Nanosuspensions of poorly soluble drugs: preparation and development by wet milling

Nanosizing techniques are important tools for improving the bioavailability of water insoluble drugs. Here, a rapid wet milling method was employed to prepare nanosuspensions: 4 types of stabilizers at 4 different concentrations were tested on 2 structurally different drug compounds: indomethacin and itraconazole. Photon correlation spectroscopy (PCS) results showed that the finest nanosuspensions were obtained when 80 wt% (to drug amount) pluronic F68 was the stabilizer for indomethacin and 60 wt% pluronic F127 for itraconazole. Compared to physical mixtures, dissolution rates of the nanosuspensions showed significant increases. The morphology of nanoparticles was observed by transmission electron microscopy (TEM). Crystalline state of the drugs before and after milling was confirmed using differential scanning calorimetry (DSC) and X-ray powder diffraction (XRPD). The physical and chemical stabilities of the nanosuspensions after storage for 2 months at room temperature and at 4°C were investigated using PCS, TEM and HPLC. No obvious changes in particle size and morphology and no chemical degradation of the drug ingredients were seen.

Dissolution studies of poorly soluble drug nanosuspensions in non-sink conditions

Sink conditions used in dissolution tests lead to rapid dissolution rates for nanosuspensions, causing difficulties in discriminating dissolution profiles between different formulations. Here, non-sink conditions were studied for the dissolution testing of poorly water-soluble drug nanosuspensions. A mathematical model for polydispersed particles was established to clarify dissolution mechanisms. The dissolution of nanosuspensions with either a monomodal or bimodal size distribution was simulated. In the experimental part, three different particle sizes of indomethacin nanosuspensions were prepared by the wet milling technique. The effects of the dissolution medium pH and agitation speed on dissolution rate were investigated. The dissolution profiles in sink and non-sink conditions were obtained by changing the ratio of sample amount to the saturation solubility. The results of the simulations and experiments indicated that when the sample amount was increased to the saturation solubility of drug, the slowest dissolution rate and the best discriminating dissolution profiles were obtained. Using sink conditions or too high amount of the sample will increase the dissolution rate and weaken the discrimination between dissolution profiles. Furthermore, the low solubility by choosing a proper pH of the dissolution medium was helpful in getting discriminating dissolution profiles, whereas the agitation speed appeared to have little influence on the dissolution profiles. This discriminatory method is simple to perform and can be potentially used in any nanoproduct development and quality control studies.

Nanocrystal-based per-oral itraconazole delivery: superior in vitro dissolution enhancement versus Sporanox® is not realized in in vivo drug absorption

Nanoscience holds true promise in enabling efficient formulation development and in vivo delivery of poorly water soluble drugs. The objective of this study was to formulate solid oral nanocrystal delivery systems of itraconazole, and thus enhance the oral bioavailability of the very poorly soluble drug. Nanocrystal suspensions were prepared by a rapid wet milling technique, after which the suspensions were transformed into solid dosage forms by both freeze drying and granulating. Finally, the obtained nanocrystalline powders were capsule-packed as well as compacted to tablets. After in vitro analysis, the formulations (nanocrystal suspension (NPs), freeze dried NPs, granulated NPs) were tested in vivo in a rat model, and compared with commercial itraconazole formulation (Sporanox). Importantly, the results indicated rapid dissolution of the nanocrystalline itraconazole with enhanced bioavailability compared to physical mixture. Drug dissolution in vitro was immediate from NPs and freeze dried powder, and differed significantly from the marketed product (P=0.004 and 0.002, correspondingly) until 30min. Freeze drying was detected to be especially advantageous for the solid dosage forms. It is possible to maintain the original character of the nanocrystals, e.g. rapid dissolution, even after tableting of the nanocrystalline powders. Interestingly, the marketed product out-performed the nanocrystalline formulations in vivo, even though the nanocrystals provided reasonable bioavailability of itraconazole absorption as well. The efficient in vitro dissolution enhancement of the nanocrystalline formulations compared to Sporanox® was not realized in in vivo drug absorption.

