Brazilian Guideline on Menopausal Cardiovascular Health ­ 2024 / Guía Brasileña de Salud Cardiovascular en el Climaterio y la Menopausia ­ 2024 / Diretriz Brasileira sobre a Saúde Cardiovascular no Climatério e na Menopausa ­ 2024

Women, who represent approximately half of the global population according to estimates as of January 2024, may experience signs and symptoms of menopause for at least one-third of their lives, during which they have a higher risk of cardiovascular morbidity and mortality. The effects of menopausal hormone therapy (MHT) on the progression of atherosclerosis and cardiovascular disease (CVD) events vary depending on the age at which MHT is initiated and the time since menopause until its initiation. Beneficial effects on CVD outcomes and all-cause mortality have been observed when MHT was initiated before the age of 60 or within 10 years after menopause. The decision regarding the initiation, dose, regimen, and duration of MHT should be made individually after discussing the benefits and risks with each patient. For primary prevention of postmenopausal chronic conditions, the combined use of estrogen and progestogen is not recommended in asymptomatic women, nor is the use of estrogen alone in hysterectomized women. Hormone-dependent neoplasms contraindicate MHT. For the treatment of genitourinary syndrome of menopause, vaginal estrogen therapy may be used in patients with known cardiovascular risk factors or established CVD. For women with contraindications to MHT or who refuse it, non-hormonal therapies with proven efficacy (antidepressants, gabapentin, and fezolinetant) may improve vasomotor symptoms. Compounded hormonal implants, or "bioidentical" and "compounded" hormones, and "hormone modulation" are not recommended due to lack of scientific evidence of their effectiveness and safety.

Mujeres, que representan aproximadamente la mitad de la población mundial según estimaciones de enero de 2024, pueden experimentar signos y síntomas de la menopausia durante al menos un tercio de sus vidas, durante los cuales tienen un mayor riesgo de morbilidad y mortalidad cardiovascular. Los efectos de la terapia hormonal de la menopausia (THM) en la progresión de la aterosclerosis y los eventos de enfermedad cardiovascular (ECV) varían según la edad en que se inicia la THM y el tiempo transcurrido desde la menopausia hasta su inicio. Se han observado efectos beneficiosos en los resultados de ECV y la mortalidad por todas las causas cuando la THM se inició antes de los 60 años o dentro de los 10 años posteriores a la menopausia. La decisión sobre la iniciación, dosis, régimen y duración de la THM debe tomarse individualmente después de discutir los beneficios y riesgos con cada paciente. Para la prevención primaria de condiciones crónicas en la posmenopausia, no se recomienda el uso combinado de estrógeno y progestágeno en mujeres asintomáticas, ni el uso de estrógeno solo en mujeres histerectomizadas. Las neoplasias dependientes de hormonas contraindican la THM. Para el tratamiento del síndrome genitourinario de la menopausia, se puede usar terapia estrogénica vaginal en pacientes con factores de riesgo cardiovascular conocidos o ECV establecida. Para mujeres con contraindicaciones a la THM o que la rechazan, las terapias no hormonales con eficacia demostrada (antidepresivos, gabapentina y fezolinetant) pueden mejorar los síntomas vasomotores. Los implantes hormonales compuestos, o hormonas "bioidénticas" y "compuestas", y la "modulación hormonal" no se recomiendan debido a la falta de evidencia científica sobre su efectividad y seguridad.

As mulheres, que representam cerca de metade da população mundial segundo estimativas de janeiro de 2024, podem sofrer com sinais e sintomas da menopausa durante pelo menos um terço de suas vidas, quando apresentam maiores risco e morbimortalidade cardiovasculares. Os efeitos da terapia hormonal da menopausa (THM) na progressão de eventos de aterosclerose e doença cardiovascular (DCV) variam de acordo com a idade em que a THM é iniciada e o tempo desde a menopausa até esse início. Efeitos benéficos nos resultados de DCV e na mortalidade por todas as causas ocorreram quando a THM foi iniciada antes dos 60 anos de idade ou nos 10 anos que se seguiram à menopausa. A decisão sobre o início, a dose, o regime e a duração da THM deve ser tomada individualmente após discussão sobre benefícios e riscos com cada paciente. Para a prevenção primária de condições crônicas na pós-menopausa, não se recomendam o uso combinado de estrogênio e progestagênio em mulheres assintomáticas nem o uso de estrogênio sozinho em mulheres histerectomizadas. Neoplasias hormônio-dependentes contraindicam a THM. Para tratamento da síndrome geniturinária da menopausa, pode-se utilizar terapia estrogênica por via vaginal em pacientes com fatores de risco cardiovascular conhecidos ou DCV estabelecida. Para mulheres com contraindicação à THM ou que a recusam, terapias não hormonais com eficácia comprovada (antidepressivos, gabapentina e fezolinetante) podem melhorar os sintomas vasomotores. Os implantes hormonais manipulados, ou hormônios "bioidênticos" "manipulados", e a 'modulação hormonal' não são recomendados pela falta de evidência científica de sua eficácia e segurança.

