Estrogen-regulated miRNA-27b is altered by bisphenol A in human endometrial stromal cells.

MicroRNAs (miRs) are small molecules important for regulation of transcription and translation. The objective was to identify hormonally regulated miRs in human endometrial stromal cells and to determine the impact of the endocrine disruptor, bisphenol A (BPA), on those miRs. miR microarray analysis and multiple confirmatory cell preparations treated with 17ß-estradiol (E2) and BPA altered miR-27b, let-7c, let-7e and miR-181b. Further, decidualization downregulated miR-27b. VEGFB and VEGFC were validated as targets of miR-27b. Identification of miR-27b target genes suggests that BPA and E2 downregulate miR-27b thereby leading to upregulation of genes important for vascularization and angiogenesis of the endometrium during the menstrual cycle and decidualization.

Malignant pericardial effusion and pericardial tumor involvement secondary to cervical cancer.

BACKGROUND: Antemortem discovery of a malignant pericardial effusion secondary to cervical cancer is uncommon and management should focus on symptom control. CASE: A patient was diagnosed with widely metastatic cervical cancer following a simple hysterectomy for presumed benign etiology. Sixteen months later, she was diagnosed with pericardial tumor involvement and a malignant pericardial effusion resulting in severe dyspnea. The patient underwent a pericardial window procedure that temporarily alleviated her symptoms. She again developed symptoms 2 weeks following the procedure and ultimately elected supportive care. CONCLUSION: Malignant pericardial effusion is a challenging clinical scenario. Although multiple treatment options exist, prognosis is poor and usually limited.

Peripartum cardiomyopathy and acute fatty liver of pregnancy: one patient with two zebras.

OBJECTIVE: Peripartum cardiomyopathy (PPCM) and acute fatty liver of pregnancy (AFLP) are rare complications of pregnancy affecting approximately 1/10,000 pregnancies each. We describe a patient who had biopsy-proven AFLP complicated by PPCM. METHODS: Chart review and literature search. RESULTS: The patient is a 22-year-old G5P1213 obese African-American female who presented at 30 weeks gestation with abdominal pain. She had normal blood pressures and mildly elevated liver enzymes. After completion of a 24 hour urine protein collection that was consistent with pre-eclampsia, an induction of labor with uncomplicated vaginal delivery was accomplished. Following delivery, a computed tomography scan of the abdomen revealed significant cardiomegaly. An echocardiogram revealed global dysfunction with an ejection fraction of 10%. Liver biopsy showed AFLP. Attempts to establish a unifying etiology were unrevealing. The PPCM was treated with diuretics and intravenous immunoglobulin. The patient's clinical status deteriorated, eventually requiring continuous dialysis, intubation, pharmacologic and mechanical inotropic support, and a feeding tube. The patient was discharged to a long-term care facility where she subsequently passed away from multiorgan failure. CONCLUSION: AFLP and PPCM are rare complications of pregnancy. We present a patient who had both. Both diseases carry a high mortality rate, and together, are likely fatal.

Surgically managed stage I endometrial cancer in a low-volume center: outcomes and complications in a military residency program.

OBJECTIVE: The purpose of this study was to compare operative outcomes and complications for patients with endometrial cancer who underwent staging by laparoscopy vs laparotomy in a low-volume facility. STUDY DESIGN: Research was conducted with a retrospective cohort of surgical patients with clinical stage I endometrial cancer from 2004-2009. RESULTS: Eighty-six demographically similar patients (50 laparotomy and 36 laparoscopy) were identified. Laparoscopy had less estimated blood loss (339 vs 558 mL; P = .013) and lower rates of transfusion (5.6% vs 24%; P = .02). Laparoscopy was longer (281 vs 202 minutes; P < .0005) but required a shorter hospital stay (2.2 vs 5.5 days; P < .0005). Laparoscopy patients had fewer overall complications (16.7% vs 32%; P = .11). No differences in final surgical stage or lymph node yields between the groups were present. CONCLUSION: Although a longer procedure, laparoscopy had fewer complications and shorter hospital stays. Prolonged operative time, compared with published experience, is potentially the result of unique factors in our center.

Hospice enrollment for terminally ill patients with gynecologic malignancies: impact on outcomes and interventions.

OBJECTIVE: To determine survival and interventions for patients with non-curative gynecologic malignancies based on supportive care enrollment. METHODS: An IRB approved retrospective review identified patients with recurrent/persistent gynecologic cancers from 2002 to 2008. Demographics, therapy, clinicopathologic data, hospice utilization, surgical/invasive procedures and survival were collected. Patients were considered hospice enrollees if they enrolled following recommendation from their provider (HOSPICE); however, patients that declined hospice when recommended were considered (NO HOSPICE), regardless if they ultimately received supportive care. Standard statistical tests including: t-test and Kaplan-Meier with Log Rank were used. RESULTS: Eighty-one patients were identified: 29 patients (36%) NO HOSPICE and 52 (64%) HOSPICE. Mean age was 61. Most patients had ovarian cancer (54.3%), were white (61.7%) and had disease recurrence (72%). Patients utilized a median of 3 anti-neoplastic therapies (range 0-10) for recurrent or progressive/persistent disease. Median time receiving hospice care was 1week for NO HOSPICE patients versus 8weeks HOSPICE patients (p<0.0005). In a subset of patients with recurrent disease, median overall survival for NO HOSPICE patients was 9months (95% CI 5.9-12.1months) versus 17months (95% CI 11.1-22.9months) for HOSPICE patients (p=0.002). NO HOSPICE patients were more likely to have a procedure performed (55% vs. 31%) within 4weeks of their death, including the administration of chemotherapy OR 2.4 (95% CI 1.1-7.1, p=0.036). CONCLUSIONS: While retrospective reviews evaluating hospice are challenging, our data suggest no detrimental impact on survival for hospice patients. Continued evaluation for patients at the end-of-life is necessary in order to optimize resource utilization.