Obesity Represses CYP2R1, the Vitamin D 25-Hydroxylase, in the Liver and Extrahepatic Tissues

Low plasma level of 25-hydroxyvitamin D (25-OH-D), namely vitamin D deficiency, is associated with obesity and weight loss improves 25-OH-D status. However, the mechanism behind obesity-induced vitamin D deficiency remains unclear. Here, we report that obesity suppresses the expression of cytochrome P450 (CYP) 2R1, the main vitamin D 25-hydroxylase, in both mice and humans. In humans, weight loss induced by gastric bypass surgery increased the expression of CYP2R1 in the s.c. adipose tissue suggesting recovery after the obesity-induced suppression. At the same time, CYP27B1, the vitamin D 1α-hydroxylase, was repressed by the weight loss. In a mouse (C57BL/6N) model of diet-induced obesity, the plasma 25-OH-D was decreased. In accordance, the CYP2R1 expression was strongly repressed in the liver. Moreover, obesity repressed the expression of CYP2R1 in several extrahepatic tissues, the kidney, brown adipose tissue, and testis, but not in the white adipose tissue. Obesity had a similar effect in both male and female mice. In mice, obesity repressed expression of the vitamin D receptor in brown adipose tissue. Obesity also upregulated the expression of the vitamin D receptor and CYP24A1 in the s.c. adipose tissue of a subset of mice; however, no effect was observed in the human s.c. adipose tissue. In summary, we show that obesity affects CYP2R1 expression both in the mouse and human tissues. We suggest that in mouse the CYP2R1 repression in the liver plays an important role in obesity-induced vitamin D deficiency. Currently, it is unclear whether the CYP2R1 downregulation in extrahepatic tissues could contribute to the obesity-induced low plasma 25-OH-D, however, this phenomenon may affect at least the local 25-OH-D concentrations. © 2020 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Solid formulations by a nanocrystal approach: critical process parameters regarding scale-ability of nanocrystals for tableting applications

Nanocrystallization is among the foremost drug delivery platform approaches for the commercial development of poorly soluble drugs. There exists an urge to enable a universal shift of the production of the solid nanocrystal formulations from laboratory scale to industrially feasible scale. The success of any formulation development depends on its transferability to large scale manufacture. The objectives of the study were to increase the nanocrystallization batch size and to screen and optimize parameters for industrially feasible itraconazole (ITC) and indomethacin (IND) nanocrystal composition for tablet formulation. Thus, ITC and IND were transformed into nanocrystal suspensions, using an increased batch size of a wet milling process, freeze-dried, and further developed into both direct compression (DC) and granulated (G) tableting masses. According to the investigated powder and tablet properties (true density, flowability, dose uniformity, maximum upper punch force, crushing strength, dissolution and disintegration) and stability testings, it was clear that the amount of the nanocrystals in the solid tablet formulation is critical in order to fully utilize the benefits of the nanocrystals, i.e., fast dissolution, and to produce high-quality tablets. The DC designs of both the model drugs with compositions including 40% of freeze-dried nanocrystalline drug powder outperformed the corresponding granulated tablets in all parameters after the stability surveillance.

Women with polycystic ovary syndrome present with altered endometrial expression of stanniocalcin-1†

Stanniocalcin-1 (STC-1) is a pro-survival factor that protects tissues against stressors, such as hypoxia and inflammation. STC-1 is co-expressed with the endometrial receptivity markers, and recently endometrial STC-1 was reported to be dysregulated in endometriosis, a condition linked with endometrial progesterone resistance and inflammation. These features are also common in the endometrium in women with polycystic ovary syndrome (PCOS), the most common endocrine disorder in women. Given that women with PCOS present with subfertility, pregnancy complications, and increased risk for endometrial cancer, we investigated endometrial STC-1 expression in affected women. Endometrial biopsy samples were obtained from women with PCOS and controls, including samples from overweight/obese women with PCOS before and after a 3-month lifestyle intervention. A total of 98 PCOS and 85 control samples were used in immunohistochemistry, reverse-transcription polymerase chain reaction, or in vitro cell culture. STC-1 expression was analyzed at different cycle phases and in endometrial stromal cells (eSCs) after steroid hormone exposure. The eSCs were also challenged with 8-bromo-cAMP and hypoxia for STC-1 expression. The findings indicate that STC-1 expression is not steroid hormone mediated although secretory-phase STC-1 expression was blunted in PCOS. Lower expression seems to be related to attenuated STC-1 response to stressors in PCOS eSCs, shown as downregulation of protein kinase A activity. The 3-month lifestyle intervention did not restore STC-1 expression in PCOS endometrium. More studies are warranted to further elucidate the mechanisms behind the altered endometrial STC-1 expression and rescue mechanism in the PCOS endometrium.