Comparison of the effect of noninvasive radiofrequency with vaginal estrogen and vaginal moisturizer in the treatment of vulvovaginal atrophy in postmenopausal women: a randomized clinical trial.

OBJECTIVE: To compare the effect of noninvasive radiofrequency (RF) with vaginal estrogen (E), and vaginal moisturizer (M) on improving vulvovaginal atrophy (VVA) in women with genitourinary syndrome of menopause. METHODS: A total of 32 postmenopausal women who met the inclusion criteria were randomized into three intervention arms to receive one of the following treatments: three sessions of noninvasive RF therapy (RF arm); intravaginal estriol cream 1 mg applied daily for 2 weeks, followed by 1 mg applied two times weekly or 1 mg of estradiol vaginal fast-dissolving film applied daily for 2 weeks, followed by 1 mg applied two times weekly (E arm); and intravaginal moisturizer two times a week (M arm). Assessments at baseline and after 4 months were conducted using Vaginal Health Index score, Vaginal Maturation, visual analog scale for VVA symptoms (dyspareunia, dryness, and burning), and Menopause Rating Scale (MRS) for urogenital symptoms. Vaginal wall biopsies were administered to participants who consented, pretreatment and posttreatment (at baseline and after 4 months of follow-up). RESULTS: After 4 months, the Vaginal Health Index showed an increase of 6.6 points in mean total score in the RF arm, also in the E arm (+7.3 points), with no significant improvement in the M arm (+1.5 points) (interaction effect: RF, E ≠ M, P < 0.001). Regarding vaginal maturation, there was a significant increase in superficial cells in the E arm (+31.3), with no significant changes in the RF (+9.3) and M (-0.5) arms (interaction effect: E ≠ M, P < 0.001). Vaginal pH decreased significantly in the E arm (-1.25), with a similar response in the RF arm (-1.7), with no significant improvement in the M arm (-0.25) (interaction effect: RF, E ≠ M, P < 0.001).There was a significant improvement in the MRS score for VVA symptoms in the three intervention arms, with no predominance of any arm, whereas the improvement in the total MRS score for urogenital symptoms showed a predominance of the RF arm (ΔRF: -7.8; ΔE: -3.5; ΔM: -2.3; RF ≠ E, M). According to histopathologic analysis, there was no statistically significant increase in glycogenation ( P = 0.691) or epithelial cone height ( P = 0.935), despite an increase in the median delta (difference between pretreatment and posttreatment) in the three intervention arms (glycogenation: RF arm Δ = +118.4%; E arm Δ = +130.9%; M arm Δ = +24.9%; epithelial cone height: RF arm Δ = +33.5%; E arm Δ = +18.6%; M arm Δ = +22.3%). CONCLUSION: The effect of noninvasive RF on the treatment of vulvovaginal symptoms of genitourinary syndrome of menopause was similar to vaginal estrogen, except for hormonal cytology, and superior to vaginal moisturizer, with improvement in some histomorphometric parameters. These findings are promising, especially for the population that cannot or prefers not to use vaginal estrogen therapy.

Sexual function after energy-based treatments of women with urinary incontinence. A systematic review and meta-analysis.

INTRODUCTION AND HYPOTHESIS: Urinary incontinence (UI) affects approximately 50% of adult women worldwide and is associated with declining sexual function (SF). Energy-based devices emerged as a minimally invasive alternative treatment. Nevertheless, their effect on sexuality is uncertain. We hypothesize that the UI energy treatment can lead to sexual function improvement. METHODS: A search was performed in PubMed, Cochrane Library, Web of Science, Embase, and Scopus for randomized clinical trials (RCTs) and nonrandomized studies of intervention, which treated incontinent women using energy, with UI and sexual function (SF) as outcomes. Severe comorbidities, pelvic organ prolapse (POP)> grade 2, and use of medication to treat UI or that affects SF were excluded. Quality assessment and meta-analysis were performed. RESULTS: From 322 articles, 11 RCTs were included for qualitative analysis. UI symptoms improved in all studies. Regarding SF, RCT with premenopausal women showed improvement in SF in the Er:Yag group (Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12 and Female Sexual Function Index). A prospective study showed improvement in SF independent of the grade of SUI. RF showed benefits for SF but was not superior to pelvic floor muscle training. One nonrandomized study of intervention with a High-Intensity Focused Electromagnetic Field showed significant improvement of SF in the Golombok Rust Inventory of Sexual Satisfaction total score, a decline in pain and dissatisfaction domains. Meta-analysis with 4 RCTs and 2 nonrandomized studies found no difference between groups (0.26 (95% CI -0.67 to 1.20, and -0.74 (95% CI -3.78 to 2.30) respectively). CONCLUSIONS: This meta-analysis did not confirm that energy equipment improved the SF of women with UI.

