Etiology and Secular Trends in Primary Amenorrhea in 856 Patients: A 17-Year Retrospective Multicenter Study in Korea

Background@#This study was performed to evaluate etiologies and secular trends in primary amenorrhea in South Korea. @*Methods@#This retrospective multi-center study analyzed 856 women who were diagnosed with primary amenorrhea between 2000 and 2016. Clinical characteristics were compared according to categories of amenorrhea (hypergonadotropic/hypogonadotropic hypogonadism, eugonadism, disorders of sex development) or specific causes of primary amenorrhea. In addition, we assessed secular trends of etiology and developmental status based on the year of diagnosis. @*Results@#The most frequent etiology was eugonadism (39.8%). Among specific causes, Müllerian agenesis was most common (26.2%), followed by gonadal dysgenesis (22.4%). Women with hypergonadotropic hypogonadism were more likely to have lower height and weight, compared to other categories. In addition, the proportion of cases with iatrogenic or unknown causes increased significantly in hypergonadotropic hypogonadism category, but overall, no significant secular trends were detected according to etiology. The proportion of anovulation including polycystic ovarian syndrome increased with time, but the change did not reach statistical significance. @*Conclusion@#The results of this study provide useful clinical insight on the etiology and secular trends of primary amenorrhea. Further large-scale, prospective studies are necessary.

Development of an endometriosis self-assessment tool for patient

Objective@#This study aimed to develop and verify an endometriosis self-assessment tool (ESAT). @*Methods@#A non-experimental, descriptive, correlational study design was used. Candidate items were developed based on a conceptual framework constructed using the results of in-depth interviews and an integrative literature review. The construct validity of the developed tool was also examined. One-hundred and forty-two participants (117 patients with endometriosis and 25 patients without endometriosis) were included in the validity and reliability tests. The data were collected between August and December 2018. Nomological validity was verified based on significant correlations between the ESAT and the quality-of-life scores. @*Results@#A 21-item ESAT was developed, and its construct validity was supported. Exploratory factor analysis indicated that the tool consisted of four components (gastrointestinal symptoms, dysmenorrhea, usual symptoms, and the amount and characteristics of menstrual bleeding) with a variance of 61.6%. The variance in quality-of-life scores, as explained by the ESAT scores, was relatively high. Receiver operator characteristics curve analysis indicated that ESAT scores significantly differentiated endometriosis from non-endometriosis with fair discriminatory power at a cut-off score of 50 (sensitivity, 0.76; specificity, 0.72; area under the curve, >0.75; P50 points were more likely to have endometriosis. Thus, the reliability of the ESAT was confirmed. @*Conclusion@#The devised tool appears valid and reliable. This tool may allow women to determine their risk of endometriosis by distinguishing between normal and pathological menstruation-related symptoms.

Clinical manifestation, diagnosis, and treatment of Klinefelter syndrome

Klinefelter syndrome is the most common congenital chromosomal syndrome in men. Clinical manifestations of Klinefelter syndrome vary greatly depending on the level of expression of the added X chromosome, the sensitivity of the androgen receptor, and the testosterone level. On average, the likelihood of a lifetime diagnosis of Klinefelter syndrome patients is less than 40%, and more than 60% of patients are unaware of their condition. Klinefelter syndrome patients in infancy sometimes have speech impairment; however, there are more cases without symptoms. In the early stages of puberty, there are many normal puberty development cases, but after mid-puberty, secondary sexual characteristics stop progressing. In adulthood, it is often diagnosed as a non-obstructive azoospermia disease. After middle-age, an increase in various metabolic disorders due to testosterone reduction appears as the main symptom. Testosterone treatment can promote the development of secondary sexual characteristics from puberty. Diagnosing a patient with Klinefelter syndrome due to infertility in adulthood may cause a psychological shock; therefore, a psychotherapeutic approach is also essential. Klinefelter syndrome is a disease that requires lifelong management, and in most cases the quality of life of patients and their families can be improved with appropriate therapeutic intervention. Because there are many cases without symptoms, it is important to screen suspected patients through active chromosomal testing.

