Effects of Bariatric Surgery on People with Obesity and Polycystic Ovary Syndrome: a Large Single Center Study from India.

PURPOSE: Bariatric surgery has been proven to be a successful management strategy for morbid obesity, but limited studies exist on its effect on polycystic ovary syndrome (PCOS) in terms of clinical, hormonal, and comorbidities. MATERIALS AND METHODS: This is a prospective observational study of 1013 PCOS patients who underwent bariatric surgery from a single high-volume center. Assessment of demographic data and menstrual irregularity as well as hirsutism and comorbidities was done preoperatively 6-month and yearly follow-up, whereas data regarding %TWL and %EWL was taken at follow-up visits conducted at regular intervals of 6 months, and 1, 2, 3, 4, and 5 years following surgery. RESULTS: Out of 1013 PCOS patients, 993 patients had hirsutism before surgery, and 741 (74.6%; p < 0.001) had complete resolution of hirsutism at end of 6 months' follow-up. A total of 202 (20.3%) had moderate resolution at follow-up of 1 year, 5 patients had minimal resolution at end of 2 years, and 45 (4.5%) patients reported no change in their hirsutism at 4 and 5 years of follow-up. Among 1007 women with PCOS who had menstrual dysfunction, 936 (93% p < 0.0001) women restored their normal menstrual cycle at 6 months post-surgery with 55.4% EWL while remaining other 71 (7%) women reported regular menses at 2 years post-surgery at 74.2% EWL and continued to have normal menstrual pattern during the entire follow-up period. Similarly, all the associated comorbidities T2DM (79.7%), HTN (78.7%), DLP (93.2%), and OSA (98.5%) and symptoms of PCOS were statistically (p < 0.0001) and completely resolved at end years of follow-up. CONCLUSION: Bariatric surgery is a good option for women with obesity and PCOS. It is effectively reducing weight along with PCOS and its disorder including hirsutism and menstrual irregularity in women with obesity and PCOS.

Retinal toxicity after facial laser epilation.

A 39-year-old man presented to the ophthalmology emergency room complaining of decreased visual acuity and metamorphopsia on his left eye after undergoing Nd:YAG facial hair epilation without wearing proper eye protection. Fluorescein angiography showed a foveal staining initially, with an increase in foveal leakage over late phases. On optical coherence tomography, a subfoveal retinal pigment epithelial detachment with associated subretinal fluid and no signs of choroidal neovascularization or cystoid macular edema was observed. Observation with monthly follow-ups was adopted. By the fourth month, the subretinal fluid had already disappeared and visual acuity had returned to 20/20. Over one-year follow-up, the retinal pigment epithelial detachment experienced a decrease in its size. Conservative management may be a valid option in assessing accidental foveal photocoagulation when choroidal neovascularization or cystoid macular edema is absent. The use of wavelength specific goggles is mandatory for the patient and the aesthetician operating the cosmetic laser, especially when operating on the face or around the eyes. Abbreviations: Nd:YAG = neodymium-doped yttrium aluminium garnet, OCT = optical coherence tomography, PED = pigment epithelial detachment, CME = cystoid macular edema.

First Report of Retroperitoneal Mucinous Cystadenoma in a Patient with Hirsutism.

Primary retroperitoneal mucinous cystadenomas (PRMC) are rare benign neoplasms with only 55 documented cases in the English literature so far. A 19-year-old female exhibited hirsutism and was found to have a cystic mass measuring 5.8 cm × 3.9 cm × 5.8 cm in the left retroperitoneum. During subsequent work up, a high pre-operative value of dehydroepiandrosterone sulfate (DHEA-S) was noted. The patient was referred to surgical oncology and underwent an uneventful laparoscopic cystectomy. Pathology classified the cyst as PRMC. Post-operatively, the patient's DHEA-S levels normalized, though there was no appreciable decrease in the patient's hirsutism in the short-term follow-up. The origin of PRMC is uncertain. Due to their unknown biological potential, surgical resection is usually recommended. To the best of our knowledge, this is the first report documenting a PRMC and elevated levels of androgens in conjunction with hirsutism.

