Ulipristal acetate in emergency contraception

Despite the widespread availability of highly effective methods of contraception, unintended pregnancy is common. Unplanned pregnancies have been linked to a range of health, social and economic consequences. Emergency contraception reduces risk of pregnancy after unprotected intercourse, and represents an opportunity to decrease number of unplanned pregnancies and abortions. Emergency contraception pills (ECP) prevent pregnancy by delaying or inhibiting ovulation, without interfering with post fertilization events. If pregnancy has already occurred, ECPs will not be effective, therefore ECPs are not abortificants. Ulipristal acetate (17alpha-acetoxy-11beta-(4N-N,N-dymethilaminophenyl)-19-norpregna--4,9-diene-3,20-dione) is the first drug that was specifically developed and licensed for use as an emergency contraceptive. It is an orally active, synthetic, selective progesterone modulator that acts by binding with high affinity to the human progesterone receptor where it has both antagonist and partial agonist effects. It is a new molecular entity and the first compound in a new pharmacological class defined by the pristal stem. Up on the superior clinical efficacy evidence, UPA has been quickly recognized as the most effective emergency contraceptive pill, and recently recommended as the first prescription choice for all women regardless of the age and timing after intercourse. This article provides literature review of UPA and its role in emergency contraception.

Ovarian torsion in adolescent with chronic immune thrombocytopenia

Ovarian torsions in adolescence are rarity, particularly bilateral, with mostly unknown etiology. Enlargement of the ovary contributes to torsion. Young girl presenting with abdominal pains, nausea and vomiting was for two days suspected and observed as gastroenteritis. By exclusion of gastroenteritis she was admitted for gynecological work-up. Ultrasound showed significantly enlarged right ovary, with tumor-like appearance. At the laparotomy, gynecologist found torsioned, necrotic ovary and ovariectomy was performed. Histology showed massive stromal bleeding (haemorrhage). Asymptomatic enlargement of remaining ovary occurred nine months after the ovariectomy. This enlargement was accompanied with platelets' fall and the possibility of repeated torsion impended. Thrombocytopenia was suspected from the first moment, but diagnosed after the surgery. Thrombocytopenia in adolescence requires additional attention as possible cause of intra-ovarian bleeding with consecutive enlargement and may lead to torsion. Oral contraceptives regulate dysfunctional bleeding, decrease ovarian volume and by so, may minimize risk of torsion. This strategy proved effective in the case we present.

Clinical, hormonal and metabolic characteristics of polycystic ovary syndrome among obese and nonobese women in the Croatian population

Obesity has a deteriorating impact on women with PCOS, although prevalence and the impact of specific traits of PCOS remain inconstant in different populations. Therefore, the aim of this study was to explore the differences in clinical, hormonal and metabolic features between obese and nonobese Croatian women diagnosed as having PCOS according to Rotterdam consensus criteria. The study included 74 obese and 208 nonobese women with PCOS. Clinical, biochemical and metabolic variables were compared among those PCOS subgroups. Obese subjects with PCOS had a higher risk of developing oligo-amenorrhea (OR 3.7; 95% CI, 1.1-12.5) and lower risk for developing hirsutism and acne (OR 0.2; 95% CI, 0.1-0.3 and OR 0.8; 95% CI 0.5-1.4, respectively). Obese PCOS subjects also had a higher risk of developing hyperandrogenemia (OR 2.5; CI 95% 0.9-6.7), insulin resistance (OR 4.5; CI 95%, 2.6-7.9), hypercholesterolemia (OR 5.0, CI 95% 2.5-10.2), hypertriglyceridemia (OR 5.2; 95% CI, 2.9-9.2) as well as elevated serum CRP levels (OR 4.1; 95% CI 1.4-12.2) compared to nonobese PCOS women. In conclusion, nonobese Croatian women with PCOS are more inclined to cosmetic problems associated with PCOS then metabolic ones. This is the first study to report the impact of obesity on acne and irregular menses as a study outcome. Obesity deteriorates menstrual regularity, insulin sensitivity and lipid profile in Croatian women with PCOS; therefore one of the fundamental treatment strategies of PCOS should be obesity prevention.