Sleep Disorders and Menopause

Sleep disorders are one of the main symptoms of menopause. Symptoms of sleep disorders that menopausal women complain about include falling asleep, frequent awakening and/or early morning awakening. There are many possible causes of sleep disorders in postmenopausal women, including vasomotor symptoms, ovarian hormone changes, restless legs syndrome, periodic leg movement syndrome, and obstructive sleep apnea. In this review, we discuss the relationship between menopause and sleep disorders.

Erratum to: Sleep Disorders and Menopause

The authors regret that the order of Youngsin Han and Jinju Lee was unintentionally changed in the original version of this article. The Journal would like to assure readers that this does not affect any other content of the article.

Effects of Di(2-ethylhexyl)phthalate on Bone Metabolism in Ovariectomized Mice

BACKGROUND: The molecular pathways of how endocrine disruptors affect bone mineral density (BMD) and bone remodeling are still unclear. The purpose of this experimental study is to determine the effects of di(2-ethylhexyl)phthalate (DEHP) on bone metabolism in ovariectomized mice. METHODS: Twenty-six-month-old female CD-1 mice were divided into 4 groups: control, low-dose DEHP, high-dose DEHP, and estrogen groups (n=5, each group). All mice were subjected to ovariectomy for the induction of artificial menopause and then exposed to corn oil, DEHP, and estrogen for 2 months. Micro-computed tomography (Micro-CT) of the bone and analysis of blood samples for bone markers were performed to observe the changes in bone metabolism. RESULTS: Osteocalcin level was decreased in the control, low-dose and high-dose DEHP group, the reduction width was greater in the high-dose DEHP group (−0.219 ng/mL) than control group (−0.077 ng/mL, P<0.05). C-terminal telopeptide of type I collagen level was increased in the control, low-dose and high-dose DEHP group, the increase range of low-dose DEHP group (0.329 ng/mL) showed greater than control group (0.093 ng/mL, P<0.05). Micro-CT analysis revealed that the BMD was significantly lower in the high-dose DEHP group (19.8×10⁻² g/cm³) than control group (27.2×10⁻² g/cm³, P<0.05). The structure model index was significantly higher in the high-dose DEHP group (2.737) than low-dose DEHP group (2.648) and estrogen group (2.63, P<0.05). It means the progression of osteoporosis in the high-dose DEHP group. CONCLUSIONS: These results confirm the negative effects of DEHP on bone health in ovariectomized mice. Further continuous studies on genetic pathways and other endocrine disruptors will be necessary to validate these findings.

Association of preoperative pain in knee and external to knee with postoperative pain outcome after total knee arthroplasty

BACKGROUND: Preoperative pain in the symptomatic knee may predict postoperative pain severity in patients undergoing total knee arthroplasty (TKA). However, the effect of preoperative pain external to the knee on postoperative pain is unclear. This study evaluated postoperative pain outcomes in TKA patients according to the presence of preoperative pain in the knee only or in the knee and external to the knee.METHODS: We retrospectively assessed medical records of patients who underwent unilateral TKA. The relationship between reported preoperative pain characteristics and morphine equivalent consumption or numerical rating scale (NRS) pain scores on postoperative day (POD) 0–3 was assessed using a multivariable generalized linear model.RESULTS: In total, 3,429 adult patients who underwent their first TKA were included; 2,864 (83.5%) patients preoperatively experienced only knee pain and 565 (16.5%) knee pain with external to knee pain. Preoperative pain in the knee and external to the knee was associated with 5% higher morphine equivalent consumption on POD 0–3 compared to preoperative knee pain only (exponentiated regression coefficient: 1.05; 95% confidence interval: 1.02 to 1.09; P = 0.004). However, the NRS pain scores on POD 0, 1, 2, and 3 and adjuvant analgesics consumption (acetaminophen and ketorolac) on POD 0–3 were not significantly different between the two groups (P > 0.05).CONCLUSIONS: This study showed that there was an increase of morphine equivalent consumption during POD 0–3 in patients with preoperative knee pain with external to knee pain than in patients with preoperative only knee pain.

