The effects of different therapeutic modalities on cardiovascular risk factors in women with polycystic ovary syndrome: A randomized controlled study.

OBJECTIVE: This study was designed to evaluate the effects of 3 mg drospirenone/30 µg ethinyl estradiol (OC) alone or combined with 1700 mg metformin on metabolic risk factors. MATERIALS AND METHODS: In this randomized, prospective, controlled study, 87 non-obese (18-30 BMI) women of reproductive age (18-39) with polycystic ovary syndrome (PCOS) were assigned to control (n = 17), OC (n = 21), combination (n = 20) and metformin (n = 29) therapy groups. RESULTS: Adiponectin levels changed -28.27%, -20.37% and 35.78% after OC, combination and metformin therapies, respectively. High sensitive C-reactive protein levels (hsCRP) changed with OC, combination and metformin therapies by 102.32%, 3.2% and -7.14%, respectively. Plasminogen activator inhibitor-1 levels decreased 41.34% in the metformin group. Apolipoprotein-B levels changed in a manner similar to changes in hsCRP levels. The homeostatic model insulin resistance index changed significantly between the groups following treatment (p = 0.001). CONCLUSION: Six cycles of treatments with OC alone may cause metabolic variables to deteriorate in non-obese women with PCOS. The addition of metformin to OC may ameliorate some aspects of this effect.

Serum betatrophin/angiopoietin-like protein 8 (ANGPTL8) levels in pregnancies affected by hyperemesis gravidarum.

OBJECTIVE: The association between serum betatrophin levels and hyperemesis gravidarum (HEG) remains unknown. The aim of this study was to determine and understand the alterations in serum betatrophin levels in pregnancies complicated by HEG compared with unaffected normal pregnancies. STUDY DESIGN: A cohort study was carried out to evaluate serum betatrophin levels in patients with HEG. Serum betatrophin concentrations were measured with other metabolic markers for lipids and glucose metabolism in 40 singleton pregnancies affected by HEG and 40 gestational age- and body mass index-matched controls. RESULTS: The serum betatrophin concentrations were significantly higher in pregnant women with HEG than in the controls (1000 [600-1100] vs. 900 [500-1000] pg/ml, p = 0.003). The serum total cholesterol (TC) and high-density lipoprotein cholesterol (HDL-C) levels were significantly higher in patients with HEG than in the healthy counterparts at the first trimester of pregnancy (158.5 ±â€¯29.4 vs. 143.8 ±â€¯29.7 mg/dl and 47.3 ±â€¯14.2 vs. 40.1 ±â€¯8.6 mg/dl, p = 0.031 and p = 0.007, respectively). Receiver operating characteristic (ROC) analyses demonstrated that the area under the curve (AUC) indicative of the betatrophin value for discriminating HEG patients was 0.690 (95% CI: 0.574-0.806, p = 0.003). The optimal cutoff value was 976 pg/ml with a sensitivity of 50% (95% CI: 33.80-66.20%) and a specificity of 82.5% (95% CI: 67.22-92.66%). We also found a positive correlation between betatrophin levels and HDL-C (r = 0.311; p = 0.005). Logistic regression analyses demonstrated that increased levels of betatrophin and HDL-C were risk factors for HEG with odds ratios (95% confidence interval) of 4.884 (1.589-15.009) and 5.346 (1.044-27.366), respectively. CONCLUSION: We conclude that serum betatrophin concentrations were increased in pregnancies affected by HEG. Furthermore, HDL-C levels seem to be associated with alterations in serum betatrophin levels.

The Value of Prostate-Specific Antigen in Diagnosis of Polycystic Ovarian Syndrome in Adolescent Girls.

