Body composition in women with premature ovarian insufficiency using hormone therapy and the relation to cardiovascular risk markers: A case-control study.

OBJECTIVE: To compare body composition between women with premature ovarian insufficiency (POI) using hormone therapy and controls with normal ovarian function, and to correlate body composition with cardiovascular risk markers in the POI group. PATIENTS AND DESIGN: A case-control study of 70 women with POI matched by age and body mass index with 70 controls. MEASUREMENTS: All were submitted to whole-body dual-energy X-ray absorptiometry (DXA) to analyse body composition. In the POI group, total cholesterol, HDL-cholesterol, LDL-cholesterol, VLDL-cholesterol, triglycerides, glucose, insulin, transaminases and C-reactive protein levels were measured, as well as the thickness of the carotid artery intima-media complex. RESULTS: Total mass, fat mass, lean mass (total, percentage and index) and the android/gynoid (A/G) ratio were similar in both groups; however, bone mineral content was lower (P < .001) in the POI group. Lean and fat mass indexes were 14.19 ± 1.63 and 11.04 ± 3.58, respectively, and the percentage of gynoid to android fat was higher (51.17 ± 6.71% versus 47.74 ± 9.19%; A/G ratio = 0.93 ± 0.15) in the POI group. In addition, the increase in total mass correlated positively with glucose and ALT levels and negatively with HDL-cholesterol. Increased A/G ratio was the measurement most frequently associated with cardiovascular risk markers. CONCLUSION: The body composition of women with POI using hormone therapy is similar to that of women with normal ovarian function with regard to lean and fat mass content and fat distribution. In women with POI, the higher the A/G ratio, the worse the cardiovascular risk markers.

Quality of life in women with premature ovarian failure.

A cross-sectional and case-control study with a matching for age was performed to evaluate quality of life in 58 women with a diagnosis of premature ovarian failure (POF) and 58 women with normal ovarian function paired for age (± 2 years) (control group). In both groups were excluded women with chronic diseases and iatrogenic or genetic causes. Quality of life was evaluated using the WHOQOL-BREF. Although there were no statistically significant differences in quality of life in general between the two groups, there were statistically significant differences in mean scores in the physical health [61.3 ± 18.0 and 72.8 ± 16.4 for the POF and control groups, respectively (p < 0.0001)] and psychological domains [64.2 ± 16.7 and 69.3 ± 14.1, respectively (p = 0.0455)]. Having POF represented an approximately 2.5-fold greater risk of scoring poorly in the physical health and psychological domains. No statistically significant differences were found between the groups with respect to the social relationships or environment domains or for overall health. Women with POF have more difficulty with respect to their physical health and psychological aspects, indicating a need to provide adequate psychosocial and clinical support for these women to minimize the repercussion of this diagnosis on their activities and quality of life.

Hormonal treatment isolated versus hormonal treatment associated with electrotherapy for pelvic pain control in deep endometriosis: Randomized clinical trial.

OBJECTIVE: The aim of the study was to evaluate the clinical effectiveness of complementary treatment using self-applied electrotherapy treatment for pain control over the standard hormonal treatment alone for deep infiltrative endometriosis (DIE). STUDY DESIGN: Multicentre randomized clinical trial. We included a hundred-one participants with DIE in electrotherapy (n = 53) (hormonal treatment + electrotherapy) or control group (n = 48) (only hormonal treatment) by 8 weeks of follow-up. The primary measurement was chronic pelvic pain (CPP) using a visual analogue scale (VAS) and deep dyspareunia. The secondary outcomes were the quality of life by endometriosis health profile (EHP-30) and sexual function by female sexual function index (FSFI). RESULTS: CPP relief was observed only in the electrotherapy group (pre:7.11 ± 2.40, post:4.55 ± 3.08, p < 0.001). In terms of deep dyspareunia, improvements were observed for both groups (electrotherapy pre:2.02 ± 0.54-1.36 ± 0.96, p < 0.001; control pre:1.95 ± 0.86-1.68 ± 0.82, p = 0.006). Considering the secondary outcomes, a higher total score post-treatment for the EHP-30 was noted in both groups. Regarding sexual function, there was a statistically significant improvement in the FSFI score for the electrotherapy group (p < 0.001), with an increase in the scores for lubrication and pain domains (p = 0.013 and p < 0.001). CONCLUSIONS: Electrotherapy treatment using transcutaneous electrical nerve stimulation proved to be a good complementary option for pain control, showing benefits in the reduction of CPP and deep dyspareunia and improving patient's quality of life and sexual function.

