Actualización del abordaje de la endometriosis / Update in endometriosis work-up and treatment

El creciente compromiso con la salud ginecológica ha puesto de manifiesto la necesidad de actualizar el abordaje de la endometriosis, por lo que se ha querido llevar a cabo una revisión exhaustiva de la literatura científica con el fin de recopilar los últimos avances relevantes en su asistencia sanitaria. En este sentido, se llevó a cabo un congreso de ginecología el 30 de septiembre y 1 de octubre que convocó a diversos expertos para revisar aspectos clínicos, farmacológicos y vanguardistas. La revisión destaca los criterios directos, indirectos y soft markers que determinan la presencia de endometriosis durante la exploración, así como las pautas adecuadas para el diagnóstico mediante pruebas de imagen. Además, analiza la importancia de realizar un diagnóstico completo y detallado en pacientes que presenten síntomas de la enfermedad. Por otra parte, resalta los avances en el tratamiento de esta enfermedad, haciendo especial énfasis en los beneficios de la N-acetil cisteína. Finalmente, estudia el papel de la cirugía, destacando sus ventajas, pero señalando que la endometriosis no debe ser siempre asociada a la operación, ya que esta puede conllevar numerosas complicaciones.(AU)

The growing commitment to gynecological health has highlighted the need to update the approach to endometriosis. Therefore, a comprehensive review of the scientific literature has been carried out to gather the latest relevant advances in its healthcare. In this regard, a gynecology congress was held on September 30 and October 1, bringing together various experts to review clinical, pharmacological, and cutting-edge aspects. The review emphasizes the direct, indirect, and soft markers that determine the presence of endometriosis during examination, as well as the appropriate guidelines for diagnosis through imaging tests. Furthermore, it discusses the importance of conducting a complete and detailed diagnosis in patients exhibiting symptoms of the disease. Additionally, it highlights advancements in the treatment of this condition, with a particular emphasis on the benefits of N-acetyl cysteine. Finally, it explores the role of surgery, emphasizing its advantages but pointing out that endometriosis should not always be associated with surgery since it can entail numerous complications.(AU)

Fisiopatología del sangrado uterino anómalo / Pathophysiology of abnormal uterine bleeding

El sangrado uterino anómalo se define como cualquier variación del patrón normal de sangrado en aquellas mujeres en edad reproductiva, no gestantes, con repercusión en su calidad de vida. Se han descrito diferentes mecanismos y situaciones clínicas en las que se puede padecer un episodio o varios de sangrado uterino anómalo.En este artículo realizamos una revisión sobre los mecanismos fisiopatológicos implicados en los episodios de sangrado uterino anómalo que nos permita comprender los posibles tratamientos para esta dolencia.(AU)

Abnormal uterine bleeding is defined as any variation in the normal pattern of bleeding in non-pregnant women of reproductive age with an impact on their quality of life. Different mechanisms and clinical situations have been described to explain the origin of abnormal uterine bleeding episodes.In this article we conduct a review of the pathophysiological mechanisms involved in episodes of abnormal uterine bleeding to understand potential treatments for this pathology.(AU)

Evolución del estrógeno en la anticoncepción hormonal combinada: del etinilestradiol al estetrol pasando por el estradiol / Evolution of oestrogen in combined hormonal contraception: From ethinylestradiol to estetrol via estradiol

El objetivo de este artículo ha sido el de analizar las evidencias disponibles sobre la eficacia y la seguridad de un nuevo anticonceptivo oral que contiene estetrol (E4) y drospirenona (DRSP). Para ellos se ha efectuado una revisión de la literatura que ha incluido los estudios publicados sobre esta nueva formulación anticonceptiva. Los ensayos clínicos en fase 2 y fase 3 realizados han puesto de manifiesto que la combinación E4 15mg/DRSP 3mg es eficaz para evitar el embarazo, es bien aceptada por las mujeres y no produce cambios de significado clínico en los parámetros de la coagulación. Para confirmar los resultados obtenidos en los ensayos en fase 2 y 3, es necesario un estudio en fase 4 que ponga de manifiesto el comportamiento de este nuevo anticonceptivo en la vida real.(AU)

The objective of this article was to analyse the available evidence on the efficacy and safety of a new oral contraceptive containing estetrol (E4) and drospirenone (DRSP). We conducted a literature review that included published studies on this new contraceptive formulation. Phase 2 and phase 3 clinical trials have shown that the E4 15mg/DRSP 3mg combination is effective in preventing pregnancy, is well accepted by women, and does not produce clinically significant changes in coagulation parameters. To confirm the results obtained in phase 2 and 3 trials, a phase 4 study is necessary to reveal the behaviour of this new contraceptive in real life.(AU)

