Special Considerations for Women of Reproductive Age on Anticoagulation.

Anticoagulation poses unique challenges for women of reproductive age. Clinicians prescribing anticoagulants must counsel patients on issues ranging from menstruation and the possibility of developing a hemorrhagic ovarian cyst to teratogenic risks and safety with breastfeeding. Abnormal uterine bleeding affects up to 70% of young women who are treated with anticoagulation. As such, thoughtful clinical guidance is required to avoid having young women who are troubled by their menses, dose reduce, or prematurely discontinue their anticoagulation, leaving them at increased risk of recurrent thrombosis. Informed by a review of the medical literature, we present current recommendations for assisting patients requiring anticoagulation with menstrual management, prevention of hemorrhagic ovarian cysts, and avoiding unintended pregnancy. The subdermal implant may be considered a first-line option for those requiring anticoagulation, given its superior contraceptive effectiveness and ability to reliably reduce risk of hemorrhagic ovarian cysts. All progestin-only formulations-such as the subdermal implant, intrauterine device, injection, or pills-are generally preferred over combined hormonal pills, patch, or ring. Tranexamic acid, and in rare cases endometrial ablation, may also be useful in managing menorrhagia and dysmenorrhea. During pregnancy, enoxaparin remains the preferred anticoagulant and warfarin is contraindicated. Breastfeeding women may use warfarin, but direct oral anticoagulants are not recommended given their limited safety data. This practical guide for clinicians is designed to inform discussions of risks and benefits of anticoagulation therapy for women of reproductive age.

A prospective, randomized study of Toremifene vs. tamoxifen for the treatment of premenopausal breast cancer: safety and genital symptom analysis.

BACKGROUND: Toremifene (TOR) is a selective oestrogen receptor modulator (SERM) and has comparable efficacy to that of tamoxifen (TAM) in breast cancer patients. Herein, we compared the safety of TOR to that of TAM in the adjuvant treatment of premenopausal breast cancer. METHODS: This was a prospective randomized and open-label clinical study. Premenopausal patients with hormonal receptor (HR)-positive early breast cancer were randomly assigned (1:1) to receive TOR) or TAM treatment. The follow-up period was 1 year. The primary end point was the incidence of ovarian cysts, and secondary end points were the incidence of endometrial thickening, changes in female hormones, the incidence of fatty liver, changes in the modified Kupperman index (mKMI) and changes in quality of life. RESULTS: There were 92 patients in the final analysis. The incidences of ovarian cysts were 42.6% in the TOR group and 51.1% in the TAM group (p = 0.441). Forty-one patients (87.2%) in the TOR group and 36 patients (80.0%) in the TAM group experienced endometrial thickening (p = 0.348). The proportions of patients with fatty liver were 31.9% in the TOR group and 26.7% in the TAM group (p = 0.581). No significant differences in the mKMI or quality of life were observed between the two groups. CONCLUSIONS: TOR and TAM have similar side effects on the female genital system and quality of life in premenopausal early breast cancer patients. TRIAL REGISTRATION: ClinicalTrials.gov NCT02344940. Registered 26 January 2015 (retrospectively registered).

Ovarian cyst formation in women of reproductive age receiving mitotane as part of the treatment of adrenocortical carcinoma: Clinical and experimental observations.

INTRODUCTION: Mitotane is an adrenolytic drug that is used as an adjuvant to treat adrenocortical carcinoma. This study aimed to evaluate the clinical course and pathogenetic mechanisms underlying ovarian cyst formation in women of reproductive age diagnosed with adrenocortical carcinoma and being treated with mitotane as an adjuvant to surgery. MATERIAL AND METHODS: Five women presented with stage III-IV adrenocortical carcinoma and ovarian cyst formation during mitotane treatment. The clinical course of the disease was followed during and after treatment. The effects of mitotane on progesterone production and cell proliferation were studied in cultured human ovarian granulosa cells. RESULTS: Computed tomography and vaginal ultrasonography during mitotane treatment repeatedly demonstrated ovarian cysts of varying size without solid intralocular structures. Two women became amenorrheic during the treatment period. After mitotane cessation, the ovarian cysts disappeared and normal menstrual cycles resumed. One woman had an uncomplicated pregnancy two years after mitotane treatment. In one woman, who underwent salpingo-oophorectomy, histological analysis demonstrated benign ovarian cysts. Mitotane impeded the synthesis of progesterone, reduced the stimulatory effect of gonadotropins on progesterone formation, and reduced labeling with [3 H]thymidine in cultured granulosa cells. CONCLUSIONS: Therapeutic concentrations of mitotane are associated with the formation of benign ovarian cysts and amenorrhea. Mitotane-induced suppression of ovarian steroidogenesis and impediment of the proliferative capacity of steroid-producing cells are suggested potential pathogenetic mechanisms underlying mitotane-induced ovarian dysfunction and cyst development. Mitotane treatment does not compromise future ovarian function.