Incontinência urinária e baixa função sexual feminina: estudo de corte transversal de base populacional / Urinary incontinence and low female sexual function: a population-based cross-sectional population-based

Contexto: A função sexual feminina é influenciada por múltiplos fatores, e as comorbidades são um desses motivos. Objetivo: Avaliar a associação entre incontinência urinária (IU) e baixa função sexual feminina (BFS) em mulheres de meia-idade em um estudo de base populacional. Metodos: Estudo de corte transversal no município de Campinas, São Paulo, com 472 mulheres sexualmente ativas, no período de setembro de 2012 a junho de 2013. O Short Personal Experiences Questionnaire (SPEQ) foi utilizado para avaliar a BFS. Fatores sociodemográficos e clínicos foram avaliados. Utilizou-se Qui-quadrado, Fischer e Mann-Whitney e modelos de regressão múltipla de Poisson para análise estatística. Resultados: Na amostra geral a BFS foi associada à baixa renda razão de prevalência (RP) 1,55, 95% intervalo de confiança, (IC) 1,01­2,38, menor atividade física (RP 2,35, 95% IC 1,34­4,14), secura vaginal na relação sexual (RP 1,94 95% IC 1,25­3,0) e problemas de sono (RP 1,68, 95% IC 1,09­2,6). No grupo com incontinência urinária, os fatores associados à BFS foram problemas de sono (RP 2,63 IC 95% 1,30­5,34 P = 0,007) e baixa atividade física (RP 3,16 IC 95% 1,11­9,05 P = 0,032). Discussão: A BFS tem origem multifatorial e a IU não sobressaiu como fator associado. Conclusoes: A IU não se associou à BFS. Em mulheres incontinentes, a BFS se associou a problemas de sono e sedentarismo. Em mulheres com IU e BFS deve-se abordar adequadamente insônia e sedentarismo.

Effects of ultra-low dose hormone therapy on biochemical bone turnover markers in postmenopausal women: A randomized, placebo-controlled, double-blind trial.

OBJECTIVE: Evaluate the effects of ultra-low-dose hormone therapy (Ultra-LD HT) with 17ß-estradiol 0.5 mg and norethisterone acetate 0.1 mg (E2 0.5/NETA 0.1) versus placebo on bone turnover markers (BTM) in postmenopausal women. STUDY DESIGN: A multicenter, double-blind, randomized, placebo-controlled study was performed with 107 participants who received one tablet daily of E2 0.5/NETA 0.1 or placebo for 24-weeks. Bone formation markers-N-terminal propeptide of type I procollagen (PINP) and Bone-specific alkaline phosphatase (BSAP), and bone resorption markers-C-telopeptide of type I collagen (CTX-I) and N-telopeptide crosslinked of type I collagen (NTX) were assessed before and at 12 and 24-weeks of treatment. RESULTS: Women treated with E2 0.5/NETA 0.1 had a significant reduction in the PINP marker from baseline (58.49 ± 21.12 µg/L) to week 12 (48.31 ± 20.99 µg/L) and week 24 (39.16 ± 16.50 µg/L). Placebo group, the PINP marker did not differ significantly. The analysis of the BSAP indicated a significant increase in the placebo group (13.8 ± 5.09 µg/L and 16.29 ± 4.3 µg/L, at baseline and week 24, respectively), whereas in the treatment group the values did not change. The analysis of the NTX marker showed a significant reduction only in the treatment group (43.21 ± 15.26 nM/mM and 33.89 ± 14.9 nM/mM, at baseline and week 24, respectively). CTX-I had a significant decrease in the treatment group from baseline (0.3 ± 0.16 ng/L) to week 12 (0.21 ± 0.14 ng/L) and week 24 (0.21 ± 0.12 ng/L). CONCLUSION: Women receiving E2 0.5/NETA 0.1 experienced reductions in bone resorption and formation markers, an expected effect during the anti-resorptive therapy, suggesting a protective bone effect with the Ultra-LD HT.

Menopause and cognitive impairment: A narrative review of current knowledge.

A severe impairment of cognitive function characterizes dementia. Mild cognitive impairment represents a transition between normal cognition and dementia. The frequency of cognitive changes is higher in women than in men. Based on this fact, hormonal factors likely contribute to cognitive decline. In this sense, cognitive complaints are more common near menopause, a phase marked by a decrease in hormone levels, especially estrogen. Additionally, a tendency toward worsened cognitive performance has been reported in women during menopause. Vasomotor symptoms (hot flashes, sweating, and dizziness), vaginal dryness, irritability and forgetfulness are common and associated with a progressive decrease in ovarian function and a subsequent reduction in the serum estrogen concentration. Hormone therapy (HT), based on estrogen with or without progestogen, is the treatment of choice to relieve menopausal symptoms. The studies conducted to date have reported conflicting results regarding the effects of HT on cognition. This article reviews the main aspects of menopause and cognition, including the neuroprotective role of estrogen and the relationship between menopausal symptoms and cognitive function. We present and discuss the findings of the central observational and interventional studies on HT and cognition.