Characteristics of different phenotypes of polycystic ovary syndrome based on the Rotterdam criteria in the Croatian population

The aim of this study was to calculate the relative prevalence of all phenotypes of polycystic ovary syndrome (PCOS) and to compare them for anthropometrical, hormonal and metabolic differences according to the Rotterdam Criteria. A total of 300 women with PCOS aged 26.7 +/- 5.6 years (mean +/- SD) and 100 women aged 28.3 +/- 4.1 years (mean +/- SD) were included in a control group. Anthropometrical, hormonal and metabolic parameters were compared between the groups. The most prevalent phenotype in our population was the most severe, phenotype A (56.7%), followed by phenotype D (26.7%) and phenotype C (14.3%). Phenotype B was present in only 2.3% of patients. The four main phenotypes did not differ in age, BMI and WHR. Women with phenotypes A and C had increased levels of LH and an increased LH/FSH ratio along with elevated androgen levels compared to the other groups. Serum glucose levels did not differ between the groups studied, however, higher levels of insulin, GIR and HOMA-IR were found between phenotype A and the control group. Phenotype C PCOS or ovulatory PCOS have the same characteristics as classic PCOS, however in a more mild form, which represents a transition between the classic form and the control group. Compared to the control group, phenotype D had higher mean levels of serum testosterone (still within normal range) along with elevated LH levels and LH/FSH ratio, similar to classic PCOS. However, compared with women diagnosed with PCOS based on hyperandrogenism, oligo-ovulation and polycystic ovaries, these patients demonstrated milder endocrine and metabolic abnormalities. Therefore, from an endocrine point of view, our study supports the inclusion of a normoandrogenic anovulatory phenotype in PCOS diagnostic criteria.

Clinical and biochemical characteristics of polycystic ovary syndrome in Croatian population

Polycystic ovary syndrome (PCOS) is a common endocrine condition affecting women of reproductive age. There are many typical signs and symptoms that allow for the diagnosis of PCOS depending on the criteria used. Interestingly, ethnicity influences the extent of these signs and symptoms; therefore, the frequency of symptoms varies between different countries and ethnic groups. The prevalence of this syndrome in Croatia is unknown, and it's clinical and biochemical characteristics have not yet been reported. During this study, we used the Rotterdam criteria to evaluate 365 Croatian women with PCOS, and compared them to 304 age matched controls to assess the clinical and biochemical abnormalities that occur in PCOS patients. The mean age of PCOS patients at presentation was 26.1 +/- 5.9 years and of controls were 28.0 +/- 4.2 years. Women with PCOS has significantly higher body mass index (BMI) than the control group, although in both groups most patients had normal weight (76.2% vs. 87.8%). Abdominal distribution of fat tissue was similar in both groups. Menstrual cycle abnormalities were observed in 90.7% of PCOS patients, and ultrasonographic appearance of polycystic ovaries was reported in 97.3% of PCOS cases. Nearly 75% of patients with PCOS had hirsutism and 49.6% had acne. We recorded significantly higher serum levels of luteinizing hormone (LH), total testosterone (TT), free testosterone (fT) and insulin, while the serum levels of sex hormone binding globuline (SHBG) and follicular stimulating hormone (FSH) were significantly lower than in the control group. Serum glucose values were not significantly different between the groups. In conclusion, chronic anovulation, hirsutism and ultrasound appearance of polycystic ovaries are the dominant features of PCOS in Croatian population. The majority of patients with PCOS had normal body weight. The incidence of insulin resistance in this group of patients is less than the previously described frequency in other populations of patients with PCOS and normal weight.

[The value of hysteroscopy in perimenopausal women]

The aim of this review is to define clinical guidelines for the management of menopausal women with abnormal uterine bleeding. Hysteroscopy has proved to be the most accurate and reliable method for the diagnosis of intrauterine diseases. Many authors have recently proposed the use of hysteroscopy as a first line procedure in the approach to menopausal women. With continuing improvement in technology, and development of modern narrow-diameter hysteroscopes, light sources and distension-medium insufflators, hysteroscopy can now be performed as an outpatient procedure. Because of its higher diagnostic accuracy, hysteroscopy is replacing dilatation and curettage for the investigation of abnormal uterine bleeding. Diagnostic dilatation and curettage should be done with hysteroscopy to obtain visual image of the endometrial cavity and to exclude focal disease. Hysteroscopy thus turns a ,"blind" procedure into one allowing directed curettage, helps prevent missing unsuspected polypes and ensures that the most visibly abnormal areas are sampled.

[Alternative hormone therapy in postmenopause]

Despite the fact that hormonal combination used in huge Wpmen's Health Initiative (WHI) is not common all over the world, and treated population is, because of age, in risk per se, study results have consternated not only lay users, but prescribers too. Namely, increased cancer, stroke and coronary heart disease risk associated with long term use of postmenopausal hormone therapy (HT) have rapidly declined the number of women treated with HT (either estrogen alone or estrogen plus progestogen). Considering recent position statements from leading organizations dealing with menopause, individualization of therapy and lower dosage HT becomes the state of the art. Not only WHI, but also results of other studies published during past few years, have induced curiosity for non-estrogen containing treatments in climacteric medicine. This review shows not only mandatory list of possibilities, but also emphasises which of the alternative and complementary treatments are evidence based regarding published randomized controlled trials.

