New development on hysteroscopy for endometrial cancer diagnosis: state of the art.

Endometrial cancer (EC) is the most common gynecologic cancer diagnosed in developed countries and represents the second most frequent gynecologic cancer-related cause of death following ovarian cancer. There are 2 subtypes of EC. Type I tumors (endometrioid adenocarcinoma) representing 85-90% of the cases. They are likely to be low-grade tumors and are thought to have a link to estrogen exposure. Type II tumors represent 10-15% of EC. They are characterized as high-grade carcinomas, with serous or clear cell histology type, and carry poor prognoses. The benefits of hysteroscopy in achieving a targeted endometrial biopsy under direct visualization over blind biopsy techniques are widely accepted. Hysteroscopic endometrial biopsy is performed under direct visualization and is the only technique that allows for the selective biopsy of targeted areas of the endometrium. There is no screening protocol for the early detection of EC. Among the general population, advanced age, obesity, nulliparity and the use of exogenous hormones are known as risk factors for EC. There are additional situations that portend an increased risk of EC that deserve special consideration such as in patients diagnosed with Lynch Syndrome, using tamoxifen, obese, or the young patient with a desire for future fertility. We presented a narrative review of the current role of hysteroscopy for the diagnosis of endometrial cancer.

Vilaprisan, a New Selective Progesterone Receptor Modulator in Uterine Fibroid Pharmacotherapy-Will it Really be a Breakthrough?

BACKGROUND: Vilaprisan (VPR) is a new orally available selective progesterone receptor modulator (SPRM), with anti-proliferative activity against uterine fibroids (UFs). It definitively causes suppression of ovulation and inhibition of proliferation of endometrial, myometrial and UF cells. PURPOSE: This review aims to summarize current knowledge on VPR from all studies, including clinical trials, conducted to date and to contextualize the potential role of VPR in future medical regimens for the treatment of UFs. METHODS: We performed a literature search in PubMed US National Library of Medicine and Google Scholar databases. Both databases were extensively searched for all original and review articles/book chapters as well as congress abstracts published in English until July 2019. The use of VPR for UF therapy was identified by using the keywords: "uterine fibroids" and "vilaprisan". RESULTS: In phase I and II clinical trials, VPR was shown to be effective in ameliorating UF-related clinical symptoms, especially abnormal or excessive uterine bleeding and in shrinking UFs. The tolerability of VPR is roughly similar to that of ulipristal acetate (UPA) and it tends to be more favorable than that of GnRH-agonists. CONCLUSION: Presently, all trials examining the utility of VPR for the treatment of UF are halted; likely, due to the recently reported cases of hepato-toxicity with UPA, in addition to non reassuring toxicology results from preclinical long-term testing on rodents, carried out in parallel with late stage testing on humans. An accurate summary of robust data related to the safety of VPR is urgently needed to draw definitive conclusions on the future clinical development of this drug for UF therapy.

Hysteroscopic endometrial resection vs. hysterectomy for abnormal uterine bleeding: impact on quality of life and sexuality. Evidence from a systematic review of randomized controlled trials.

PURPOSE OF REVIEW: The aim of this systematic review is to summarize the current evidence regarding the effectiveness of hysterectomy and hysteroscopic endometrial resection in improving quality of life (QoL), sexual function and psychological wellbeing of women abnormal uterine bleeding. RECENT FINDINGS: We performed a systematic literature search in PubMed/MEDLINE and Embase for original studies written in English (registered in PROSPERO 2019 CRD42019133632), using the terms 'endometrial ablation', 'endometrial destruction', 'endometrial resection', 'hysterectomy', 'menorrhagia', 'dysfunctional uterine bleeding', 'quality of life', 'sexuality' published up to April 2019. Our literature search produced 159 records. After exclusions, nine studies were included showing the following results: both types of treatment significantly improve QoL and psychological wellbeing; hysterectomy is associated with higher rates of satisfaction; hysterectomy is not associated with a significant deterioration in sexual function. SUMMARY: Hysterectomy is currently more advantageous in terms of improving abnormal uterine bleeding and satisfaction rates than hysteroscopic endometrial destruction techniques. Furthermore, there is some evidence of a greater improvement in general health for women undergoing hysterectomy. However, high-quality prospective randomized controlled trials should be implemented to investigate the effectiveness of hysterectomy and endometrial ablation in the improvement of QoL outcomes in larger patient cohorts.

Unraveling a difficult diagnosis: the tricks for early recognition of ovarian cancer.

Epithelial ovarian cancer (EOC) is the predominant type of ovarian cancer (OC). The 5-year survival of patients has improved over the last three decades, although the overall cure rate of OC if about 30%. Despite high response rates after initial chemotherapy, most patients with advanced ovarian cancer ultimately develop the recurrent disease because of resistance to chemotherapy. A proper early diagnosis and treatment of patients with ovarian cancer are urgently needed. Nowadays the diagnosis is performed by means of clinical symptoms and signs, often indicators of a disease already at an advanced stage, tumor markers (CA125 and HE4), transvaginal ultrasonography and imaging, very useful in distinguishing adnexal masses. Understand the nature of an adnexal mass is the primary point to begin the diagnosis of OC. Validated different model to approach and characterize adnexal pathology preoperatively are described, such as the International Ovarian Tumor Analysis (IOTA) and the Assessment of Different NEoplasias in the AdneXa (ADNEX) model. New tumor markers, such as PRSS8, FOLR1, KLK6/7, GSTT1, and miRNAs, are getting ahead and are worth noting for early detection of ovarian cancer. Despite the development of numerous ultrasound models for the diagnosis of adnexal masses and the analysis of different tumor markers, the early diagnosis of ovarian cancer is still difficult to practice. Moreover, identifying genetic risk alleles, such as germline BRCA1 and BRCA2 mutations, for ovarian cancer has had a significant impact on disease prevention strategies.