BMI in childhood and adolescence is associated with impaired reproductive function-a population-based cohort study from birth to age 50 years

STUDY QUESTION

What is the association between childhood and adolescent BMI and reproductive capacity in women?

SUMMARY ANSWER

Adolescent girls with obesity had an increased risk of infertility and childlessness in adulthood independently of their marital status or the presence of polycystic ovary syndrome (PCOS).

WHAT IS KNOWN ALREADY

Girls with obesity (BMI (kg/m2)>95th percentile) more often exhibit menstrual irregularities and infertility problems as compared to those with normal weight, and premenarcheal girls with obesity have an increased risk of childlessness and infertility in adulthood. Follow-up studies on the relation between childhood and adolescence growth patterns and fertility or parity throughout the reproductive life span are limited.

STUDY DESIGN, SIZE, DURATION

A prospective, population-based cohort study (the Northern Finland birth cohort 1966) was performed with 5889 women born in 1966 and followed from birth to age 50 years. Postal questionnaires at ages 31 and 46 years addressed questions on reproductive capacity evaluated by decreased fecundability, need for infertility assessment and treatment by 46 years of age. Childlessness and number of children by age 50 years were recovered from registers. Women who did not report ever having attempted to achieve pregnancy (n = 1507) were excluded. The final study population included 4382 women who attempted to achieve pregnancy before age 46 years.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Data on BMI were collected by trained personnel at all stages. We assessed association with both prospectively measured BMI at various time points and with early adiposity phenotypes derived from linear mixed models including the timing and the BMI at adiposity peak (AP) and adiposity rebound (AR). Self-reported infertility assessments and treatments were assessed at ages 31 and 46 years. Data on deliveries were collected from the national birth register. Decreased fecundability was defined at age 31 years as time to achieve pregnancy over 12 months. Logistic regression analyses were conducted with adjustments for marital status, education level and smoking at age 31 years. Women with PCOS were excluded from stratification-based sensitivity analyses. Obesity at a specific age group was defined by having at least one BMI value above the 95th percentile during the related period.

MAIN RESULTS AND THE ROLE OF CHANCE

BMI at the age of AR (5-7 years) was not associated with fertility outcomes after adjustments, but girls with AR <5.1 years had a higher risk of remaining childless compared to girls with AR over 5.1 years (adjusted odds ratio (OR): 1.45 (1.10-1.92)). At ages 7-10 and 11-15 years, obesity was associated with decreased fecundability (adjusted OR 2.05 (1.26-3.35) and 2.04 (1.21-3.44), respectively) and a lower number of children. At age 11-15 years, both overweight and obesity were associated with a higher risk of childlessness (adjusted OR 1.56 (1.06-2.27), 1.77 (1.02-3.07), respectively), even after excluding women with PCOS. Underweight at age 11-15 years was associated with an increased risk for infertility treatment (adjusted OR 1.55 (1.02-2.36)) and a tendency for an increased risk for infertility assessment (adjusted OR 1.43 (0.97-2.10)) after excluding women with PCOS.

LIMITATIONS, REASON FOR CAUTION

Despite a high participation rate throughout the follow-up, some growth data for children over the different age groups were missing. Infertility outcomes were self-reported. A potential over-diagnosis of obesity may have reduced the significance of the association between childhood obesity and fertility outcomes, and the diagnosis of PCOS was self-reported.

