Phenotypic variation in anti-Mullerian hormone (AMH) production per follicle in women with polycystic ovary syndrome (PCOS) and isolated polycystic ovarian morphology (PCOM): an observational cross-sectional study

This observational study compares the ratio of serum anti-Mullerian hormone (AMH) to the total antral follicle count (AFC) (as a marker of AMH production per follicle) in the various phenotypes of women with polycystic ovary syndrome (PCOS) and isolated polycystic ovarian morphology (PCOM). Two hundred and sixty-two women were recruited. Women with PCOS were divided into four phenotypes based on the diagnostic inclusion criteria of oligo-anovulation (OA), hyperandrogenism (HA) and polycystic ovarian morphology (PCOM). These included Group A (OA?+?HA?+?PCOM), Group B (OA?+?HA), Group C (HA?+?PCOM) and Group D (OA?+?PCOM). A ratio of serum AMH to total AFC was calculated and expressed as the AMH/AFC ratio which was compared in the phenotypes of PCOS and isolated PCOM. The median AMH/AFC ratios in PCOS-A, PCOS-D, PCOS-C and PCOM were 1.5, 1.6, 1.2 and 1.1, respectively. There were significant differences in the groups compared [F(3, 238)?=?6.14, p?=?0.000)]. The ratios were significantly higher in the oligo-anovulatory phenotypes PCOS-A and PCOS-D than the PCOM (p?=?0.004 and 0.002, respectively). There was no significant difference in the ratio between ovulatory phenotype PCOS-C and PCOM (p?=?0.59). The role of androgens and LH in per-follicle AMH production remains limited. The findings support the hypothesis of a key role for AMH in the mechanism of anovulation in PCOS.     

Hirsutism and oligomenorrhea are appropriate screening criteria for polycystic ovary syndrome in adolescents

Abstract

We evaluated the association of hirsutism and oligomenorrhea (persistent menstrual cycles?>?45 days) as screening criteria for the detection of biochemical hyperandrogenism (BH) and polycystic ovaries (PCOM) during adolescence and determined which androgens, granulosa cell hormone, ultrasonographic parameters have the best association with polycystic ovary syndrome (PCOS). Hirsute girls with oligomenorrhea (N?=?26 Hirs/Oligo group) and non-hirsute girls with regular cycles (N?=?63, C group) were studied. Prevalence of BH and PCOM, diagnostic performance of androgens and ultrasound parameters for PCOS diagnosis were analyzed. BH and PCOM prevalence were higher in the Hirs/Oligo girls than in the C girls (76.9% versus 25.5%; 92.3% versus 33.3%, respectively; p?<?0.0001). A complete PCOS phenotype (Hirs/Oligo with BH and PCOM) was observed in 73.1% of the Hirs/Oligo group. The presence of both BH and PCOM was observed in 7.9% of the C group. The parameters with the best diagnostic performance were free androgen index ≥6.1, testosterone ≥2.4?nmol/L, follicle number ≥12 and ovarian volume ≥10?ml anti-Müllerian hormone (AMH) exhibited a low diagnostic accuracy. Hirsutism and persistent menstrual cycle over 45 days are highly associated with BH and PCOM suggesting that the presences of both criteria are necessary for the diagnosis of PCOS during adolescence.     

Anti-Müllerian hormone as a diagnostic tool for PCOS under different diagnostic criteria in an unselected population