Interferential current: a new option for the treatment of sexual complaints in women with premature ovarian insufficiency using systemic hormone therapy: a randomized clinical trial.

OBJECTIVE: The aim of the study was to evaluate the efficacy of interferential current (IC) in the sexual function of women with premature ovarian insufficiency (POI) using systemic hormone therapy (HT), compared to topical estriol. METHODS: A randomized clinical trial with 40 women with POI using systemic HT, who were sexually active and referred for dyspareunia and reduction of lubrication. The women were divided into two treatment groups for 4 weeks: IC group (eight electrotherapy sessions twice a week); or E group (estriol vaginal cream, daily application, 0.5 mg/d). The Female Sexual Function Index was used to evaluate pre-/posttreatment sexual function. RESULTS: Mean age was 37.13 ±â€Š7.27 years and mean treatment time with HT was 8.20 ±â€Š8.73 years, similar data for both groups. There was an improvement in global sexual function, lubrication, and pain domains for both treatments. The differences between the pre-/posttreatment lubrication scores were respectively 0.75 ±â€Š3.31 (P = 0.014) for IC and 1.16 ±â€Š1.22 (P < 0.001) for estriol, whereas for dyspareunia the differences were 1.00 ±â€Š1.47 (P = 0.005) for IC, and 0.68 ±â€Š1.30 (P = 0.006) for estriol. There was no pre-/posttreatment difference for the desire and arousal domains. Only in the IC group did orgasm (difference 0.90 ±â€Š1.42, P = 0.010) and satisfaction improve (difference 0.70 ±â€Š1.28, P = 0.021). CONCLUSION: The use of perineal IC seems to be a new option for women with POI using systemic HT and presenting with sexual complaints, leading to an improvement in pain, lubrication, satisfaction, and orgasm.

Gonadoblastoma-Associated Mixed Gonadal Germ Cell Tumor with Dysgerminoma and Hepatoid Yolk Sac Tumor Components in 46XY Gonadal Dysgenesis.

BACKGROUND: Disorders of sex development are congenital conditions with atypical chromosomal, gonadal, or anatomical sex development. Gonadal dysgenesis in patients containing a Y chromosome have a high risk of developing germ cell tumors with potential for malignant transformation. CASE: We present the case of a 17-year-old phenotypic female with primary amenorrhea and 46,XY complete gonadal dysgenesis. Pelvic ultrasound showed a solid cystic lesion in the right gonad. Pathology showed a gonadoblastoma-associated mixed gonadal germ cell tumor with dysgerminoma and hepatoid yolk sac tumor. SUMMARY AND CONCLUSION: To our knowledge, this mixed neoplasm association has not been previously reported and this case illustrates the challenges for the diagnosis of gonadal dysgenesis-associated tumors, emphasizing its recognition and prognostic implications.

Control of endometriosis-associated pain with etonogestrel-releasing contraceptive implant and 52-mg levonorgestrel-releasing intrauterine system: randomized clinical trial.