WIDER IMPLICATIONS OF THE FINDINGS

This study supports previous results showing that girls with obesity in late childhood and in adolescence displayed reduced fertility and an increased risk of remaining childless in adulthood, independently of marital history and PCOS in adulthood. These findings corroborate the body of evidence for a causal relation between early adiposity and the reproductive functions in women. We recommend reinforcing the prevention of obesity in school-age girls to reduce the risk of impaired reproductive functions.

STUDY FUNDING/COMPETING INTEREST(S)

NFBC1966 received financial support from University of Oulu Grant no. 65354, Oulu University Hospital Grant no. 2/97, 8/97, Ministry of Health and Social Affairs Grant no. 23/251/97, 160/97, 190/97, National Institute for Health and Welfare, Helsinki Grant no. 54121, Regional Institute of Occupational Health, Oulu, Finland Grant no. 50621, 54231. The Finnish Medical Foundation, the North Ostrobothnia Regional Fund, the Academy of Finland (project grants 315921, 104781, 120315, 129269, 1114194, 24300796), Center of Excellence in Complex Disease Genetics and SALVE, the Sigrid Juselius Foundation, Biocenter Oulu, University Hospital Oulu and University of Oulu (75617), Jalmari ja Rauha Ahokkaan säätiö, The Finnish Medical Foundation, Medical Research Center Oulu, National Institute for Health Research (UK). M. R. J., S. S. and R. N. received funding by the Academy of Finland (#268336) and the European Union's Horizon 2020 research and innovation program (under Grant agreement no. 633595 for the DynaHEALTH action and GA 733206 for LifeCycle). The funders had no role in study design, in the collection, analysis and interpretation of the data, in the writing of the article and in the decision to submit it for publication. The authors have no conflict of interest to disclose.

TRIAL REGISTRATION NUMBER

N/A.

In vivo effects of AZD4547, a novel fibroblast growth factor receptor inhibitor, in a mouse model of endometriosis

Endometriosis is a chronic disease, characterized by the growth of endometrial-like cells outside the uterine cavity. Due to its complex pathophysiology, a totally resolving cure is yet to be found. The aim of this study was to compare the therapeutic efficacy of AZD4547, a novel fibroblast growth factor receptor inhibitor (FGFRI), with a well-characterized progestin, etonogestrel (ENG) using a validated in vivo mouse model of endometriosis. Endometriosis was induced by transplanting uterine fragments from donor mice in proestrus into the peritoneal cavity of recipient mice, which then developed into cyst-like lesions. AZD4547 and ENG were administered systemically either from the day of endometriosis induction or 2-weeks post-surgery. After 20 days of treatment, the lesions were harvested; their size and weight were measured and analyzed histologically or by qRT-PCR. Stage of estrous cycle was monitored throughout. Compared to vehicle, AZD4547 (25 mg/kg) was most effective in counteracting lesion growth when treating from day of surgery and 2 weeks after; ENG (0.8 mg/kg) was similarly effective in reducing lesion growth but only when administered from day of surgery. Each downregulated FGFR gene expression (p < 0.05). AZD4547 at all doses and ENG (0.008 mg/kg) caused no disturbance to the estrous cycle. ENG at 0.08 and 0.8 mg/kg was associated with partial or complete estrous cycle disruption and hyperemia of the uteri. AZD4547 and ENG both attenuated endometriotic lesion size, but only AZD4547 did not disrupt the estrous cycle, suggesting that targeting of FGFR is worthy of further investigation as a novel treatment for endometriosis.

Laparoscopically guided transversus abdominis plane block versus local wound analgesia in laparoscopic surgery for peritoneal endometriosis: study protocol for a prospective randomized controlled double-blinded LTAP-trial

Background

Ultrasound-guided transversus abdominis plane block (TAP) performed by anesthesiologist has been shown to be an effective and safe analgesia method in abdominal surgery, reducing postoperative opioid consumption. Recently, there has been growing interest to insert TAP under laparoscopic vision (LTAP) by surgeon. LTAP has been used in laparoscopic gastrointestinal surgery, but studies on LTAP in gynecologic laparoscopic surgery are sparse and inconsistent. The purpose of this study is to compare the efficacy of LTAP and local wound analgesia in laparoscopic surgery due to suspected or diagnosed superficial peritoneal endometriosis.