STUDY OBJECTIVE: This study was designed to evaluate and compare the serum total prostate-specific antigen (PSA) levels in adolescent girls in with and without polycystic ovarian syndrome (PCOS) to show whether evaluation of PSA levels have a diagnostic benefit over existing diagnostic criteria. DESIGN: Case-control study. SETTING: A territory referral center. PARTICIPANTS: A total of 89 (15-19 years) nonobese (body mass index, 18-24.9) adolescents with PCOS (n = 42) and controls without PCOS (n = 47) were enrolled in the study. INTERVENTIONS: Pathophysiological features of PCOS and serum total PSA levels were determined at the time of study enrollment. MAIN OUTCOME MEASURES: Determination, comparison, and diagnostic performance of serum total PSA levels in diagnosis of PCOS in adolescent girls were the main outcome measures of the study. RESULTS: The serum total PSA levels of adolescents with PCOS were detected to be higher than for control participants (0.63 ± 1.38 ng/mL vs 0.48 ± 0.95 ng/mL) without meeting statistical significance (P = .923). There was a correlation between total PSA levels and indices of insulin resistance like the homeostasis insulin resistance model (r = 0.414; P = .010). The serum total PSA level was not a discriminative parameter for diagnosis of PCOS in adolescent girls (area under the curve, 0.559; P = .476). CONCLUSION: The serum total PSA level was not a predictor of PCOS in adolescent girls. This finding might be related to the extemporal nature of tissues capable of PSA production and lack of sufficient exposure interval to hyperandrogenemia, rather than lack of stimulatory relationship between serum androgens.

Hereditary leiomyomatosis and renal cell carcinoma syndrome: a case report and implications of early onset.

Hereditary leiomyomatosis and renal cell carcinoma (HLRCC) is an autosomal dominant manifestation of cutaneous and uterine leiomyomas together with renal cancer due to autosomal dominant germline mutations of fumarate hydratase gene. A twenty-year-old female patient presented with type-II segmental piloleiomyoma and increased menstruation due to uterine leiomyomas, with a history of bilateral nephrectomy performed at 13 and 16 years of age for type 2 papillary renal cell carcinoma. This case represents one of the very early onsets of hereditary leiomyomatosis and renal cell carcinoma syndrome. As genetic anticipation for renal cancer is a well-documented entity for HLRCC syndrome, early recognition is crucial for both the patient and her family in order to provide appropriate counseling and initiation of surveillance.

Anemia prevalence at the time of pregnancy detection.

OBJECTIVE: Anemia in the first trimester of pregnancy is the situation as described by the World Health Organization when the level of hemoglobin (Hb) is less than 11 g in 100 cc of blood. The prevalence of this problem is 18% in developed countries, whereas it is between 35-75% in developing countries. In this study, we aimed to determine the prevalence of anemia at the time of pregnancy detection. MATERIALS AND METHODS: A retrospective cross-sectional study was designed to determine the prevalence of anemia. A total of 5228 first trimester pregnant women were admitted to the study between 2012 and 2014. Hb levels of 11 to 9.5 g/dL, 9.5 to 8 g/dL, and less than 8 g/dL were considered as mild, moderate, and severe anemia, respectively. RESULTS: We detected mild, modarate, and severe anemia at rates of 16.64%, 3.07%, and 0.28%, respectively, in our population. The overall prevalence of anemia at the time of detection of pregnancy was 20.0%. CONCLUSION: Anemia is a significant risk factor for maternal mortality in developing countries. The prevalence of anemia at the time of pregnancy detection was 20% and this rate is close to those indicated in developed countries.

Arm reduced robotic-assisted laparoscopic hysterectomy with transvaginal cuff closure.