Self-care agency and associated factors in postmenopausal women.

OBJECTIVE: The aging process in women is marked by several changes, including the transition to menopause. The evaluation of self-care management is essential and has great relevance for public health. The aim of the present study was to evaluate self-care management and associated factors in postmenopausal women. METHOD: This study was a cross-sectional study performed with 260 postmenopausal women who attended routine consultations at the Menopause Outpatient Clinic of the Hospital of the State University of Campinas-SP. Women aged 50 years or older with amenorrhea for at least 12 months were included. The women were interviewed by a researcher during the routine consultation, and the self-care agency assessment was performed using the Appraisal of Self-Care Agency Scale-Revised questionnaire. RESULTS: The average total self-care score for the women in this study was 62.27 (± 9.64). Higher Appraisal of Self-Care Agency Scale-Revised scores were associated with performing outdoor activities, better self-perceived health, and a higher score on knowledge about vitamin D. Active smoking was associated with a lower self-care score. CONCLUSION: We observed that the self-care management of postmenopausal women was satisfactory and was associated with lifestyle, self-perceived health, and knowledge about vitamin D.

Topical estrogen, testosterone, and vaginal dilator in the prevention of vaginal stenosis after radiotherapy in women with cervical cancer: a randomized clinical trial.

BACKGROUND: We aimed to evaluate the effects of different therapeutic options to prevent the evolution of vaginal stenosis after pelvic radiotherapy in women with cervical cancer. METHODS: open-label randomized clinical trial of 195 women, stage I-IIIB, aged 18-75 years, using topical estrogen (66), topical testosterone (34), water-based intimate lubricant gel (66), and vaginal dilators (29) to assess the incidence and severity of vaginal stenosis after radiotherapy at UNICAMP-Brazil, from January/2013 to May/2018. The main outcome measure was vaginal stenosis assessed using the Common Terminology Criteria for Adverse Events (CTCAE) scale and percental changes in vaginal volume. The women were evaluated at four different times: shortly after the end of radiotherapy, and four, eight, and 12 months after the beginning of the intervention. Statistical analysis was carried out using Symmetry test, Kruskal-Wallis test and multiple regression. RESULTS: the mean age of women was 46.78 (±13.01) years, 61,03% were premenopausal and 73,84% had stage IIB-IIIB tumors. The mean reduction in vaginal volume in the total group was 25.47%, with similar worsening in the four treatment groups with no statistical difference throughout the intervention period. There was worsening of vaginal stenosis evaluated by CTCAE scale after 1 year in all groups (p < 0.01), except for the users of vaginal dilator (p = 0.37). CONCLUSIONS: there was a reduction in vaginal volume in all treatment groups analyzed, with no significant difference between them. However, women who used vaginal dilators had a lower frequency and severity of vaginal stenosis assessed by the CTCAE scale after one year of treatment. TRIAL REGISTRATION: Brazilian Registry of Clinical Trials, RBR-23w5fv . Registered 10 January 2017 - Retrospectively registered.

Urinary Incontinence in Climacteric Women With or Without Depressive Symptoms: A Cross-Sectional Study.

OBJECTIVE: This study aimed to investigate whether the occurrence of urinary incontinence (UI) is associated with increased odds of depression in perimenopausal and postmenopausal women. METHODS: This cross-sectional study included 208 women with depressive symptoms, confirmed by the Beck Depression Inventory, and 247 patients without depression. All participants were perimenopausal or postmenopausal women aged 35 to 65 years who attended an outpatient clinic from a tertiary-academic hospital in Northeastern Brazil. Urinary incontinence symptoms were assessed using patient's self-report and the validated versions of the International Consultation on Incontinence Questionnaire-Short Form and the Questionnaire for Urinary Incontinence Diagnosis. To investigate the severity of climacteric symptoms, the Blatt-Kupperman Index was used, and menopause-related quality of life was analyzed using the Utian Quality of Life Questionnaire. RESULTS: In univariate analysis, the Beck Depression Inventory-II mean scores for UI and non-UI women were, respectively, 15.5 (95% confidence interval, 14.28-16.72) and 11.83 (10.52-13.13; P < 0.05). Patients with moderate and severe scores of depression reported higher International Consultation on Incontinence Questionnaire-Short Form and Questionnaire for Urinary Incontinence Diagnosis scores when compared with women with mild depression scores and women without depression (P < 0.001). Conversely, in multivariate analysis, having UI was not associated with having depression (odds ratio [OR], 0.85; 0.52-1.37; P = 0.50), after adjusting for confounders. Older age (>55 years) was associated with decreased odds of depression (OR, 0.43; 0.21-0.88; P = 0.02), whereas moderate (OR, 2.28; 1.40-3.71; P = 0.001) and severe (OR, 7.70; 2.79-21.23) intensities of menopause symptoms were associated with increased odds of depression. CONCLUSION: Urinary incontinence was not associated with depression within climacteric women after multivariate analysis.