Uso de inhibidores de la aromatasa en el tratamiento del dolor pélvico asociado a endometriosis: revisión sistemática / Aromatase inhibitors in the treatment of endometriosis-associated pelvic pain: A systematic review

ObjetivoConocer el efecto del uso de los inhibidores de la aromatasa (IA) en el tratamiento del dolor pélvico asociado a endometriosis (DPAE).Material y métodosRevisión sistemática de la literatura.ResultadosSe identificaron 173 artículos de los que resultaron válidos para la revisión 25, de los cuales 4 resultaron ser ensayos clínicos aleatorizados, 3 ensayos clínicos no aleatorizados, 10 estudios prospectivos no comparativos y 8 reportes de casos clínicos. En la mayoría de los estudios y/o casos clínicos (24 de 27) el uso de los IA se asoció a una mejoría en el DPAE. Se identificaron importantes sesgos que pueden influir en el análisis de la eficacia, fundamentalmente el uso combinado de IA con otros fármacos ampliamente utilizados en el tratamiento de la endometriosis.ConclusionesA pesar de la existencia de numerosos artículos que presentan y/o analizan el efecto de los IA en el control del DPAE, los sesgos de interpretación de sus resultados, junto con el perfil de efectos secundarios de este grupo de fármacos, hacen que su uso no se haya extendido y siga siendo considerado como un tratamiento experimental de la endometriosis. A día de hoy no existen evidencias de suficiente calidad para poder recomendar el uso de los IA en el tratamiento del DPAE en la práctica clínica habitual.

ObjectiveTo know the effect of the use of aromatase inhibitors (AI) in the treatment of endometriosis-associated pelvic pain (EAPP).Material and methodsSystematic review of the literature.Results173 articles were identified of which 25 were valid for the review, of which 4 were randomized clinical trials, 3 were non-randomized clinical trials, 10 were prospective non-comparative studies and 8 were clinical case reports. In most of the studies and/or case reports (24 of 27) the use of AI was associated with an improvement in EAPP. Important biases were identified that may influence the efficacy analysis, primarily the combined use of AI with other drugs widely used in the treatment of endometriosis.ConclusionsDespite the existence of numerous articles presenting and/or analysing the effect of AIs in the control of EEAP, the biases in the interpretation of their results, together with the side effect profile of this group of drugs, mean that their use has not become widespread, and they continue to be considered an experimental treatment for endometriosis. To date, there is insufficient evidence of sufficient quality to recommend the use of AI in the treatment of EEAP in routine clinical practice.

ESC expert statement on the effects on mood of the natural cycle and progestin-only contraceptives.

Hormonal fluctuations during the natural cycle, as well as progestins used for hormonal contraception, can exert effects on mood especially in vulnerable women. Negative effects of levonorgestrel-releasing intrauterine contraception on mood are rare.

Morcelación intraabdominal de un sarcoma uterino no diagnosticado / Intra-abdominal morcellation of an undiagnosed uterine sarcoma

Presentamos el caso de una paciente con un leiomiosarcoma no diagnosticado que fue tratada mediante histerectomía subtotal laparoscópica y morcelación. Con posterioridad, la paciente fue tratada mediante traquelectomía y doble anexectomía y unos meses más tarde presentó una recidiva local del leiomiosarcoma

We present the case of a patient with unsuspected leiomyosarcoma who underwent a supracervical hysterectomy and morcellation. After this diagnosis we performed a traquelectomy and anexectomy. A few months later, the patient developed local recurrence of the leiomyosarcoma

Growing teratoma syndrome after ovarian inmature teratoma: a case report and review of the literature.

Growing teratoma syndrome is an uncommon complication of malignant germ cell cancer, characterised by the development of large tumours during or after chemotherapy, despite normalisation of tumour marker levels and metastasis, which contain only mature teratoma. Given its low incidence, little is data available. The authors present the case of a 15-year-old girl with a growing teratoma and the literature review outlines the current knowledge of its pathogenesis, common sites, diagnosis, natural course, treatment, and prognosis.

Cost-effectiveness analysis in the treatment of heavy menstrual bleeding in Spain.

