BCL-6 Overexpression as a Predictor for Endometriosis in Patients Undergoing In Vitro Fertilization.

OBJECTIVE: To evaluate the positive predictive value (PPV) of endometrial BCL-6 overexpression as a noninvasive screening test endometriosis in patients undergoing in vitro fertilization (IVF). METHODS: Retrospective cohort study at a university-affiliated private practice. Inclusion criteria were reproductive age females currently undergoing IVF with a diagnosis of unexplained infertility or unexplained recurrent pregnancy loss. Those with endometrial BCL-6 overexpression underwent laparoscopic surgery with an indication for treatment of suspected endometriosis. The primary outcome was the PPV of endometrial BCL-6 testing to surgically diagnose endometriosis. Statistical analysis was performed using SPSS v.25.0. RESULTS: Seventy-five patients met inclusion criteria for our study. The PPV of BCL-6 testing for endometriosis was 96%. Of those patients without endometriosis, 100% had other inflammatory pelvic pathologies, which were diagnosed and treated at the time of laparoscopy. CONCLUSIONS: Endometrial BCL-6 overexpression has a high PPV for diagnosing endometriosis and can help identify a patient population that may require surgical treatment before embryo transfer.

The role of the endogenous opioid system in polycystic ovary syndrome.

OBJECTIVE: To review the complex role of the opioid system in reproduction and carbohydrate metabolism, abnormalities in the opioid system in women with polycystic ovary syndrome (PCOS), and the role of opioid antagonists in the management of PCOS-related infertility. DESIGN: Pertinent articles were identified through a computer PubMed search. References of selected articles were hand searched for additional citations. CONCLUSION(S): Endogenous opioids are generally considered inhibitory central neurotransmitters. Peripherally, opioids are involved in the regulation of pancreatic islet function, hepatic insulin clearance, and glucose metabolism, potentially contributing to the pathogenesis of hyperinsulinemia and insulin resistance in PCOS. The presence of sex steroids is required for normal function of the opioid system in both GnRH secretion and carbohydrate metabolism. In women with PCOS, growing evidence suggests dysregulation of the opioid system both centrally and peripherally, with complex interactions. The opioid system effects on carbohydrate metabolism appear to be modulated by obesity. Finally, naltrexone has been demonstrated to successfully augment traditional ovulation induction regimens, but has limited support as a single ovulation induction agent for PCOS.

A rare case of vulvar endometriosis in an adolescent girl.

OBJECTIVE: To describe a case of vulvar endometriosis in a teenager after a history of vulvar ulcers in the same location. DESIGN: Case report. SETTING: University medical center. PATIENT(S): A 13-year-old girl with a history of vulvar ulcers. MAIN OUTCOME MEASURE(S): None RESULT(S): A 13-yr-old female presented with painful, open vulvar ulcerations on the inner side of her labia minora. Biopsy revealed dermatitis with ulceration. One year later she noted an ulcer and blood in her undergarments. Biopsy results were consistent with endometriosis. Five years later, the lesions persisted and bled during menses. A bilateral labial excision was performed. Pathology again revealed endometriosis. CONCLUSION(S): Vulvar endometriosis is extremely unusual. This rare case of vulvar endometriosis in the same location as a previous vulvar ulcer is most likely due to ectopic transplantation of endometrial cells during a menstrual cycle. Excision is considered definitive treatment.

Black cohosh has central opioid activity in postmenopausal women: evidence from naloxone blockade and positron emission tomography neuroimaging.

OBJECTIVE: To test whether black cohosh (BC) exhibits an action on the central endogenous opioid system in postmenopausal women. DESIGN: This was a mechanistic study conducted in the same individuals of luteinizing hormone pulsatility with a saline/naloxone challenge (n = 6) and positron emission tomography with [C]carfentanil, a selective micro-opioid receptor radioligand (n = 5), before and after 12 weeks of unblinded treatment with a popular BC daily supplement. RESULTS: BC treatment for 12 weeks at a standard dose (Remifemin, 40 mg/day) had no effect on spontaneous luteinizing hormone pulsatility or estrogen concentrations. With naloxone blockade, there was an unexpected suppression of mean luteinizing hormone pulse frequency (saline vs naloxone = 9.0 +/- 0.6 vs 6.0 +/- 0.7 pulses/16 h; P = 0.056), especially during sleep when the mean interpulse interval was prolonged by approximately 90 minutes (saline night interpulse interval = 103 +/- 9 min vs naloxone night interpulse interval = 191 +/- 31 min, P = 0.03). There were significant increases in mu-opioid receptor binding potential in the posterior and subgenual cingulate, temporal and orbitofrontal cortex, thalamus, and nucleus accumbens ranging from 10% to 61% across brain regions involved in emotional and cognitive function. In contrast, binding potential reductions of lesser magnitude were observed in regions known to be involved in the placebo response (anterior cingulate and anterior insular cortex). CONCLUSIONS: Using two different challenge paradigms for the examination of central opioid function, a neuropharmacologic action of BC treatment was demonstrated in postmenopausal women.

Change in adipocytokines and ghrelin with menopause.

