Management of women with abnormal uterine bleeding: Clinical practice guidelines of the French National College of Gynaecologists and Obstetricians (CNGOF).

OBJECTIVE: To provide French guidelines for the management of women with abnormal uterine bleeding (AUB). DESIGN: A consensus committee of 26 experts was formed. A formal conflict-of-interest policy was developed at the beginning of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding (i.e. pharmaceutical or medical device companies). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. METHODS: The last guidelines from the Collège National des Gynécologues et Obstétriciens Français on the management of women with AUB were published in 2008. The literature seems now sufficient for an update. The committee studied questions within 7 fields (diagnosis; adolescents; idiopathic AUB; endometrial hyperplasia and polyps; type 0-2 fibroids; type 3 or higher fibroids; and adenomyosis). Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and evidence profiles were compiled. The GRADE® methodology was applied to the literature review and the formulation of recommendations. RESULTS: The experts' synthesis work and the application of the GRADE method resulted in 36 recommendations. Among the formalized recommendations, 19 are strong and 17 weak. No response was found in the literature for 14 questions. We chose to abstain from recommendations rather than providing advice based solely on expert clinical experience. CONCLUSIONS: The 36 recommendations make it possible to specify the diagnostic and therapeutic strategies for various clinical situations practitioners encounter, from the simplest to the most complex.

Hormone-dependent gynaecological disorders and contraceptive modalities in women with a history of venous thromboembolic event: The THROMBOGYN study.

CONTEXT: Hormone-dependent gynaecological disorders, such as polycystic ovary syndrome (PCOS) or endometriosis, have been recently discussed as potential risk factors for venous thromboembolism (VTE). Combined hormonal contraceptive (CHC) therapy, which is a well-known risk factor for VTE, is usually used to alleviate symptoms related to these gynaecological disorders. Nevertheless, prevalence of hormone-dependent gynaecological disorders at the time of VTE event and the management of hormonal contraceptives are not well known. OBJECTIVE: To assess retrospectively the prevalence of hormone-dependent gynaecological disorders in patients with VTE event and the hormonal therapy at the time of VTE event and at the time of inclusion in the present study. METHODS: Women aged between 18 to 50-year-old who were hospitalized at Saint-Joseph Hospital (Paris) for a VTE event from January 1st, 2016 to December 31st, 2020 were included in this retrospective observational study. RESULTS: In total, 125 women were included. At the time of VTE event, mean age was 39-years-old (±8) and mean body mass index (BMI) 26kg/m2 (±8). Pulmonary embolism represented more than two third (68%) of VTE events. Fourteen women (11%) had PCOS and among them, 6 (43%) were using CHC. Eleven women (9%) had endometriosis and among them, 1 (9%) was using CHC. Women with PCOS appeared to be younger at the time of VTE compared to non-PCOS women (mean age 32 years (±6.0) vs. 40 years (±8.0), respectively, P<0.001), whereas women with endometriosis were older with a mean age of 43-year-old (±7.8), which did not differ significantly from women without endometriosis. Among PCOS women, 1 (7%) VTE event was idiopathic, whereas among those with endometriosis, 5 (46%) VTE events were idiopathic. Regarding contraceptive use at the time of inclusion, with a mean delay between VTE event and inclusion of 3 years (±1), 1 woman pursued CHC, 35 (28%) used non-hormonal contraceptive. Seventy-three women (58%) were aware of hormonal contraindications due to VTE event. CONCLUSION: The present study, including 125 young women with a mean age of 39 years, allowed a description of gynecological pathologies and history of contraceptive use potentially involved in VTE events.

Management of postmenopausal women: Collège National des Gynécologues et Obstétriciens Français (CNGOF) and Groupe d'Etude sur la Ménopause et le Vieillissement (GEMVi) Clinical Practice Guidelines.

AIM: The aim of these recommendations is to set forth an individualized approach to the management of early postmenopausal women (i.e., within the first 10 years after natural menopause) covering all aspects of lifestyle and therapeutic management, with or without menopause hormone therapy (MHT). MATERIALS AND METHODS: Literature review and consensus of French expert opinion. Recommendations were graded according to the HAS methodology and levels of evidence derived from the international literature, except when there was no good-quality evidence. SUMMARY RECOMMENDATIONS: The beginning of menopause is an ideal time for each woman to evaluate her health status by assessing her bone, cardiovascular, and cancer-related risk factors that may be amplified by postmenopausal estrogen deficiency and by reviewing her lifestyle habits. Improving lifestyle, including nutrition and physical activity, and avoiding risk factors (notably smoking), should be recommended to all women. MHT remains the most effective treatment for vasomotor symptoms but it could be also recommended as first-line treatment for the prevention of osteoporosis in early postmenopausal women at low to moderate risk for fracture. The risks of MHT differ depending on its type, dose, duration of use, route of administration, timing of initiation, and whether a progestogen is used. There is reasonable evidence that using transdermal estradiol in association with micronized progesterone or dydrogesterone may limit both the venous thromboembolic risk associated with oral estrogens and the risk of breast cancer associated with synthetic progestins. Treatment should be individualized to each woman, by using the best available evidence to maximize benefits and minimize risks, with periodic reevaluation of its benefit-risk balance. For bothersome genitourinary syndrome of menopause (GSM) symptoms, vaginal treatment with lubricants and moisturizers is recommended as first-line treatment together with low-dose vaginal estrogen therapy, depending on the clinical course. No recommendation of an optimal duration of MHT can be made, but it must take into consideration the initial indication for MHT as well as each woman's benefit-risk balance. Management of gynecological side-effects of MHT is also examined. These recommendations are endorsed by the Groupe d'Etude sur la Ménopause et le Vieillissement hormonal (GEMVI) and the Collège National des Gynécologues-Obstétriciens Français (CNGOF).