OBJECTIVE: To assess the efficacy of an etonogestrel (ENG)-releasing contraceptive implant or the 52-mg levonorgestrel-releasing intrauterine system (LNG-IUS) in the control of endometriosis-associated pelvic pain. DESIGN: Noninferiority randomized clinical trial in which women with endometriosis were assigned to use an ENG implant (experimental treatment) or an LNG-IUS (active comparator). Monthly follow-up visits were conducted up to 6 months. SETTING: University teaching hospital. PATIENT(S): One hundred three women, with endometriosis-associated chronic pelvic pain, dysmenorrhea, or both for more than 6 months. In cases of deep endometriosis, vaginal ultrasonography and magnetic resonance imaging were used as additional diagnostic tools. INTERVENTION(S): The ENG implant or the LNG-IUS were inserted within the first 5 days of the menstrual cycle. MAIN OUTCOME MEASURE(S): Daily scores of noncyclic pelvic pain and dysmenorrhea were evaluated using a daily visual analogue scale. Health-related quality of life was evaluated using the Endometriosis Health Profile-30 questionnaire at baseline and up to 6 months. Bleeding patterns were assessed daily from a menstrual calendar. RESULT(S): Both contraceptives improved significantly the mean visual analogue scale endometriosis-associated pelvic pain and dysmenorrhea, without significant differences between treatment group profiles. Health-related quality of life improved significantly in all domains of the core and modular segments of the Endometriosis Health Profile-30 questionnaire, with no difference between both treatment groups. The most common bleeding patterns at 180 days of follow-up were amenorrhea and infrequent bleeding and infrequent bleeding and spotting among ENG implant and LNG-IUS users, respectively. CONCLUSION(S): In this noninferiority study both contraceptives improved significantly pelvic pain, dysmenorrhea, and health-related quality of life in endometriosis. CLINICAL TRIAL REGISTRATION NUMBER: Clinicaltrials.gov under number NCT02480647.

Comparison of endometrial assessment by transvaginal ultrasonography and hysteroscopy.

OBJECTIVE: To compare transvaginal ultrasonography and hysteroscopy for the diagnosis of endometrial pathologies. METHODS: In the present retrospective cohort study, data were reviewed from women with ultrasonography findings suggestive of endometrial lesions and/or abnormal uterine bleeding who underwent hysteroscopy at a single center in Campinas, Brazil, between January 2011 and December 2013; data were stratified based on reproductive-aged and postmenopausal groups. The accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of ultrasonography and hysteroscopy for the diagnosis of endometrial lesions were determined. Histopathology was used as the gold standard. RESULTS: There were 754 patients included (256 reproductive age, 498 postmenopausal). In the reproductive-age group, ultrasonography had a sensitivity of 96.0%, specificity of 58.0%, PPV of 94.4%, NPV of 66.6%, and accuracy of 91.5%, whereas hysteroscopy had a sensitivity of 91.8%, specificity of 76.6%, PPV of 96.0%, NPV of 60.5%, and accuracy of 89.7% for the diagnosis of endometrial disease. In the postmenopausal group, ultrasonography had a sensitivity of 99.0%, specificity of 19.0%, PPV of 96.1%, NPV of 50.0%, and accuracy of 95.3%, whereas hysteroscopy had a sensitivity of 96.7%, specificity of 86.9%, PPV of 99.2%, NPV of 58.8%, and accuracy of 96.2%. CONCLUSION: Ultrasonography was found to be an effective method for the diagnosis of endometrial disease, especially among postmenopausal women.

WITHDRAWN: corrigendum to "Effectiveness of complementary pain treatment for women with deep endometriosis through Transcutaneous Electrical Nerve Stimulation (TENS): Randomized controlled trial" [Eur. J. Obstet. Gynecol. Reprod. Biol. 194 (2015) 1-6].

This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause.

Systematic review and meta-analysis of complementary treatments for women with symptomatic endometriosis.