Factors Associated with the Complications of Hysteroscopic Myomectomy.

OBJECTIVE: To evaluate the factors associated with complete myomectomy in a single surgical procedure and the aspects related to the early complications. METHODS: A cross-sectional study with women with submucous myomas. The dependent variables were the complete myomectomy performed in a single hysteroscopic procedure, and the presence of early complications related to the procedure. RESULTS: We identified 338 women who underwent hysteroscopic myomectomy. In 89.05% of the cases, there was a single fibroid to be treated. According to the classification of the International Federation of Gynecology and Obstetrics (Fédération Internationale de Gynécologie et d'Obstétrique, FIGO, in French), most fibroids were of grade 0 (66.96%), followed by grade 1 (20.54%), and grade 2 (12.50%). The myomectomies were complete in 63.31% of the cases, and the factors independently associated with complete myomectomy were the diameter of the largest fibroid (prevalence ratio [PR]: 0.97; 95% confidence interval [95%CI]: 0.96-0.98) and the classification 0 of the fibroid according to the FIGO (PR: 2.04; 95%CI: 1.18-3.52). We observed early complications in 13.01% of the hysteroscopic procedures (4.44% presented excessive bleeding during the procedure, 4.14%, uterine perforation, 2.66%, false route, 1.78%, fluid overload, 0.59%, exploratory laparotomy, and 0.3%, postoperative infection). The only independent factor associated with the occurrence of early complications was incomplete myomectomy (PR: 2.77; 95%CI: 1.43-5.38). CONCLUSIONS: Our results show that hysteroscopic myomectomy may result in up to 13% of complications, and the chance of complete resection is greater in small and completely intracavitary fibroids; women with larger fibroids and with a high degree of myometrial penetration have a greater chance of developing complications from hysteroscopic myomectomy.

OBJETIVO: Avaliar os fatores associados a miomectomia por histeroscopia completa em um único procedimento e as suas complicações. MéTODOS: Estudo de corte transversal com mulheres submetidas a histeroscopia para exérese de miomas submucosos. As variáveis dependentes foram a miomectomia completa realizada em um tempo cirúrgico único, e a presença de complicações precoces relacionadas ao procedimento. RESULTADOS: Analisamos 338 mulheres que foram submetidas a miomectomia histeroscópica. Em 89,05% dos casos, o mioma a ser tratado era único. Quanto à classificação da Federação Internacional de Ginecologia e Obstetrícia (Fédération Internationale de Gynécologie et d'Obstétrique, FIGO, em francês), a maioria era de grau 0 (66,96%), seguidos pelos graus 1 (20,54%) e 2 (12,50%). As miomectomias foram completas em 63,31% das mulheres, sendo que os fatores independentemente associados à miomectomia completa foram o diâmetro do maior mioma (razão de prevalência [RP]: 0,97; intervalo de confiança de 95% [IC95%]: 0,96­0,98) e a classificação FIGO grau 0 (RP: 2,04; IC95%: 1,18­3,52). Foram observadas complicações precoces em 13,01% dos procedimentos (4,44% apresentaram sangramento excessivo durante o procedimento, 4,14%, perfuração uterina, 2,66%, falso pertuito, 1,78%, intoxicação hídrica, 0,59%, laparotomia exploradora, e 0,3%, infecção pós-operatória). O único fator independentemente associado à ocorrência de complicações precoces foi a realização de miomectomia incompleta (RP: 2,77; IC95%: 1,43­5,38). CONCLUSãO: Nossos resultados mostram que as complicações da miomectomia por histeroscopia podem ocorrer em até 13% dos procedimentos. A chance de ressecção completa é maior em miomas pequenos e completamente intracavitários; mulheres com miomas maiores e com maior grau de penetração miometrial têm maiores chances de desenvolver complicações.

Changes in seminal parameters among Brazilian men between 1995 and 2018.

Aiming to investigate trends in seminal parameter values among Brazilian men between 1995 and 2018, we performed a retrospective analysis of spermograms of couples admitted for infertility testing at UNICAMP/Brazil. For the present study, only the first sample produced by each man was analyzed (9,267 samples). Total motile sperm count (TMSC), percentage of spermatozoa with normal morphology (NM), and sperm concentration after seminal processing (SCA) were considered dependent variables. Statistical analysis was carried out through linear regression for the median values both in the general population and in the population categorized by age group (<30, 30-39, and ≥40 years). During the study period, the mean age of men was 32.46 (± 6.48) years, with a median of 32 (18-67) years. We found a significant decrease in the median values of TMSC (reduction of 2.84 million/year), NM (reduction of 0.52% each year) and SCA (reduction of 0.24 million/mL each year). In conclusion, we observed that Brazilian men undergoing infertility investigation had a decline in seminal parameters in the past 23 years. Surveillance should be maintained in the coming years, and further studies are needed to elucidate possible causes for seminal deterioration and to devise strategies to reverse this trend.