Methods

The LTAP-trial is a prospective randomized controlled double-blinded study comparing the efficacy and safety of LTAP with local wound analgesia in laparoscopic endometriosis surgery. Patients are randomized to receive LTAP with levobupivacaine and wound infiltration with placebo or wound infiltration with levobupivacaine and LTAP with placebo. The primary outcome is postoperative opioid consumption measured by patient-controlled analgesia (PCA) pump. Secondly, subjective postoperative pain up to 24 h postoperatively will be measured by Numeric Rating Scale (NRS). Additional outcome measures are factors related to recovery and length of stay in the hospital as well as a 6-month follow-up survey regarding pain (NRS) and endometriosis-related wellbeing (endometriosis-related health profile, EHP-30) after surgery. A total of 46 patients will be randomized in a proportion of 1:1.

Discussion

Patients with peritoneal endometriosis are often prone to severe postoperative pain that may prohibit their enhanced recovery after laparoscopy. Thus, there is a need for effective postoperative pain management with minimal side-effects. This study focusing on laparoscopically inserted transversus abdominis plane block may provide new insight in dealing with postoperative pain after laparoscopic endometriosis surgery as well as after other gynecologic surgery.

Trial registration

The LTAP-trial -protocol has been prospectively registered to ClinicalTrials.gov, ID: NCT04735770. Registered on February 2021.

Long-term results of a prospective randomized trial comparing tension-free vaginal tape versus transobturator tape in stress urinary incontinence

INTRODUCTION AND HYPOTHESIS

This study was aimed at investigating the long-term effectiveness of minimally invasive mid-urethral sling (MUS) surgery and at comparing the outcomes between retropubic (tension-free vaginal tape, TVT) and transobturator tape (TOT) methods in the treatment of stress urinary incontinence (SUI) and mixed urinary incontinence (MUI) with a predominant stress component in a long-term follow-up of a randomized controlled trial.

METHODS

This work is a long-term follow-up study of a previous prospective randomized trial conducted in the Department of Obstetrics and Gynecology at Oulu University Hospital between January 2004 and November 2006. The original 100 patients were randomized into the TVT (n=50) or TOT (n=50) group. The median follow-up time was 16 years, and the subjective outcomes were evaluated using internationally standardized and validated questionnaires.

RESULTS

Long-term follow-up data were obtained from 34 TVT patients and 38 TOT patients. At 16 years after MUS surgery, the UISS significantly decreased from a preoperative score in the TVT (11.88 vs 5.00, p<0.001) and TOT (11.05 vs 4.95, p<0.001) groups, showing a good long-term success of the MUS surgery in both groups. In comparing the TVT and TOT procedures, the subjective cure rates did not differ significantly between the study groups in long-term follow-up according to validated questionnaires.

CONCLUSION

Midurethral sling surgery had good long-term outcomes in the treatment of SUI and MUI with a predominant stress component. The subjective outcomes of the TVT and TOT procedures were similar after a 16-year follow-up.

Urinary incontinence associates with poor work ability in middle-aged women: A Northern Finland Birth cohort 1966 study

INTRODUCTION

Urinary incontinence is a common ailment in women and is likely to affect their work ability. We investigated the associations between the different subtypes of urinary incontinence and several dimensions of perceived work ability in middle-aged general population.

MATERIAL AND METHODS

Cross-sectional survey at age 46 among participants of the Northern Finland Birth Cohort 1966 study (n = 3706, response rate 72%). Urinary incontinence symptoms and several items of Work Ability Index were collected by postal questionnaire. Work ability was dichotomized as good or poor work ability in general, in relation to physical job demands, to diseases and own 2-year prospect of work ability. The associations between urinary incontinence and work ability measures were assessed using logistic regression models, with further adjustments for biological, behavioral and work-related factors as well as general health.