OBJECTIVE: To compare the effectiveness and costs associated with first-line medical treatments for chronic heavy menstrual bleeding (HMB) in Spain. STUDY DESIGN: A cost-effectiveness analysis was conducted comparing the levonorgestrel-releasing intrauterine system (LNG-IUS) with the estradiol valerate/dienogest multiphase oral contraceptive (E2V/DNG), combined oral contraceptives (COC) and progestins (PROG). Study patients were fertile women diagnosed with HMB who initially wished to remain fertile. A Markov model based on reported clinical data and the opinion of a panel of experts was used. The time horizon of the analysis was 5 years. The analysis was conducted from the perspective of the Spanish National Health System (NHS), discounting both costs (€ 2013) and future effects at an annual rate of 3%. One-way sensitivity analyses and probabilistic sensitivity analysis were performed to test the robustness of the results. RESULTS: In the analysis at 5 years, the LNG-IUS was associated with a gain of 0.67, 2.22, and 3.53 symptoms free months (SFM) compared with E2V/DNG, COC and PROG, respectively. LNG-IUS contributed more quality-adjusted life months (QALM) than the other treatment alternatives (+1.74 vs. E2V/DNG, +3.33 vs. COC +3.53 vs. PROG). First-line LNG-IUS treatment resulted in savings of € 583, € 988, and € 1891 vs. E2V/DNG, COC and PROG, respectively. These cost benefits, coupled with the greater clinical benefits in terms of SFM and QALM, show that LNG-IUS is the dominant option (less costly and more effective). CONCLUSION: LNG-IUS is the medical treatment of choice and cost-saving option for the control of HMB in Spain.

El radiodiagnóstico ante la violencia de género: un tema de actualidad a tener en cuenta / Domestic violence: a current issue to take into account in diagnostic imaging

La violencia de género es en la actualidad un tema de gran repercusión política y social. Su incidencia real es difícil de determinar debido al entorno en el que se produce y al escaso número de denuncias. Por otra parte, la violencia, en todas sus formas, supone un importante problema de salud pública. Describimos un caso de maltrato doméstico en una mujer joven con una presentación inusual; fenómenos tromboembólicos en distintas localizaciones. Queríamos incidir en que en algunos casos es necesario pensar en la posibilidad del maltrato a la hora de establecer el diagnóstico, tanto por parte del personal sanitario en general como por el especialista en diagnóstico por imagen. Esto puede ser decisivo para determinar los casos existentes, disminuir las secuelas y poder contribuir a tiempo a las denuncias pertinentes (AU)

Domestic violence is currently an issue of great political and social importance. The real incidence of domestic violence is difficult to determine due to the environment where it takes place and the reluctance of victims to report abuse. On the other hand, all types of violence represent an important public health problem. We report the case of a young woman who presented with thromboembolic phenomena at different sites due to domestic violence. We emphasize that it is necessary for radiologists and other healthcare professionals to consider the possibility of domestic violence when establishing the diagnosis. This can be important for determining the incidence of abuse, diminishing its sequela, and help increase its reporting (AU)

[Domestic violence: a current issue to take into account in diagnostic imaging]. / El radiodiagnóstico ante la violencia de género: un tema de actualidad a tener en cuenta.

Domestic violence is currently an issue of great political and social importance. The real incidence of domestic violence is difficult to determine due to the environment where it takes place and the reluctance of victims to report abuse. On the other hand, all types of violence represent an important public health problem. We report the case of a young woman who presented with thromboembolic phenomena at different sites due to domestic violence. We emphasize that it is necessary for radiologists and other healthcare professionals to consider the possibility of domestic violence when establishing the diagnosis. This can be important for determining the incidence of abuse, diminishing its sequela, and help increase its reporting.

Position of the Spanish Menopause Society regarding the management of perimenopause.

Perimenopause is an imprecise period in woman over 40 years of age, which comprises the time between the moment that the first changes in the menstrual cycle appear and the year following the definitive cessation of the menses. Besides irregular bleeding, many women also complain of hot flashes and other characteristic symptoms of postmenopause. Moreover, most of them are concerned about the future impact that these events may have on their health, such as needing health exams or continuing to use contraceptive methods. A panel of experts from the Spanish Menopause Society has met to establish diagnostic and therapeutic guidelines for this period based on the best available evidence.

Versión cefálica externa en presentación de nalgas: una técnica ancestral muy actual / External cephalic version in breech presentation: An old but very current technique

La presentación podálica representa el 3-4% de los embarazos y es una indicación habitual de cesárea. La versión externa se ha realizado en nuestro medio desde tiempo de Hipócrates, sin embargo, pese a la importante opción que representa en el descenso de la tasa de cesáreas, solo se ofrece a un pequeño porcentaje de pacientes debido al desconocimiento y a la carencia de obstetras experimentados. El éxito oscila entre el 40-74%. La edad gestacional, el índice de líquido amniótico, la presentación y la situación de la placenta son factores que pueden influir en el éxito de la maniobra. La utilización de tocolíticos y una buena analgesia pueden facilitar la maniobra y mejorar su porcentaje de éxito. Un protocolo estandarizado de la técnica realizado por un ginecólogo experimentado, logra convertirla en una maniobra con un perfil de seguridad excelente que ofrece a las gestantes una interesante opción para evitar una cirugía (AU)

