Violence against women in Rome: An analysis of cases treated in the gynecology emergency department of the hospital Umberto I between 1999 and 2013.

BACKGROUND: The gynecological emergency department of the Policlinico Umberto I, Rome sees an average of about 30 cases of violence against females each year. It is stressed that these cases are not representative of all cases of violence against women in Rome and they cannot be used to estimate the prevalence or incidence of the phenomenon, but they may provide some insight on the victims and their aggressors, the use of drugs or alcohol, factors which may affect the decision to report the attack to the police and attacks on children. METHODS: The case records of all 458 females seen in the emergency department between 1999 and 2013 were retrieved, data were extracted and an Excel worksheet was prepared. Temporal variation in the numbers of cases, the types of aggression, the use of drugs or alcohol, reporting the attack to the police and violence against children were specifically investigated using frequency tabulations and appropriate statistical tests. RESULTS: There has been little change in the number of cases seen during the 15 year period; there is no significant seasonal effect or difference between the days of the week. Just over half of the attacks were reported to the police, but this was less likely among the older victims. About 87% of the cases involved vaginal and/or anal penetration. The use of drugs and/or alcohol was most common, 43%, among unmarried women aged 21-25. There were 32 cases of violence against children aged under 16. CONCLUSIONS: There has been little change in the number and characteristics of violent attacks on women seen at this large hospital in Rome over the years 1999-2013.These cases provide little information about the general epidemiology of violence against women, although they do imply that this great social and cultural problem continues unabated in Rome.

Laser vaporization in the management of CIN.

AIMS: To evaluate the effectiveness of laser CO2 vaporization in high-grade cervical intraepithelial neoplasias and to assess the diagnostic reliability of cytology, colposcopy, microbiology and HPV tests in predicting recurrence in a long-term outcome. METHODS: Forty-four patients affectd by high-grade cervical intraepithelial neoplasia (HG-CIN) were submitted to laser CO2 vaporization and followed-up a minimum of five years. Vaginal smears for microbiological examination were detected. HPV testing was performed by polymerase chain reaction (PCR). RESULTS: The average age of the patients was 19.5 years (range 15-24). The cure rate after a single treatment was 95%. Two cases (5%) revealed HG-CIN persistence after three months. The five year follow-up of all cases submitted to a second laser procedure revealed negative cytologic and colposcopic findings. CONCLUSIONS: A higher degree of expertise and experience from the colposcopist and long-term follow-up proves the effectiveness of laser vaporization in the management of CIN in young women. It has been suggested that HPV infection alone may not be sufficient to promote carcinogenesis and that other cofactors could be involved. Microbiological tests are important to identify and treat any inflammation which might represent a cofactor of HPV infection in the pathogenesis of cervical dysplasia. Cytocolposcopic long-term follow-up, microbiological and HPV tests can improve regression of disease.

Sequential Gn-RH superagonist and medroxyprogesterone acetate treatment of uterine leiomyomata.

A group of 48 women with symptomatic leiomyomata were treated during 6 months with the short-acting Gn-RH superagonist analog buserelin. The first (group C) was followed up for an additional six months of no medication. The second (group M) was treated for 6 additional months with medroxyprogesterone acetate (MPA) at doses decreasing from 200 to 25 mg/day. Buserelin therapy significantly decreased uterine size (P less than 0.001) in all patients, the average final volume being 48.5% of the original (from 262 +/- 147 ml to 127 +/- 85.4 ml). In group C there was a significant (P less than 0.001) re-growth during the post-treatment observation period (from 120 +/- 81.0 ml to 198 +/- 77.2 ml); a significant (P less than 0.01) re-growth was also observed in group M during MPA medication (from 132 +/- 77.2 ml to 170 +/- 96.0 ml). The agonist had also a marked effect on fibroids: on average they decreased from 75.1 +/- 74.3 ml to 24.7 +/- 23.3 ml (P less than 0.025). In group C during the post-buserelin period of observation without treatment, there was a significant re-growth from 23.7 +/- 21.6 ml to 47.7 +/- 27.5 ml (P less than 0.001), whereas in group M treatment with MPA prevented any significant re-growth (from 25.6 +/- 24.8 to 30.6 +/- 32.9 ml; P greater than 0.3).

Laparoscopic surgery in treatment of stage IIb cervical cancer after neoadjuvant chemotherapy. A case report and review of the literature.

