[Is there a place for stepped hormone assay in the development of hyperandrogenism?] / Comment j'explore Le dosage hormonal étagé a-t-il une place dans la mise au point des hyperandrogénies ?

Clinical hyperandrogenism is common in women. Nevertheless, it is important to identify the cause. As the hyperandrogenism may be ovarian or adrenal in origin, making the difference requires hormonal testing and ovarian and/or adrenal imaging. We present the case report of a patient explored in our clinic, that illustrates the difficulties to determine the origin of the endocrine disorder. The interest of employing selective ovarian and adrenal venous catheterization to aid in the diagnosis and the localization of the androgen-secreting tumor is discussed.

L'hyperandrogénie clinique est un motif de consultation fréquent. Le diagnostic différentiel permet d'établir l'étiologie parmi les causes ovariennes ou surrénaliennes. Outre le repérage de signes pathognomoniques cliniques, des examens complémentaires biologiques et iconographiques sont nécessaires pour la mise au point. Les difficultés diagnostiques sont illustrées à partir d'un cas clinique traité dans notre institution. L'intérêt du bilan hormonal étagé par cathétérisation des veines ovariennes et surrénaliennes afin de localiser l'origine de la sécrétion hormonale pathologique est discuté.

[Timing of gonadectomy in patients with complete androgen insensitivity syndrome]. / Quand proposer une gonadectomie chez les patientes présentant une insensibilité complète aux androgènes ?

Complete androgen insensitivity syndrome is the most frequent cause of disorder of sexual development in 46 XY patients. It is caused by mutations of the AR gene coding for the androgen receptor. Transmission is X-linked and mutations are most of the time inherited. It leads to a complete lack of response to androgen resulting in the presence of female external genitalia in 46 XY patients, normal but undescended testes and lack of female internal genitalia due to the secretion of anti-Müllerian hormone by male gonads. Traditionally, gonadectomy was proposed before puberty to decrease the risk of gonadal malignancy. However, more recent studies underlined the benefits of postponing gonadectomy until after pubertal development. Benefits of deferred gonadectomy are spontaneous pubertal development through peripheral aromatization of testosterone into oestrogens and the chance for the patient to have an active role in the decision-making process. After gonadectomy, hormone replacement therapy is required in order to prevent complications due to hypogonadism such as osteoporosis, cardiovascular diseases and a reduction of life expectancy.

L'insensibilité aux androgènes est l'étiologie principale des troubles du développement sexuel chez des patientes 46 XY. Elle est due à des mutations du gène AR qui code pour le récepteur des androgènes. Le mode de transmission est lié à l'X et les mutations sont le plus souvent héritées. Il en résulte une absence d'action des androgènes sur leurs récepteurs entraînant la présence d'organes génitaux externes féminins chez des patientes 46 XY, de testicules normalement développés en position abdominale ou inguinale et en l'absence d'organes génitaux internes féminins due à la sécrétion d'hormone anti-müllérienne par les gonades masculines. La gonadectomie était auparavant effectuée en période pré-pubertaire en raison du risque suspecté de développement de néoplasie maligne. Des données récentes suggèrent la possibilité de postposer cette intervention après le développement pubertaire. Le risque de transformation maligne pré-pubertaire des gonades est faible, et différer la gonadectomie permet un développement pubertaire naturel grâce à l'aromatisation périphérique de la testostérone en œstradiol. Ce délai permet d'impliquer activement la patiente dans la prise en charge de sa pathologie. Après la gonadectomie, un traitement hormonal substitutif par œstrogènes est indiqué pour prévenir les complications dues à l'hypogonadisme telles que l'ostéoporose, les maladies cardio-vasculaires et la réduction de l'espérance de vie.

[An update in intrauterine contraception]. / Nouveautés en contraception intra-utérine.