INTRODUCTION: The use of robotics for benign etiology in gynecology has not proven to be more beneficial when compared to traditional laparoscopy. The major concern regarding robotic hysterectomy stems from its high cost. AIM: To evaluate the clinical utility and effectiveness of one-arm reduced robotic-assisted laparoscopic hysterectomy as a cost-effective surgical option for total robotic hysterectomy. MATERIAL AND METHODS: A sample population of 54 women who underwent robotic-assisted laparoscopic surgery for benign gynecologic indications was evaluated, and two groups were identified: (1) the two-armed robotic-assisted laparoscopic surgery group (n = 38 patients), and (2) the three-armed robotic-assisted laparoscopic surgery group (n = 16 patients). RESULTS: An increased cost was observed when three-armed robotic surgery was employed for benign gynecologic surgery (p < 0.001). The cost reduction observed in the study group was primarily derived from one robotic arm reduction and vaginal closure of the cuff. This cost reduction was achieved without an increase in complication rates or undesirable postoperative outcomes. An estimated profit between $399.5 and $421.5 was made for each patient depending on the suture material chosen for cuff closure. Two-armed surgery resulted in an 18.6% reduction in procedure-specific costs for robotic hysterectomy. CONCLUSIONS: Two-armed robotic-assisted laparoscopic hysterectomy appears to be a cost-effective solution for robotic gynecologic surgery. This surgical solution can be performed as effectively as classical three-armed robotic hysterectomies for benign indications without the risk of increased surgical-related morbidities. This approach has the potential to be a widely preferred surgical approach in medical communities where cost reduction is one of the primary determinants of surgery type.

Unicornuate uterus with a rudimentary horn diagnosed at scheduled third Cesarean Section.

A unicornuate uterus with a rudimentary horn is an anomaly caused by defective fusion of the Müllerian duct, estimated to occur in one in 76,000 pregnancies. Life threateningly heavy bleeding is a highly expected clinical consequence of such pregnancies. According to the known literature, only two living twins and few living singleton pregnancies have been reported up to now. Here we report on an incidentally diagnosed unicornuate uterus with a communicating rudimentary horn, found during a cesarean section of a gravida 3, parity 2 (G3 P2) patient. This case is rather unique since the patient has had three full term pregnancies and three cesarean sections without significant fetal compromise. This delivery and the existing literature showed us that extensive uterine correction surgeries need not be automatically proposed when a unicornuate uterus is diagnosed in the preconception period. Such deliveries indicate that women with this uterine anomaly may have the potential to carry pregnancies to full term.

Cytohistological discrepancies of cervico-vaginal smears and HPV status.

OBJECTIVES: Discrepancies between abnormal cervical cytology or high-risk human papillomavirus (HR-HPV) status (cytolo-gy negative/HPV positive) and subsequent histological findings are a common occurrence. After using co-testing, the dis-crepancies between the HR-HPV status and cervical cytology have become an issue. In this study, we aimed to determine the characteristics of women with a discrepancy between histology and cytology/HR-HPV status, in terms of diagnosis, review and identification. MATERIAL AND METHODS: A total of 52 women, patients of the University Hospital between 2013-2015, with cytohistologi-cal or HR-HPV status discrepancy were recruited for the study and retrospectively analyzed. The cytological samples were liquid-based Pap smears, classified according to the 2001 Bethesda system. The HR-HPV status was identified using the Hybrid Capture 2 HR-HPV DNA assay. The histological samples were obtained by cervical biopsy as well as large loop exci-sion of the transformation zone (LLETZ). RESULTS: A cytohistological discrepancy was demonstrated in patients with (-)cytology/HR-HPV(+), ASCUS, LSIL, ASC-H, HSIL, AGC-NOS: 17.3%, 23.07%, 26.9%, 9.5%, 17.3% and 5.7%, respectively. When the degree of atypia in cytology increases, the concurrency of cervical cytology with biopsy also increases. A positive HR-HPV co-test result (19/24, 79.1%) was observed in nearly all CIN2 ≥ (+) cases. Our study emphasizes the significance of HR-HPV testing to determine CIN2 ≥ (+) cases, even in the presence of a normal cytological result. CONCLUSIONS: In case of cytohistological or HR-HPV discrepancies, a careful review of the HR-HPV status and the degree of cytological atypia should be performed before further intervention.

The effect of anatomical placental location on the third stage of labor.