Induction of cystic ovarian follicles (COFs) in cattle by using an intrafollicular injection of indomethacin.

The aim of this study was to establish a model to induce cystic ovarian follicles (COFs) in cattle using the cyclooxygenase inhibitor, indomethacin. Eighteen Holstein-Frisian cattle were synchronized with prostaglandin F2alpha (PGF2α) and gonadotropin-releasing hormone (GnRH). Ultrasound-guided transvaginal intrafollicular injections were performed in 23 preovulatory follicles with different concentrations of indomethacin 16 h after GnRH administration. An injection of 0.2 ml 35 µM indomethacin solution (resulting in a final concentration of 8 µg/ml in the follicular fluid) was the minimal dosage leading to COF formation. The induced COFs reached a maximum mean diameter of 36.9 ± 4.5 mm eleven days after injection. The estrous cycle was extended to 25-39 days. Luteinization was first observed 4 days after injection, accompanied by a slight increase in plasma progesterone concentration. The bioactivity of indomethacin was demonstrated by the decrease of prostaglandin E2 in the follicular fluid of three animals. The method presented here is minimally invasive and allows for the generation of defined COFs for further investigations.

Expression of TGFBR1, TGFBR2, TGFBR3, ACVR1B and ACVR2B is altered in ovaries of cows with cystic ovarian disease.

The objective of this study was to examine the expression of transforming growth factor beta receptor (TGFBR)1, TGFBR2, TGFBR3, activin receptor (ACVR)1B and ACVR2B in ovaries of cows with cystic ovarian disease (COD). The expression of the selected receptors was determined by immunohistochemistry in sections of ovaries from cows with ACTH-induced and spontaneous COD. Expression of TGFBR1 and TGFBR3 was higher in granulosa cells of cysts from cows with spontaneous COD than in tertiary follicles from the control group. Additionally, TGFBR3 expression was higher in granulosa cells of cysts from cows with ACTH-induced COD than in those from the control group and lower in theca cells of spontaneous and ACTH-induced cysts than in tertiary control follicles. There were no changes in the expression of TGFBR2. ACVR1B expression was higher in granulosa cells of tertiary follicles of cows with spontaneous COD than in the control group, whereas ACVR2B expression was higher in cysts of the spontaneous COD group than in tertiary follicles from the control group. The alterations here detected, together with the altered expression of the ligands previously reported, indicate alterations in the response of the ligands in the target cells, modifying their actions at cellular level.

Prenatal exposure to an environmentally relevant phthalate mixture disrupts reproduction in F1 female mice.

Phthalates are used in a large variety of products, such as building materials, medical devices, and personal care products. Most previous studies on the toxicity of phthalates have focused on single phthalates, but it is also important to study the effects of phthalate mixtures because humans are exposed to phthalate mixtures. Thus, we tested the hypothesis that prenatal exposure to an environmentally relevant phthalate mixture adversely affects female reproduction in mice. To test this hypothesis, pregnant CD-1 dams were orally dosed with vehicle (tocopherol-stripped corn oil) or a phthalate mixture (20 and 200µg/kg/day, 200 and 500mg/kg/day) daily from gestational day 10 to birth. The mixture was based on the composition of phthalates detected in urine samples from pregnant women in Illinois. The mixture included 35% diethyl phthalate, 21% di(2-ethylhexyl) phthalate, 15% dibutyl phthalate, 15% diisononyl phthalate, 8% diisobutyl phthalate, and 5% benzylbutyl phthalate. Female mice born to the exposed dams were subjected to tissue collections and fertility tests at different ages. Our results indicate that prenatal exposure to the phthalate mixture significantly increased uterine weight and decreased anogenital distance on postnatal days 8 and 60, induced cystic ovaries at 13months, disrupted estrous cyclicity, reduced fertility-related indices, and caused some breeding complications at 3, 6, and 9months of age. Collectively, our data suggest that prenatal exposure to an environmentally relevant phthalate mixture disrupts aspects of female reproduction in mice.