Breech presentation occurs in 3-4% of pregnancies and is a routine indication for cesarean section. The external version is a maneuver that has been performed since Hippocrates’ time. Nevertheless, despite decreasing the cesarean section rate, this technique is only offered to a small percentage of patients due to lack of awareness and the shortage of experienced obstetricians. The success rate ranges from 40-74%. Factors that can influence the success of the maneuver are gestational age, the amniotic fluid index, presentation, and the location of the placenta. The use of tocolytics and effective analgesia can facilitate the maneuver and improve the success rate. When a standardized protocol is followed and the technique is performed by an experienced gynecologist, the external cephalic version has an excellent safety profile and is an effective option that avoids surgery (AU)

Progestin-only contraception and venous thromboembolism.

Combined oral contraceptives (COC) are the most popular contraceptive method in developed countries. Since their introduction there have been numerous changes and modifications in its composition with the aim to improve safety and tolerability while maintaining contraceptive efficacy. Most of the changes have been conducted on the progestin component, since most of the combinations include ethinyl estradiol as oestrogen. One of the adverse effects of COC is the increased risk of venous thromboembolism (VTE) in two clinical forms of presentation: deep vein thrombosis or pulmonary embolism. This review details the changes in haemostasis induced by progestin-only contraceptives and the risk of VTE in women who utilize this type of contraception; the relationship with other risk factors such as thrombophilia; the interactions of these contraceptives with anticoagulant treatment and finally the eligibility criteria for the use of hormonal contraception in women with previous VTE or thrombophilia carriers.

Economic evaluation of the levonorgestrel-releasing intrauterine system for the treatment of dysfunctional uterine bleeding in Spain.

OBJECTIVE: To compare the cost and effectiveness of the levonorgestrel-releasing intrauterine system (LNG-IUS) versus combined oral contraception (COC) and progestogens (PROG) in first-line treatment of dysfunctional uterine bleeding (DUB) in Spain. STUDY DESIGN: A cost-effectiveness and cost-utility analysis of LNG-IUS, COC and PROG was carried out using a Markov model based on clinical data from the literature and expert opinion. The population studied were women with a previous diagnosis of idiopathic heavy menstrual bleeding. The analysis was performed from the National Health System perspective, discounting both costs and future effects at 3%. In addition, a sensitivity analysis (univariate and probabilistic) was conducted. RESULTS: The results show that the greater efficacy of LNG-IUS translates into a gain of 1.92 and 3.89 symptom-free months (SFM) after six months of treatment versus COC and PROG, respectively (which represents an increase of 33% and 60% of symptom-free time). Regarding costs, LNG-IUS produces savings of € 174.2-309.95 and € 230.54-577.61 versus COC and PROG, respectively, after 6 months-5 years. Apart from cost savings and gains in SFM, quality-adjusted life months (QALM) are also favourable to LNG-IUS in all scenarios, with a range of gains between 1 and 2 QALM compared to COC and PROG. CONCLUSIONS: The results indicate that first-line use of the LNG-IUS is the dominant therapeutic option (less costly and more effective) in comparison with first-line use of COC or PROG for the treatment of DUB in Spain. LNG-IUS as first line is also the option that provides greatest health-related quality of life to patients.

Efectos beneficiosos no anticonceptivos de la píldora anticonceptiva / No disponible

El primer objetivo del uso de un anticonceptivo oral combinado (AOC) es el de evitar un embarazo. En ocasiones el AOC se asocia a efectos secundarios, pero cada día se conocen mejor los efectos beneficiosos no anticonceptivos del mismo. Existe evidencia de una buena calidad que asocia el uso de AOC con la mejoría de la dismenorrea, la disminución del sangrado menstrual y la mejoría del síndrome premenstrual. También se sabe que el uso de AOC protege frente a la enfermedad inflamatoria pélvica (EIP) y el embarazo ectópico, reduce la pérdida mineral ósea y es eficaz en el tratamiento del acné leve y moderado. Además, la AOC disminuye la incidencia de cáncer de ovario y cáncer de endometrio. Conocer estos efectos beneficiosos resulta de interés tanto para los profesionales sanitarios como para las mujeres (AU)

The first objective of using a combined oral contraceptive(COC) is that of avoiding pregnancy. COC is sometimes associated to side effects, but its non-contraceptive beneficial effects are becoming known day by day. There is evidence of the good quality associated to the use of COC with the improvement of dysmenorrhea, decrease of menstrual bleeding and improvement of premenstrual syndrome. It is also known that the use of COC protects against pelvic inflammatory disease (PID), and ectopic pregnancy, reduces bone mineral loss and is effective in the treatment of mild and moderate acne. Furthermore, COC decreases the incidence of ovarian cancer and endometrial cancer. Knowing these beneficial effects is of interest, both for the health care professionals and for women (AU)

The levonorgestrel intrauterine system (Mirena) for treatment of idiopathic menorrhagia. Assessment of quality of life and satisfaction.