Intrauterine devices (IUD) are the oldest of the modern contraceptives. There are currently two types of IUDs: copper IUD (Cu-IUD) and levonorgestrel IUD (LNG-IUD). Both offer high contraceptive effectiveness. Although they have been used for decades, the literature still brings its share of new information on IUDs: impact on oncological risk, non-contraceptive benefits, rare adverse effects, and impact on women's well-being. In addition, Cu-DIU is recognized as the most effective emergency contraceptive and can be inserted up to 5-7 days after the at-risk sexual intercourse. Research is now looking at the effectiveness of LNG-IUD in emergency contraception. Finally, new IUD concepts are also being evaluated: they should allow a reduction in the rate of expulsion, intermenstrual and heavy menstrual bleeding, an increase in comfort and in IUDs duration of use. This article makes an update on the latest developments in terms of intrauterine contraceptives.

Le dispositif intra-utérin (DIU) est le plus ancien des contraceptifs modernes. On distingue les DIU au cuivre (Cu-DIU) et les DIU au lévonorgestrel (LNG-DIU). Ils offrent une haute efficacité contraceptive. Bien qu'ils soient utilisés depuis des décennies, la littérature apporte encore aujourd'hui son lot de nouvelles informations sur les DIU: impact sur le risque oncologique, bénéfices non contraceptifs, effets indésirables rares et impact sur le bien-être des femmes. Par ailleurs, le Cu-DIU est reconnu comme étant le contraceptif d'urgence le plus efficace, pouvant être inséré jusqu'à 5-7 jours après le rapport à risque. La recherche se penche maintenant sur l'efficacité du LNG-DIU en contraception d'urgence. Enfin, de nouveaux concepts de DIU sont aussi à l'étude : ils devraient permettre une réduction du taux d'expulsion, une diminution des méno- et métrorragies, une augmentation du confort et une plus longue durée d'utilisation. Cet article fait le point sur les dernières nouveautés en termes de contraceptifs intra-utérins.

[How to explore... hyperandrogenism associated with insulin resistance ? An example based on the HAIR-AN syndrome.] / Comment j'explore une hyperandrogénie dans un contexte d'insulinorésistance. Un exemple basé sur le syndrome HAIR-AN.

HAIR-AN, a syndrome associating hyperandrogenism, insulin resistance and acanthosis nigricans, is currently considered as a severe form of polycystic ovary syndrome. The physiopathology of this syndrome relies on the insulin resistance which is the basis of a vicious circle : the resulting hyperinsulinism leads to an excessive production of androgens. The latter increases abdominal fat deposition which in turn worsens the insulin resistance. Hyperinsulinism is also responsible for the acanthosis nigricans by stimulating the IGF-1 receptors on keratinocytes and fibroblasts. Hyperandrogenism is clinically translated into hirsutism that can be severe. Frequently, menstrual irregularity and obesity are part of the syndrome. HAIR-AN syndrome begins soon after puberty and is currently under-diagnosed. Treatment relies on an improvement in insulin-resistance by a loss of body weight and the use of insulin sensitizers. Moreover, anti-androgenic drugs will help improving hirsutism. Although more invasive, bariatric surgery has shown a great efficacy in this syndrome : by permitting a substantial loss of weight, it often normalizes insulin-sensitivity, allowing for improvements in hyperandrogenism and acanthosis nigricans.

Considéré comme une forme sévère du syndrome des ovaires micropolykystiques, le syndrome de HAIR-AN associe une hyperandrogénie, une résistance à l'insuline et un acanthosis nigricans. La base physiopathologique du syndrome HAIR-AN est un cercle vicieux ayant pour point de départ la résistance à l'insuline : l'hyperinsulinisme qui en résulte entraîne une production excessive d'androgènes. Ces derniers, en aggravant le dépôt de graisse abdominale, majorent la résistance à l'insuline. Il s'agit donc d'un phénomène auto-entretenu. En stimulant le récepteur à l'IGF-1 des kératinocytes et des fibroblastes, l'hyperinsulinisme est également responsable de l'acanthosis nigricans. L'hyperandrogénie se traduit cliniquement par un hirsutisme pouvant être sévère. On notera fréquemment aussi une irrégularité menstruelle et une obésité. Le syndrome HAIR-AN débute tôt après la puberté et est actuellement sous-diagnostiqué. Le traitement est, avant tout, celui de la résistance à l'insuline et nécessite donc une perte de poids associée à l'utilisation de molécules insulino-sensibilisatrices. De plus, des traitements hormonaux anti-androgéniques aideront également à diminuer le hirsutisme. Plus invasive, la chirurgie bariatrique a cependant démontré une grande efficacité chez ces patientes : en permettant une perte de poids conséquente, elle normalise souvent la sensibilité à l'insuline, ce qui améliore significativement l'hyperandrogénie et l'acanthosis nigricans.