Role of Glucocorticoids in Cystic Ovarian Disease: Expression of Glucocorticoid Receptor in the Bovine Ovary.

The aim of this study was to characterize the expression of glucocorticoid receptor (GR) in the components of normal bovine ovary and in animals with cystic ovarian disease (COD). Changes in the protein and mRNA expression levels were determined in control cows and cows with COD by immunohistochemistry and real-time PCR. GR protein expression in granulosa cells was higher in cysts from animals with spontaneous COD and adrenocorticotropic hormone-induced COD than in tertiary follicles from control animals. In theca interna cells, GR expression was higher in cysts from animals with spontaneous COD than in tertiary follicles from control animals. The increase in GR expression observed in cystic follicles suggests a mechanism of action for cortisol and its receptor through the activation/inactivation of specific transcription factors. These factors could be related to the pathogenesis of COD in cattle.

[Ovarian cysts and hyperestrogenia as a result of treatment with tamoxifen in breast cancer patients of reproductive age].

There is considered one of the side effects of tamoxifen - the formation of ovarian cysts associated by also excessive production of estradiol. Data on likely mechanism of development of hyperestrogenia and its possible influence on anti-tumor effect of tamoxifen are presented.

Altered expression of transforming growth factor-beta isoforms in bovine cystic ovarian disease.

Cystic ovarian disease (COD) is one of the main causes of infertility in dairy cattle. It has been shown that intra-ovarian factors may contribute to follicular persistence. Transforming growth factor-beta (TGFB) isoforms are important paracrine and autocrine signalling molecules that regulate ovarian follicle growth and physiology. Considering the importance of these factors in the ovarian physiology, in this study, we examined the expression of TGFB isoforms (TGFB1, TGFB2 and TGFB3) in the ovary of healthy cows and animals with spontaneous and adrenocorticotrophic hormone (ACTH)-induced COD. In the oestrous-synchronized control group, the expression of TGFB1 in granulosa and theca cells was higher in spontaneous cysts than in atretic or tertiary follicles. When we compared TGFB2 expression in granulosa cells from atretic or tertiary follicles from the oestrous-synchronized control group with that in ACTH-induced or spontaneous follicular cysts, we found a higher expression in the latter. The expression of the TGFB isoforms studied was also altered during folliculogenesis in both the spontaneous and ACTH-induced COD groups. As it has been previously shown that TGFB influences steroidogenesis, ovarian follicular proliferation and apoptosis, an alteration in its expression may contribute to the pathogenesis of this disease.

Supraphysiological leptin levels shift the profile of steroidogenesis in porcine ovarian follicles toward progesterone and testosterone secretion through increased expressions of CYP11A1 and 17b-HSD: a tissue culture approach.

Evidence from both clinical and animal studies suggests that exposure to excess androgens results in cyst formation. The present in vitro study assessed the effects of supraphysiological concentrations of leptin (20 and 40 ng/ml) on progesterone (P(4)), androstenedione androstendione (A(4)), testosterone and estradiol (E(2)) secretion by ELISA and the expression of CYP11A1, CYP17, 17b-hydroxysteroid dehydrogenase (17b-HSD) and CYP19 by western blot to answer the question of whether leptin could be independent risk factor for cystformation in pigs. Small- and medium-sized ovarian follicles were collected from prepubertal and cycling pigs. Increased P(4) and testosterone secretions were observed in both small- and medium-sized follicles in prepubertal and cycling animals whereas there was no change in E2 secretion. Leptin treatment resulted in an increase in CYP11A1 and 17b-HSD protein expression but had no effect on CYP17 and CYP19 expression in follicles of either size from prepubertal and cycling pigs. Results of presented data suggest that leptin in elevated doses, by stimulatory effect on CYP11A1 and 17b-HSD protein expression resulting in elevated P(4) and testosterone secretions could be an independent risk factor for cyst formation in both prepubertal and cycling pigs.