Efficacy of Fractional CO2 Laser, Promestriene, and Vaginal Lubricant in the Treatment of Urinary Symptoms in Postmenopausal Women: A Randomized Clinical Trial.

BACKGROUND AND OBJECTIVES: Evaluating the efficacy of the fractional CO2 laser, promestriene, and vaginal lubricant to treat urinary symptoms in women with genitourinary syndrome of menopause. STUDY DESIGN/MATERIALS AND METHODS: We conducted a randomized clinical trial with 72 postmenopausal women aged 50 years or older. The participants were randomized to one intervention each in three treatment groups fractional CO2 laser, promestriene, and vaginal lubricant. Urinary symptoms were assessed prior to treatment and 2 weeks after treatment completion using validated questionnaires, the International Consultation on Incontinence Questionnaire (ICIQ-UI SF), and the International Consultation on Incontinence Questionnaire Overactive Bladder (ICIQ-OAB). RESULTS: There was a significant reduction in the total ICIQ-UI SF score in the intragroup comparison (baseline vs. week 14) of the CO2 laser group (P = 0.004). This group also showed a statistically significant reduction in nocturia (1.33 ± 0.87 vs. 1.00 ± 0.76, respectively; P = 0.031). In the intergroup comparison after treatment, nocturia in the lubricant group had worsened compared with that of the other two groups (P = 0.002). Regarding the total ICIQ-OAB score, the results of the CO2 laser group were superior to those of the lubricant group in the intergroup comparison (7.76 ± 3.36, P = 0.020; analysis of variance P = 0.038). CONCLUSION: The results were significantly different between the intravaginal fractional CO2 laser and topical estrogen groups for treating urinary symptoms related to the genitourinary syndrome of menopause. Further controlled and randomized studies are needed. Lasers Surg. Med. © 2020 Wiley Periodicals, Inc.

Randomized double-blind placebo-controlled trial of the effect of Morus nigra L. (black mulberry) leaf powder on symptoms and quality of life among climacteric women.

OBJECTIVE: To test the efficacy of Morus nigra L. (MN) leaf powder for treating climacteric symptoms by comparison with hormone therapy (HT) and placebo. METHODS: A randomized controlled trial among 62 climacteric women attending Hospital of the Federal University of Maranhão, Brazil. Women were divided into MN, HT, and placebo groups, and received 250 mg of MN leaf powder, 1 mg of estradiol, or placebo for 60 days. Primary outcomes were the Blatt-Kupperman index (BKI) for climacteric symptoms and SF-36 health questionnaire scores. RESULTS: Baseline sociodemographic variables, BKI scores, symptoms, and SF-36 domains did not differ among the groups. There was a reduction in mean BKI in the MN (17.5 vs 9.7, P<0.001), HT (15.4 vs 8.6, P=0.001), and placebo (16.1 vs 12.4, P=0.040) groups. Analysis of quality of life (QoL) showed that functional capacity (P=0.006), vitality (P=0.031), mental health (P=0.017), and social aspect (P<0.01) improved after treatment in the MN group. The HT group showed improvement in emotional limitation (P=0.040), and the placebo group showed better functional capacity (P=0.030) after treatment. CONCLUSIONS: Climacteric symptoms and QoL improved after administration of 250 mg of MN leaf powder for 60 days, similar to the effects of HT. The trial is registered in the Brazilian Registry of Clinical Trials (REBEC) under registration number RBR-9t4xxk.

Factors associated with the complications of hysteroscopic myomectomy / Fatores associados às complicações da miomectomia por histeroscopia

Abstract Objective To evaluate the factors associated with complete myomectomy in a single surgical procedure and the aspects related to the early complications. Methods A cross-sectional study with women with submucous myomas. The dependent variables were the complete myomectomy performed in a single hysteroscopic procedure, and the presence of early complications related to the procedure. Results We identified 338 women who underwent hysteroscopic myomectomy. In 89.05% of the cases, there was a single fibroid to be treated. According to the classification of the International Federation of Gynecology and Obstetrics (Fédération Internationale de Gynécologie et d'Obstétrique, FIGO, in French),most fibroids were of grade 0 (66.96%), followed by grade 1 (20.54%), and grade 2 (12.50%). The myomectomies were complete in 63.31% of the cases, and the factors independently associated with complete myomectomy were the diameter of the largest fibroid (prevalence ratio [PR]: 0.97; 95% confidence interval [95%CI]: 0.96-0.98) and the classification 0 of the fibroid according to the FIGO (PR: 2.04; 95%CI: 1.18-3.52). We observed early complications in 13.01% of the hysteroscopic procedures (4.44% presented excessive bleeding during the procedure, 4.14%, uterine perforation, 2.66%, false route, 1.78%, fluid overload, 0.59%, exploratory laparotomy, and 0.3%, postoperative infection). The only independent factor associated with the occurrence of early complications was incomplete myomectomy (PR: 2.77; 95%CI: 1.43-5.38). Conclusions Our results show that hysteroscopic myomectomy may result in up to 13% of complications, and the chance of complete resection is greater in small and completely intracavitary fibroids; women with larger fibroids and with a high degree of myometrial penetration have a greater chance of developing complications from hysteroscopic myomectomy.