[Emergency contraception : practical guideline]. / Attitude pratique face à la contraception d'urgence.

The goal of emergency contraception (EC) is to avoid unintended pregnancies after unprotected sexual intercourse (UPSI) or incorrect use of regular contraception. EC is intended for occasional use and does not replace effective regular contraception. A thorough understanding of EC is mandatory for optimal use of EC by healthcare professionals. Three EC methods are available in Belgium : oral levonorgestrel (LNG), oral ulipristal acetate (UA) and copper intrauterine device (Cu-IUD). EC should be offered as soon as possible after UPSI. The guidance aims to summarise the available evidence on EC methods, mechanism of action, and advantages/disadvantages of each method.

La contraception d'urgence (CU) a pour but d'éviter les grossesses non désirées après un rapport sexuel non protégé ou une prise incorrecte d'une contraception habituelle. Elle doit être réservée pour un usage occasionnel et ne doit pas remplacer la contraception régulière. La connaissance des méthodes de CU est indispensable pour optimaliser leur usage en pratique quotidienne. Trois méthodes de CU existent en Belgique : la prise de lévonorgestrel oral (LNG), l'acétate d'ulipristal oral (AU) ou l'insertion d'un dispositif intra-utérin (DIU) au cuivre. Il est recommandé d'utiliser la CU le plus rapidement après le rapport à risque. Nous donnerons une description détaillée des méthodes de CU, leurs mécanismes d'action, leurs avantages et inconvénients.

[Polycystic ovary syndrome : the advantages of multidisciplinary management]. / Le syndrome des ovaires micropolykystiques : l'avantage d'une prise en charge multidisciplinaire.

The polycystic ovary syndrome is one of the most frequent endocrine disorders in women of reproductive age. The first signs and symptoms of the disease may be present as early as puberty. Diagnostic criteria include hyperandrogenism (clinical or biological), ovulatory dysfunction and polycystic ovarian morphology on ultrasound. The consequences of the syndrome are multiple. These consist of fertility issues and metabolic anomalies with increased cardiovascular risk, but also sleep disturbances, increased risk of endometrial hyperplasia and endometrial cancer and a potentially important psychological impact with decreased quality of life. The management of polycystic ovary syndrome is multidisciplinary and treatment is variable, depending on symptoms and the patient's desire for fertility. In all cases, measures aiming to improve the metabolic dysfunction are essential, going from adopting a healthy lifestyle to adequate therapy of each metabolic anomaly.

Le syndrome des ovaires micropolykystiques est une des endocrinopathies les plus fréquentes de la femme en âge de reproduction. Les premiers signes et symptômes peuvent se manifester dès la puberté. Les critères de diagnostic reposent sur une hyperandrogénie (clinique ou biologique), une anovulation chronique et un aspect d'ovaires micropolykystiques à l'échographie. Les conséquences du syndrome sont multiples, essentiellement concernant les troubles de la fertilité et les perturbations métaboliques avec un risque cardio-vasculaire augmenté, mais également des anomalies du sommeil, un risque augmenté d'hyperplasie endométriale et de cancer endométrial et un impact psychologique parfois important avec diminution de la qualité de vie. La prise en charge est multi-disciplinaire et le traitement variable, en fonction des symptômes et des souhaits de fertilité de la patiente. Dans tous les cas, une prise en charge métabolique, avec une hygiène de vie saine et des traitements visant les perturbations métaboliques individuelles, est essentielle.