Ovarian cysts during tamoxifen use may affect the prognostic markers of premenopausal breast cancer.

OBJECTIVES: Only a few studies have suggested the association between ovarian cysts and serum estrogen levels during tamoxifen use. However, increased estrogen levels with ovarian cysts would affect the prognosis of breast cancer; this association has not yet been studied. We aimed to investigate the association between ovarian cysts and prognostic markers in premenopausal breast cancer patients undergoing tamoxifen treatment. METHODS: A retrospective review of 65 premenopausal breast cancer patients who underwent tamoxifen treatment was performed. Serum hormone levels were measured either specifically between cycle days 2 and 5 in menstruating patients or at any time in amenorrheic participants. RESULTS: The study population consisted of premenopausal patients with (n = 23) and without ovarian cysts (n = 42). Serum estradiol (E(2)) levels and tumor markers were not statistically different based on ovarian cyst status. In the subgroup analysis, serum E(2) levels were significantly higher in menstruating women with ovarian cysts, and E(2) levels were positively correlated with serum cancer antigen 15-3 and insulin-like growth factor-1 in these women. CONCLUSIONS: Ovarian cysts during tamoxifen use may affect the markers associated with the clinical course of premenopausal breast cancer.

Unfavorable biological behavior and treatment response of neuroendocrine ovarian metastases of midgut neuroendocrine tumors.

Neuroendocrine ovarian metastases (NOM) predominantly derive from midgut neuroendocrine tumors (NETs) and develop in about 25% of women with advanced stage of this malignancy. Little is known of the growth rate and treatment response of NOM. We therefore evaluated the efficacy of different management options for patients with NOM, including peptide receptor radionuclide therapy (PRRT), somatostatin analogues (SSAs) and oophorectomy. Records were screened for patients with well-differentiated NOM of midgut origin that presented in our NET referral center between 1991 and 2022. Progression-free survival (PFS) and tumor growth rate (TGR) of ovarian and extra-ovarian metastases were determined using RECIST (response evaluation criteria in solid tumors) 1.1. In 12 available patients undergoing PRRT, NOM were associated with a shorter PFS than extra-ovarian metastases (P = 0.003). While PRRT induced a similar decrease in TGR for ovarian and extra-ovarian lesions in nine patients with available data (-2.3 vs -1.4, P > 0.05), only the TGR of NOM remained positive after PRRT. In 16 patients treated with SSAs, the TGR of NOM was almost three times that of extra-ovarian lesions during treatment (2.2 vs 0.8, P = 0.011). Oophorectomy was performed in 46 of the 61 included patients and was significantly associated with a prolonged OS (115 vs 38 months, P < 0.001). This association persisted after propensity score matching and correction for tumor grade and simultaneous tumor debulking. In conclusion, NOM have a higher TGR compared to extra-ovarian metastases, resulting in a shorter PFS after PRRT. Bilateral salpingo-oophorectomy should be considered for postmenopausal women with NOM undergoing surgery for metastatic midgut NETs.

Alternative treatment of ovarian cysts with Tribulus terrestris extract: a rat model.

Tribulus terrestris has long been used in traditional medicine to treat impotency and improve sexual functions in man. The aim of this study was to evaluate the efficiency of T. terrestris extract in the treatment of polycystic ovary (PCO) in Wistar rat. Estradiol valerate was injected to 15 mature Wistar rats to induce PCO. Rats were randomly divided into three groups (control, low-dose and high-dose groups) of five each and received 0, 5 and 10 mg of T. terrestris extract, respectively.Treatments began on days 50 and 61 after estradiol injection; at the same time, vaginal smear was prepared. The ovaries were removed on day 62, and histological sections were prepared accordingly. The number and diameter of corpora lutea, thickness of the theca interna layer and the number of all follicles were evaluated in both ovaries. In comparison with the control group, the number of corpora lutea and primary and secondary follicles significantly increased following T. terrestris treatment; however, the number of ovarian cysts significantly decreased. It can be concluded that T. terrestris have a luteinizing effect on ovarian cysts, which may relate to its gonadotropin-like activity; also, a high dose of the extract can efficiently remove ovarian cysts and resume ovarian activity.

Follicular persistence induced by adrenocorticotropic hormone administration in goats.