Research questionIs anti-Müllerian hormone (AMH) a valid tool to diagnose polycystic ovary syndrome (PCOS) according to different subsets of criteria among an unselected group of women?DesignIn this cross-sectional study, AMH concentrations were measured in an unselected group of women. The ability of AMH to diagnose PCOS according to National Institutes of Health (NIH), Rotterdam-2003 and Androgen Excess and PCOS Society (AE-PCOS) criteria was tested by using frozen serum aliquots (n = 392) that had been collected from a previous prevalence study of PCOS.ResultsThe respective age and body mass index adjusted area under the curve (aAUC, 95% confidence interval) values were 0.80 (0.71–0.89), 0.74 (0.67–0.81) and 0.71 (0.64–0.79). When the definition of polycystic ovary morphology (PCOM) was set to an antral follicle count (AFC) of 20 instead of 12, the prevalence of syndrome dropped from 19.9% to 10.2% and from 15.3% to 8.9% according to Rotterdam-2003 and AE-PCOS criteria, respectively. In patients with Phenotype A, who had hyperandrogenism, ovulatory dysfunction and PCOM, AMH had an aAUC of 0.85 (0.77–0.92) to diagnose the syndrome. In Phenotypes B (hyperandrogenism + ovulatory dysfunction), C (hyperandrogenism + PCOM) or D (ovulatory dysfunction + PCOM), AMH had poor to fair ability to diagnose the syndrome.ConclusionAMH has poor to fair validity to diagnose PCOS among an unselected group of women, except for patients bearing all features of the syndrome (Phenotype A). This finding is valid using the NIH, Rotterdam-2003 and AE-PCOS criteria and even after revising the definition of PCOM as AFC ≥20.     

Polycystic Ovarian Morphology in Normocyclic Non-hyperandrogenic Adolescents

ObjectiveTo understand whether polycystic ovarian morphology (PCOM) represents a transient phase, and whether an increased stroma could help to characterize the phenotype of the ovary in adolescence.MethodsCross-sectional population-based study on high-school students in Cagliari, Italy.The study population consisted of 257 normocyclic non-hyperandrogenic girls selected from a sample of 600 healthy volunteers recruited from 2012 to 2016. Clinical examination, medical history, blood sampling, and pelvic ultrasound (US) were performed. Postmenarchal years and body mass index (BMI) were estimated. Follicle-stimulating hormone (FSH), luteinizing hormone (LH), 17β estradiol (E2), total testosterone (tT), delta-4-androstenedione (A), and 17-hydroxyprogesterone (17-OHP) were measured. Ovarian volume, follicular number per section (FNPS), and S/A ratio were measured by pelvic US.ResultsFollowing the Rotterdam guidelines for US PCOS diagnosis and setting the normal S/A ratio at ≤0.3, subjects were categorized into 3 groups: (1) normal ovarian morphology (NOM; n = 154, 60%); (2) polycystic ovarian morphology (PCOM) with normal S/A ratio (PCOM-NS; n = 70, 27%); and (3) PCOM with increased S/A ratio (PCOM-IS; n = 33, 13%). The NOM group had more postmenarchal years and a lower LH than both the PCOM groups, and lower A and tT than the PCOM-IS group. The PCOM-NS group had fewer postmenarchal years and lower A than the PCOM-IS group. Interestingly, unlike NOM and PCOM-NS, the prevalence of PCOM-IS remained constant among the 3 phases of postmenarchal age (10% vs 16% vs 15%, P = not significant).ConclusionThis study demonstrates that PCOM can be a transient condition, whereas a high S/A ratio is a stable US alteration present from early postmenarchal years.     

Serum anti-mullerian hormone levels in the main phenotypes of polycystic ovary syndrome

Objective

To characterize the difference in circulating anti-Müllerian hormone (AMH) levels between the main polycystic ovary syndrome (PCOS) phenotypic groups and evaluate the role of AMH in predicting the severity of PCOS.

Study design

Cross-sectional, retrospective study. A total of 251 women were divided into four groups based on the main features of PCOS, as follows: Group 1 (polycystic ovarian morphology [PCOM]+/oligo-anovulation [OA]+/hyperandrogenism [HA]+), Group 2 (PCOM+/OA+/HA−), Group 3 (PCOM+/OA−/HA+), and Group 4 (PCOM−/OA+/HA+). AMH and other hormone levels were measured in serum. The main outcome was serum AMH concentrations in the main phenotypes of PCOS.