Use of Clomiphene Citrate in minimal stimulation in vitro fertilization negatively impacts endometrial thickness: an argument for a freeze-all approach.

OBJECTIVE: Minimal stimulation IVF is a treatment option that uses clomiphene citrate (CC). We sought to evaluate how CC impacts endometrial thickness during minimal stimulation IVF cycles. METHODS: We retrospectively analyzed a cohort of 230 cycles in 119 poor ovarian response patients. The IVF cycles were studied in three groups: 130 minimal stimulation cycles, 29 mild stimulation cycles, and 30 conventional high dose gonadotropin releasing hormone (GnRH) antagonist cycles. Thirty-three minimal stimulation IVF patients had 41 frozen embryo transfers (FET) which allowed us to study whether the CC effects were prolonged. RESULTS: Endometrial thickness in the minimal stimulation group was significantly lower than the mild and conventional stimulation groups (7.3±2.2mm versus 11.4±3.3mm versus 12.9±3.8mm, respectively, p<0.0001). In patients who underwent minimal stimulation IVF followed by FET, significantly thicker endometrial thickness was achieved during their FET cycles as compared to their minimal stimulation cycles (7.95±2.1mm versus 10.3±1.8mm, p<0.0001). CONCLUSION: We concluded that endometrial thickness is impacted during minimal stimulation IVF cycles. Since negative effects on endometrial thickness are not observed in the patients' subsequent FET cycle, a freeze-all approach is justified to mitigate adverse endometrial effects of CC in minimal stimulation IVF cycles.

Has testosterone passed the test in premenopausal women with low libido? A systematic review.

BACKGROUND: There are limited evaluation and treatment options for low libido in premenopausal women. This review sought to evaluate the available evidence supporting the evaluation of testosterone serum levels and testosterone treatment of premenopausal women with low libido. METHODS: MEDLINE, PubMed, and ClinicalTrials.gov were searched for articles that referenced the evaluation of testosterone serum level and/or testosterone treatment on premenopausal women with low libido from 1995 to 2015. Additional references were obtained from the reference sections of other papers and from peer review. Studies that included only postmenopausal women were excluded. A total of 13 studies were reviewed in detail. Nine studies examined the relationship between testosterone serum levels and sexuality, an additional three studies examined the effect of testosterone treatment on premenopausal women with low libido, and one study examined both the topics. RESULTS: Six of the ten testosterone serum evaluation studies failed to show a significant association between testosterone serum level and libido. Only one out of four studies examining testosterone treatment in premenopausal women was able to show any clear improvement in libido; however, the effect was limited to only the intermediate dose of testosterone, with the low and high doses of testosterone not producing any effect. CONCLUSION: The currently available evidence does not support testosterone serum evaluation or treatment in premenopausal women with low libido. Hence, further studies are warranted.

Shifting paradigms in diminished ovarian reserve and advanced reproductive age in assisted reproduction: customization instead of conformity.

As women are increasingly delaying childbearing into their 30s and beyond, diminished ovarian reserve (DOR) and advanced reproductive age (ARA) patients are bound to become a large proportion of all assisted reproductive technology practices. Traditional controlled ovarian stimulation (COS) protocols for DOR and/or ARA have had some limited success, but pregnancy rates are lower and cycle cancellation rates are higher than their younger counterparts with normal ovarian reserve. Though many physicians have a selection of favorite standard protocols that they use, patients with DOR may require closer monitoring and customization of the treatment cycle to address the common problems that come with low ovarian reserve. Frequent issues that surface in women with DOR and/or ARA include poor follicular response, premature luteinizing hormone surge, and poor embryo quality. Limited published evidence exists to guide treatment for DOR. However, use of minimal or mild doses of gonadotropins, avoidance of severe pituitary suppression, and consideration for luteal phase stimulation and a "freeze all" approach are possible customized treatment options that can be considered for such patients who have failed more traditional COS protocols.

Vulvar pyoderma gangrenosum originating from a healed obstetric laceration.

BACKGROUND: Pyoderma gangrenosum is a rare dermatologic disorder that can occur on the vulva. CASE: A 25-year-old woman, gravida 2 para 1 abortus 1, had development of pain and subsequent ulceration at the location of her previously healed vulvar obstetric laceration. The ulceration and pain continued to worsen despite wound management. Once the diagnosis of vulvar pyoderma gangrenosum was made, cyclosporine was started and the wound rapidly healed. CONCLUSION: Vulvar pyoderma gangrenosum should be considered when a vulvar wound is not healing with conservative measures. Cyclosporine can be considered as an alternative to steroids for treatment.