OBJECTIVES: To evaluate patient satisfaction and improvement in quality of life (QoL) among women with idiopathic menorrhagia treated with the levonorgestrel intrauterine system (LNG-IUS). STUDY DESIGN: Prospective-observational study with one-year follow-up in which 225 women were enrolled who had a LNG-IUS inserted for control of idiopathic menorrhagia. Bleeding, tolerability, user satisfaction, and health-related QoL (by means of the SF-36 QoL questionnaire) were assessed. RESULTS: There was a statistically significant reduction in the amount of bleeding, an increase of haemoglobin and ferritin levels, and an improved QoL score. A high degree of satisfaction was reported by over 98% of patients. CONCLUSIONS: The LNG-IUS is an effective and well-tolerated treatment modality in idiopathic menorrhagia. The QoL of women treated with the LNG-IUS is markedly improved, causing high levels of patient satisfaction. This IUS can be regarded as a first-choice therapy in idiopathic menorrhagia.

LEO stent monotherapy for the endovascular reconstruction of fusiform aneurysms of the middle cerebral artery.

We present the case of a patient with a fusiform aneurysm of the M1 segment of the middle cerebral artery (MCA) in which endovascular stent placement without coiling was performed. A 3.5-mm x 25-mm LEO self-expanding stent was deployed along the fusiform aneurysm of the horizontal MCA M1 segment. Digital subtraction angiography showed progressive thrombosis at 6 months and complete thrombosis of the fusiform MCA aneurysm at 12 months.

Contraceptive practices and trends in Spain: 1997-2003.

OBJECTIVE: To know the contraceptive use and trends in the Spanish female population. STUDY DESIGN: Since 1997, we have conducted a survey every 2 years on the use of contraceptive methods among a representative sample of Spanish women of childbearing potential (15-49 years). RESULTS: In the period 1997-2003, the percentage of use of contraceptive methods in Spain rose from 55.6% to 71.2%. The most commonly used method was the condom (21% in 1997, 21.9% in 1999, 29.5% in 2001 and 35.7% in 2003), followed by the contraceptive pill (14.2%, 16.5%, 19.2% and 18.3%, respectively). Male or female sterilization remained stable with percentages of use of 5-7%. IUDs are used by about 5% of women. CONCLUSIONS: The use of contraceptive methods among Spanish women of childbearing potential generally fits quite well the patterns found in other developed countries, and we observed a trend towards increased use of effective methods.

Use of contraceptive methods and risk of unwanted pregnancy in Spanish women aged 40-50 years: results of a survey conducted in Spain.

A survey intended to ascertain the rate of use and type of contraceptive methods applied by Spanish women aged 40 to 50 years, and to determine the proportion of women in this group at risk of an unwanted pregnancy, was designed and validated. To achieve representative national results for the study population, it was estimated that a sample size of 2000 women was required. Women were selected using probabilistic, stratified random sampling. The survey questionnaire was prepared by the research group with the collaboration of experts in the conduct of population studies of this type. Participants were interviewed face to face by qualified and trained staff from a specialised company external to the research group. Overall, 1039 women (52%) resorted to some contraceptive method, of which (male or female) sterilisation was the most common. We estimate that in Spain there are 840,000 women (31.8%) aged 40 to 50 years at risk of unwanted pregnancy.

Contraception in the Spanish press: an analysis of the 1997-2002 period.

OBJECTIVE: Based on the hypothesis that the media represent an important source of information about contraceptive methods and sexuality, this paper reviews the news items about contraception published by four important Spanish newspapers and four women's magazines. MATERIALS AND METHODS: All news items appearing from January 1, 1997 to December 31, 2002 in the following publications: El País, El Mundo, ABC, La Vanguardia, Mía, Clara, Ragazza, and Epoca were collected during the first 6 months of 2003. Results Seven hundred and ten news items about contraception were identified during the period analysed, of which 117 (16.5%) had a negative character. CONCLUSIONS: Over 80% of news items appearing in the Spanish press in the 1997-2002 period give a positive information about contraceptive methods.