Is robot-assisted laparoscopic myomectomy limited in multiple myomas?: a feasibility for ten or more myomas

OBJECTIVE: To evaluate the feasibility of robot-assisted laparoscopic myomectomy in multiple myomas over 10. METHODS: A retrospective study was conducted for 662 patients who underwent robot-assisted laparoscopic myomectomy and open myomectomy by a single operator in a tertiary university hospital. RESULTS: A total of 30 women underwent removal of 10 or more uterine myomas by robotics and 13 patients were selected for this study. The average number of myomas removed was 13.7 (range 10–20). The maximum diameter of the myomas was 6.8 cm (range 5.0–10.0 cm). The sum of the diameters of each myoma was 34.7 cm (range 20.0–54.5 cm) and the mass of resected myomas for each case was 229.1 g (range 106.8–437.9 g). In no case was the robotic procedure converted into conventional laparoscopy or laparotomy, and all patients recovered without any major complications. In comparison with 13 cases of open myomectomy during the same period, robotic surgery took longer time than open surgery (360.5 vs. 183.8 minutes; P=0.001) but had shorter postoperative hospital days after surgery (mean 2.5 vs. 3.5 days; P=0.003). CONCLUSION: Robot-assisted laparoscopic myomectomy could be an alternative to laparotomic myomectomy for numerous myomas over 10 in number.

The expression of Müllerian inhibiting substance/anti-Müllerian hormone type II receptor in myoma and adenomyosis

OBJECTIVE: We compared the expression levels of Müllerian inhibiting substance (MIS)/anti-Müllerian hormone type II receptor (AMHRII) in uterine myoma and adenomyosis to evaluate the possibility of using MIS/anti-Müllerian hormone (AMH) as a biological regulator or therapeutic agent in patients with uterine leiomyoma and adenomyosis. METHODS: We studied normal uterine myometrium, leiomyoma, endometrial tissue, and adenomyosis from 57 patients who underwent hysterectomy for uterine leiomyoma (22 cases) or adenomyosis (28 cases) and myomectomy for uterine myoma (7 cases). Immunohistochemical staining was used to confirm the MIS/AMHRII protein expression level in each tissue. Reverse transcription-polymerase chain reaction was performed to quantify MIS/AMHRII mRNA expression. RESULTS: The MIS/AMHRII protein was more strongly expressed in uterine myoma (frequency of MIS/AMHRII expressing cells: 51.95%±13.96%) and adenomyosis (64.65%±4.85%) tissues than that in the normal uterine myometrium (3.15%±1.69%) and endometrium (31.10%±7.19%). In the quantitative analysis of MIS/AMHRII mRNA expression, MIS/AMHRII mRNA expression levels in uterine myoma (mean density: 4.51±0.26) and adenomyosis (6.84±0.20) tissues were higher than that in normal uterine myometrial tissue (0.08±0.09) and endometrial tissue (1.63±0.06). CONCLUSION: This study demonstrated that MIS/AMHRII was highly and strongly expressed on uterine myoma and adenomyosis. Our data suggest that MIS/AMH may be evaluated as a biological modulator or therapeutic agent on MIS/AMHRII expressing uterine myoma and adenomyosis.

Successfully removed uterine angioleiomyoma by robot-assisted laparoscopic myomectomy

Angioleiomyoma is a rare type of leiomyoma variant and there are a few cases reported to date. Herein, we present a case of angioleiomyoma in a 36-year-old woman with lower abdominal pain, initially diagnosed by degenerated uterine leiomyoma. The transvaginal ultrasonogram showed an ovoid-shaped heterogeneously hyperechoic lesion in left cornual site of uterus and pelvic magnetic resonance image showed an about 5.1 cm sized heterogenous T2 intermediate high mass with poor enhancement. The patient underwent a robot-assisted laparoscopic myomectomy, and final histopathologic diagnosis revealed uterine angioleiomyoma. This case is the first case of angioleiomyoma resected by robotic surgery. The patient is on follow up for over 1 year and shows no evidence of recurrence until now.