BACKGROUND: Despite advances in treatments for endometriosis, some symptoms persist owing to the chronic inflammation observed in this disease. OBJECTIVE: To identify resources, methods, and/or complementary treatments to alleviate the pain symptoms of endometriosis, and to identify adverse effects of treatments. SEARCH STRATEGY: Lilacs, Scielo, PEDro, Scopus, Pubmed, CENTRAL Cochrane, Science Direct, and Google Scholar were searched for studies published in Portuguese, English, and Spanish to July 31, 2017, using the terms "physical therapy" OR "complementary treatment" AND "endometriosis". SELECTION CRITERIA: Randomized controlled trials relating to complementary pelvic pain treatment and adverse effects. DATA COLLECTION AND ANALYSIS: Eight studies were identified; two studies were included in the meta-analysis. MAIN RESULTS: The complementary interventions studied were acupuncture, exercise, electrotherapy, and yoga. All were inconclusive in affirming benefit, but demonstrated a positive trend in the treatment of symptoms of endometriosis. Meta-analysis of acupuncture showed a significant benefit in pain reduction as compared with placebo (P=0.007). CONCLUSIONS: Numerous complementary treatments have been used to alleviate the symptoms of endometriosis, but only acupuncture has demonstrated a significant improvement in outcomes. Nevertheless, other approaches demonstrated positive trends toward improving symptoms; this should encourage investigators to design controlled studies to support their applicability.

Efficacy of misoprostol before diagnostic hysteroscopy in postmenopausal women: a randomized clinical trial.

OBJECTIVE: To evaluate pain and determine the efficacy of misoprostol, compared with placebo, for postmenopausal women before diagnostic hysteroscopy. METHODS: This randomized, double-blind, placebo-controlled clinical trial included 158 postmenopausal women who received either 200 µg of misoprostol or placebo through the vaginal route before diagnostic hysteroscopy (79 women/group). The primary outcome was pain assessment (presence and intensity) during the four steps of hysteroscopy: cervical grasping with a Pozzi tenaculum forceps immediately before hysteroscopy, during hysteroscopy, during performance of the endometrial biopsy, and postprocedure. The secondary outcomes were duration of the procedure, need for additional cervical dilatation, complications, and adverse effects. RESULTS: Mean ages of the women were 62 ±â€Š8.2 years and 60 ±â€Š7.3 years in the misoprostol and placebo groups, respectively. Abnormal bleeding (misoprostol group, 45.6%; placebo, 43%) and endometrial thickening (54.4% in the misoprostol group and 57% in the placebo group) were the most common indications for the examination in both groups (P = 0.49). There was no significant difference between groups in the pain intensity of the four steps of the procedure. The duration of hysteroscopy was similar in both groups (misoprostol group, 2.5 ±â€Š2.7 minutes; placebo, 2.1 ±â€Š1.6 minutes; P = 0.43). Additional cervical dilatation was needed in 11 women in the misoprostol group versus 9 in the placebo group (P = 0.63). In both groups, there was no significant difference in terms of complications. Adverse effects were reported by 25.3% of women using misoprostol (vaginal bleeding, 11.3%; cramping, 12.6%; diarrhea, 2.5%; 1 woman reported both vaginal bleeding and cramping). In the placebo group, only 2.5% of women developed adverse effects (P < 0.0001). CONCLUSION: Misoprostol does not reduce pain intensity, the duration of the procedure, or need for additional cervical dilatation, and causes more adverse effects when used in postmenopausal women before diagnostic hysteroscopy.

Skewed X-chromosome inactivation and shorter telomeres associate with idiopathic premature ovarian insufficiency.

OBJECTIVE: To analyze whether telomere length, X-chromosome inactivation (XCI), and androgen receptor (AR) GAG polymorphism are related to idiopathic premature ovarian insufficiency (POI). DESIGN: Case-control study. SETTING: University hospital. PATIENT(S): A total of 121 women, including 46 nonsyndromic POI and 75 controls. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Age, weight, height, body mass index (BMI), systolic and diastolic arterial pressure, E2, androstenedione, T, and C-reactive protein were assessed. Telomere length was estimated by quantitative real-time polymerase chain reaction, XCI was measured using the Human Androgen Receptor and X-linked retinitis pigmentosa 2 (RP2) methylation assays. AR and FMR1 polymorphism was assessed by quantitative fluorescent polymerase chain reaction and sequencing. RESULT(S): Premature ovarian insufficiency women had a higher mean age, weighed less, and exhibited lower C-reactive protein, E2, and androstenedione levels. The AR polymorphism did not differ between the groups. Four patients had premutation (55-200 CGG repeats), and none displayed a full mutation in the FMR1 gene. However, patients with POI showed shorter telomere length and higher frequency of skewed XCI. Extreme skewing (≥90%) was observed in 15% of women with POI, and shorter telomeres correlated with XCI skewing in both groups. CONCLUSION(S): Skewed XCI and shortened telomere length were associated with idiopathic POI, despite no alterations in the AR and FMR1 genes. Additionally, there is a tendency for women with short telomeres to exhibit skewed XCI.