BACKGROUND: A detailed operative procedure of laparoscopic radical hysterectomy (type III) with pelvic and aortic lymphadenectomy after neoadjuvant chemoterapy in treatment of Stage IIb cervical cancer is described. CASE REPORT: A 50-year-old patient with Stage IIb squamous cell carcinoma of the uterine cervix, who initially was not surgically resectable, received three courses of neoadjuvant chemotherapy that included ifosfamide 5 g/m2, cisplatin 50 mg/m2 and paclitaxel 175 mg/m2 (TIP). Following a partial clinical response to chemotherapy, the patient underwent laparoscopic type III radical hysterectomy with bilateral salpingo-oophorectomy and pelvic and paraaortic lymphadenectomy. The surgical procedure lasted 250 minutes. Blood loss was 310 ml. The patient was discharged on postoperative day 4. The mean length of the resected parametria and paracolpia was 4.1 cm and 2.0 cm, respectively. The number of dissected lymph nodes was 48:29 pelvic and 19 paraaortic nodes. No major intraoperative or postoperative complications occurred. The patient also underwent adjuvant radiation therapy. Follow-up was performed at six months so far. CONCLUSIONS: This experience suggests that such a surgical procedure is safe. Laparoscopic radical hysterectomy potentially allows for decreased perioperative morbidity and blood loss, faster recovery and better cosmetic results. Large studies with long term follow-up are needed to confirm that this approach may be proposed as an alternative to conventional surgery.

[The role of the pineal body in the endocrine control of puberty]. / Il ruolo della pineale nel controllo endocrino della pubertà.

The pineal gland plays an important role in reproductive endocrinology. The epiphysis regulates seasonal variations in reproductive function of seasonally breeding animals. In humans, even if they are not seasonal breeders, the role of the pineal in reproductive endocrinology seems to be important as well. It appears to be of particular importance the endocrine control of the gland on pubertal sexual maturation. Even if not all researchers agree, several data suggest that elevated melatonin levels-characteristic of prepubertal age-keep the hypothalamic-pituitary-gonadal axis in quiescence: thus, an inhibitory effect on pubertal development is exerted. Subsequently, the decreasing serum melatonin with advancing age would result in activation of the hypothalamic pulsatile secretion of GnRH- and therefore of the reproductive axis-with consequent onset of pubertal phenomena. The production rate of melatonin does not change with age and no growth in pineal size from 1 to 15 years of age has been demonstrated by nuclear magnetic resonance (NMR) studies. Therefore the decrease of serum melatonin concentrations has been proposed to be due to the increase in body mass or, according to another hypothesis, to be also temporally linked to sexual maturation. Furthermore, recently, it has been suggested in rats that the pineal influences not only the pubertal sexual maturation, but even the gonadal and genital development and function of offspring, already during intrauterine life. Investigations are needed to evaluate this hypothesis in humans.

[Contraception after heart transplantation]. / Contraccezione dopo trapianto cardiaco.

It was observed that fertility and menstrual function in heart-transplanted women, impaired before the operation, become normal with a new heart. The restoration of reproductive function is also confirmed by many cases of pregnancy in heart-transplant recipients, reported in the literature. Twenty-four cases were published worldwide up to 1997, out of which eighteen had a positive result. Also a case personally treated was successful. The outcome of a pregnancy after heart transplantation is, then, generally positive. Nevertheless, such a pregnancy involves important maternal and fetal risks. Thus, the gynecologist has to provide correct information about both such risks and the most suitable contraceptive methods, for these patients. Oral contraceptives are very effective and, in the new low-dose formulations, free from serious adverse effects. No adverse effects have been observed in our patient, who represents the only case, reported in the literature, in which an estroprogestinic contraception was utilized before a pregnancy. In conclusion, during an oral contraception or after a tubal sterilization, pregnancy is really unlikely to occur. Thus, when the couple either has completed the familial nucleus or does not desire offspring, a doubt is at least justified as to whether these safer methods of contraception are advisable in such women.