RESULTS

The odds ratio (OR), from lowest to highest, for poor work ability were 1.4-fold among women with stress urinary incontinence (OR 1.37, 95% confidence interval [CI] 1.09-1.72), 2.5-fold with mixed urinary incontinence (OR 2.51, 95% CI 1.68-3.74) and 3.3-fold with urgency urinary incontinence (OR 3.34, 95% CI 1.95-5.70). We note that our results reflect work ability in a Nordic society.

CONCLUSIONS

Especially urgency and mixed types of urinary incontinence are associated with poor work ability among middle-aged women.

Cotadutide reversible self-assembly based long-acting injectable depot for sustained delivery of GLP-1 glucagon receptor agonists with controlled burst release

Cotadutide (Cota) is a lipidated dual GLP-1 and Glucagon receptor agonist that was investigated for the treatment of various metabolic diseases, it is designed for once daily subcutaneous (SC) administration. Invasive daily injections can result in poor patient compliance with chronic disease, and here, we demonstrate an innovative strategy of encapsulating reversible cota self-assembled fibers within an in-situ forming depot of low molecular weight poly(lactic-co-glycolic) acid (LWPLGA) for sustained delivery GLP-1 and Glucagon receptor agonist with controlled burst release. This could be a suitable alternative to other sustained delivery strategies for fibrillating peptides. We investigated a range of cationic ions (Na+, Ca2+, Zn2+) and studied their influence on the secondary structure, morphology and the monomer release profile of cota fibers. Fibers forming hierarchy structures such as twisted filament and ribbons with beta sheet secondary structure resulted in better controlled burst. The subcutaneous administration of Ca2+ fiber/LWPLGA depot formulation in rats resulted in 60-fold reduction in maximum concentration (Cmax) compared with cota immediate release (IR) SC formulation and a prolonged plasma exposure over a month with plasma half-life extended from the 10 h observed with the cota daily formulation to 100 h. This extended-release formulation also maintains smaller peak and trough fluctuation within therapeutic window, and PK modelling of repeated dose indicates this formulation could enable a possible dose frequency of 14 days in rat with assumed therapeutic concentration (ratios of the maximum concentration and the trough concentration) Cmax/Ctrough window. This new long-acting injectable (LAI) method could open the door to transforming short-life peptides with sub-optimal half-life into candidates for weekly or even monthly dosing regimens, potentially leading to novel drug products with increased patient comfort.

An optimal growth pattern during pregnancy and early childhood associates with better fertility in men

OBJECTIVE

This study aimed to evaluate the association between birth weight (BW), childhood and adolescent BMI, with reproductive capacity in men.

DESIGN

A prospective, population-based cohort study (Northern Finland birth cohort 1966).

METHODS

Around 6196 men born in 1966 were followed from birth to age 50 years. Weight and height were measured repeatedly by professionals. Reproductive capacity (infertility assessment, male factor infertility and infertility treatment by age 46 years) was evaluated by questionnaires at ages 31 and 46 years. The number of children by the age of 50 years was recovered from registers. After excluding the men who reported never having attempted to have children or not answering the question at age 31 or 46 years (n = 2041), 4128 men were included in the final study population. Results were adjusted for BW, BW for gestational age (GA), mother's smoking status, marital status, educational level and smoking status.

RESULTS

Being small for GA (10.5% vs 8.2%, P = 0.012) or having a lower BW (3495 g vs 3548 g, P = 0.003) were associated with childlessness. The association was however no longer significant after adjusting for marital status. Being underweight in early childhood was associated with an increased risk of infertility assessment (adjusted, aOR: 2.04(1.07-3.81)) and childlessness (aOR: 1.47(1.01-2.17)) compared to the normal weight group. Conversely, overweight or obesity in early childhood was associated with a decreased risk of infertility assessment (aOR: 0.60 (0.41-0.87)), treatment (aOR: 0.42 (0.25-0.70)) and male factor infertility (aOR: 0.45 (0.21-0.97)). BMI in mid-childhood or puberty had no association with infertility or childlessness.

CONCLUSION

In boys, an optimal growth trajectory during pregnancy and early childhood seems to be very important for life-long fertility.