Impact of implementation of a breech clinic in a tertiary hospital.

BACKGROUND: The incidence of breech presentation in single pregnancies at term is between three to 5 %. In order to support eligible women in their choice of mode of delivery, a dedicated breech clinic with a care pathway was developed in December 2015 in a tertiary referral centre in Brussels. The primary objective of this study was to evaluate the vaginal birth rate before and after the introduction of a dedicated breech clinic. The secondary objective was to compare the early neonatal outcomes before and after the breech clinic was introduced. METHODS: This was a single centre retrospective and prospective study. The inclusion criteria were term (from 37 weeks), singleton fetus and breech presentation at delivery. The exclusion criteria were suspected intrauterine growth restriction, severe fetal malformations and intrauterine fetal demise. We used a composite outcome as an indicator of neonatal morbidity and mortality. RESULTS: After the introduction of the breech clinic, we observed a significant increase in planned vaginal delivery from 7.4% (12/162) to 53.0% (61/115) (OR: 13.5; 95% CI: 6.7-27.0). The effective vaginal breech delivery rate (planned and unexpected) significantly increased from 4.3% (7/162) pre-implementation of breech clinic to 43.5% (50/115) post-implementation (OR: 17.0; 95% CI: 7.3-39.6). Neonatal outcomes were not statistically different between the before and after periods. CONCLUSION: The introduction of a dedicated breech clinic has led to an increase in vaginal deliveries for breech babies without adversely affecting neonatal outcomes.

[Management of dysmenorrhea]. / Prise en charge des dysménorrhées.

Dysmenorrhea is one of the most common reasons for consultation in gynecology. The social and economic burdens are important. Dysmenorrhea may therefore be considered as a major public health issue. Its management is not yet optimal as dysmenorrhea still affects the quality of life of many patients. Primary dysmenorrhea, with no underlying organic cause, results from myometrial hyper contractility, arteriolar vasoconstriction, and tissue hypoxia. Secondary dysmenorrhea may involve the pathophysiological mechanisms of primary dysmenorrhea, but is mainly the expression of an underlying gynecological pathology. Although the pathophysiology of primary dysmenorrhea is well established, studies are now focusing on treatments to improve the management of these patients, who are often young. Nonsteroidal anti-inflammatory drugs and oral contraception remain the recommended firstline drugs, but their effectiveness can be enhanced by complementary therapy such as local heat application or regular exercise. Studies on other unconventional complementary therapies, such as ginger consumption, are very encouraging and need to be reinforced to incorporate recommendations for the management of primary dysmenorrhea.

Les dysménorrhées représentent un des motifs de consultation les plus fréquents en gynécologie. Les répercussions sociales et économiques qu'elles engendrent en font un phénomène de santé publique. Leur prise en charge n'est pas encore optimale et les dysménorrhées altèrent toujours la qualité de vie de nombreuses patientes. Les dysménorrhées primaires, sans cause organique sous-jacente, sont le résultat d'une hyper contractilité myométriale, d'une vasoconstriction artériolaire et d'une hypoxie tissulaire. Les dysménorrhées secondaires peuvent faire intervenir les mécanismes physiopathologiques des dysménorrhées primaires mais sont surtout l'expression d'une pathologie gynécologique sous-jacente. Si la physiopathologie des dysménorrhées primaires est de mieux en mieux connue, les études s'intéressent à présent aux options thérapeutiques pour améliorer la prise en charge de ces patientes souvent jeunes. Les antiinflammatoires non stéroïdiens et la contraception orale restent les molécules recommandées en première intention mais leur efficacité peut être potentialisée par des traitements complémentaires comme l'application locale de chaleur ou la pratique régulière d'exercices physiques. Des premiers résultats concernant d'autres thérapies complémentaires non conventionnelles, comme la consommation de gingembre, sont très encourageants et doivent être renforcés pour intégrer les recommandations de la prise en charge des dysménorrhées primaires.