Result(s)

The mean serum AMH levels were 9.50 ± 6.1 ng/mL in Group 1; 8.02 ± 6.2 ng/mL in Group 2; 6.12 ± 3.6 ng/mL in Group 3; and 3.06 ± 2.4 ng/mL in Group 4. Circulating AMH levels in Group 1 (PCOM+/OA+/HA+) were three times higher than those in Group 4 (PCOM−/OA+/HA+).

Conclusions

The highest AMH levels were found in cases where all three main diagnostic criteria existed. AMH levels correlate best with PCOM. In addition, oligo-anovulation contributes to increased AMH levels. Hyperandrogenism criteria were found to have less influence on AMH levels. AMH levels seem to have a diagnostic role in determining the severity of PCOS.     

Treatment of Acute Abnormal Uterine Bleeding in Adolescents: What Are Providers Doing in Various Specialties?

Study ObjectiveThe purpose of this study was to assess whether variability exists in the management of acute abnormal uterine bleeding (AUB) in adolescents between pediatric Emergency Department (ED) physicians, pediatric gynecologists, and adolescent medicine specialists.DesignRetrospective chart review.SettingTertiary care medical center ED.Participants, Interventions, and Main Outcome MeasuresWe included girls aged 9-22 years who presented from July 2008 to June 2014 with the complaint of acute AUB. Patients were identified using the International Classification of Diseases, ninth revision codes for heavy menstrual bleeding, AUB, and irregular menses. Exclusion criteria included pregnancy and current use of hormonal therapy. One hundred fifty patients were included.ResultsAmong those evaluated, 61% (n = 92) were prescribed hormonal medication to stop their bleeding by providers from the ED, Adolescent Medicine, or Pediatric Gynecology. ED physicians prescribed mostly single-dose and multidose taper combined oral contraceptive pills (85%; n = 24), compared with Adolescent Medicine (54%, n = 7), and Gynecology (28%, n = 13). Pediatric gynecologists were more likely than ED physicians to treat patients with norethindrone acetate, either alone or in combination with a single dose combined oral contraceptive pill (61%, n = 33 vs 7%, n = 2; P < .001).ConclusionVariations in treatment strategies for adolescents who present with acute AUB exist among pediatric specialties, which reflects a lack of standardized care for adolescents. Prospective evaluation of the shortest interval to cessation of bleeding, side effects, and patient satisfaction are valuable next steps.     

Bleeding-related outcomes of low-risk total placenta previa are equivalent to those of partial/marginal placenta previa

ObjectiveTo clarify whether “low-risk total PP” patients bleed more than partial/marginal PP patients.Materials and methodsThe retrospective cohort study was performed involving patients with PP between April 2006 and December 2018. The placental position was determined by ultrasound. From medical charts, the backgrounds as well as obstetric and neonatal outcomes of PP patients were retrieved.ResultsThis study included 349 patients with PP, which was classified into three types according to the distance between the placenta and internal ostium: total (n = 174), partial (n = 52), and marginal (n = 123) PP. In total PP patients, three factors (prior CS, anterior placenta, and placental lacunae on ultrasound) significantly increased blood loss at CS, the need for hysterectomy, homologous transfusion (≥10 U), and ICU admission. No significant difference was observed in bleeding-related poor outcomes (rate of blood loss ≥2000 mL, amount of homologous transfusion, need for hysterectomy, and ICU admission) between total PP patients without all three factors: “low-risk total PP patients” and partial/marginal PP patients (19.8 vs. 17.1%; p = 0.604, 3.7 vs. 1.1%; p = 0.330, 1.2 vs. 1.1%; p = 1.000, and 1.2 vs. 1.1%; p = 1.000, respectively).ConclusionPrior CS, anterior placenta, and placental lacunae on ultrasound were risk factors for a bleeding-related poor outcome in total PP patients. Total PP patients without these three factors showed the same bleeding-related poor outcome as partial/marginal PP patients.     