PIP: During the period of 1988-97, in the medical literature, 24 cases of pregnancy were reported in women who had undergone heart transplant operations (18 of them with positive outcome). There were 3 cases of spontaneous abortion between the 8th and 14th weeks of pregnancy. The clinical condition of 19 newborns (one case of twins) was good in 15 cases and pathological in 4 cases. The choice of a contraceptive for such women has to take into account the immunosuppressive therapy that is often associated with arterial hypertension. IUDs may increase the risk of infection, but barrier methods are well suited for such women. However, the use of oral contraceptives (OCs) is more controversial because of their effects on lipid and carbohydrate metabolism, on arterial pressure, and coagulation. However, the new types of OCs with less than 35 mcg of ethinyl estradiol do not seem to alter coagulative homeostasis or increase the risk of thromboembolism. Prior to becoming pregnant, among the 24 cases of pregnancy 2 had been dissuaded of using contraception, 2 had used spermicides, 2 others had used barrier methods, and 3 resorted to abortion, while in the rest of the cases the contraceptive was not specified. In one case observed by the authors, the patient had used a low-dose OC for 4 years (0.030 mg ethinyl estradiol and 0.075 mg gestodene) prior to pregnancy and pregnancy occurred when the OC use was suspended at her own decision. No side effects occurred during OC use nor was there any need for increasing the doses of antihypertensive drugs.

[Use of GnGH (GnRH-A) in gynecology]. / Uso degli analoghi del GnRH (GnRH-A) in ginecologia.

GnRH-agonist therapy is used in the management of many gynaecological pathologies: uterine fibroids, endometriosis, ovarian cystic pathology, breast cancer, dysfunctional uterine bleeding and, in males, prostatic cancer. In the case of uterine fibroids, this therapy can be used as a pre-treatment before conservative or demolitive surgery or as an alternative to hysterectomy. At the Centre for Therapy of Uterine Pathologies (I Institute of Obstetrics and Gynaecology of the University of Rome "La Sapienza") the use of Gn-RH-A therapy in uterine fibroids has been investigated and results consistent with those of many other groups of study have been obtained. The two most important results are: 1. the decrease of both the myoma's size and the uterine volume; 2. the block of menometrorrhagiae symptoms, with improvement of the haematic crasis and possibility to convert a demolitive surgery to a conservative surgery. GnRH-agonists can represent a definitive treatment for patients with symptomatic uterine fibroids and in perimenopausal age.

[Directions of future research on GnGH analogs in the treatment of endometriosis and uterine fibromyoma]. / Le direzioni della ricerca futura con gli analoghi del GnRH nel campo dell'endometriosi e del fibro-mioma uterino.

A variety of new data on the biology, pathophysiology and metabolic changes occurring in leiomyomas and in the ectopic endometrium have opened new avenues for research in a neglected area, that of benign proliferations of the female reproductive tract. In addition, the availability of potent inhibitors of ovarian function which, like the super-agonist analogues of GnRH, have no hormonal activity (oestrogenic, progestogenic or androgenic) has allowed for the first time to evaluate the effect of oestrogen deprivation on endometriosis and uterine fibrosis. The results, although impressive, are only temporary: in both cases hypoestrogenism produces an important relief of symptoms, but--once treatment is discontinued--both conditions usually continue to evolve. For this reason, much remains to be done to optimize Gn-RH analogue utilization. In the case of endometriosis, there seem to be three main areas for future research: pain, infertility and the possibility of modifying its natural history. In addition, the role of combined, medico-surgical therapy remains to be established, especially in the case of severe disease. In the treatment of fibrosis, analogues can be utilized as pre-treatment before conservative or demolitive surgery, or as an alternative to hysterectomy. The role of analogues as a pre-surgical adjuvant has probably been overemphasized and it is time to carry out well controlled studies to narrow down indications. At present they include: severe anemia caused by chronic heavy uterine bleeding, and the need to minimize intraoperative blood loss. Much remains to be done before analogues can become a real alternative to surgery. To date no single sequential therapeutic regimen has been identified which is capable of prolonging the beneficial effects of agonists without their well known negative consequences. Temporary results can be obtained interrupting analogue therapy and substituting it with the administration of a progestogen. Finally, analogue administration can be prolonged by associating an oestrogen-progestogen sequential combination as in HRT. In all of these instances, what are urgently needed are well controlled randomized clinical trials.

[Medium term treatment and prophylaxis of dysfunctional metrorrhagia in adolescence]. / Trattamento a medio termine e profilassi delle metrorragie disfunzionali della adolescenza.