Multidisciplinary eyelid reconstruction in Barber-Say syndrome: A case report. / Reconstrucción palpebral multidisciplinar en el síndrome de Barber-Say: a propósito de un caso.

Barber-Say syndrome is an unusual dysplasia caused by the mutation of the TWIST2 gene (2q37.3), which encodes a protein that acts at an epigenetic level. The case is presented of a 2-day-old male child in whom ectropion, hypertelorism, hypertrichosis and other dysmorphic features led to the clinical diagnosis of Barber-Say syndrome, which was later confirmed with genetic tests. Around 20 cases have been reported on this syndrome, of which less than half have described the surgical technique, as it represents a surgical challenge. The approach in this case included a lateral tarsorrhaphy and skin grafts taken from the volar surface of the forearm, retroauricular area and supraclavicular fossa, as well as autologous lipografts from the inner side of both thighs for palpebral reconstruction. This is the first case of Barber-Say syndrome in which the use of skin grafts are taken from supraclavicular fossa and forearms.

Effectiveness of short-pulse width Nd:YAG in laser hair reduction.

INTRODUCTION: Laser hair reduction (LHR) is a safe and effective way of reducing unwanted hairs over body. Long-pulse Nd:YAG laser has over the years, been proven to be particularly safe and effective in darker skin types. While conventionally, long-pulse Nd:YAG laser has been used, recently short-pulse width Nd:YAG laser of 0.6-1.6 ms which is 10-50 times less than the standard method (long-pulse) of Nd:YAG LHR, has become available. OBJECTIVES: To study the effectiveness of short-pulse width Nd:YAG laser in LHR in Indian patients. MATERIAL AND METHODS: This was a prospective observational study conducted over a period of 1 year. Fifty female patients with fitzpatrick skin type 3-5 were included. Patients underwent four sessions of LHR, with an interval of 6 weeks and then follow up was done for 6 months after the last session. RESULTS: The mean age of patient was 29.92 years ranging from 17 to 48 years. After finishing four sessions of LHR procedure 58%, 34%, 6%, and 2% of the patients showed excellent, good, moderate, and poor improvement respectively. No complications were seen during the treatment and after follow-up. Statistical analysis by paired t test showed the results to be statistically significant. CONCLUSION: Hair reduction using unique short-pulse width Nd:YAG laser is easy to use, safe, and effective in Indian skin.

Clinical Description, Molecular Analysis of TWIST2 Gene, and Surgical Treatment in a Patient With Barber-Say Syndrome.

Barber-Say syndrome is a rare autosomal dominant disease characterized by dysmorphic features, mainly of the eyelids and skin. It is caused by heterozygous mutations in gene TWIST2, localized in chromosome 2q37.3. The authors present the case of a pediatric patient with a clinical diagnosis of Barber-Say syndrome with ocular symptoms related to exposure keratitis. Molecular analysis of her DNA revealed a mutation on TWIST2 gene confirming the diagnosis of Barber-Say syndrome. Surgical treatment of the patient's eyelids resolved her signs and symptoms.

[Dermatologic laser surgery].

In this article we give an overview of which skin conditions that are currently treated with laser and explains the basic principles of treatment. In addition, we summarize recommendations of the Danish Dermatological Society for demarcation of medical treatments which can be provided free of charge from cosmetic self-payment treatments.

Safety and efficacy of low fluence, high repetition rate versus high fluence, low repetition rate 810-nm diode laser for axillary hair removal in Chinese women.

BACKGROUND: High-fluence diode lasers with contact cooling have emerged as the gold standard to remove unwanted hair. Lowering the energy should result in less pain and could theoretically affect the efficacy of the therapy. OBJECTIVE: To compare the safety and efficacy of a low fluence high repetition rate 810-nm diode laser to those of a high fluence, low repetition rate diode laser for permanent axillary hair removal in Chinese women. METHODS: Ninety-two Chinese women received four axillae laser hair removal treatments at 4-week intervals using the low fluence, high repetition rate 810-nm diode laser in super hair removal (SHR) mode on one side and the high fluence, low repetition rate diode laser in hair removal (HR) mode on the other side. Hair counts were done at each follow-up visit and 6-month follow-up after the final laser treatment using a "Hi Quality Hair Analysis Program System"; the immediate pain score after each treatment session was recorded by a visual analog scale. RESULTS: The overall median reduction of hair was 90.2% with the 810-nm diode laser in SHR mode and 87% with the same laser in HR mode at 6-month follow-up. The median pain scores in SHR mode and in HR mode were 2.75 and 6.75, respectively. CONCLUSION: Low fluence, high repetition rate diode laser can efficiently remove unwanted hair but also significantly improve tolerability and reduce adverse events during the course of treatment.