The objective of the present study was to examine the effect of adrenocorticotropic hormone (ACTH) administration on the induction of persistent cystic follicle in the goat in order to establish a method to experimentally induce cystic follicle. Four cross-bred goats were intramuscularly administered ACTH at 0.78 and 6.25 µg/10 kg twice a day from Days 15 to 21 (Day 0 was defined as the day of last estrus). Follicular status in the ovary was monitored by ultrasound examination. The plasma concentrations of estradiol, progesterone and cortisol were measured. Treatment with ACTH at the 0.78 and 6.25 µg/10 kg levels caused persistent follicles (> 10 days delay from the expected ovulation date) in 50% of the goats in both treatment groups. In those animals, ovulation occurred 17 and 27 days and 11 and 12 days after the expected days in the 0.78 and 6.25 µg/10 kg groups, respectively. The maximum follicle diameters were 10 and 9 mm in the 0.78 and 6.25 µg/10 kg ACTH groups, respectively. In the control group, the estradiol concentration increased on Day 18 and remained at a high level for a few days. However, such an increase was not seen in both ACTH groups. The estradiol concentration increased gradually from Days 21 to 27 in the 6.25 µg/10 kg ACTH group. These results suggest the possibility that ACTH induces persistent follicles in goats, which may be related to the delay of the onset of estradiol secretion followed by its maintenance at a high concentration.

mTOR inhibitors and risk of ovarian cysts: a systematic review and meta-analysis.

OBJECTIVE: To summarise the available evidence on frequency of ovarian cyst development during mammalian target of rapamycin inhibitors (mTORi) treatment. METHODS: PubMed/Medline and EMBASE databases were searched, from 1990 up to March 2020, using the following keywords: 'tacrolimus', 'sirolimus', 'temsirolimus', 'everolimus', 'deforolimus', 'mTOR' and 'ovarian cysts' (Limit: Human, English, full article). Studies were selected for the review if they met the following criteria: clinical studies, studies reporting original data, studies reporting the number of patients using mTORi, studies reporting the number of patients with ovarian cysts.We selected 7 of 20 retrieved studies. Study design, population, sample size, criteria for diagnosis of ovarian cysts, drug doses and follow-up length were extracted. Pooled estimate of incidence was calculated for ovarian cysts as a percentage, with 95% CI. RESULTS: Four hundred-six women were included in the selected studies. The pooled incidence was 37.0% (95% CI 16.0% to 58.1%) for all ovarian cysts, and 17.3% (95% CI 5.6% to 29.1%) for clinically significant ovarian cysts. Based on two articles, comparing mTORi and non-mTORi for immunosuppression, pooled OR for ovarian cyst incidence was 4.62 (95% CI 2.58 to 8.28). CONCLUSION: Ovarian cyst development is a common adverse event during immunosuppression treatment with mTORi. These cysts are benign conditions, but they require pelvic ultrasound follow-up and in some cases hospital admission and surgery.

The effect of ovarian cyst aspiration on IVF treatment with GnRH.

OBJECTIVE: The formation of cysts during IVF treatment may negatively influence the outcome. The aim of this study is to compare conservative management versus aspiration for functional ovarian cysts before ovarian stimulation for ART. MATERIALS AND METHODS: Women who underwent IVF cycle with a long protocol, and developed ovarian cysts, they were randomly divided into a cyst aspiration group (n = 90) in which the cysts were aspirated after diagnosis and a no-intervention group (n = 90) for which the conservative treatment was continued following cyst diagnosis. RESULTS: The FSH level in women with ovarian cysts in the aspiration group was significantly higher than that in the no-intervention group (9.1 +/- 4.5 vs. 6.5 +/- 1.78 mIU/ml, p = 0.001). HMG requirement in that aspiration group was significantly higher than that in the non- intervention group (26.2 +/- 9.7 vs. 21.85 +/- 7.7, p = 0.0001). The embryo score in the no-intervention group was higher than the aspiration group (18 vs. 16, p = 0.0001).The cycle cancellation rate was significantly higher in the aspiration group than the no-intervention group. The pregnancy rate was higher but not significantly in the aspiration group than no-intervention group. CONCLUSION: Cyst aspiration did not promote retrieved oocyte in quality and in number. Because cyst aspiration requires anesthesia and is expensive, conservative management is better and without improving the IVF outcome.

