Does Nomegestrol Acetate Plus 17ß-Estradiol Oral Contraceptive Improve Endometriosis-Associated Chronic Pelvic Pain in Women?

Background: To evaluate the effects of a 24/4 regimen combined oral contraceptive (COC) containing 1.5 mg 17ß-estradiol (E2) and 2.5 mg nomegestrol acetate (NOMAC) compared to on-demand nonsteroidal anti-inflammatory drugs (NSAIDs) on women affected by endometriosis-associated chronic pelvic pain (the primary end point) and their quality of life (QoL) and sexual function (the secondary end points). Materials and Methods: Ninety-nine women on E2/NOMAC constituted the study group; and 63 women on NSAIDs constituted the control group. The visual analogic scale was used to measure the levels of pelvic pain, dysmenorrhea, and dyspareunia. To assess their QoL, sexual function, and sexual distress, the Short Form-36 (SF-36), the Female Sexual Function Index (FSFI), and the Female Sexual Distress Scale (FSDS) were used, respectively. The study included two follow-ups at 3 and 6 months. Results: Improvement in chronic pelvic pain was observed in the study group at both the 3- and 6-month follow-ups (p < 0.001). SF-36, FSFI, and FSDS had a similar trend at the 3- and 6-month follow-ups (p < 0.001). Women on NSAIDs did not report any reduction in pain symptoms or improvement in QoL (p ≤ 0.4). However, they had a limited improvement of their FSFI and FSDS (p < 0.001). The improvement of the pain symptoms, QoL, FSFI, and FSDS, was more evident in women on E2/NOMAC than in those on NSAIDs, when the study group and control group values were compared at the 3- and 6-month follow-ups (p < 0.001). Conclusions: Women on E2/NOMAC COC showed a better reduction of endometriosis-associated chronic pelvic pain and an improvement of their QoL and sexual activity than those of the women on NSAIDs.

Surgical Technique for Endometrioma in 10 Steps.

OBJECTIVE: Laparoscopic cystectomy for endometrioma has the advantages of a minimally invasive approach. The standardization and description of the technique are the main objectives of this video. We described the surgery in 10 steps, which could help to make this procedure easier and safer. DESIGN: Step-by-step video demonstration of the technique. SETTING: A French university tertiary care hospital. INTERVENTION: Two standardized laparoscopic cystectomy were recorded to realize the video. The local institutional review board ruled that approval was not required because the video describes a technique and does not report a clinical case. This video presents a systematic approach to cystectomy for endometrioma clearly divided into 10 steps: (1) preoperative evaluation [1]; (2) diagnosis and exploration [2]; (3) adhesiolysis, mobilization of the ovary; (4) cyst rupture, exposition of the entry site; (5) identification of the cleavage plan; (6) endometrioma easy dissection; (7) endometrioma difficult dissection; (8) hemostasis, reconstruction of the ovary [3]; (9) exploration of the ovarian fossa; and (10) washing, extraction of the cyst [3,4]. CONCLUSION: Standardization of laparoscopic cystectomy for endometrioma could make this procedure easier and safer to perform. The 10 steps presented help to perform each part of the surgery in a logical sequence, making the procedure easier to realize. Moreover, the standardization of the surgical techniques may reduce the learning curve.

Laparoscopic Resection of Diaphragmatic Endometriosis in 10 Steps.

STUDY OBJECTIVE: Laparoscopic resection of diaphragmatic endometriosis has the advantages of a minimally invasive approach [1]. The standardization and description of the technique are the main objectives of this video. We described the procedure in 10 steps to make it easier and safer. DESIGN: A step-by-step video demonstration of the technique (Video 1). SETTING: A French university tertiary care hospital. PATIENTS: Patients with diaphragmatic endometriosis confirmed by magnetic resonance imaging [2]. The local institutional review board ruled that approval was not required for this video article because the video describes a technique and does not report a clinical case. INTERVENTION: There are no guidelines on the surgical treatment of diaphragmatic endometriosis [3]. We propose a laparoscopic approach using a right lateral access with the patient in the left lateral decubitus position [4]. MEASUREMENTS AND MAIN RESULTS: This video presents the procedure divided into the following 10 steps: step 1, set up; step 2, patient position; step 3, installation of the trocars; step 4, releasing the liver; step 5, exposure of the diaphragmatic endometriosis; step 6, making a diaphragmatic defect; step 7, exploring the thoracic cavity; step 8, resection of diaphragmatic endometriosis; step 9, inserting the suction catheter; and step 10, closing the diaphragmatic defect. CONCLUSION: Standardization of laparoscopic resection of diaphragmatic endometriosis could make this procedure easier and safer to perform. The left lateral decubitus position helps to have complete exposure of the right diaphragmatic muscle and endometriosis. We presented 10 steps to help perform each part of the surgery in logical sequence, making the procedure ergonomic and easier to adopt and learn [5]. Standardization of laparoscopic techniques could help to reduce the learning curve.