Polycystic ovary syndrome: a review for dermatologists: Part II. Treatment.

Dermatologists are in a key position to treat the manifestations of polycystic ovary syndrome (PCOS). The management of PCOS should be tailored to each woman's specific goals, reproductive interests, and particular constellation of symptoms. Therefore, a multidisciplinary approach is recommended. In part II of this continuing medical education article, we present the available safety and efficacy data regarding treatments for women with acne, hirsutism, and androgenetic alopecia. Therapies discussed include lifestyle modification, topical therapies, combined oral contraceptives, antiandrogen agents, and insulin-sensitizing drugs. Treatment recommendations are made based on the current available evidence.

"Occult" ovarian Leydig cell tumor: when laboratory tells more than imaging.

Hyperandrogenism is a common finding in premenopausal age and is generally caused by polycystic ovarian syndrome or other benign disease. Androgen-secreting tumors represent only 0.2 % of the causes of hyperandrogenism and usually present with severe clinical features, abrupt onset, and very high androgens levels. We describe here three cases of occult ovarian Leydig cell tumors suspected on the basis of severe clinical features of hyperandrogenism rapidly worsening, with elevated serum total testosterone levels, in which bilateral ovariectomy was performed and tumor was confirmed by post-operative histology. In all three cases, imaging was negative for ovarian tumor. Moreover, in one case the confounding concomitant finding of bilateral adrenal masses posed an additional challenge. Our experience highlights that testosterone levels represent the most helpful marker in the diagnosis of androgen-secreting ovarian tumor. In the absence of imaging findings, bilateral ovariectomy should be indicated, if supported by unequivocal clinical and laboratory data.

Increasing hirsutism due to a granulosa-cell tumor in a woman with polycystic ovary syndrome: case report and review of the literature.

BACKGROUND: Granulosa-cell tumors (GCT), rare malignancies that arise from sex-cord stromal cells, account for less than 5% of ovarian tumors. These tumors present with an endocrine syndrome and mass signs. Surgery is the primary treatment approach. The risk of recurrence is more frequent in the juvenile-onset form. CASE REPORT: We report the case of an obese 18-year-old Caucasian women with hirsutism and oligomenorrhea. Abdominal palpation revealed a voluminous firm mass. Hormonal evaluation documented severe hyperandrogenism. The ovary-specific tumor marker CA125 was elevated, whereas human-chorionic-gonadotropin was in the normal range. Abdominal imaging examination revealed a 19 cm mass in the left ovary. Twenty-four hours after removal of the mass, menstrual flow reappeared and androgens progressively normalized. Microscopically, the predominant pattern was one of uniform, bland, epithelioid to spindle-shaped cells. After three months, a significant weight loss was recorded, hirsutism had decreased slightly and oligomenorrhea reappeared. Δ4-Androstenedione levels remained elevated (4200 ng/L), whereas CA125 had normalized. In light of the pre-existing polycystic-ovary-syndrome (PCOS), the patient started estrogen-progestin treatment. CONCLUSION: We report an interesting case of a woman with severe hirsutism due to GCT, and a history of oligomenorrhea caused by PCOS. After surgery, a dramatic clinical improvement was observed, whereas PCOS signs persisted.

Fast intraoperative testosterone assay confirms the location of an ovarian virilizing tumor in a young girl.