[Retrospective assessment of the influence of gestational age on the first trimester medical abortion efficiency]. / Evaluation rétrospective de l'efficacité de l'interruption volontaire de grossesse médicamenteuse au premier trimestre en fonction de l'âge gestationnel.

There are two methods of abortion : the medical and the surgical methods, each with its own specific benefits. Theoretically, the limit of medical abortion gestational age is 7 weeks of amenorrhea. However, since 2011, our university department provides the opportunity of a drug regimen until 9 weeks of amenorrhea. This paper describes the results of a retrospective study which covers 804 patients who were submitted to a medical abortion with gestational ages of 6 to 9 weeks. The purpose is to investigate the efficiency of the medical approach up to 9 weeks and to assess the drug dose required according to the term of pregnancy. Our work shows an efficiency of 95 % of medical abortion up to 9 weeks gestation, with no significant variation with the gestational age. However, maintaining this level of efficiency during the progress of pregnancy requires an increase of the administered doses of misoprostol. In addition, there is a significant increase in the use of analgesics. The medical abortion procedure remains effective until 9 weeks of gestation. This pharmacological approach reduces the risks induced, in the short and long term by the surgical procedure.

Il existe deux méthodes d'interruption de grossesse : la méthode médicamenteuse et la méthode chirurgicale, présentant chacune leurs avantages et leurs inconvénients. Théoriquement, la limite d'âge gestationnel pour l'IVG médicamenteuse est de 7 semaines d'aménorrhée. Cependant, depuis 2011, notre service universitaire a évalué la possibilité d'étendre l'indication à 9 semaines d'aménorrhée (SA).Cet article décrit les résultats d'une étude rétrospective qui porte sur 804 patientes ayant subi une IVG médicamenteuse avec un âge gestationnel allant de 6 SA à 9 SA. Le but de cette étude est de démontrer l'efficacité de la méthode médicamenteuse d'IVG jusqu'à 9 SA et d'évaluer les dosages médicamenteux nécessaires en fonction du terme de la grossesse. L'efficacité de l'IVG médicamenteuse est de l'ordre de 95 % jusqu'à 9 SA sans variation significative en fonction de l'âge gestationnel. Toutefois, le maintien de ce taux d'efficacité, lors de l'avancement de la grossesse, requiert une augmentation des doses de misoprostol administrées. De plus, on note une majoration significative du recours aux antalgiques. La procédure médicamenteuse d'IVG demeure efficace jusqu'à 9 SA. Cette approche réduit les risques induits par la procédure chirurgicale à court mais aussi à long terme.

Coping with menopausal symptoms: An internet survey of Belgian postmenopausal women.

OBJECTIVES: An internet survey was performed to obtain data on the current use in Belgium of hormone replacement therapy and alternative treatments for the alleviation of menopausal symptoms. A supplementary aim was to assess the use of opt-in internet opinion panels (TalkToChange, http://www.talktochange.com, and GMI, http://www.gmi-mr.com/global-panel) as a potential new way to obtain data on menopausal issues. STUDY DESIGN: Data were collected via an internet platform from 696 postmenopausal women aged 45-60 years. OUTCOME MEASURES: Respondents were asked questions about their socio-demographic profile, their experience of the menopause, the burden of the menopause, its impact on their quality of life and the treatment of menopausal symptoms (if any). RESULTS: The opt-in internet opinion panels proved a quick way (19days) to obtain reliable information with a low error margin (3.7%). The online survey collected detailed socio-demographic data. Almost all of the women (98%) had heard about the menopause before. Sixty-one percent perceived the menopause as a temporary phase (17% thought it lasted for one or two years and 44% thought it lasted for three to five years) and only 39% realized the menopause would last for the rest of their life. Twenty-three percent of the women reported any kind of impact of the menopause on their quality of life. However, for the other 77% the menopause had resulted in complaints. No differences according to the women's age, level of education or professional status were found in this respect. Sixty-nine percent of the women had 'ever' used some type of treatment for menopausal symptoms and 53% were currently using a treatment. Forty percent of those with more than three symptoms were currently untreated. Of those who were not on hormone replacement therapy (HRT), 61% would not consider taking it (54% were 'strongly opposed' and 7% simply 'opposed'), while 8% would consider asking their doctor for HRT. Among those women who were opposed to HRT, 25% indicated that they were afraid of the increased risk of breast cancer, 34% cited cardiovascular risks and 26% were worried about weight gain. In this Belgian sample, HRT was used significantly more often by French-speaking women (32%) than by Dutch-speaking women (9%) (OR 4.4, p<0.0001). The alternatives to HRT had a high satisfaction rate among users. Relaxation techniques, regular physical activity, acupuncture and avoiding stress had satisfaction rates similar to that with HRT. It was not possible to compare the alternatives in the same women. Nor was it possible to assess whether more pronounced symptoms required a specific treatment. CONCLUSION: Opt-in internet opinion panels proved a quick and efficient way to gather data on menopausal issues in Belgium. Despite the high levels of awareness and knowledge, there is some confusion concerning the duration of the menopause, and its common perception as a temporary condition is likely to mean that the menopausal burden is substantially underestimated. Many symptomatic women are untreated.