Ultrastructural Study of Clitoral Cavernous Tissue and Clitoral Blood Flow From Type 1 Diabetic Premenopausal Women on Phosphodiesterase-5 Inhibitor.

BACKGROUND: The effects of phosphodiesterase-type 5 (PDE5) inhibitors on the in vivo clitoral structure of women with diabetes have never been investigated. AIM: To study the in vivo structural and hemodynamic changes of the clitoris in premenopausal women with type 1 diabetes on PDE5 inhibitors. METHODS: 38 premenopausal women with type 1 diabetes aged 36 -46 years. A randomized 1:1 study design was used: Study Group (group A) on Tadalafil 5 mg daily, and control group (group B). Blood samples were taken from each woman to measure HbA1c, testosterone, and Free Androgen Index. The women underwent microbiopsy of the clitoral body by means of semiautomatic gun during total anesthesia for surgery therapy of a benign gynecological pathology. The tissue removed was processed for electron microscopy. Translabial color Doppler ultrasound was used to measure the peak systolic velocity (PSV), the end diastolic velocity (EDV), and the pulsatility index (PI) of clitoral arteries. MAIN OUTCOME MEASURES: Micro-ultrastructure observation of clitoral tissue and color Doppler sonography of clitoral blood flow. RESULTS: Of the 38 women, 13 (68.4%) of group A and 15 (78.9%) of group B completed the study. Group A showed a mean PSV and EDV increase, and a mean PI decrease with respect to baseline (P < .001). Group B did not show any change in both the parameters (P = NS). By a quantitative study in both groups a variable degree of ultrastructural abnormalities of smooth muscle cells (SMCs) was observed, consisting in increased glycogen and lipoic deposits, cytoplasmic vacuoles, and focal increase of electron density of SMCs. Moreover, the mean SMC thickness of group A (1.83 ± 0.68 µm) was larger than that of group B (1.3 ± 0.41 µm) (P = .02). CLINICAL IMPLICATIONS: PDE5 inhibitors could be used to treat diabetic women with genital arousal disorder. STRENGTHS & LIMITATIONS: The study shows a clear effect of PDE5 inhibitors on clitoral SMCs. However, a limit was to not have investigated the sexual function/behavior of women of both groups, this was because of the short time of the study. CONCLUSION: This study could help to understand in what way PDE5 inhibitors act on the ultrastructural pathophysiological clitoral cavernous tissue of women with diabetes. It could support PDE5 inhibitor usage in women with genital sexual arousal disorder due to metabolic diseases. Caruso S, Cianci A, Cianci S, et al. Ultrastructural Study of Clitoral Cavernous Tissue and Clitoral Blood Flow From Type 1 Diabetic Premenopausal Women on Phosphodiesterase-5 Inhibitor. J Sex Med 2019;16:375-382.

Laparoscopic Myomectomy in 10 Steps.

STUDY OBJECTIVE: Laparoscopic myomectomy has the advantages of a minimally invasive approach for the surgical treatment of myomas. The standardization and description of the technique are the main objectives of this video. We described laparoscopic myomectomy in 10 steps, which could help make this procedure easier and safer [1]. SETTING: A French university tertiary care hospital. PATIENTS: Patients with indication for laparoscopic myomectomy. The local institutional review board ruled that approval was not required for this video article because the video describes a technique and does not report a clinical case. INTERVENTION: Standardized laparoscopic myomectomies were recorded to realize the video. MEASUREMENTS AND MAIN RESULTS: This video presents a systematic approach to myomectomy clearly divided into 10 steps: (1) prepare your surgery, make selection and prehabilitation of patient [2], provide a good cartography of the myoma(s), and plan the surgery [3,4]; (2) ergonomy and material; (3) preventive hemostasis: triple occlusion; (4) hysterotomy; (5) enucleation by fast dissection and traction; (6) bipolar hemostasis; (7) check for missing myomas; (8) suture; (9) extraction/morcellation; and (10) prevent adhesions [5]. CONCLUSION: Standardization of laparoscopic myomectomy could make this procedure easier and safer to perform. The 10 steps presented help to perform each part of surgery in logical sequence making the procedure ergonomic and easier to adopt and learn. Standardization of laparoscopic techniques could help to reduce the learning curve.