The reproductive tract microbiome in women with polycystic ovary syndrome and across different menstrual cycle phases

STUDY QUESTION

Do polycystic ovary syndrome (PCOS), menstrual cycle phases, and ovulatory status affect reproductive tract (RT) microbiome profiles?

SUMMARY ANSWER

We identified microbial features associated with menstrual cycle phases in the upper and lower RT microbiome, but only two specific differences in the upper RT according to PCOS status.

WHAT IS KNOWN ALREADY

The vaginal and uterine microbiome profiles vary throughout the menstrual cycle. Studies have reported alterations in the vaginal microbiome among women diagnosed with PCOS.

STUDY DESIGN, SIZE, DURATION

This prospective case-control study included a cohort of 37 healthy control women and 52 women diagnosed with PCOS. Microbiome samples were collected from the vagina as vaginal swabs (VS) and from the uterus as endometrial flushing (EF) aspirate samples, and compared according to PCOS diagnosis, the menstrual cycle phases, and ovulatory status, at Oulu University Hospital (Oulu, Finland) from January 2017 to March 2020.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A total of 83 VS samples and 80 EF samples were collected. Age and body mass index (BMI) were matched between women with and without PCOS. Clinical characteristics were assessed using blood samples collected between cycle days 2 and 8, and microbial DNA was sequenced on the Ion Torrent platform. Microbial alpha diversity (i.e. the observed number of unique genera and Shannon diversity index) was analysed across sample types, PCOS diagnosis and menstrual cycle phases. Linear mixed-effects models were utilised to identify microbial features in relation to PCOS and the menstrual cycle phases. Associations between the beta diversity of the RT microbiome and PCOS- and cycle-related clinical features were calculated using PERMANOVA.

MAIN RESULTS AND THE ROLE OF CHANCE

Microbial alpha diversity showed no difference with PCOS (VS: Pobserved feature = 0.836, Pshannon = 0.998; EF: Pobserved feature = 0.366, Pshannon = 0.185), but varied with menstrual cycle phases (VS: Pobserved feature = 0.001, Pshannon = 0.882; EF: Pobserved feature = 0.026, Pshannon = 0.048). No difference was observed in beta diversity based on either PCOS or the menstrual cycle phases (VS: PPCOS = 0.280, Pcycle = 0.115; EF: PPCOS = 0.234, Pcycle = 0.088). In the endometrial flushing samples, we identified two novel microbial features, characterised by the ratio of differential abundance of two genera, associated with PCOS (FDR ≤ 0.1) and 13 novel features associated with the menstrual cycle phases (FDR ≤ 0.1).

LIMITATIONS, REASONS FOR CAUTION

Although this was the first study to simultaneously analyse, the lower and upper RT microbiome in women with and without PCOS, the limited sample size of anovulatory cases may hinder the detection of differences related to PCOS and ovulatory status.

WIDER IMPLICATIONS OF THE FINDINGS

The main finding suggests that PCOS and the menstrual cycle phases are associated with specific microbial features in the upper RT, indicating that the analysis of the upper RT microbiome can potentially identify biomarkers for both PCOS and menstrual cycle phases.

STUDY FUNDING/COMPETING INTEREST(S)

This research was funded by the Research Council of Finland (grants no. 315921, 321763, 336449), the Sigrid Jusélius Foundation, Novo Nordisk Foundation (grant no. NNF21OC0070372), and the European Union's Horizon 2020 research and innovation programme under the Marie Sklodowska-Curie grant (MATER, grant no. 813707). This research was also funded by the Estonian Research Council (grants no. PRG1076, PRG1414), the Horizon Europe grant (NESTOR, grant no. 101120075) of the European Commission, and EMBO Installation Grant (grant no. 3573). The funders did not participate in any processes of the study. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

TRIAL REGISTRATION NUMBER

N/A.

Hysterectomy is not associated with increased risk of urinary incontinence-a northern Finland birth cohort 1966 study

INTRODUCTION

Hysterectomy has been suggested to increase the risk of urinary incontinence (UI), although evidence is controversial. In our population-based cohort study, we aimed to assess the independent effect of hysterectomy on the risk of de novo UI.