Different phenotypes of polycystic ovary syndrome in Turkish women: clinical and endocrine characteristics

Abstract

This study presents the differences in clinical, endocrine and metabolic parameters among different polycystic ovary syndrome (PCOS) phenotypes in Turkish women. Four hundred and ten women with PCOS were evaluated, while 97 healthy women served as controls. PCOS were defined by oligo-anovulation (OA), hyperandrogenism (HA) and polycystic ovaries on ultrasound (PCO). Patients were subdivided into four phenotypes: OA?+?HA?+?PCO (phenotype 1), OA?+?HA (phenotype 2), HA?+?PCO (phenotype 3), OA?+?PCO (phenotype 4). Phenotypes 1–4 were present in 47.1%, 13.2%, 21.2% and 18.5% of patients, respectively. They were also divided into three groups according to the BMI (<25?kg/m²; 25≤ and ≤30?kg/m²; and >30?kg/m²). ANOVA and Tukey post-hoc HSD tests were used. The LH levels and LH/FSH ratio were higher in phenotype 1 and 2 than phenotype 3. The LDL-C levels were higher in women with phenotype 1 and 4 than in women with phenotype 2. Women with BMI <25?kg/m² had higher levels of LH, LH/FSH ratio, and the HDL-C than other two groups. The levels of TG, LDL, fasting insulin and HOMA-IR increased with increasing BMI in four phenotypes. Results suggest that obesity seems to be the primary cause of metabolic disturbances in PCOS women.     

A Comparison Between Hyaluronic Acid and Polylactic Acid Filler Injections for Temporary Penile Augmentation in Patients with Small Penis Syndrome: A Multicenter,Patient/Evaluator-Blind,Comparative, Randomized Trial

IntroductionThere are only a few studies on the clinical utility of filler injections for penile augmentation (PA) in patients with small penis syndrome (SPS), which is a type of anxiety or body dysmorphic disorder, not a true micropenis.AimTo compare the clinical outcomes of hyaluronic acid (HA) with polylactic acid (PLA) filler injection for temporary PA in patients with SPS.MethodsOur prospective, patient/evaluator-blind, comparative, randomized, non-inferiority trial consisted of a single filler injection and a 24-week post-injection period. Seventy-four men with SPS were included between November 2017 and February 2018. Patients were divided into those injected with HA (n = 39) and those injected with PLA filler (n = 35).Main Outcome MeasureThe psychological effects of PA, based on the Beliefs about Penis Size Scale, penile girth, and satisfaction, were assessed at baseline and at 4, 12, and 24 weeks post-injection.ResultsAt 24 weeks, the mean penile girth increases were 2.1 ± 1.0 cm (P < .001) in the HA group and 1.6 ± 0.9 cm (P < .001) in the PLA group, with a mean difference of 0.5 ± 0.2 cm between groups (P = .031). In both groups, satisfaction levels significantly increased at 24 weeks, with 1.8 ± 1.7 and 1.6 ± 1.4 mean increases in the visual analog scale for penile appearance satisfaction in the HA and PLA groups, respectively (each P < .001), and 1.0 ± 1.1 and 0.7 ± 1.2 mean increases in the visual analog scale for sexual life satisfaction in the HA and PLA groups, respectively (each P < .001), with no significant differences between groups (P = .950 and P = .287). The mean Beliefs about Penis Size Scale scores significantly decreased at 24 weeks, with 7.8 ± 8.3 and 5.3 ± 7.2 mean decreases in the HA and PLA groups, respectively (each P < .001), and no significant difference between the groups (P = .920). There were no serious adverse events, but filler injection-related adverse events in the HA and the PLA groups were reported in 2 cases (5.13%) and 5 cases (14.29%), respectively (P = .245).Clinical ImplicationsOur study provides an overview of clinical course after HA and PLA filler injections for PA and suggests that filler injections can be considered an alternative approach in patients with SPS.Strengths & LimitationsOur study is the first to assess the psychological symptoms in patients with SPS who received the filler injection for PA; however, the follow-up duration was insufficient to prove the long-term outcomes of fillers.ConclusionWithout serious adverse events, HA and PLA filler injections for PA significantly resulted in not only an augmentative effect but also improvement of psychological distress, and the clinical utility was comparable between the fillers.Yang DY, Jeong HC, Ahn ST, et al. A Comparison Between Hyaluronic Acid and Polylactic Acid Filler Injections for Temporary Penile Augmentation in Patients with Small Penis Syndrome: A Multicenter, Patient/Evaluator-Blind, Comparative, Randomized Trial. J Sex Med 2020;17:133–141.     