Restoring testosterone levels by adding dehydroepiandrosterone to a drospirenone containing combined oral contraceptive: I. Endocrine effects.

OBJECTIVES: Combined oral contraceptives (COCs) decrease testosterone (T) levels. This study investigated restoration of T and other androgen concentrations during COC use by 'co-administration' of dehydroepiandrosterone (DHEA). STUDY DESIGN: In this randomized, double-blind, placebo-controlled study in 99 new COC starters (18-35 years old with body mass index range 18-34 kg/m²), a COC containing 30mcg ethinylestradiol (EE) and 3 mg drospirenone (DRSP) was used for 3cycles, followed by 6cycles of the same COC combined with either 50 mg/day DHEA or placebo. Total T, albumin, sex hormone-binding globulin (SHBG), DHEA-sulfate (DHEA-S), Δ4-androstenedione (AD), 3α-androstanediol glucuronide (ADG) and estradiol (E2) were measured, whereas free T and the free T index (FTI) were calculated. Assessments took place at baseline (no COC use), after the run-in period (COC use alone) and during the treatment period (DHEA or placebo). RESULTS: During COC use alone, androgen levels decreased, especially total T by 62% and free T by 86%, and SHBG increased by 243%. Total T increased with DHEA compared to placebo (change from end of run-in period to end of treatment period -- 1.3±1.2 nmol/L vs. 0.0±0.4 nmol/L; p<.0001) -- and was restored to baseline levels. Free T and the FTI increased significantly (p<.0001), but the free T level was still 53% below baseline levels. DHEA-S, AD and ADG increased significantly to levels above baseline (p<.0001 for each). DHEA had no effect on SHBG, albumin and E2. CONCLUSIONS: An EE/DRSP containing COC strongly suppressed endogenous androgen concentrations in all users. The addition of 50 mg DHEA to a COC regimen containing EE/DRSP restored total T to baseline levels, but free T levels were restored by only 47% as most of the T remains bound to SHBG. IMPLICATIONS: When using a COC that increases SHBG considerably, a daily dose of 50 mg DHEA is insufficient to normalize free T levels completely.

Restoring testosterone levels by adding dehydroepiandrosterone to a drospirenone containing combined oral contraceptive: II. Clinical effects.