The caries preventive effect on permanent teeth adjusted for number of fissure-sealed teeth and surfaces from 6-year community water fluoridation program in Geoje City / 대한구강보건학회지

OBJECTIVES: The water fluoridation program has been implemented since 2008, in a region of Geoje City. This study aimed to evaluate the effectiveness of the water fluoridation program on caries prevention in the permanent dentition. METHODS: Evaluation surveys were conducted on 8-, 10- and 12-year-old children in the fluoridated and non-fluoridated regions of Geoje City, in 2015. The survey included 834 children from the fluoridated regions and 703 from the non-fluoridated regions. The data obtained from the survey were analyzed using the IBM SPSS statistical package version 23.0. The effectiveness of community water fluoridation in caries prevention was estimated by the differences in the decayed, missing, filled teeth (DMFT) and decayed, missing, filled surfaces (DMFS) scores, between the program and control groups. The mean numbers of fissure-sealed teeth and surfaces were adjusted to reduce their confounding effect. RESULTS: The mean DMFT and DMFS scores (0.69 and 0.91, respectively) of 10-year-olds from the fluoridated regions, after adjusting for the numbers of fissure-sealed teeth and surfaces, were significantly lower than those of the 10 year olds (DMFT: 0.95, DMFS: 1.32) from the non-fluoridated regions. The effectiveness of water fluoridation on caries prevention in the permanent dentition, estimated based on the differences in the mean DMFT and DMFS scores, adjusted for the number of fissure-sealed teeth and surfaces, between the program and control groups of 10-year-old children, was 27.4% and 31.1%, respectively. CONCLUSIONS: These results suggest that the effectiveness of water fluoridation on caries prevention in the permanent dentition, in Geoje City was so high that this program should be implemented in other regions in Korea as well.

Association of the number of existing permanent teeth with the intake of macronutrients and macrominerals in adults aged 55-84 years based on the 5th KNHNES (2010-2012) / 대한구강보건학회지

OBJECTIVES: The aim of this study was to analyze the association between energy sources, fiber and mineral intake, and the number of existing permanent teeth in adults aged 55-84 years from the 5th Korea National Health and Nutrition Examination Survey (KNHNES) (2010-2012). METHODS: The subjects included 6,763 people who received oral examinations and answered questions on household income, smoking status and diet. We estimated the number of existing permanent teeth and food intake according to age group, sex, household income, and smoking status. A complex samples general linear model was applied to analyze the effect of nutrient intake on the number of existing permanent teeth adjusted for sex, household income, smoking status, and food intake. We calculated the mean intake of nutrients related to the number of existing permanent teeth in each tooth group. RESULTS: The reduction in the number of existing permanent teeth correlated with an increased carbohydrate intake and a decreased potassium intake. The carbohydrate intake was lower in subjects with 25 or more teeth than that in subjects with 9 or less teeth. Potassium intake was higher in subjects with 20 or more teeth. CONCLUSIONS: The number of existing permanent teeth showed a negative correlation with carbohydrate intake and a positive correlation with potassium intake. We should reduce carbohydrate intake and increased potassium intake from fruits and vegetables to prevent systemic disease caused by tooth loss.

Robot-Assisted Laparoscopic Adenomyomectomy for Patients Who Want to Preserve Fertility

An adenomyomectomy is a conservative-surgical option for preserving fertility. Conventional laparoscopic adenomyomectomies present difficulties in adenomyoma removal and suturing of the remaining myometrium. Robot-assisted laparoscopic surgery could overcome the limitations of conventional laparoscopic surgery. Four patients with severe secondary dysmenorrhea and pelvic pain visited Seoul St. Mary's Hospital and were diagnosed with adenomyosis by pelvic ultrasonography and pelvic magnetic resonance imaging (MRI). The four patients were unmarried, nulliparous women, who desired a fertility-preserving treatment. We performed robot-assisted laparoscopic adenomyomectomies. The dysmenorrhea and pelvic pain of the patients nearly disappeared after surgery. No residual adenomyosis was observed on the follow-up pelvic MRI. A robot-assisted laparoscopic adenomyomectomy was feasible, and could be a minimally invasive surgical option for fertility-sparing treatment in patients with adenomyosis.