Twelve-month Continuation of the Etonogestrel Implant in Adolescents With Polycystic Ovary Syndrome

Study ObjectiveTo identify why adolescents with polycystic ovary syndrome (PCOS) chose the etonogestrel (ENG) contraceptive implant, to determine the 12-month continuation rate, and to characterize factors related to discontinuation.Design, Setting, and ParticipantsRetrospective chart review of adolescents seen at a tertiary care children's hospital between July 1, 2008, and August 30, 2019, with PCOS diagnosis confirmed per National Institutes of Health criteria and ≥12-month ENG follow-up.Interventions and Main Outcome MeasuresDemographic characteristics, reasons for ENG insertion and removal, and information on other hormonal/contraceptive therapies were collected. Patients were categorized as ENG continuers (use ≥12 months) or discontinuers (removal at <12 months), and groups were compared.ResultsA total of 96 patients met inclusion criteria (age 17.7 ± 2.2 years, body mass index 34.8 ± 8 kg/m²). Reasons for ENG were documented in 74% (51% contraception, 32% ease of use, 15% other, 13% estrogen avoidance). In all, 27% had never been sexually active, and 67% had had prior sexual activity. Treatments prior to ENG placement included 74% combined hormonal contraception, 20% medroxyprogesterone acetate withdrawal, and 17% depot medroxyprogesterone. A total of 77% continued ENG at 12 months. The main reasons for discontinuation were bleeding (41%), concern about weight gain (23%), and mood changes (18%). No preimplantation characteristics were independently predictive of continuation, although 100% of patients with type 2 diabetes (n = 11) continued. Patients who sought additional care, including telephone calls (41% vs 12%, P = .006) and clinic visits (64% vs 20%, P < .001) were more likely to discontinue.ConclusionsThe ENG implant was well tolerated in adolescents with PCOS and similar to published 12-month continuation rates.     

Utility of the Oral Glucose Tolerance Test to Assess Glucose Abnormalities in Adolescents with Polycystic Ovary Syndrome

Study ObjectiveThe aim of this study was to examine the prevalence of and risk factors for abnormal glucose metabolism in a large population of adolescents with polycystic ovary syndrome (PCOS).Design, Setting, Participants, Interventions, and Main Outcome MeasuresA retrospective chart review was performed of 360 patients who presented to the pediatric gynecology outpatient clinic for evaluation of PCOS between January 2004 and May 2012.ResultsA total of 163 patients fulfilled criteria for a diagnosis of PCOS and had adequate clinical and laboratory data. Twenty-six adolescents (16.0%) had impaired glucose tolerance and 2 patients (1.2%) met criteria for a provisional diagnosis of type 2 diabetes. All 28 subjects with abnormal glucose metabolism were identified using the 2-hour plasma glucose of the oral glucose tolerance test. Conversely, the fasting glucose values only successfully detected 2 patients with hyperglycemia, both of whom also had abnormal 2-hour glucose levels. Adolescents with abnormal glucose metabolism were more likely to have reported a positive family history (P = .02) and had higher body mass index z scores (2.8 ± 1.1 vs 1.8 ± 1.2; P < .01). When patients were classified into normal weight (n = 29) and obese/overweight groups (n = 117), all of the patients with abnormal glucose metabolism were overweight or obese.ConclusionIn the largest series to date, we describe a prevalence of abnormal glucose metabolism in adolescent patients with PCOS of 17.2%. Abnormal glucose metabolism is associated with many of the known risk factors for metabolic syndrome. Our results support that the oral glucose tolerance test is a superior diagnostic test to assess abnormal glucose levels in overweight and obese adolescents but that this test might have limited utility in normal weight adolescents with PCOS.     