OBJECTIVES: Combined oral contraceptives (COCs) decrease androgen levels, including testosterone (T), which may be associated with sexual dysfunction and mood complaints in some women. We have shown that 'co-administration' of dehydroepiandrosterone (DHEA) to a drospirenone (DRSP)-containing COC restored total T levels to baseline and free T levels by 47%. Here we describe the effects on sexual function, mood and quality of life of such an intervention. STUDY DESIGN: This was a randomized, double-blind, placebo-controlled study in 99 healthy COC starters. A COC containing 30 mcg ethinylestradiol (EE) and 3 mg DRSP was used for three cycles, followed by six cycles of the same COC combined with 50 mg/day DHEA or placebo. Subjects completed the Moos Menstrual Distress Questionnaire (MDQ), the McCoy Female Sexuality Questionnaire and the short form of the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q). Safety and tolerability, including effects on skin, were evaluated. RESULTS: The addition of DHEA induced small but significant improvements compared to placebo in the MDQ score for autonomic reactions during the menstrual (-2.0 vs. 0.71; p=0.05) and the premenstrual phase (-3.1 vs. 2.9; p=0.01) and for behavior during the intermenstrual phase (-1.4 vs. 3.6; p=0.02). A significant difference was found in the MDQ score for arousal during the premenstrual phase in favor of placebo (-5.0 vs. 1.0; p=0.01). There were no statistically significant differences between groups for the MSFQ and Q-LES-Q scores. DHEA 'co-administration' resulted in an acceptable safety profile. DHEA negated the beneficial effect of the COC on acne according to the subjects' self-assessment. CONCLUSIONS: 'Co-administration' with DHEA did not result in consistent improvements in sexual function, mood and quality of life indicators in women taking EE/DRSP. Retrospectively, the 50 mg dose of DHEA may be too low for this COC. IMPLICATIONS: A well-balanced judgment of the clinical consequences of normalizing androgens during COC use may require complete normalization of free T.

[Ulipristal acetate (Esmya): a selective modulator of progesterone receptors, new treatment of uterine fibromatosis]. / Le médicament du mois. L'acétate d'ulipristal (Esmya): un modulateur sélectif des récepteurs à la progesterone, nouveau traitement de la fibromatose utérine.

Uterine fibromatosis is a frequent benign gynaecological disease causing heavy menstrual bleeding and in some cases anaemia. Until now, medical treatment aimed to obtain amenorrhea by administration of progestins or Gn-RH agonists. By inducing hypo-oestrogenism, a reduction of myoma size is observed with Gn-RH agonists but after cessation of the treatment, initial myoma size is noted. The impact of progesterone in myoma growth is nowadays demonstrated and use of selective modulators of progesterone receptors represents a new medical approach of this disease.

[Management of gestational diabetes]. / Prise en charge du diabète gestationnel.

Pregnancy is associated with relative carbohydrate intolerance and insulin resistance. Gestational diabetes mellitus (GDM) is recognized as a risk factor for a number of adverse outcomes during pregnancy, including excessive fetal growth, increased incidence of birth trauma and neonatal metabolic abnormalities. This recognition has led to recommendations to screen all pregnant women for GDM and to treat those whose glucose tolerance tests exceed threshold criteria. Numerous epidemiological studies show that GDM affects between 1 and 25% of pregnancies, depending on the ethnicity of the population studied and the diagnostic criteria. Intervention to change lifestyle and, if maternal hyperglycemia persists, treatment with additional oral medication or insulin injections have shown to improve perinatal outcomes. Patients with GDM have a high risk of developing type 2 diabetes in the years after delivery and these women are encouraged to practice specific health behaviours (dietary habits, physical activity) during the postpartum period. The present article discusses the management of GDM in the light of data from the latest studies and international recommendations.

[Premature ovarian failure, from genetics to clinical]. / Insuffisance ovarienne prématurée: de la génétique à la clinique.

Premature Ovarian Failure (POF) is a condition with complicated clinical presentation. An estimated 1% of the population is affected before the age of 40, with 0.1% affected prior to the age of 30. There are many causes of POI: genetic aberrations, auto-immune ovarian damage, iatrogenic factors following surgery, radiotherapy or chemotherapy, environmental factors (viruses, toxins, smoking) and metabolic. The majority of POF cases have idiopathic etiologies.

[Screening strategy and diagnostic criteria for gestational diabetes. Proposals of the GGOLFB]. / Stratégie de dépistage et critères diagnostiques du diabète gestationnel. Propositions du GGOLFB.