According to the lower uterine segment and trophotropism hypotheses of placental implantation, placentation occurs in uterine segments with a high blood supply. The present study was designed to determine the clinical implications of these hypotheses by assessing the dynamics of the third stage of labor. Two-hundred and ninety-two prospectively followed pregnant women were assessed at the time of delivery. The uterine locations of the placentas were determined according to the position of the main placental volume and mass under a sagittal view obtained using a centrally located ultrasonography probe. Depending on the location of the placental mass, the patients were assigned to three groups: anterior, posterior, and fundal. The placenta was located in the anterior, posterior, and fundal wall in 52.7% (154/292), 37.7% (110/292), and 9.6% (28/292) of cases, respectively. The duration of the third stage of labor was 6.26 ± 3.89, 6.47 ± 3.68, and 7.42 ± 3.67 min in the anterior, posterior, and fundal placental groups, respectively (P = 0.06). The placenta was separated peripherally in 25% (n = 73) of the patients in each group and centrally in 75% (n = 219). The delta hematocrit value (hematocrit change) was 2.99 ± 4.39, 3.15 ± 6.52, and 2.76 ± 3.04 in the anterior, posterior, and fundal groups, respectively (P = 0.99). This study showed that the location of the placenta did not affect the dynamics of the third stage of labor. Clin. Anat. 30:508-511, 2017. © 2017 Wiley Periodicals, Inc.

Value of vaginal cervical position in estimating uterine anatomy.

The anatomy of the uterus is defined with the angles of the vagina, cervix and uterine corpus. Hereunder there are angles of version and flexion. The cervical position observed during the vaginal speculum examination, may give information about the uterine anatomy. In this study, we investigated the place of the cervical position in the estimation of the uterine anatomy observed during the cervical examination. We enrolled 240 patients in our study, who applied to our routine gynecology outpatient clinic with various complaints. We divided these patients into two groups according to the cervical position (anterior cervical position and posterior cervical position) observed during the speculum examination. We recorded the uterine anatomy also with the transvaginal ultrasonography. During the speculum examination, we determined that 90% of the cases with posterior fornix position were anteverted and 10% retroverted; 64.2% of the cases with anterior fornix position were anteverted and 35.8% retroverted. According to these findings, cervical position observed during the speculum examination might be useful in the estimation of the uterine anatomy regarding the angles of the version. However, the ultrasonographic examination is essential for a definitive determination of the uterine anatomy. Clin. Anat. 30:404-408, 2017. © 2017 The Authors. Clinical Anatomy published by Wiley Periodicals, Inc. on behalf of American Association of Clinical Anatomists.

Hereditary leiomyomatosis and renal cell carcinoma syndrome: a case report and implications of early onset

Abstract Hereditary leiomyomatosis and renal cell carcinoma (HLRCC) is an autosomal dominant manifestation of cutaneous and uterine leiomyomas together with renal cancer due to autosomal dominant germline mutations of fumarate hydratase gene. A twenty-year-old female patient presented with type-II segmental piloleiomyoma and increased menstruation due to uterine leiomyomas, with a history of bilateral nephrectomy performed at 13 and 16 years of age for type 2 papillary renal cell carcinoma. This case represents one of the very early onsets of hereditary leiomyomatosis and renal cell carcinoma syndrome. As genetic anticipation for renal cancer is a well-documented entity for HLRCC syndrome, early recognition is crucial for both the patient and her family in order to provide appropriate counseling and initiation of surveillance.

Safety, Efficiency, and Outcomes of Perineoplasty: Treatment of the Sensation of a Wide Vagina.