The detection of testosterone-producing ovarian tumors in childhood and adolescence by imaging techniques only can be difficult because of the tumors' radiological structure and sometimes diminutive size. We describe an 11.5-year-old girl with a 9-month history of voice deepening, mild hirsutism, minor acne, increased growth velocity, weight gain, and clitoromegaly. Laboratory investigation revealed an extremely elevated serum testosterone level without any additional endocrine abnormalities. Abdominal ultrasound and MRI showed a sparsely noticeable solid mass in the center of the right ovary. At laparotomy, blood was selectively drawn from the right and the left ovarian veins. Rapid testosterone measurement revealed a 70-fold higher testosterone concentration in the right ovarian vein within 45 min. Based on this finding, a right salpingo-oophorectomy was performed. The patient's postoperative testosterone level declined within 24 h. The histopathological diagnosis was Leydig cell tumor. In conclusion, the implementation of a fast intraoperative testosterone assay enabled the localization and curative therapy of a Leydig cell tumor. This technique seems to be a good alternative to preoperative selective venous blood sampling when body imaging does not unveil the tumor's site.

Laser hair reduction and removal.

Hair removal by any means is unlikely to decrease in popularity, especially with the advent of laser technology allowing for effective treatment of hypertrichosis and hirsutism. There are many effective laser and intense light sources. Although virtually all skin types can be treated, the ideal target is a dark hair on light colored skin, and treatment of nonpigmented or vellus hairs has been disappointing with this method. The physical hair removal methods will continue to be popular options. The practice of aesthetic medicine should include consideration of offering hair reduction using lasers or light sources.

Safety and efficacy of low-fluence, high-repetition rate versus high-fluence, low-repetition rate 810-nm diode laser for permanent hair removal--a split-face comparison study.

BACKGROUND: This study was designed to evaluate the hypothesis that low-level fluences done repetitively on a hair follicle will produce permanent hair removal with less discomfort and fewer side effects than a single high-fluence pulse. OBJECTIVE: To compare the safety and efficacy of a low-fluence, high-repetition rate versus a high-fluence, low-repetition rate 810-nm diode laser for permanent hair reduction in patients with facial hirsutism. METHODS: Forty-two female patients with confirmed polycystic ovaries by ultrasonography with facial hirsutism were subjected to the low-fluence, high-repetition Soprano® XL laser in SHR mode and the LightSheer™ laser on each side of the face using preset parameters once a month for six sessions. Hair counts were done at the end of the sixth session using a 'Hi Quality Hair Analysis Program System' and the pain score was recorded by a visual analog scale. RESULTS: The overall median reduction of hair was 90.5% with the Soprano XL and 85% with the LightSheer, with a standard deviation of 7 and 8.5 respectively. DISCUSSION: This new technology, with low fluence and high repetition, showed a statistically insignificant increase in hair reduction compared to the LightSheer, but did show a significant reduction in hair thickness and a low pain score.

An unusual case of oral hirsutism in a patient with polycystic ovarian syndrome.

Hirsutism is the presence of terminal hair in women in a male-like pattern, which represents the clinical expression of an underlying excess of androgen (hyperandrogenism). Numerous conditions and serious diseases can result in high levels of circulating androgens, although the most common cause of hirsutism is polycystic ovary syndrome (PCOS). The following classic clinical features characterize PCOS: irregular menstrual periods, infertility, excess hair growth, and obesity. The diagnosis of this disease is related to the discovery of clinical signs that are confirmed by hematochemical examinations. We present a clinical case that is relatively unusual owing to the appearance of black hairs that are similar to nasal hair in the oral mucosa, which is an atypical location. This unusual case was considered to be oral hirsutism, and its presence constituted the essential element in the diagnosis of PCOS. The hypothesis proposed for this unusual condition could be correlated to the high rate of circulating testosterone that may have influenced and led to the development and appearance of the hair follicles in the oral mucosa.

Within-patient right-left blinded comparison of diode (810 nm) laser therapy and intense pulsed light therapy for hair removal.