The authors compared the therapeutic effectiveness of these different pharmacological methods of preventing dysfunctional menometrorrhagia in adolescents, which were: 1) chorionic gonadotropin, 2) cyclofenil, 3) ovariostatics. Therapy was given during 2 menstrual cycles, and effects were evaluated both during the treatment and for the succeeding 2 cycles. Parameters followed were: a) clinical recovery, b) persistence of spotting, c) effectiveness in inducing ovulation. The results were equally good both in treatment with ovariostatics and ovulation inducers. The latter proved however, more effective during follow-up. Side-effects were very rare, so much so that, in no case was it necessary to suspend treatment.

[Immune tolerance in pregnancy. Maternal-fetal interactions]. / La tolleranza immunitaria in gravidanza. Interazioni materno-fetali.

The conceptus may be considered as a sort of semi-allogenic graft for the maternal organism, since it shares a half of genomic complement with the father. Nevertheless, its rejection does not take place physiologically during a pregnancy. The mechanisms resulting in the maternal immune tolerance versus the conceptus are not yet completely clarified. Such mechanisms are probably multiple and interacting with each other. In animal and in vitro studies provide evidence suggesting that the following factors are important in producing the maternal immune tolerance: the anatomical position of the fetus; the absence of expression of the class I and II Major Histocompatibility Complex (MHC) molecules in trophoblast tissues; the activity of blocking antibodies; a modification of the immune response; the fetal-placental production of immunosuppressive hormones and substances. Amongst pregnancy-related changes in the immune response, a reduced Natural Killer (NK) cell activity and an increased synthesis of Th2 cytokines (which inhibit the cell-mediated immunity) with an altered Th1/Th2 balance appear to be remarkably important. With regard to fetal-placental hormones, progesterone seems to exert an important immunosuppressive influence mediated by the protein named "Progesterone Induced Blocking Factor" (PIBF). Nevertheless, the real contribution of each of the above mentioned mechanisms still remains to be elucidated in humans.

[Destructive cesarean section: hysterectomy for obstetric reasons and post-abortive hysterectomy. Analysis of 35 cases]. / Taglio cesareo demolitore: isterectomia da causa ostetrica ed isterectomia post-abortiva. Analisi di 35 casi.

The Authors examined surgical case studies for the 20-year period from February 1968 to February 1988 concerning hysterectomies performed for obstetric reasons at the "La Sapienza" University of Rome, Obstetrics and Gynaecology Department; these numbered 35 out of 69,677 births. They also considered hysterectomies carried out during caesarean sections, during birth or the postpartum period, during the puerperium and after miscarriage. They also analyzed reasons for the action taken, the type of operation, the length of the gestation period, the mother's age, and transfusions given.

[Current clinical features of septic abortion in Western countries. A series of cases observed during 1998 at the 1st and 2nd department of obstetrics and gynecology of the University of Rome La Sapienza]. / Attuali caratteristiche cliniche dell'aborto settico nei paesi occidentali. Casistica 1998 del I e II istituto di clinica osterica e ginecologica dell'Università di Roma "La Sapienza".

BACKGROUND: Advances in diagnostic techniques and therapy and the institution of both legislative measures and Centres for the protection of mother-infant health are major factors to which the reduced incidence of septic abortion in should probably be ascribed in Western Countries, where it reaches approximately 10%. The aim of this study was to analyse the current problems related to this pathology in a Western Country, such as Italy. METHODS: Cases of septic abortion observed at the I and II Department of Obstetrics and Gynaecology of University of Rome La Sapienza during 1998 were retrospectively analysed. RESULTS: 42 cases of septic abortion were observed. Fever was present in 100 % of cases, genital bleeding in 57 %, abdominal-pelvic pain in 16.7%, genital purulent discharge in one case (2.4%), pain of the fornices at vaginal examination in another (2.4%). Leucocytosis was detected in 21.5% of patients. Disseminated intravascular coagulation (DIC) occurred in one patient (2.4%). No maternal deaths were observed. Antibiotic therapy was carried out in 81% of cases, a uterine curettage in 95.2%. CONCLUSIONS: Currently, the possibility of early diagnosis of abortion due to the routine use of ultrasonography and, as a consequence, of early antibiotic therapy, whenever a sepsis is suspected, account for the predominance of mild or even doubtful clinical pictures of this pathology in Western Countries. Nevertheless, severe complications are possible in the case of septic abortion, including septicaemia, septic shock, DIC, renal insufficiency. Thus, a correct and careful attitude of prophylaxis and therapy is required.