Cardiovascular and metabolic characteristics of infertile Chinese women with PCOS diagnosed according to the Rotterdam consensus criteria

Polycystic ovary syndrome (PCOS) is strongly associated with metabolic abnormalities in Western women. However, data from other populations and geographical regions are scarce. This study evaluated cardiovascular and metabolic risk factors in Chinese infertile women diagnosed with PCOS using the 2003 Rotterdam consensus criteria. A total of 615 women representing the four PCOS phenotypes (oligo- or anovulation (AO) + hyperandrogenism (HA) + polycystic ovaries (PCO), AO + HA, AO + PCO and HA + PCO) underwent standardized metabolic screening including a 75 g oral glucose tolerance test. All groups presented with similar reproductive characteristics, with the only difference being a significantly higher Ferriman–Gallwey score for hirsutism (P = 0.01) in the subgroup characterized by HA + PCO. Overall, the prevalence of metabolic syndrome was 6.4%, with no difference among the four groups (range of 2.3–12.2%). Metabolic syndrome was associated with body mass index (P < 0.001), waist/hip ratio (P = 0.002), index of insulin resistance (P = 0.005) and fasting insulin (P = 0.009) in multivariate analysis. Compared with Caucasians and Chinese women in Westernized societies, mainland Chinese women with PCOS have a low risk of metabolic syndrome and its presence does not vary across the specific PCOS phenotypes.Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in women of reproductive age. PCOS is diagnosed if at least two of three of the following characteristics are present: lack of ovulation (oligo- or anovulation), specific ultrasound characteristics of the ovaries (enlarged ovary and/or increased number of antral follicles), and increased production of androgen hormones and/or its clinical manifestations such as hirsutism and acne. Therefore, four presentations of PCOS can be distinguished. PCOS is also associated with the metabolic syndrome, a clustering of from three to five risk factors of cardiovascular disease. Unfortunately, knowledge about PCOS and its metabolic associations for the Asian region is scarce. The objective of this study was to evaluate cardiovascular and metabolic risk factors in a group of 615 Chinese infertile women with PCOS representing the four PCOS subgroups, from mainland China. Overall, women in the four PCOS subgroups had similar physical, hormonal and biochemical characteristics, with only more hirsutism in the subgroup characterized by overproduction of androgen hormones and ovarian ultrasound characteristics. Of the total group, 6.4% had metabolic syndrome with no differences among subgroups (range 2.3–12.2%). We found that the presence of metabolic syndrome was associated with higher body mass index, higher waist/hip ratio, and a higher index of insulin resistance (HOMA-IR) and higher fasting insulin concentrations. We conclude that in contrast to Caucasians and Chinese women in Westernized societies, mainland Chinese women with PCOS have a low risk of metabolic syndrome and that its presence does not vary among the four PCOS phenotypes.     

Effects of lisinopril treatment on the pathophysiology of PCOS and plasminogen activator inhibitor-1 concentrations in rats