[Management of women with abnormal uterine bleeding: Clinical practice guidelines of the French National College of Gynecologists and Obstetricians (CNGOF)]. / Prise en charge des ménorragies : recommandations pour la pratique clinique du Collège national des gynécologues et obstétriciens français (CNGOF).

OBJECTIVE: To provide French guidelines for the management of women with abnormal uterine bleeding (AUB). DESIGN: A consensus committee of 26 experts was formed. A formal conflict-of-interest (COI) policy was developed at the beginning of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e. pharmaceutical, or medical devices). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. METHODS: The last guidelines from the Collège national des gynécologues et obstétriciens français (CNGOF) on the management of women with AUB was published in 2008. The literature seems now sufficient for an update. The committee studied questions within 7 fields (diagnosis; adolescent; idiopathic AUB; endometrial hyperplasia and polyps; fibroids type 0 to 2; fibroids type 3 and more; adenomyosis). Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology. RESULTS: The experts' synthesis work and the application of the GRADE method resulted in 36 recommendations. Among the formalized recommendations, 19 present a strong agreement and 17 a weak agreement. Fourteen questions did not find any response in the literature. We preferred to abstain from recommending instead of providing expert advice. CONCLUSIONS: The 36 recommendations made it possible to specify the diagnostic and therapeutic strategies of various clinical situations managed by the practitioner, from the simplest to the most complex.

[Menopause and risk of thromboembolic events. Postmenopausal women management: CNGOF and GEMVi clinical practice guidelines]. / Ménopause et risque thromboembolique veineux. RPC Les femmes ménopausées du CNGOF et du GEMVi.

The incidence of venous thromboembolism (VTE) increases with age with an annual incidence of 1.25/1000 women in the 40-59 age group. Menopausal hormone therapy (MHT) may also increase the risk of VTE. This risk must be assessed during the first consultation before initiating MHT and assess each renewal of the MHT. MHT with oral estrogen combined (or not) with progestin increases the risk of VTE by about 70%. Using transdermal estrogen does not appear to increase the risk of VTE in women. VTE risk appears to be modulated by the type of progestin combined in MHT. The risk of VTE associated with MHT with transdermal estradiol appears to be safe in women using micronised progesterone and pregnane derivatives and higher in women using norpregnane derivatives . To limit the risk of VTE associated with MHT, transdermal estradiol use is recommended. In women at risk of VTE, MHT with oral estrogen is contraindicated. MHT with transdermal estradiol associated (or not) with micronised progesterone or dydrogesterone may be used in women with low or moderate risk of VTE.

Aging and health: effects of the sense of control.

The relation between health and a sense of control may grow stronger in old age. This could occur through three types of processes: experiences particularly relevant to control may increase markedly in old age; the association between control and some aspect of health may be altered by age; and age may influence the association between control and health-related behaviors or the seeking of medical care. Studies show that there are detrimental effects on the health of older people when their control of their activities is restricted; in contrast, interventions that enhance options for control by nursing home patients promote health. With increasing age, however, variability in preferred amounts of control also increases, and sometimes greater control over activities, circumstances, or health has negative consequences including stress, worry, and self-blame. Mechanisms mediating the control-health relation include feelings of stress, symptom labeling, changes in the neuroendocrine and immune systems, and behavior relevant to health maintenance.

Sex attractant of the black carpet beetle.

The principal component of the sex attractant of the black carpet beetle Attagenus megatoma (Fabricius) is trans-3, cis-5-tetradecadienoic acid.

Sex Attractant of Female Dermestid Beetle Trogoderma inclusum Le Conte.

Two components of the sex attractant of a female dermestid beetle Trogoderma inclusum Le Conte were identified. They are (-)-14-methyl-cis-8-hexadecen-1-ol and (-)-methyl-14-methyl-cis-8-hexadecenoate. Other Trogoderma species also respond to the compounds.