[Hysterectomy in obstetrics. Analysis and comparison of a group of cases from the Italian and the international literature (536 cases)]. / Interventi demolitori in ostetricia. Analisi e confronto di un gruppo di casistiche della letteratura italiana ed internazionale (536 casi).

The Authors made a comparison between the frequency of obstetric hysterectomies carried out at the "La Sapienza" University Obstetrics and Gynaecology Departments and of those reported in international publications regarding Great Britain, USA, Australia, Saudi Arabia and Libya. Data obtained covered the 462 hysterectomies effected out of the 442,174 births from 1972 to 1895. Results were compared as under: general frequency per number of births, reasons for surgery, type of operation carried out, age of the patient, gestation period, obstetrical history and complications.

[Use of low-dose danazol in adenosis of the breast]. / Utilizzazione del danazolo a basso dosaggio nella adenosi mammaria.

Mammary adenosis is a very common affliction which, it has been calculated, affects between 7 and 15% of women of child-bearing age. The Authors report the results obtained during treatment of this condition with danazol in those different dosages (50, 100 and 200 mg per day). Results were evaluated at 3 and 6 months during therapy, and then 4 months after suspension of the treatment. Effects were evaluated in terms of changes in the symptomatic pain and in the actual clinical record. Side effects were also examined in terms of age and obstetric history. The therapy produced good results with all those dosages used. The lowest dosage gave the most favourable long-term effects, also in terms of the scarsity of side-effects.

[Current epidemiologic features of septic abortion]. / Attuali caratteristiche epidemiologiche dell'aborto settico.

BACKGROUND: This article deals with the current epidemiological features of septic abortion. METHODS: Forty-two of 431 abortions (9,74%) were diagnosed as septic abortions during 1998 at the I and II Institute of Obstetrics and Gynecology, University of Rome La Sapienza , and are retrospectively analyzed. RESULTS: Thirty-four women (81%) came from an EEC country, whereas 8 (19%) from a developing country. Their mean age was 31,4 years (range: 18-43 years). Eighteen patients (43%) were nulliparous; 24 (57%) multiparous; 14 (33%) had previous abortions, none had previous septic abortions. Among risk factors, premature rupture of membranes was found in 5 cases (12%); whereas amniocentesis, HIV positivity, diabetes, positive urine culture and illegal pregnancy termination procedures were found in 5 further cases. No risk factors were found in 76% of patients. CONCLUSIONS: It is observed that, due to medical-scientific advances, previously unknown risk factors have emerged during the last three decades in Western Countries, such as invasive procedures of prenatal diagnosis, IUD contraception and AIDS immunodepression. However, other previously frequent risk factors, such as sepsis from illegal abortion, may emerge again in Countries where abortion is legal (such as Italy), due to massive immigration of clandestine women from developing Countries.

[Prenatal diagnosis of congenital diaphragmatic hernia: an update]. / Aggiornamento in tema di diagnosi prenatale di ernia diaframmatica congenita.

Congenital diaphragmatic hernia (CDH) has an incidence of approximately 1:4000 live births. Most frequently the diaphragmatic defect is a left and posterolateral (Bochdalek) one. Prenatal diagnosis is made at ultrasonography; the relevant sonographic features will be described in the paper. Cystic adenomatoid malformation of the lung (CAML), pulmonary sequestration, bronchogenic cysts, pulmonary hypoplasia/agenesia need to be considered in differential diagnosis. In some cases, diagnosis of CDH is not possible "in utero": in such cases, herniation of abdominal viscera into the thorax takes place presumably just at delivery through a small diaphragmatic defect. CDH may be associated with intrauterine growth retardation (IUGR), chromosomal abnormalities (3%) and/or other malformations (10-50%): such as Central Nervous System, digestive, cardiac and urogenital anomalies. Therefore, search of associated malformations and amniocentesis with analysis of fetal karyotype are mandatory, whenever a CDH is diagnosed. CDH is still at present characterised by a high mortality (reportedly, about 45%). Many prognostic factors have been correlated to postnatal outcome of CDH: some of them are valuable prenatally by ultrasonography. However, the role of sonography in the prediction of neonatal outcome is still controversial: in particular, although many ultrasonographic parameters have been proposed, prenatal evaluation of pulmonary hypoplasia (a crucial factor related to postnatal survival) has not proved to be very accurate so far. Nevertheless, it is undisputable that prenatal diagnosis itself represents a crucial prognostic factor for CDH, since it allows birth of the affected fetuses in 3d level Perinatologic Centres provided with a Neonatal Intensive Care Unit and Neonatal Surgery.