Research questionAngiotensin-converting enzyme inhibition results in a significant reduction in plasma concentrations of plasminogen activator inhibitor-1 (PAI-1). What are the effects of lisinopril treatment on PAI-1 concentrations and the morphology and function of the ovaries in the letrozole-induced polycystic ovary syndrome (PCOS) rat model?DesignThis prospective randomized controlled animal study involved female Wistar albino rats. Twelve rats were assigned as controls (group I). In the study group (n = 48), letrozole (an aromatase inhibitor) was administered for PCOS modelling for 9 weeks. After confirming disrupted oestrous cycles, the study group was randomized into two groups: group II (n = 24; letrozole only) and group III (n = 24; letrozole + lisinopril 15 mg/kg per day). After 12 weeks, each group was divided randomly into two. Biochemical, histopathological and immunohistochemical analyses was performed in subgroups designated A, and fertilization rates were studied in subgroups designated B.ResultsLisinopril treatment reduced the weight and area of the ovaries, the number and wall thickness of cystic follicles, and serum concentrations of LH and testosterone, relative to group II (P < 0.001). Circulating PAI-1 concentrations were significantly different among three groups (7.7 ± 0.9 ng/ml, 9.8 ± 0.7 ng/ml and 8.6 ± 0.7 ng/ml for groups IA, IIA and IIIA; P < 0.001). Pregnancy rates were 100%, 0% and 16.7% in groups IB, IIB and IIIB.ConclusionsIn the letrozole-induced rodent PCOS model, lisinopril modifies the action of letrozole, possibly by inhibition of systemic and ovarian production of PAI-1. The use of PAI-1 inhibitors deserves further investigation in understanding the pathogenesis of PCOS.     

Preoperative Risk Stratification of Adnexal Masses: Can We Predict the Optimal Surgical Management?

Study ObjectiveTo characterize preoperative risk stratification with aim of identifying the accurate surgical approach of benign and malignant adnexal masses in pediatric patients.DesignA retrospective chart review of all cases of adnexal masses surgically managed between January 2001 and December 2006.SettingThe Hospital for Sick Children, Toronto, Canada.Participants129 cases of 126 pediatric and adolescent patients who underwent operative management of their adnexal masses.Main Outcome MeasuresUltrasonographic characteristics (cyst size and character), surgical approach (laparoscopy vs laparotomy) and method of cyst removal (cystectomy vs oophorectomy). Data was assessed with a Fisher Exact test where appropriate (P < .05).ResultsMalignancies were more frequently treated by laparotomy (n = 14, 98.6%, P < .001), and benign cases by laparoscopy (n = 78, 97%, P < .001). On ultrasonography, malignant masses were more often complex (n = 16, 100%, P = .006) and ≥8 cm (n = 16, 100%, P < .001) than benign masses (≥8 cm n = 60, 53%, complex n = 76, 67%). Combining ultrasonographic measurements of ≥8 cm and complexity identified 100% of malignant masses (n = 16) and 36% of benign masses (n = 41, P < .001, PPV = 37.1, NPV = 100%). Additional imaging including CT/MRI was ordered by pediatric surgeons (n = 17, 77%) more often than pediatric gynecologists (n = 44, 41%, P = .002). Furthermore, pediatric surgeons managed adnexal masses by oophorectomy (n = 12, 55%) more often as compared to pediatric gynecologists (n = 19, 18%, P < .001).ConclusionUsing preoperative characteristics of complexity and ≥8 cm reduces the number of benign masses treated with laparotomy while ensuring malignant masses are managed with an open approach.     

A Randomized Double-Blind Placebo-Controlled Pilot Trial on the Effects of Testosterone Undecanoate Plus Dutasteride or Placebo on Muscle Strength,Body Composition,and Metabolic Profile in Transmen