Letrozole and human menopausal gonadotropin for ovulation induction in clomiphene resistance polycystic ovary syndrome patients: A randomized controlled study.

OBJECTIVE: To compare the effects of letrozole and human menopausal gonadotropin (HMG) in the treatment of patients with polycystic ovary syndrome (PCOS) resistant to clomiphene citrate (CC). METHODS: A total of 96 clomiphene resistance polycystic ovary syndrome patients infertility were randomly divided into an LE group, and HMG group (n = 48). LE group orally received letrozole at 5.0 mg/d on the 3rd-5th days of menstrual cycle for 5 consecutive days, and 75 U/d HMG was given through intramuscular injection for 5 days starting from the third day of menstrual cycle in HMG group. Number of growing and mature follicles, serum E2 (pg/mL), serum P (ng/mL), endometrial thickness, occurrence of pregnancy and miscarriage were observed. RESULTS: There was no significant difference in the number of ovulation cycles between the 2 groups (53.6% vs 64.7%, P > .05). The number of mature follicular cycles in the HMG group was higher than that of the letrozole group (P < .01). There were no significant differences in the clinical pregnancy rate (22.9% vs 27.1%, P > .05) and abortion rate (6.2% vs 10.4%, P > .05). There was no significant difference in the endometrial thickness between the 2 groups on the day of HCG injection [(9.1 ±â€Š0.2) mm vs (10.7 ±â€Š1.6) mm, P > .05]; the serum estradiol (E2) was lower in the letrozole group. The incidence of ovarian cysts was lower than that of HMG group (P < .05). There was2 ovarian hyperstimulation syndrome in the letrozole group; the incidence of ovarian hyperstimulation syndrome in the HMG group was 12.5%. CONCLUSION: Letrozole-induced ovulation can obtain ovulation rate and pregnancy rate similar to gonadotropin, but reduce the risk associated with treatment. It can be used as an effective ovulation option for patients with polycystic ovary syndrome who are resistant to clomiphene.

DDT administered to neonatal rats induces persistent estrus syndrome.

The o,p'-isomer of the insecticide DDT when injected into neonatal female rats significantly advanced puberty, induced persistent vaginal estrus after a period of normal estrous cycles, and caused the ovaries to develop follicular cysts and a reduced number of corpora lutea. The uterotropic response to administered estradiol was reduced, and the female pattern of mating behavior was slightly disturbed. Residues of DDT in ovarian, brain, and adipose tissues of the adult animals were the same in both treated and control groups.

Treatment of clomiphene citrate-related ovarian cysts in a prospective randomized study. A single center experience.

AIM: The present study aims to compare the effectiveness of placebo, low dose and very low dose oral contraceptives (OC) in the treatment of clomiphene citrate (CC)-related ovarian cysts. METHODS: A prospective randomized placebo controlled study was undertaken at the Infertility Department of Dr. Zekai Tahir Burak Women's Health Education and Research Hospital. A total of 3250 primary infertile patients were administered CC for ovulation induction because of ovulatory dysfunction and/or unexplained infertility. One hundred and eighty-six women who were diagnosed with CC-related ovarian cysts greater than 20 mm on the third day of the following menstrual cycle, were eligible for the study. Group 1 (n = 62) was treated with very low dose OC (100 microg levonorgestrel + 20 microg ethinyl estradiol [EE]), group 2 (n = 62) with low dose OC (150 microg desogestrel + 30 microg EE) and group 3 (n = 62) with a placebo. The first control was 4 weeks later. Women with persistent cysts (n = 57) were called in 4 weeks later to continue the same treatment. RESULTS: Demographic data were similar among the groups. At the first month, the regression rates of ovarian cysts were 64.5, 61.3 and 66.1% in groups 1, 2 and 3, respectively (P = 0.849). Among the 57 women (20, 19 and 18 from groups 1, 2 and 3, respectively) with persistent cysts, the regression rates were 65.0, 63.2 and 55.6%, respectively at the second month (P = 0.821). Persistence of ovarian cysts was significantly higher in women with a longer duration of CC treatment than in women with a shorter duration (P < 0.001). CONCLUSION: Any treatment might be appropriate for patients with a CC-related ovarian cyst. However, there is no evidence to administer OC for treating CC-related ovarian cysts. Expectant management may also achieve similar success rates.