Advantages and disadvantages of hysterosonosalpingography in the assessment of the reproductive status of uterine cavity and fallopian tubes

BACKGROUND

Hysterosonosalpingography as a contrast ultrasound method is safer, cheaper and easier to perform than hysterosalpingography in the assessment of the uterine cavity and fallopian tubes. Is it feasible for all patients? Which is the main problem in the evaluation of target structures by ultrasound?

METHODS

In a prospective study, 68 patients in the initial stage of the infertility treatment were examined by hysterosonosalpingography using saline NaCl infundibile and Echovist as contrast media. Subsequently, further status of the tubes and uterine cavity was assessed by the "gold standards", laparoscopy and hysteroscopy.

RESULTS

Sensitivity and specificity of hysterosonosalpingography using NaCl infundibile for evaluation of the uterine cavity was 100 and 88.8%, respectively. Negative predictive value was 100% and positive predictive value 97%. Sensitivity and specificity of the method for the assessment of the tubal status was 100 and 66%, respectively, negative predictive value was 100% and positive predictive value was 61%. For the assessment of tubal patency using positive contrast Echovist the method has shown 100% sensibility and negative predictive value again but it reached a specificity of 77% and a positive predictive value of 70%. There were no evident complications during or after the procedure.

CONCLUSION

Hysterosonosalpingography is useful in making decisions regarding further procedures for the diagnosis and treatment of infertility. Uterine cavity evaluation using saline is the method of choice. Tubal patency can be assessed only under ideal sonographic conditions. The method is feasible for early assessment of the reproductive status of uterine cavity and fallopian tubes as a simple, safe and cheap outpatient method prior to any following invasive procedure or even histerosalpingography.

[Transvaginal sclerosing therapy of cystic ovarian lesions with alcohol]

AIM

Description of puncture technique for conservative treatment of cystic ovarian lesions.

METHOD

The cyst should be unilocular, sonolucent, with a smooth inner wall of the capsule, without septa and neovascularisation on transvaginal colour Doppler. Serum CA-125 levels must be lower than 35 U/ml. The capsule of the cyst was punctured with a 18 gauge needle, sonographically guided with a 5 MHz transvaginal probe. After complete emptying of the cyst, (cytological examination of the cystic fluid was negative), we injected an amount of sterile 96 % alcohol equalling 50 % of the volume of the cyst. The alcohol remained in the cyst for 5 minutes and was then aspirated completely.

RESULTS

152 patients aged 18 to 60 with an ovarian cyst volume between 40 and 140 ml were treated. Five of the patients (3.3 %) had intensive pelvic pain and therefore received intravenous analgesics. After three months, relapse appeared in 8 patients (5.3 %), in most of whom the volume of the cyst had been more than 100 ml.

CONCLUSION

The proposed puncture technique is simple and easily performed. Treatment with 96 % alcohol showed good results. In cases where the cyst volume exceeds 100 ml, we advise surgical treatment by laparoscopy or laparotomy.

[Electromyography of the uterus in monitoring pregnancies with symptoms of premature labor]

Characteristics of uterine muscle action potentials in 100 gravidas with symptoms of preterm labor or imminent abortion (presence of contractions with cervical changes) from 18th till the 32nd weeks of pregnancy are analysed. Twenty four gravidas with uncomplicated pregnancy were monitored electromyographically from the 20th weeks until term, once a week. There was low electrical activity in uncomplicated pregnancies up to 7 days before labor. A similar trend was observed in pregnancies that were finished before term. But, in symptomatic pregnancies finished preterm, the index of uterine muscle electrical activity (expressed in the percentage of voltage plus frequency) was continuously, although not significantly, above the values in symptomatic and asymptomatic term pregnancies. In only 2 out of 18 (11.1%) before term terminated pregnancies and in 45 out of 82 (54.9%) in term accomplished pregnancies, was electrical silence was registered during clinical symptoms (p less than 0.01). In preterm accomplished pregnancies, higher voltages and more frequent occurrence of biphasic and polyphasic spikes were registered (p less than 0.05), although the single parameter was of no prognostic significance. With a successful tocolytic treatment, the index of uterine muscle electrical activity was significantly reduced (from 57.16 to 20.86, t = 2.52, p less than 0.02) and was similar to that registered in symptomatic term pregnancies subjected to no tocolytic treatment. Although intravenous tocolysis was shown diminish voltage and frequency, in preterm delivered pregnancies no reduction in electrical activity was observed. Uterine electromyography could be used as a predictor of successful or unsuccessful tocolytic treatment.