Background. The sensation of a wide vagina is a common problem for women after childbirth. As its etiology is unknown, there is no uniform management strategy. We hypothesized that, rather than vaginal laxity, the cause was level 3 pelvic support deficiency. Methods. This retrospective study compared preoperative and postoperative genital hiatus length, perineal length, and total vaginal length in patients treated with perineoplasty for the sensation of a wide vagina. A telephone survey was used to determine postoperative patient and male partner satisfaction rates. Results. Mean age of patients was 48 (26-68) years; mean body mass index (BMI) was 25.3 (17.6-33.2); and mean parity was 2.5 (2-5). Preoperative and postoperative genital hiatus, perineal length, and total vaginal length were 4.62 and 3.18 (p < 0.01), 3.06 and 4.04 (p < 0.01), and 9.43 and 9.43 (p = 0.882), respectively. At the 6-month follow-up, the success rate of the perineoplasty procedure was 87.9%; according to a visual analog scale, partner satisfaction rate was 92.6%. Ten percent (n = 4) of patients said they experienced dyspareunia during sexual intercourse at the introitus of the vagina. Conclusion. With low dyspareunia rates, low complication rates, high patient satisfaction, and satisfactory anatomical success, perineoplasty can be considered successful for treatment of the sensation of a wide vagina.

Systematic review: What is the best first-line approach for cesarean section ectopic pregnancy?

This systematic review aims to analyze the case reports, case series, or clinical studies describing the women with cesarean scar ectopic pregnancy (CSEP), and thus, to determine the efficacy and safety of different primary treatment modalities in the management of CSEP. A thorough search of electronic databases showed that 274 articles on CSEP were published between January 1978 and April 2014. Systemic methotrexate, uterine artery embolization, dilatation and curettage (D&C), hysterotomy, and hysteroscopy were the most frequently adopted first-line approaches. The success rates of systemic methotrexate, uterine artery embolization, hysteroscopy, D&C, and hysterotomy were 8.7%, 18.3%, 39.1%, 61.6%, and 92.1%, respectively. The hysterectomy rates were 3.6%, 1.1%, 0.0%, 7.3%, and 1.7% in CSEP cases that were treated by systemic methotrexate, uterine artery embolization, hysteroscopy, D&C, and hysterotomy, respectively. The ability to achieve a subsequent term pregnancy is related to successful systemic methotrexate treatment (p = 0.001) or hysterotomy (p = 0.009). Future term pregnancy was significantly more frequent in the hysterotomy group (p = 0.001). Hysteroscopy and laparoscopic hysterotomy are safe and efficient surgical procedures that can be adopted as primary treatment modalities for CSEP. Uterine artery embolization should be reserved for cases with significant bleeding and/or a high suspicion index for arteriovenous malformation. Systemic methotrexate and D&C are not recommended as first-line approaches for CSEP, as these procedures are associated with high complication and hysterectomy rates.

The clinical significance of classical and new emerging determinants of adenomyosis.

OBJECTIVE: The present study aims to analyze the diagnostic accuracy of clinical characteristics together with new emerging laboratory markers of adenomyosis. METHODS: This study was a retrospective analysis of clinical and laboratory characteristics of 99 women who underwent hysterectomies with (study group) or without (control group) a diagnosis of adenomyosis, 56 and 43 patients in each group, respectively. RESULTS: The women with adenomyosis were more likely to have younger age (OR = 1.14, 0.789-0.971 95% CI, P = 0.010), higher parity (OR = 1.81, 0.308-0.988 95% CI, P = 0.046), higher number of curettage (OR = 1.90, 1.189-3.041 95% CI, P = 0.007), dysmenorrhea (OR = 117.49, 2.715-5084.883 95% CI, P = 0.013) and elevated mean platelet volume (OR = 5.17, 2.054-13.028 95% CI, P = 0.000). After receiver-operating-characteristics curve analysis, using a cut-point of 8.5 fL, the preoperative mean platelet volume predicted adenomyosis with a sensitivity of 56.6% and specificity of 82.6%. CONCLUSIONS: Those findings suggest gynecologists to give priority on adenomyosis when premenopausal paraous patient with a history of curettages admitted with a complaint of dysmenorrhea and elevated levels of MPV.

Changes in Markers of Ovarian Reserve After Laparoscopic Ovarian Cystectomy.