OBJECTIVES: To determine if ghrelin and adipocytokine (leptin, adiponectin, resistin) levels vary with menopause stage or with estradiol (E2), testosterone (T), follicle-stimulating hormone (FSH) and sex hormone-binding globulin (SHBG) concentrations measured in three stages of the menopause transition. METHODS: A study of adipocytokines and menopause was nested in a population-based, longitudinal study of Caucasian women [Michigan Bone Health and Metabolism Study (MBHMS)]. Annual serum and urine samples, available from the MBHMS repository, were selected to correspond to the pre-, peri-, and postmenopause stages of the menopause transition. Participants included forty women, stratified into obese versus non-obese groups based upon their baseline body mass index, who had specimens corresponding to the three menopause stages. RESULTS: Mean resistin levels were approximately two times higher during premenopause compared to peri- or postmenopause. There were significantly lower adiponectin and higher ghrelin levels in the perimenopause stage, compared to either the pre- or postmenopause stage. Increases in FSH concentrations were significantly and positively associated with higher leptin in non-obese women (P<0.01) but not in obese women (P<0.23). Increases in FSH concentrations were also significantly (P<0.005) and positively associated with higher adiponectin concentrations but were negatively associated with ghrelin concentrations (P<0.005). Associations remained following adjustment for waist circumference, waist circumference change, chronological age, and time between measures. CONCLUSIONS: Menopause stages and underlying FSH changes are associated with notable changes in levels of the metabolically active adipocytokines and ghrelin and these changes may be related to selected health outcomes observed in women at mid-life.

Physical functioning and menopause states.

OBJECTIVE: To assess whether losses in physical functioning are related to the natural menopause, hysterectomy, or calendar time during midlife, after adjustment for body size and smoking. METHODS: A longitudinal assessment of physical functioning was conducted from 2000/01 through 2005/06 in a population-based sample of 544 women at midlife enrolled in the Michigan Bone Health and Metabolism Study. Longitudinal mixed models were used to relate menopausal status to measures of physical functioning. Perception of physical functioning was assessed with the Medical Outcomes Study Short-Form 36 questionnaire. Eight performance-based measures of physical functioning were also included. RESULTS: Women with hysterectomy (with or without estrogen from ovarian conservation or exogenous replacement) had reduced levels of functioning and greater rates of change in the 2-lb lift (P<.005), sit-to-stand (P<.01), timed stair climb (P<.01), timed walk (P<.01), velocity (P<.05), and perception of physical functioning (P<.01) compared with premenopausal and perimenopausal women after adjustment for time since baseline, body size, and smoking. Diminished functioning in postmenopausal women was observed in hand grip (P<.005), 2-lb lift (P<.05), sit-to-stand (P<.05), velocity (P<.05), and perceived physical functioning (P<.05). Based on regression analyses, there was greater loss in women with hysterectomy compared with natural menopause. Level of functioning among postmenopausal women with exogenous hormone replacement was similar to premenopausal women on eight of nine physical functioning measures. CONCLUSION: Hysterectomy, even with availability of an estrogen source, seems to be a "risk" state for diminishing physical function at midlife, and this may initiate a vulnerable stage for future compromised quality of life. LEVEL OF EVIDENCE: II.

MR imaging evaluation of acute appendicitis in pregnancy.

PURPOSE: To retrospectively assess the diagnostic performance of magnetic resonance (MR) imaging in pregnant patients suspected of having acute appendicitis. MATERIALS AND METHODS: The study was approved by the committee on clinical investigations and was HIPAA compliant. The informed consent requirement was waived. MR images were obtained in 51 consecutive pregnant patients (mean age, 28.3 years) who were clinically suspected of having acute appendicitis. In this protocol for pregnant patients, MR imaging is performed when findings at ultrasonography (US) are inconclusive or additional information is needed. Four patients had appendicitis, which was confirmed at surgery in three patients and at follow-up computed tomography in one patient. Initial interpretations were used for patient care and to calculate diagnostic accuracy. The appendix was considered normal at MR imaging if its diameter was less than or equal to 6 mm or if it was filled with air, oral contrast material, or both. An enlarged fluid-filled appendix (>7 mm in diameter) was considered an abnormal finding. An appendix with a diameter of 6-7 mm was considered an inconclusive finding; in those cases, the presence of periappendiceal inflammation was used for the final diagnosis. Three radiologists retrospectively assessed the visualization of the appendix by using a 5-point scale. Statistical analysis was performed by using the median and Fisher exact tests and the Spearman correlation coefficient. RESULTS: MR images were positive for appendicitis in four patients and inconclusive in three. In the three patients with inconclusive results, the appendix was not seen in two patients and was borderline enlarged (7 mm in diameter) in the third. The overall sensitivity, specificity, prevalence-adjusted positive and negative predictive values, and accuracy for MR imaging was 100%, 93.6%, 1.4%, 100%, and 94.0%, respectively. CONCLUSION: MR imaging is an excellent modality for use in excluding acute appendicitis in pregnant women who present with acute abdominal pain and in whom a normal appendix is not visualized at US.

Relaxation techniques for reducing pain and anxiety during screening mammography.

OBJECTIVE: The purpose of this study was to determine whether listening to a relaxation audiotape before and during mammography decreases subjective reports of pain and anxiety. CONCLUSION: Listening to a relaxation or music audiotape before and during mammography does not reduce subjective reports of anxiety or pain. Women undergoing screening mammography report minimal levels of distress.