Response of Ips confusus to synthetic sex pheromones in nature.

The first flight response of bark beetles to synthetic sex pheromones under natural conditions is reported. Two insect species predaceous on this bark beetle also responded. The synthetic compounds delivered in an airstream from a substrate of Carbowax 20M on Chromosorb A appear to elicit the same response as the natural attractant from male-infested bolts of ponderosa pine elicits.

Western pine beetle: field response to its sex pheromone and a synergistic host terpene, myrcene.

In the field, both sexes of the western pine beetle, Dendroctonus brevicomis, are attracted by the female-produced bicyclic ketal exo-brevicomin; this response is enhanced by myrcene (a constituent of the beetle's host, ponderosapine), which is not an attractant by itself. This synergism may be part of the phenomenon of the mass attack on its host. Temnochila virescens chlorodia, one of the principal insectan predators of this beetle, is attracted by exo-brevicomin alone.

[Hormonal contraception and vascular risk: CNGOF Contraception Guidelines]. / Contraception hormonale et risque vasculaire. RPC Contraception CNGOF.

Venous thromboembolism and arterial ischemic events are the main deleterious diseases associated with the use of combined hormonal contraceptives (CHC). Even though their composition has been substantially improved, the vascular risk persists with the most recent CHCs use. If the vascular risk associated with CHCs containing 50µg EE is significantly higher than with those containing less than 50µg, there is no evidence that the CHCs containing either 30 or 20µg of EE induce different venous risks. CHC containing gestodene, desogestrel, drospirenone or cyproterone acetate are associated with a higher risk of venous thrombosis compared with levonorgestrel-containing CHCs. CHC containing norgestimate are associated with similar venous thrombosis risk than CHC containing levonorgestrel. Venous thrombosis risk of non-oral routes of administration of CHC appears to be equivalent to the risk of CHC containing gestodene or desogestrel, but this result is based on a small number of epidemiological studies. Before prescribing a CHC, it is important to determine all vascular risk factors. Family history of ischemic arterial event or venous thromboembolism disease should be routinely sought before any CHC prescription. All CHCs are contraindicated in women with biological thrombophilia, in women with combined vascular risk factors, in women with first-degree family history of arterial or venous event (under age 50) as well as in women suffering of migraine with aura. Progestin-only contraceptives are not associated with vascular risk (arterial or venous) outside of medroxyprogesterone acetate. In women with higher vascular risk, progestin-only contraceptives (administered by oral, sous-cutaneous or intra-uterine routes) can be prescribed.

[Learning the gynecological examination on low-fidelity simulation: Impact on the feelings of medical students]. / Apprentissage de l'examen gynécologique sur simulateur : impact sur le ressenti des étudiants en médecine.

OBJECTIVES: The use of anatomic model is particularly suitable for teaching gynecological examination. Although simulation training was proved to be effective in improving medical students' technical skills, its interest in reducing their apprehension about pelvic examination was poorly evaluated. The aim of the present study was to evaluate low-fidelity simulation sessions to reduce the discomfort and apprehension of medical students towards gynecological examination. The secondary objective was to appreciate student satisfaction with these sessions. METHODS: Descriptive analysis of simulation-based teaching of breast and pelvic examination on Ilumens platform at the university Paris 5 among 3rd and 4th year medical students. It consisted in a before/after evaluation, using an anonymous questionnaire of self-evaluation and satisfaction at the beginning and at the end of the session. RESULTS: Four hundred and thirty-two students answered both questionnaires. Seventy-two percent apprehended the pelvic examination initially and 62% were uncomfortable with the idea of performing it. Among the students who had never performed pelvic examination, more than 80% felt less uncomfortable with the idea of performing pelvic examination and were less apprehensive about it at the end of the simulation session. CONCLUSION: The benefits of low-fidelity simulation in gynecology extend to the well-being of medical students who are less apprehensive about performing gynecological examination.

Failure of genetically selected miniature swine to model NIDDM.

Ten young adult miniature swine from a line reported to be genetically selected for glucose intolerance and eight normal controls were obtained from Colorado State University. They were consecutively exposed to 4 mo of a high-fiber, low-fat standard swine diet; 4 mo of a high-sucrose, high-fat, low-fiber diabetogenic diet; and 4 mo of excess diabetogenic diet for obesification. Results of oral glucose tolerance and intravenous insulin tolerance tests conducted at the end of each regimen were compared. Hyperglycemia was not observed in any animals after any manipulation. Insulin sensitivity was also not influenced by diet. We conclude that F7 low-K miniature swine from this colony fail to model human non-insulin-dependent diabetes.

Medical, metabolic, and psychological effects of weight cycling.