STUDY OBJECTIVE: This study was conducted to determine the changes in ovarian reserve markers after laparoscopic ovarian cystectomy (LOC). DESIGN: Prospective cohort study (Canadian Task Force classification II-2). SETTING: University teaching hospital. PATIENTS: Fifty 50 patients who underwent LOC were prospectively examined to determine the changes in serum markers of ovarian reserve, starting from 1 month before and 3 months after consecutive operations. INTERVENTIONS: Changes in serum markers were compared between the following groups: endometrioma cysts (n = 26) versus nonendometrioma cysts (n = 24), unilateral cystectomy (n = 38) versus bilateral cystectomy (n = 12), and bilateral endometrioma extirpation (n = 10) versus other cystectomy operations (n = 40). MEASUREMENTS AND MAIN RESULTS: A significant change was noticed between the preoperative and postoperative antimüllerian hormone (AMH) levels (2.67 ± 2.67 ng/mL vs 1.84 ± 1.72 ng/mL, p < .0001). Serum AMH levels were found to be significantly decreased in endometrioma (p = .002), nonendometrioma (p = .019), unilateral cystectomy (p = .001), bilateral cystectomy (p = .005), bilateral endometrioma (p = .011), and cysts other than bilateral endometrioma (p = .000) groups. CONCLUSION: The ovarian reserve was found to be diminished after LOC regardless of the presence of endometrioma that could be distinguishable by serum AMH levels.

Recurrent pregnancy loss is associated with increased red cell distribution width and platelet distribution width.

AIM: The present study aims to evaluate how components of complete blood count are altered in women with a history of recurrent pregnancy loss. MATERIAL AND METHODS: This was a retrospective evaluation of 60 women who had a history of recurrent pregnancy loss, 60 healthy women who had a first trimester pregnancy and 60 healthy parous women. RESULTS: When compared with pregnant women and healthy controls, the women with a history of recurrent pregnancy loss had significantly higher red cell distribution width (RDW) and platelet distribution width (PDW) (P = 0.001 for both). Thrombophilia was detected in 31.7% of the women who had a history of recurrent pregnancy loss (19 out of 60). When compared to the women without thrombophilia, the women with thrombophilia had significantly lower body mass index (P = 0.034) but significantly higher RDW, PDW and plateletcrit (respectively, P = 0.043, P = 0.001 and P = 0.002). There were significant and positive correlations between RDW and PDW (r = 0.615, P = 0.001), RDW and plateletcrit (r = 0.343, P = 0.007) and PDW and plateletcrit (r = 0.340, P = 0.008) in women with a history of recurrent pregnancy loss. CONCLUSION: An elevation in PDW and RDW values was found to be associated with recurrent pregnancy loss.

Safety of uneventful cesarean section in terms of hemorrhage.

OBJECTIVE: Hemorrhage still continues to be reported as one of the leading causes of maternal mortality and morbidity. Intraoperative estimation of the blood loss seems to be complex and misleading as it is impaired by the amount of amniotic fluid and blood from the placenta. The present study was aimed to investigate the safety of intraoperative deciding on an uneventful cesarean section in a low risk patient population. MATERIAL AND METHODS: One hundred patients free from hemorrhage risks and experienced an uneventful elective cesarean section, were included to the study. The decline in hemoglobin and hematocrit values, calculated blood loss, transfusion rate and presence of hemorrhage related symptoms and signs were accepted as the main outcomes of the study. RESULTS: The average preoperative and postoperative hemoglobin values were detected as 12.09±0.18 g/dl and 10.72±1.39 g/dl, respectively. The average decrease in hemoglobin was 1.36±1.06 g/dl. The observed decrease in hemoglobin values were less than 10% in 34.4% of the patients. The average blood loss was calculated to be 517.06±417.55 ml. There were no patients with signs and symptoms of hemorrhage. Cross match transfusion ratio, transfusion probability and transfusion index was calculated as zero. CONCLUSION: The decision of uneventful cesarean section provides obstetricians a safe postoperative and postpartum period after following standardized surgical procedures in terms of hemorrhage and related complications.