Effectiveness of complementary pain treatment for women with deep endometriosis through Transcutaneous Electrical Nerve Stimulation (TENS): randomized controlled trial.

OBJECTIVE: Evaluate TENS effectiveness as a complementary treatment of chronic pelvic pain and deep dyspareunia in women with deep endometriosis. STUDY DESIGN: This randomized controlled trial was performed in a tertiary health care center, including twenty-two women with deep endometriosis undergoing hormone therapy with persistent pelvic pain and/or deep dyspareunia. This study was registered in the Brazilian Record of Clinical Trials (ReBEC), under n RBR-3rndh6. TENS application for 8 weeks followed a randomized allocation into two groups: Group 1 - acupuncture-like TENS (Frequency: 8Hz, pulse duration: 250µs) - VIF (n=11) and Group 2 - self-applied TENS (Frequency: 85Hz, pulse duration: 75µs) (n=11). The intensity applied was "strong, but comfortable". We evaluated patients before and after treatment by the use of the Visual Analogue Scale, Deep Dyspareunia Scale and Endometriosis Quality of Life Questionnaire. We used the Wilcoxon and Mann-Whitney tests to compare before and after treatment conditions. RESULTS: Despite the use of hormone therapy for 1.65±2.08 years, the 22 women with deep endometriosis sustained pelvic pain complaints (VAS=5.95±2.13 and 2.45±2.42, p<.001) and/or deep dyspareunia (DDS=2.29±0.46 and 1.20±1.01, p=.001). We observed significant improvement for chronic pelvic pain, deep dyspareunia and quality of life by the use of TENS. Both application types of TENS were effective for improving the evaluated types of pain. CONCLUSIONS: Both resources (acupuncture-like TENS and self-applied TENS) demonstrated effectiveness as a complementary treatment of pelvic pain and deep dyspareunia, improving quality of life in women with deep endometriosis regardless of the device used for treatment.

Factors associated with the reduction of bone density in patients with gonadal dysgenesis.

OBJECTIVE: To correlate bone mineral density (BMD) in women with primary hypoestrogenism caused by 46,XX pure gonadal dysgenesis or Turner's syndrome with age, age at estrogen therapy initiation, length of estrogen use, and body mass index (BMI). DESIGN: Cross-sectional study. SETTING: Academic tertiary-care hospital. PATIENT(S): Thirty-eight women, aged 16 to 35 years (mean, 24.6 years), affected by these genetic disorders. INTERVENTION(S): Measurement of lumbar spine and femoral neck BMD using double x-ray absorptiometry. The results were correlated with the control variables by using Pearson's coefficient of correlation. Variables associated with BMD were evaluated by multiple linear regression analysis. MAIN OUTCOME MEASURE(S): Bone mineral density. RESULT(S): Bone mineral density of the lumbar spine showed that 90% of the women presented osteopenia or osteoporosis. The femoral neck was affected in 55% of these women. The length of estrogen therapy and the BMI showed a positive association with BMD at the lumbar spine and femoral neck, respectively. CONCLUSION(S): Women affected by pure gonadal dysgenesis or Turner's syndrome presented a marked decrease in BMD of the lumbar spine and femoral neck. Medical attention for their diagnosis and early hormone replacement therapy are advised.