MATERIAL AND METHODS

This is a population-based cohort study on the women of the Northern Finland Birth Cohort 1966 (n = 5889). We identified all hysterectomies among the cohort (n = 461) using the national Care Register for Health Care and classified them according to surgical approach into laparoscopic (n = 247), vaginal (n = 107), and abdominal hysterectomies (n = 107). Women without hysterectomy formed the reference group (n = 3495). All women with UI diagnoses and operations were identified in the register, and women with preoperative UI diagnosis (n = 36) were excluded from the analysis to assess de novo UI. Data on potential confounding factors were collected from registers and the cohort questionnaire. Incidences of different UI subtypes and UI operations were compared between the hysterectomy and the reference groups, and further disaggregated by different hysterectomy approaches. Logistic regression models were used to analyze the association between hysterectomy and UI, with adjustments for several UI-related covariates.

RESULTS

We found no significant difference in the incidence of UI diagnoses or the rate of subsequent UI operations between the hysterectomy and the reference groups (24 [5.6%] vs. 166 [4.7%], p = 0.416 and 14 [3.3%] vs. 87 [2.5%], p = 0.323). Hysterectomy was not significantly associated with the risk of any subtype of UI (overall UI: OR 1.20, 95% CI 0.77-1.86; stress UI (SUI): OR 1.51, 95% CI 0.89-2.55; other UI: OR 0.80, 95% CI 0.36-1.74). After adjusting for preoperative pelvic organ prolapse (POP) diagnoses, the risk was decreased (overall UI: OR 0.54, 95% CI 0.32-0.90; other than SUI: OR 0.40, 95% CI 0.17-0.95). Regarding different hysterectomy approaches, the risks of overall UI and SUI were significantly increased in vaginal, but not in laparoscopic or abdominal hysterectomy. However, adjusting for preoperative POP diagnosis abolished these risks.

CONCLUSIONS

Hysterectomy is not an independent risk factor for de novo UI. Instead, underlying POP appears to be a significant risk factor for the incidence of UI after hysterectomy.

Low testosterone at age 31 associates with maternal obesity and higher body mass index from childhood until age 46: A birth cohort study

BACKGROUND

Low testosterone (T) levels in men associate with increased risks of obesity, type 2 diabetes, metabolic syndrome, and cardiovascular diseases. However, most studies are cross-sectional with follow-up-time < 10 years, and data on early growth are limited.

OBJECTIVE

To compare prenatal factors and body mass index (BMI) development from birth to age 46 in relation to low T at age 31.

MATERIALS AND METHODS

Men with low T (T < 12.1 nmol/L, n = 132) and men with normal T at age 31 (n = 2561) were derived from the Northern Finland Birth Cohort 1966. Prenatal factors, longitudinal weight and height data from birth to age 14, and cross-sectional weight and height data at ages 31 and 46, and waist-hip-ratio (WHR) and T levels at age 31 were analyzed. Longitudinal modeling and timing of adiposity rebound (AR, second BMI rise at age 5-7 years) were calculated from fitted BMI curves. Results were adjusted for mother's pre-pregnancy BMI and smoking status, birth weight for gestational age, alcohol consumption, education level, smoking status, and WHR at age 31.

RESULTS

Neither gestational age nor birth weight was associated with low T at age 31; however, maternal obesity during gestation was more prevalent among men with low T (9.8% vs. 3.5%, adjusted aOR: 2.43 [1.19-4.98]). Men with low T had earlier AR (5.28 vs. 5.82, aOR: 0.73 [0.56-0.94]) and higher BMI (p < 0.001) from AR onward until age 46. Men with both early AR and low T had the highest BMI from AR onward.

CONCLUSIONS

In men, maternal obesity and early weight gain associate with lower T levels at age 31, independently of adulthood abdominal obesity. Given the well-known health risks related to obesity, and the rising prevalence of maternal obesity, the results of the present study emphasize the importance of preventing obesity that may also affect the later reproductive health of the offspring.