medical College, Beijing, China
| | - Jinhua Leng
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science/Peking Union Medical College, Beijing, China
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Swain D, Parida SP, Jena SK, Das M, Das H. Prevalence and risk factors of obstetric fistula: implementation of a need-based preventive action plan in a South-eastern rural community of India. BMC Womens Health 2020; 20:40. [PMID: 32131799 PMCID: PMC7055058 DOI: 10.1186/s12905-020-00906-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 02/14/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The study was conducted to estimate the prevalence and risk factors of obstetric fistula in the rural area of the south eastern community of India and the training of community health workers for its prevention. METHODS A population-based cross-sectional analytical study was conducted in the south eastern rural community of India. A total of 3939 women were included in the study and Probability proportional to size sampling was used in the study. Frequency distribution and logistic regression were computed to analyse the data using STATA version 11.2. RESULTS Out of 3939 participants interviewed, 23.7% women reported obstetric fistula symptoms whereas after clinical diagnosis and speculum examination the obstetric morbidity pattern was: Obstetric fistula 0.3%, stress urinary incontinence 20.0%, pelvic inflammatory diseases 1.2%, uterine prolapse 1.4% and urinary tract infection 3.8%. The awareness level of the rural women regarding the obstetric fistula was assessed by a structured knowledge questionnaire and found to be very poor, hence community based fistula training was implemented among community health workers as a health system based strategy for its prevention. Obstetric fistula found to be more prevalent among women of poor educational level, low socioeconomic status, less no of antenatal visits, delay in accessing the emergency obstetric care and prolonged labour (p ≤ 0.05). CONCLUSION Finding of the study indicated that the prevalence and risk of developing obstetric fistula was associated with less number of antenatal visits, prolonged labour, delay in timely intervention, delay in accessing emergency obstetric care and more number of movements from home to the delivery place. Finally, our study suggests that emphasis needs to be placed on training of community health workers to facilitate early screening for identification and referral of women with obstetric fistula.
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Affiliation(s)
- Dharitri Swain
- College of Nursing, AIIMS Bhubaneswar, Bhubaneswar, Odisha India
| | - Swayam Pragyan Parida
- Department of Community Medicine & Family Medicine, AIIMS Bhubaneswar, Bhubaneswar, Odisha India
| | - Saubhagya Kumar Jena
- Department of Obstetrics & Gynaecology, AIIMS Bhubaneswar, Bhubaneswar, Odisha India
| | - Mahasweta Das
- College of Nursing, ICMR Project, AIIMS Bhubaneswar, Bhubaneswar, Odisha India
| | - Hrushikesh Das
- College of Nursing, DST Project, AIIMS Bhubaneswar, Bhubaneswar, Odisha India
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Brasil DL, Montagna E, Trevisan CM, La Rosa VL, Laganà AS, Barbosa CP, Bianco B, Zaia V. Psychological stress levels in women with endometriosis: systematic review and meta-analysis of observational studies. Minerva Med 2019; 111:90-102. [PMID: 31755674 DOI: 10.23736/s0026-4806.19.06350-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Endometriosis is defined as the presence of endometrial-like tissue outside the uterus, associated with chronic and inflammatory reaction. Symptoms range from dysmenorrhea, dyspareunia, chronic pelvic pain, unexplained infertility to asymptomatic. The patients' quality of life is affected by anxiety, depression and stress. We aimed to verify the prevalence and levels of psychological stress among women with endometriosis. EVIDENCE ACQUISITION The systematic review followed the PRISMA statement and the MOOSE guideline. Databases searched were MEDLINE, EMBASE, PsychNET and SciELO. The risk of bias was assessed with a modified Newcastle-Ottawa Scale. The meta-analysis of proportions used inverse variance method for pooling and random-effects model. For the stress levels we used the restricted maximum likelihood estimator for summary effects. Heterogeneity was assessed through I2 and Q statistics. Publication bias was assessed through funnel plots. Meta-regression adopted a mixed-effects model, considering patient age, endometriosis staging, stress assessment tool and data collection as categorical moderators. EVIDENCE SYNTHESIS We included 15 studies encompassing 4,619 women with endometriosis. The overall prevalence of mild/high stress was 68% (95%CI:57%-79%), I2=98% and τ2=0.0228. The mean level of stress was 41.78% (95%CI =34.05%-49.51%), I2=99.9% and τ2=83.35. Meta-regression showed relationship with endometriosis staging. CONCLUSIONS This is the first meta-analysis exploring the association between endometriosis and psychological stress. The interdisciplinary management of the disease should expand the mental health support in this patient care, beyond pain management. Finally, the attitude of the medical team acknowledging the patients' psychological stress may positively affect their treatment.
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Affiliation(s)
- Diogo L Brasil
- Facultade de Medicine do ABC/Centro Universitário Saúde ABC, Santo André, Brazil
| | - Erik Montagna
- Facultade de Medicine do ABC/Centro Universitário Saúde ABC, Santo André, Brazil -
| | - Camila M Trevisan
- Facultade de Medicine do ABC/Centro Universitário Saúde ABC, Santo André, Brazil
| | - Valentina L La Rosa
- Unit of Psychodiagnostics and Clinical Psychology, University of Catania, Catania, Italy
| | - Antonio S Laganà
- Department of Obstetrics and Gynecology, Filippo Del Ponte Hospital, University of Insubria, Varese, Italy
| | - Caio P Barbosa
- Facultade de Medicine do ABC/Centro Universitário Saúde ABC, Santo André, Brazil.,Discipline of Sexual and Reproductive Health and Populational Genetics, Department of Collective Health, Faculdade de Medicina do ABC/Centro Universitário Saúde ABC, Santo André, Brazil
| | - Bianca Bianco
- Facultade de Medicine do ABC/Centro Universitário Saúde ABC, Santo André, Brazil.,Discipline of Sexual and Reproductive Health and Populational Genetics, Department of Collective Health, Faculdade de Medicina do ABC/Centro Universitário Saúde ABC, Santo André, Brazil
| | - Victor Zaia
- Facultade de Medicine do ABC/Centro Universitário Saúde ABC, Santo André, Brazil.,Discipline of Sexual and Reproductive Health and Populational Genetics, Department of Collective Health, Faculdade de Medicina do ABC/Centro Universitário Saúde ABC, Santo André, Brazil
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