[Differential diagnosis and management of abnormal uterine bleeding in adolescence].

Abnormal uterine bleeding (AUB) is defined as any atypical genital bleeding originating from the uterine cavity, without the characteristics of normal menstrual period. AUB is an important symptom both for adolescents and their parents, and it usually leads to a state of anxiety. Although about 95% of AUB could be considered as a dysfunctional disorder, AUB requires well-defined diagnostic procedures in order to detect a physical cause, ruling out complex or systemic diseases, including oncological ones. Diagnostic procedures require the acquisition of a full and detailed history, and it is also crucial to obtain as much compliance from the patient as possible. A complete gynecological evaluation (whenever possible) and a full physical examination are useful to detect any kind of general disease which can compromise the hormonal reproductive system. Auxiliary tools such as gynecological ultrasonography for pelvic examination are allowed in sexually-active women, otherwise transrectal ultrasonography could be considered, if needed. Hematic ß-hCG must be dosed in every fertile woman with AUB and laboratory tests must be tailored on each patient. The first-line treatment consists of combined oral contraceptives and, when they are contraindicated, progesterone alone, medicated intrauterine devices, GnRH-analogues, or desmopressin are the most common second-line treatments.

Management of uterine fibroids in pregnancy: recent trends.

PURPOSE OF REVIEW: The review analyzes how fibroids may influence pregnancy and how myomas may be modified by pregnancy. The most important clinical aspect concerns the impact of myoma on pregnancy and the possibility of a well tolerated surgical treatment for the mother and her fetus, preserving maternal reproductive capacity. RECENT FINDINGS: Fibroids significantly increase in size during early pregnancy and then decrease in the third trimester. Although most women with uterine fibroids have a regular pregnancy, data from the literature suggest that they may have a higher risk of fertility problems and pregnancy complications. SUMMARY: Myomectomy can increase the rate of pregnancy in women with infertility, attempting to restore a normal anatomy and reduce uterine contractility and local inflammation associated with the presence of fibroids, improving the blood supply. Current evidence does not suggest routine myomectomy during pregnancy or at the cesarean birth, as fibroids-related complications are rare and may be overcome by the risks of surgery. However, in selected cases, myomectomy is a feasible and safe technique and associated to a good outcome.The diagnosis of myomas in pregnancy may require attention for the adequate management to preserve maternal and fetal well-being.

Alcohol and illicit drug use among emergency room patients in the Netherlands.

AIMS: To clarify alcohol and illicit drug use within the emergency room population in three different regions in The Netherlands, focusing on whether interventions for these substances should be region specific. METHODS: Alcohol and illicit drug use were assessed using a self-report questionnaire filled in by the patients, and by combining self-report with staff judgement on alcohol and illicit drug use. RESULTS: Data on alcohol use (self-reported and staff judgement combined) resulted in prevalence rates of 4.9-18.2%. Patients positive for alcohol are more likely to be male, aged 48-58 years, more likely to be a frequent excessive drinker, and to have injuries as a result of violence. Patients positive for illicit drugs are more likely to be male, aged 28-38 years, unemployed, and frequent excessive drinkers. Among men aged 18-35 years with a Dutch cultural background, some differences emerge regarding alcohol consumption between the various hospitals, but most variation exists in the case of illicit drug use. CONCLUSIONS: This paper confirms that the emergency room seems to provide an opportunity to initiate interventions regarding alcohol use and seems to suggest that this is independent of the region concerned. However, in the case of illicit drug use interventions seem to be more region specific.

Self-reported alcohol use among Dutch emergency room patients: variations in prevalence rates owing to methodological differences.

AIMS: This study compared different methods of assessing self-reported alcohol use among emergency room patients in order to explain the variations in reported prevalence rates. METHODS: Alcohol use prior to patient's injury or illness was assessed in one hospital by a self-report questionnaire in three different ways: (i) administered by emergency room staff, (ii) administered by research staff, or (iii) sent to the patient's home by post. RESULTS: Results show variations in self-reported alcohol use 6 h prior to the injury or illness ranging from 4.6 to 9.1%; these variations may be explained by sample selection bias and characteristics of the included study populations. When self-report is combined with staff judgement the corresponding prevalence rates are 6.8% for research staff and 16.2% for emergency room staff. This shows that the latter judge the patient's alcohol use more efficiently than the research staff. Using research staff 24 h a day resulted in almost no sample bias. Data collection via emergency room staff leads to the highest alcohol use prevalence rates and to the highest sample bias; this was influenced by the emergency room characteristics. A retrospective mail survey results in an older sample with age-related (lower) alcohol use and emergency room characteristics related to this age group. CONCLUSIONS: Future studies using patient self-report among emergency room samples should consider carefully the influence of sample selection bias. The combination of the research staff handing out the questionnaire and the emergency room staff giving their judgement on the patient's alcohol use seems to be a useful method.