Three cases of complications after high-intensity focused ultrasound treatment in unmarried women

High-intensity focused ultrasound (HIFU) has been regarded as a non-surgical, minimally invasive therapeutic option for patients who prioritize uterus-conservation. Although many studies have shown that HIFU therapy is a safe and effective treatment of uterine fibroid, not all fibroids are suitable for HIFU due to risks of serious complications. We experienced three cases of complications after the HIFU ablation for huge uterine fibroids, including two cases of rapid myoma enlargement and one case of heavy vaginal bleeding.

Clinical Characteristics and Prognostic Factors in Early-Onset Alopecia Totalis and Alopecia Universalis

Alopecia totalis (AT) and alopecia universalis (AU), severe forms of alopecia areata (AA), show distinguishable clinical characteristics from those of patch AA. In this study, we investigated the clinical characteristics of AT/AU according to the onset age. Based on the onset age around adolescence ( or = 13 yr), 108 patients were classified in an early-onset group and the other 179 patients in a late-onset group. We found that more patients in the early-onset group had a family history of AA, nail dystrophy, and history of atopic dermatitis than those in the late-onset group. These clinical differences were more prominent in patients with AU than in those with AT. In addition, significantly more patients with concomitant medical disorders, especially allergic diseases were found in the early-onset group (45.8%) than in the late-onset group (31.2%). All treatment modalities failed to show any association with the present hair condition of patients. In the early-onset group, patients with AU or a family history of AA showed worse prognosis, whereas this trend was not observed in the late-onset group. Systemic evaluations might be needed in early-onset patients due to the higher incidence of comorbid diseases. It is suggested that patients with AU or family history of AA make worse progress in the early-onset group than in the late-onset group.

Febrile Ulceronecotic Pityriasis Lichenoides et Varioliformis Acuta Successfully Treated with Oral Cyclosporin / 대한피부과학회지

Febrile ulceronecrotic pityriasis lichenoides et varioliformis acuta (PLEVA), or febrile ulcerative Mucha-Haberman disease (FUMHD) is very rare, but potentially lethal variants of PLEVA. This subtype is characterized by rapidly progressive ulceronecrotic lesions and systemic manifestations, such as high fever, gastrointestinal, neurological, cardiologic and pulmonary involvement, and rheumatologic manifestations. Several treatments with variable response have been challenged, such as systemic steroid, antibiotics, methotrexate, dapsone, cyclosporine and ultraviolet therapy. But there is no standard therapy for FUMHD to date. We report a 59-year-old woman with FUMHD, who recurred after discontinuation of systemic steroid, but successfully treated with oral cyclosporine.

Cutaneous Angiosarcoma Developed at Site of Herpes Zoster Scar: Wolf's Isotopic Response / 대한피부과학회지

Angiosarcoma is a rare malignant vascular tumor of endothelial origin. It can involve any organ, including the skin, soft tissue, liver, bone, spleen, and orbit. Skin is the most frequent site of primary angiosarcoma, however, metastatic skin involvement of angiosarcoma is exceptional. Wolf's isotopic response implies that the new disease appeared at the site of an already healed skin disease. Several types of cutaneous lesions have been described, occurring within cleared cutaneous herpes zoster, or herpes simplex lesions. These lesions include comedones, granulomatous diseases, tinea, furunculosis, wart, psoriasis, pseudolymphoma, leukemia, lymphoma, basal cell carcinoma, squamous cell carcinoma and cutaneous metastases, from internal carcinoma. Herein, we report a case of cutaneous angiosarcoma of unknown origin that has developed at the site of a scar, after herpes zoster in a 79-year-old man as isotopic response.

Relationship between Body Composition and Bone Mineral Density in Pre- and Post-menopausal Women / 대한폐경학회지