[Asthma and pregnancy]. / Asma e gravidanza.

During pregnancy the asthma has an incidence of 1-4%. In addition to this pathology we find, during pregnancy, an increased incidence of complications both maternal and fetal. These complications, often serious, happen nearly exclusively in patients with severe asthma and/or badly controlled. Therefore, to reduce the risk of beginning of these complications it's necessary to assess correctly the gravity of asthma before becoming pregnant, to make a careful and periodic control of the respiratory function of the patient, to effect a suitable preventive and/or symptomatic pharmacological therapy and to establish specific sanitary-action measures able to prevent the disease becomes acute.

[Female genital mutilation: FGM patients treated at the "Umberto I" polyclinic of Rome: 1985-1996]. / Mutilazioni genitali femminili: pazienti con esiti di FGM ricoverate nel Policlinico "Umberto I" di Roma: periodo 1985-1996.

The article deals with the medical aspect regarding female genital mutilations (FGM). The cultural origin of this tradition is also considered. Such a practice lies in the partial or complete excision of the external genitalia: it is highly widespread in Central Africa, especially in Ethiopia and Somalia. Currently, approximately 130,000,000 women are involved worldwide. In Italy, it is estimated that about 30,000 women amongst the immigrant population are involved (1). Due to the increasing immigration of women from Countries with FGM tradition, knowledge of the pathologies related to such a practice has become urgently necessary to physicians of western Countries. The aim of this study was to analyze the short-term complications of FGM, which are severe and often even deadly, as well as the long-term ones, which are more likely to be faced in the clinical practice of a western Country physician. In particular, a sample of nine women who had undergone infibulation, amongst the patients admitted at the Departments of Obstetrics and Ginaecology of university of Rome "La Sapienza" during the period 1 January 1985-31 december 1996, has been analyzed. Five out of these women suffered form gynaecological pathologies, whilst four from obstetrical pathologies. Our data on complications associated with FGM are in agreement with those of the world literature and highlight how a more specific expertise is necessary for a correct health care of these women.

The impact of the factor V Leiden mutation on pregnancy.

A resistance to the anticoagulant activity of activated protein C (APC), most frequently due to a point mutation in the Factor V gene (the Leiden mutation), represents the most common genetic cause of thrombophilia. The Leiden mutation has been significantly related to pregnancy complications associated with hypercoagulation, e.g. deep vein thrombosis during pregnancy (8-fold increased risk), pre-eclampsia (prevalence of the mutation up to 26%), placental infarction extending to > 10% of the placenta (10-fold increased risk), abruptio placentae (prevalence of the mutation up to 29.6%), and second- and third-trimester pregnancy failure (prevalence of the mutation up to 31.3%). An association of the maternal mutation with recurrent first-trimester miscarriage does not emerge from the literature, although fetal mutation (frequency higher than twice compared with that of the general population) has been related to early spontaneous miscarriage. Although some evidence suggests an association between APC resistance and intrauterine growth retardation, no significant relationship emerges currently from the literature. Screening for the Leiden mutation would seem advisable in women with previous pregnancy complications amongst those associated with APC resistance. Carriers of the mutation should be given appropriate counselling. The screening of asymptomatic women is not recommended at present.

The pineal gland and reproduction.

The hormonal activity of the pineal gland is influenced by both the dark-light cycle and the seasonal cycle, causing it to play an important role in the neuroendocrine control of reproductive physiology. This is especially evident in seasonally breeding animals, in which reproductive function is clearly influenced by seasonal variations in the duration of night and day. Humans are not seasonal breeders. Nevertheless, seasonal fluctuations have been described in human reproduction, and the pineal gland also appears to exert an important role in the neuroendocrine regulation of human reproductive physiology. There is evidence that the epiphysis is involved in the control of sexual maturation. In rats, the maternal pineal appears to influence the gonadal and genital development and function of offspring; this hypothesis has yet to be confirmed in humans. The pineal apparently influences human reproductive function not only at the hypothalamic-pituitary level, by inhibition of the hypothalamic pulsatile secretion of gonadotrophin-releasing hormone, but also at the gonadal level, where melatonin receptors have also been found. In addition, melatonin is reported to increase serum prolactin concentrations in both rats and humans. It has been suggested that melatonin is involved in the control of menstrual cyclicity.