Resumo Objetivo Avaliar os fatores associados a miomectomia por histeroscopia completa em um único procedimento e as suas complicações. Métodos Estudo de corte transversal com mulheres submetidas a histeroscopia para exérese de miomas submucosos. As variáveis dependentes foram a miomectomia completa realizada em um tempo cirúrgico único, e a presença de complicações precoces relacionadas ao procedimento. Resultados Analisamos 338 mulheres que foram submetidas a miomectomia histeroscópica. Em 89,05% dos casos, o mioma a ser tratado era único. Quanto à classificação da Federação Internacional de Ginecologia e Obstetrícia (Fédération Internationale de Gynécologie et d'Obstétrique, FIGO, em francês), a maioria era de grau 0 (66,96%), seguidos pelos graus 1 (20,54%) e 2 (12,50%). As miomectomias foram completas em 63,31% das mulheres, sendo que os fatores independentemente associados à miomectomia completa foram o diâmetro do maior mioma (razão de prevalência [RP]: 0,97; intervalo de confiança de 95% [IC95%]: 0,96-0,98) e a classificação FIGO grau 0 (RP: 2,04; IC95%: 1,18-3,52). Foram observadas complicações precoces em 13,01% dos procedimentos (4,44% apresentaram sangramento excessivo durante o procedimento, 4,14%, perfuração uterina, 2,66%, falso pertuito, 1,78%, intoxicação hídrica, 0,59%, laparotomia exploradora, e 0,3%, infecção pósoperatória). O único fator independentemente associado à ocorrência de complicações precoces foi a realização de miomectomia incompleta (RP: 2,77; IC95%: 1,43-5,38). Conclusão Nossos resultados mostram que as complicações da miomectomia por histeroscopia podem ocorrer em até 13% dos procedimentos. A chance de ressecção completa é maior em miomas pequenos e completamente intracavitários; mulheres com miomas maiores e com maior grau de penetração miometrial têm maiores chances de desenvolver complicações.

Patient-Specific Bone Multiscale Modelling, Fracture Simulation and Risk Analysis-A Survey.

This paper provides a starting point for researchers and practitioners from biology, medicine, physics and engineering who can benefit from an up-to-date literature survey on patient-specific bone fracture modelling, simulation and risk analysis. This survey hints at a framework for devising realistic patient-specific bone fracture simulations. This paper has 18 sections: Section 1 presents the main interested parties; Section 2 explains the organzation of the text; Section 3 motivates further work on patient-specific bone fracture simulation; Section 4 motivates this survey; Section 5 concerns the collection of bibliographical references; Section 6 motivates the physico-mathematical approach to bone fracture; Section 7 presents the modelling of bone as a continuum; Section 8 categorizes the surveyed literature into a continuum mechanics framework; Section 9 concerns the computational modelling of bone geometry; Section 10 concerns the estimation of bone mechanical properties; Section 11 concerns the selection of boundary conditions representative of bone trauma; Section 12 concerns bone fracture simulation; Section 13 presents the multiscale structure of bone; Section 14 concerns the multiscale mathematical modelling of bone; Section 15 concerns the experimental validation of bone fracture simulations; Section 16 concerns bone fracture risk assessment. Lastly, glossaries for symbols, acronyms, and physico-mathematical terms are provided.

The effect of vaginal erbium laser treatment on sexual function and vaginal health in women with a history of breast cancer and symptoms of the genitourinary syndrome of menopause: a prospective study.

OBJECTIVES: To assess the effects of vaginal erbium laser treatment on the vaginal health and sexual function of postmenopausal women with a history of breast cancer. METHODS: An open, prospective, therapeutic intervention study was conducted with 24 postmenopausal women with a history of breast cancer and vaginal dryness, and/or dyspareunia, who had not used vaginal hormone therapy for at least 6 months. The women were treated using a 2,940-nm Erbium: YAG laser (Etherea-MX, Athena, São Carlos, São Paulo, Brazil), with 90 and 360 scanning scopes, between August, 2017 and October, 2017 in a private clinic in a city of southeastern Brazil. Vaginal erbium laser treatment was performed at three sessions with a 30-day interval between each session. Sexual function was assessed before and 1 month after treatment using the Short Personal Experiences Questionnaire. Questions related to genitourinary symptoms were also applied. Vaginal health was assessed before each laser session using the Vaginal Health Index Score. RESULTS: Mean age was 53.7 years. Vaginal health improved, as shown by an increased overall score (P < 0.001). The effect size was large between pretreatment and post-treatment scores for vaginal elasticity, fluid volume, epithelial integrity, and moisture. The effect size was also significant for the overall sexual function score and for the score in the dyspareunia domain between pretreatment and 1 month after the final treatment session. CONCLUSION: Vaginal erbium laser may represent a novel therapeutic option for improving vaginal health and sexual function in postmenopausal women with a history of breast cancer.