Excessive facial hair in women can cause significant psychological distress. A variety of treatment methods are available, including lasers and, more recently, intense pulsed light (IPL) sources. There are very few studies comparing laser and IPL devices. The purpose of our study was to compare a laser diode device with an IPL, using a within-patient, right-left, assessor-blinded, controlled, study design. Hair counts were made, using coded close-up photographs. Treatments were carried out on three occasions at 6-week intervals, and a final assessment was made 6 weeks following the third treatment. Patient self-assessment was also included. Nine women were recruited, and seven completed the study. Average hair counts in a 16 cm(2) area before and after treatment were, respectively, 42.4 and 10.4 (laser), 38.1 and 20.4 (IPL), 45.3 and 44.7 (control). Both laser and IPL reduced the hair count substantially; laser vs control was significant at P=0.028, but IPL vs control had P=0.13, suggesting that more subjects or more treatments were required if statistical significance were to be achieved. Despite subjecting the patients to higher pain scores and more inflammation, laser was preferred by five patients; two preferred IPL and one had no preference.

A qualitative study to assess the effectiveness of laser epilation using a quality-of-life scoring system.

BACKGROUND: Facial hirsutism has a negative effect on the quality of life (QOL) of female patients. AIM: To assess the efficacy of laser epilation on the quality of life in hirsute women. METHODS: Over a 6-month period, we recruited 38 patients with severe pathological facial hirsutism. Each patient completed a pretreatment questionnaire consisting of a modified Dermatology Life Quality Index (DLQI), a visual analogue scoring system, and an 'out-of-10' scoring system. The patients were also scored independently by a doctor and a nurse. Each patient received a laser-epilation treatment programme and was reassessed in an identical fashion. RESULTS: Following laser epilation, the mean patient DLQI score fell by 5 points. All three scoring groups scored lower across all scoring methods following laser treatment. There was also correlation in scoring between disciplines. CONCLUSION: DLQI provides a valid scoring system to assess the efficacy of laser epilation. The interdisciplinary scores in this study indicate that an objective grading system for facial hirsutism could be developed in the future.

Pilonidal sinus disease treated by depilation using an 800 nm diode laser and review of the literature.

BACKGROUND: Pilonidal sinus disease is a debilitating, disfiguring chronic ailment that is often resistant to therapy. Its etiology and treatment remain in question. OBJECTIVE: To assess the efficacy of an 800 nm diode laser in the treatment of recalcitrant pilonidal sinus disease. METHODS: Two patients with recalcitrant pilonidal sinus disease were treated in the lower back, buttocks, and perigluteal cleft area with an 800 nm diode laser with a spot size of 9 x 9 mm, fluences of 30 to 48 J/cm2, and pulse widths of 15 to 24 milliseconds. RESULTS: Long-term relief of pilonidal sinus disease was produced with as few as two treatments 2 months apart to as many as six treatments over a 2-year period. With each successive treatment, fewer pulses were needed and the interval between treatments increased. CONCLUSION: The 800 nm diode laser may be an effective tool in the treatment of pilonidal sinus disease. By eliminating the source of hair and hair fragments that course along the surface of the lower back and buttocks, interruption of the etiologic source for pilonidal sinus disease can be accomplished.

Is ovarian surgery effective for androgenic symptoms of polycystic ovarian syndrome?

The effectiveness of laparoscopic ovarian drilling for treatment of anovulation in polycystic ovarian syndrome (PCOS) has been proved. The role of ovarian surgery in the treatment of symptoms related to hyperandrogenaemia, such as hirsutism and acne, has been less clear. This review sought to evaluate the effectiveness of ovarian surgery in the treatment of non-infertility symptoms related to PCOS. A systematic literature review was undertaken, by searching the Medline database for the years 1966-2002 inclusive. The search yielded 19 studies recording the outcomes of hirsutism, acne or androgen levels from surgical treatment for women with PCOS: three assessed unilateral oophorectomy; two ovarian wedge resection; and 14 ovarian drilling. There was no consensus of a clear improvement in hirsutism or acne in women undergoing surgery. There was a trend towards a decrease in serum androgen levels in most studies. We conclude that, while there is evidence that ovarian surgery may decrease androgen levels in some women with PCOS, the evidence that this translates into a clear improvement in hirsutism and acne is less clear. Further high quality clinical research, including data from randomisation, would be required to answer this question.