OBJECTIVES: We analyzed the relationship between body composition, metabolic parameters, and lumbar and femur bone mineral density (BMD) in pre-and post-menopausal women. METHODS: Of 394 females who participated in a medical check-up program, anthropometric measurements and fasting glucose levels and lipid profiles were measured. Body composition analysis was performed using the bioimpedence method and the BMD of the lumbar spine, femur neck, trochanter, ward's triangle, and total were measured by dual energy X-ray absorptiometry. RESULTS: The mean age was 49.5 +/- 9.8 years, and among the subjects, 203 (51.5%) were pre-menopausal and 191 (48.5%) were post- menopausal women. Skeletal muscle mass, fat- free mass, lean body mass, and basal metabolic rate had a positive correlation with the lumbar and femur spine BMD, even after adjustment for age and weight in pre-menopausal women. The abdominal fat ratio, fat mass, waist circumference, percent fat, and total cholesterol had a negative correlation with the lumbar and femur spine BMD, even after adjustment for age and weight in pre-menopausal women. The lean body mass in the legs and trunk, skeletal muscle mass, and fat free mass had a positive correlation with the BMD of the lumbar spine and femur neck, unlike the lean body mass of the arms did not, after adjustment for age and weight in post-menopausal women. CONCLUSION: In pre- and post-menopausal Korean women, body composition, lean body mass, fat -free mass, and skeletal muscle mass were positive correlates, and fat mass and percent fat were negative correlates with the lumbar spine and femur BMD.

Live Interactive Teledermatologic Consultation: Clinical Evaluation and the Patients' Satisfaction / 대한피부과학회지

BACKGROUND: Telemedicine is broadly defined as using telecommunication technology to transfer medical information. Teledermatology is defined as using telemedicine in the field of dermatology, and this can be divided into a storage-and-forward system and a live interactive system. The latter uses video-conferencing equipment and it is known to be more useful than the former. However, there have been few studies on live interactive teledermatologic consultation in Korea. OBJECTIVE: We wanted to describe and quantify teledematologic consultation and to assess patients' satisfaction with the live interactive consultation by using a questionnaire. METHODS: We retrospectively reviewed the records of the patients who were consulted through the teledermatologic system. To assess patients' satisfaction with the live interactive teledermatologic consultation, we asked the patients to complete a questionnaire after the consultation. RESULTS: A total of 98 patients were consulted for 112 skin problems. The most frequent skin problem was eczematous diseases (33.9%), followed by infectious diseases (25.0%). Concerning the treatment efficacy, 90.7% of the patients experienced improvement of their initial symptom. Only one main diagnosis was recorded for 64.3% of the cases, and one main diagnosis with one other possible diagnosis to be differentiated was recorded for 30.4% of the cases. For the aspect of the technical quality, 66.1% of the patients were satisfied or very satisfied with the performance of the instruments for live interactive communication. In addition, half of the patients were satisfied or very satisfied with the teledermatologic consultation, and 59.7% of the patients answered that they would use teledermatologic consultation system again if another skin problem develops. CONCLUSION: With its good performance, teledermatologic consultation seems to be helpful and satisfactory for the patients who are unable to visit the dermatologic out-patients clinic.

The relationship between serum leptin level and metabolic syndrome in postmenopausal women / 대한산부인과학회지

OBJECTIVE: Menopause status may lead to increases of body fat, abdominal obesity, and the incidence of metabolic syndrome (MS). Leptin is an adipokine that is secreted by adipocytes and plays an important role in regulating energy homeostasis and the reproductive system. This study examined the relationship among obesity, MS, and serum leptin levels in pre- and postmenopausal women. METHODS: We divided 168 women who visited St. Vincent Hospital of the Catholic University of Korea in 2006 and 2007 into premenopausal vs. postmenopausal, obese vs. non-obese groups based on their body mass index (BMI) and the presence of MS. We measured serum follicle-stimulating hormone (FSH) level, serum estradiol level, BMI, the waist-hip ratio (WHR) and visceral fat area (VFA), serum fasting glucose, lipid profile, blood pressure, and serum leptin level. RESULTS: Of 56 premenopausal and 112 postmenopausal women, there were 21 (37.5%) premenopausal and 51 (45.5%) postmenopausal women with MS. In the non-obese premenopausal and postmenopausal women, there were positive correlations between FSH, markers of abdominal obesity such as WHR and VFA, and serum leptin after adjusting for BMI in postmenopausal women. In the MS group, only WHR was correlated with the serum leptin level after adjusting for BMI in all groups. CONCLUSION: Increased serum FSH level and abdominal obesity lead to an increased serum leptin level in postmenopausal women. Further studies are needed to clarify the relationship between leptin and the metabolic syndrome, risk of cardiovascular disease in postmenopausal women.