Medication Use and Sexual Function: A Population-Based Study in Middle Aged Women.

INTRODUCTION: Medications used to treat chronic diseases have contributed to increasing longevity and improving quality of life. These medications are considered an indispensable resource in the management of most treatable diseases. However, they can affect sexual function through their effects on the central or the peripheral nervous system or due to hormonal effects. AIM: To evaluate the association between the use of medication for chronic diseases and sexual dysfunction in Brazilian women 45-60 years of age. METHODS: A secondary analysis of household survey data from a previous cross-sectional, population-based study conducted with a sample of 749 women of a population of 257,434 female urban residents in the age bracket of interest. Sexual function was evaluated using the Short Personal Experiences Questionnaire (SPEQ). Associations between the use of medication and sexual function were evaluated, as were correlations with other variables. MAIN OUTCOME MEASURE: We found associations of the individual SPEQ domains with the use of some medications. RESULTS: Mean age of participants was 52.5 ± 4.4 years. Mean age at menopause was 46.5 ± 5.8 years. The overall prevalence of medication use was 68.8%, with the drugs predominantly consisting of those used for cardiovascular diseases. In the Poisson regression analysis, sexual dysfunction, as based on the overall SPEQ score, was associated with sexual inactivity (prevalence ratio [PR] = 4.05; 95% CI 3.16-5.20; P < .001), a sedentary lifestyle (PR = 1.49; 95% CI 1.06-2.09; P = .021), and untreated anxiety (PR = 1.44; 95% CI 1.08-1.92; P = .014). Analysis of the individual SPEQ domains revealed that women who scored low in the desire domain were more likely to use antihypertensive agents (P = .019), whereas a lower score for the arousal domain was associated with the use of antidepressants, with treatment for osteoarticular diseases and with polypharmacy (P = .003). Women with lower scores in the satisfaction domain were more likely to use antidepressants, drugs for osteoarticular diseases, diabetes medication, and polypharmacy (P = .019). A lower score in the orgasm domain was associated with the use of antidepressants, the treatment of osteoarticular diseases, and diabetes (P < .001). Hormone therapy proved protective against loss of libido (P = .036). CLINICAL IMPLICATIONS: Some medications can interfere with sexual function negatively and, clinicians have to be aware of it to choose the treatment with fewer collateral effects. STRENGTH & LIMITATIONS: The strength of our study is the large, population-based sample of middle-aged women evaluated for sexual dysfunction with the SPEQ. However, it was a self-reported cross sectional study. CONCLUSION: This study found no association between the use of medication for chronic diseases and the overall SPEQ score, whereas untreated anxiety was 1 of the main factors associated with female sexual dysfunction. On the other hand, medical treatments were found to contribute to lower scores in the different sexual function domains. Common drug culprits included antihypertensives, antidepressants, treatment for osteoarticular disease, diabetes medications, and polypharmacy. Hormone therapy protected against loss of libido. Gueldini de Moraes AV, Ribeiro Valadares AL, Lui Filho JF, et al. Medication Use and Sexual Function: A Population-Based Study in Middle Aged Women. J Sex Med 2019;16:1371-1380.

Opinions and main sources of information about menopause among middle-aged Brazilian women.

OBJECTIVES: The aim of this study was to evaluate women's opinions about menopause and the sources of information they use to deepen their understanding of the topic. METHODS: Population-based study with 749 Brazilian women aged 45 to 60 years. The answers to the question "What is menopause?" were typed and coded, and categories that emerged from the interviewees' own speech were created. The answers to the question: "Where or from whom did you get information about menopause?" were also analyzed. RESULTS: The mean age of women was 52.5 (± 4.4) years. Of them, 68% were postmenopausal. According to 67.5% of the interviewees, the concept of menopause encompassed changes in the menstrual cycle and hormones. For 48%, menopause meant physical changes such as "hot flushes and vaginal dryness." For 22.7%, menopause represented psychological changes. The concept of menopause was associated with some change in sexuality for 7.6% of the interviewees. Approximately 18% could not explain what menopause meant. Regarding the sources of information, 44.5% of the women attributed this knowledge to friends and relatives. Doctors or health services were mentioned by 44.3% of women. Television or radio was cited by 22.0%; magazines, newspapers, or books were cited by 14.0%; and the Internet was cited by 6.8% of women. Fifty-two women (6.9%) reported having no source of information about menopause. CONCLUSIONS: Most of the interviewees relate the term "menopause" to physiological events. There seems to be a suppressed demand for information on the various aspects of the menopausal transition among middle-aged Brazilian women.