HPV genotype determination and E6/E7 mRNA detection for management of HPV positive women.

BACKGROUND: Clinical management of HPV positive women is difficult since many of the infections, including high-risk oncogene genotypes (hr-HPV), are transient. Therefore only a limited number of patients have a high-grade lesion and sending all HPV positive women for colposcopy would only increase costs and unnecessary treatment, with serious psychological consequences for patients. The need has emerged to identify other HPV related markers able to correctly detect women with a high-risk of developing high-grade lesions. Genotyping and the search for E6/E7 mRNA are among the possible candidates. METHODS: The study was carried out by means of an observational analysis of the data relative to 674 HR-HPV positive women who we had observed from January 2013 to June 2015; the data had been gathered in a database at the HPV Center of the University Hospital of Catania, Italy. Women were considered eligible for this study if the following data was present in the database: Pap TEST, histologic evaluation, HPV TEST and E6/E7 mRNA detection. We calculated the Odds Ratio (OR) of woman who were mRNA positive, with CIN2+ lesions, and Odds Ratio of HPV16 positive women. RESULTS: Transcripts were detected in 23.6% (69/292) of the women with CIN1 and in 97.2% (210/220) of those with CIN2 + . Regarding genotyping, the 81,8% (180/220) of the women with CIN2+ had genotype 16, while only 18.1% (40/220) had genotype 18, 31, 33, 45. We calculated the OR in the group of HPV16 women with CIN2+ (OR = 4.62; 95% CI = 3.13 to 6.82), this value increased (OR = 106.12; 95% CI = 53.71 to 209.69) in women with CIN2+ and positive mRNA. DISCUSSION: The presence of the HPV16 genotype in our study was associated with a risk 5 times greater of developing a high-grade lesion (CIN2+) (OR = 4.62 95% CI:3.13-6.82); this supports the hypothesis that it would be opportune to have targeted protocols for the management of HPV 16 positive women. The results showed that there was an association between E6/E7 mRNA expression and histology (OR = 106.12; 95% CI = 53.71 to 209.69). The E6/E7 mRNA test showed a higher prevalence of E6 and E7 transcripts in patients with higher-grade lesions. CONCLUSION: The results of this study suggest that the HPV genotype determination and E6/E7 mRNA detection would find an important application for management of HPV positive women.

Improvement of Low Sexual Desire Due to Antiandrogenic Combined Oral Contraceptives After Switching to an Oral Contraceptive Containing 17ß-Estradiol.

OBJECTIVES: To investigate the effects of a combined oral contraceptive (COC) containing 17ß-estradiol (E2) 1.5 mg and nomegestrol acetate 2.5 mg (NOMAC/E2) on the sexual health of women affected by low sexual desire due to COCs containing ethinylestradiol. MATERIALS AND METHODS: Eighty-three women (age range 19-32) participated in the study. Sex hormone-binding globulin (SHBG), total testosterone (TT), and free androgen index (FAI) were measured. The Female Sexual Function Index (FSFI) and the Female Sexual Distress Scale (FSDS) questionnaires were used to assess sexual function and distress, respectively. Hormonal levels were measured and questionnaires were administered before the women switched COC NOMAC/E2 usage (baseline) and at the 3-month (first) and 6-month (second) follow-ups. RESULTS: SHBG reduction (p < 0.001), TT (p < 0.05), and FAI increases (p < 0.001) were observed during the first and second follow-ups with respect to baseline values. Sexual desire increased from baseline to the first and second follow-ups (p < 0.001). At baseline, the total FSFI score was 22 ± 1.5 and the FSDS score was 16.6 ± 1.3, both indicating sexual dysfunction with sexual distress. At the first follow-up, the total FSFI score and the FSDS score increased toward sexual health values, being 28.3 ± 1.6 and 12.1 ± 1.5, respectively (p < 0.001). At the second follow-up, the FSFI score had risen to 30.6 ± 1.3 (p < 0.001) and the FSDS score had dropped to 8.3 ± 1.4 (p < 0.001). CONCLUSIONS: COCs containing E2 are an innovation that could help women to not suffer from low sexual desire during hypoandrogenic COC usage.