For nearly 50 years, the strategy of screening and the diagnostic criteria for gestational diabetes have been the subject of endless controversies. They differ between countries and from one center to another, mainly because of the lack of hard data allowing to define glycemic thresholds at which a therapeutic management is needed. Recently, a large observational study has demonstrated the existence of a robust relationship between maternal blood sugar and several fetomaternal perinatal complications. This relationship is linear, with no clear threshold that would define gestational diabetes unambiguously. Meanwhile, two randomized intervention trials have shown that the therapeutic management of mild gestational diabetes was associated with improved perinatal outcomes. Based on these data, the " International Association of Diabetes and Pregnancy Study Group "(IADPSG) released new recommendations on screening methods and diagnostic criteria for gestational diabetes. Although already endorsed by several international associations and implemented in some countries, these recommendations still raise questions and criticisms. This is why the "Groupement des Gynécologues Obstétriciens de Langue Française de Belgique " (GGOLFB) organized a meeting between diabetologists and gynecologists which allowed to reach a consensus on the strategy that we intend to implement in our respective centers. The purpose of this paper is to briefly overview the recent advances in gestational diabetes and more particularly to make our key conclusions known to the medical community. This will enable the standardization of the management of gestational diabetes in the French-speaking part of Belgium.

[Screening strategy and diagnostic criteria for gestational diabetes. Proposals of the GGOLFB]. / Stratégie de dépistage et critères diagnostiques du diabète gestationnel. Propositions du GGOLFB.

For nearly 50 years, the strategy of screening and the diagnostic criteria for gestational diabetes have been the subject of endless controversies. They differ between countries and from one center to another, mainly because of the lack of hard data allowing to define glycemic thresholds at which a therapeutic management is needed. Recently, a large observational study has demonstrated the existence of a robust relationship between maternal blood sugar and several fetomaternal perinatal complications. This relationship is linear, with no clear threshold that would define gestational diabetes unambiguously. Meanwhile, two randomized intervention trials have shown that the therapeutic management of mild gestational diabetes was associated with improved perinatal outcomes. Based on these data, the "International Association of Diabetes and Pregnancy Study Group" (IADPSG) released new recommendations on screening methods and diagnostic criteria for gestational diabetes. Although already endorsed by several international associations and implemented in some countries, these recommendations still raise questions and criticisms. This is why the "Groupement des Gynécologues Obstétriciens de Langue Française de Belgique" (GGOLFB) organized a meeting between diabetologists and gynecologists which allowed to reach a consensus on the strategy that we intend to implement in our respective centers. The purpose of this paper is to briefly overview the recent advances in gestational diabetes and more particularly to make our key conclusions known to the medical community. This will enable the standardization of the management of gestational diabetes in the French-speaking part of Belgium.

[Zoely, a combined oral contraceptive, monophasic pill containing estradiol and nomegestrol acetate]. / La médicament du mois. Zoely, une association monophasique d'estradiol et d'acétate de nomégestrol.

A new combined oral contraceptive called Zoely has just been marketed in Belgium. It contains nomegestrol acetate, a progestin known for its high contraceptive reliability based on its antigonadotropic power and long half-life. This progestin is associated with estradiol and Zoely is devoid of ethinyl estradiol, which is the usual component of the majority of combined oral contraceptives and is primarily responsible for thrombotic side effects of the pill. The compositon and type of regimen of this new oral contraceptive contribute to its efficacy and excellent clinical tolerance.

[Management of estrogen deficiency after breast cancer]. / Prise en charge des conséquences de la carence oestrogénique après cancer du sein.

The prevention and the treatment of oestrogen deficiency induced by breast cancer treatments are crucial in the management of patients. The impacts of this deficiency must not be neglected: quality of life impairments inducing eventually premature withdrawal of hormonotherapies, and excess of bone and cardio-vascular morbidities and mortalities, especially in good prognosis young women. Management strategies of short and long term effects of this deficiency are reviewed and discussed here.

[Therapeutic inertia in contraception]. / L'inertie thérapeutique en contraception.

The efficiency of contraception is linked to the method and the patient's compliance. The advice given by the physician about contraception use is essential to avoid unintended pregnancy. The accuracy of contraceptive choice and the individualized adaptation over time contribute to safe contraception.