This article reviews studies on the effects of weight cycling and weight variability on metabolism, psychological status, morbidity, and mortality. Repeated bouts of weight loss and regain, known as weight cycling or yo-yo dieting, are highly prevalent, occur in males and females, and are common in both overweight and nonoverweight individuals. While there has been no consistent demonstration that, as was first thought, weight cycling makes subsequent weight loss more difficult or regain more rapid, it is possible that this does occur under some conditions or in particular individuals. There are stronger and more consistent links between body weight variability and negative health outcomes, particularly all-cause mortality and mortality from coronary heart disease. Weight cycling may also have negative psychological and behavioral consequences; studies have reported increased risk for psychopathology, life dissatisfaction, and binge eating. The bulk of epidemiologic research shows an association of weight variability with morbidity and mortality, although the mechanisms are not clear at present. There is a clear need for further research on the effects of weight cycling on behavior, metabolism, and health. Understanding and promoting weight maintenance is an important priority.

Comparative effects of fructose, aspartame, glucose, and water preloads on calorie and macronutrient intake.

Using a within-subjects design, we gave over-weight and normal-weight subjects a 500-mL drink of fructose, glucose, or aspartame diluted in lemon-flavored water or plain water in a randomized fashion at about weekly intervals. Food intake was assessed at a buffet lunch that began 38 min after the preload was completed. Blood was drawn throughout and assayed for concentrations of glucose, insulin, glucagon, and free fatty acid. When subjects drank the fructose preload, they subsequently ate fewer overall calories and fewer grams of fat than when they drank any of the other preloads. The aspartame load did not stimulate intake beyond the plain-water control. The effects of the oxidation of fructose as a possible mechanism for the reduction in food intake is discussed. The effects of insulin in stimulating intake are also discussed.

Fructose and behavior: does fructose influence food intake and macronutrient selection?

Fructose, as compared with other sugars, may have a suppressant effect on subsequent food intake and may result in a different selection of macronutrients. The research investigating these effects and the possible underlying mechanisms of action is reviewed. These mechanisms include fructose's effects on the rate of gastric emptying, concentrations of plasma glucose and insulin, and hepatic metabolism. The research is not conclusive. Questions that remain to be examined more thoroughly are the time course of fructose's effects on food intake and macronutrient selection in the short-term, and effects of long-term administration of fructose on these appetitive processes.

Smoking and its effects on body weight and the systems of caloric regulation.

Cigarette smoking and excess body weight, each of which contributes to poor health and risk of death, appear themselves to be inversely related. Data indicate that smokers weigh less than nonsmokers and that weight gain occurs after the cessation of smoking. The popular wisdom is that this is due to differences in caloric intake: smokers weigh less because they consume less and they gain weight upon stopping smoking as a consequence of consuming more. Cross-sectional data on this point are conflicting, however, with some studies of daily caloric intake suggesting that smokers may, in fact, consume more calories per day than nonsmokers. In addition to affecting ingestive behavior, however, cigarette smoking has a variety of physiological effects that may play a more important role than amount of calories consumed per se in accounting for lower body weights among smokers and weight gain after cessation. Evidence regarding the effects of cigarette smoking and nicotine upon the behavioral, sensory and metabolic components of the processes of caloric regulation and nutrition is reviewed in order to suggest mechanisms by which smoking may affect weight. Longitudinal within-subject designs investigating changes associated with the cessation and initiation of smoking are recommended.

Metabolic effects of fructose and glucose: implications for food intake.

Differential effects of fructose and glucose preloads on carbohydrate metabolism and later food intake were examined in both lean and obese subjects. In study 1, a preload of either 50 g of fructose or glucose was administered in solution, and food intake at a buffet lunch presented 2.25 h after preload was assessed. Significant differences in caloric intake were observed between load conditions with the fructose group consuming fewer calories than the glucose group. Obese subjects demonstrated significantly greater insulin responses to the preload compared with lean subjects, and insulin levels of obese subjects at 15, 30, and 45 min after preload were found to correlate significantly with amount consumed. Incorporation of fructose or glucose into a mixed meal format in study 2 revealed no differences in subsequent caloric intake as a function of either type of preload or percent overweight. Differing insulin levels are discussed as a possible mechanism for differential food intake.

Intestinal bypass surgery for obesity decreases food intake and taste preferences.

Food intake was measured in 22 obese patients before and after jejunioleostomy for obesity. Most of the weight loss could be accounted for by the observed reduction of caloric intake. Malabsorption was also present as indicated by increased loss of fat in the stools, and decreased absorption of D-xylose and vitamin B12. A dislike for sweet tastes developed after surgery in most patients. Preferences for concentrated solutions of sucrose and glucose were reduced after patients showed a depression of food intake by a 440-calorie preload which had not been detected before surgery. These studies show a decrease in food intake after intestinal bypass surgery and suggest a role for taste or other gastrointestinal factors in regulating food intake.