BackgroundWhile the effects of androgens on muscle are well described in hypogonadal men, literature is still scarce on muscular strength or size variations in transmen; in this population there are no data regarding the relative effect of testosterone (T) and its metabolite dihydrotestosterone on muscle.AimOur primary objective was to compare the effects on muscle strength of 54-week administration of testosterone undecanoate (TU) combined with the 5α-reductase inhibitor dutasteride (DT) or placebo (PL). Secondary outcomes included evaluation of body composition, bone, cutaneous androgenic effects, and metabolic variations.MethodsIn this randomized, double-blind PL-controlled pilot trial, 16 ovariectomized transmen were randomized to receive TU 1,000 mg IM at week 0, 6, 18, 30, 42 plus a PL pill orally daily (TU + PL, n = 7) or plus DT 5 mg/d (TU + DT, n = 7).OutcomesAt week 0 and 54 the following parameters were evaluated: isokinetic knee extension and flexion peak torque and handgrip strength, body composition, and bone mineral density, biochemical, hematological, and hormonal parameters.ResultsHandgrip and lower limb strength increased significantly in both groups with no differences between the 2 groups. Fat mass decreased and lean mass increased significantly similarly in both groups. Metabolic parameters remained stable in the 2 groups except for high-density lipoprotein cholesterol that was reduced in both groups. Hepatic and renal function remained normal in both groups and no major adverse effects were registered in either group.Clinical ImplicationsThese results may be particularly relevant for transmen experiencing cutaneous androgenic adverse events such as acne and androgenetic alopecia and in light of the development of non-5α-reduced androgens.Strengths & LimitationsThe strength of this study was the randomized, double-blind PL-controlled design, while the small number of subjects was definitely the biggest limitation.ConclusionFor the first time we demonstrated that the addition of DT does not impair the anabolic effects of T on muscles in transmen previously exposed to T, supporting the hypothesis that the conversion in dihydrotestosterone is not essential for this role.Gava G, Armillotta F, Pillastrini P, et al. A Randomized Double-Blind Placebo-Controlled Pilot Trial on the Effects of Testosterone Undecanoate Plus Dutasteride or Placebo on Muscle Strength, Body Composition, and Metabolic Profile in Transmen. J Sex Med 2021;18:646–655.     

Characteristics of different phenotypes of polycystic ovary syndrome in a Bulgarian population

Aim. Our aim was to investigate the percentage occurrence of different phenotypes of polycystic ovary syndrome (PCOS) in a Bulgarian population, and their clinical, biochemical and hormonal characteristics.

Methods. The study included 70 women with PCOS, diagnosed according to the European Society of Human Reproduction & Embryology/American Society for Reproductive Medicine criteria. The women were divided into four phenotypes: hyperandrogenism (HA) + oligo-/anovulation (OA) + polycystic ovaries at ultrasound (PCO) (full-blown syndrome, phenotype A); HA + OA (former National Institutes of Health definition, phenotype B); OA + PCO (phenotype C); and HA + PCO (phenotype D). Serum levels of testosterone, immune-reactive insulin, sex hormone-binding globulin, dehydroepiandrosterone sulfate and lipid metabolism parameters were measured. Free androgen index and homeostasis model assessment of insulin resistance were calculated. Body mass index and waist-to-hip ratio were assessed.

Results. The percentages of phenotypes A, B, C and D in a Bulgarian population are 58.6%, 11.4%, 10.0% and 20.0%, respectively. The women with the classical form of PCOS (phenotypes A and B) were more obese, had more strongly expressed hyperandrogenemia, and were more insulin-resistant compared with the women of phenotypes C and D.

Conclusion. There is a significant difference in anthropometric, hormonal and metabolic indices between the classical form and the clinical variants of PCOS in the studied Bulgarian population.     

Outcomes after Laparoscopic Excision of Bladder Endometriosis Using a CO2 Laser: A Review of 207 Cases in a Single Center

Study ObjectiveAssess efficacy, safety, fertility outcomes and recurrence after laparoscopic resection of bladder endometriosis (BE) using a CO₂ laser.DesignRetrospective cohort study.SettingsUniversity gynecologic surgery unit, referral center for endometriosis.PatientsA total of 207 women having undergone laparoscopic BE excision between January 1998 and January 2019.InterventionsNone.Main Outcome MeasuresIntra- and postoperative complication rates. Disease recurrence and fertility outcomes in patients with a minimum 1-year follow-up (n = 176) for “isolated” and “non-isolated” BE groups.ResultsForty-three patients presented with isolated BE. Bladder “shaving” without mucosae opening was performed in 50.7% cases. No intraoperative complications were noted. One postoperative grade 3 complication was related to BE excision: a bladder breach requiring closure by repeat laparoscopy. Mean (± SD) follow-up was 7.05 (± 4.65) years. In patients wishing to conceive (n = 132), the total pregnancy rate (PR) was 75% (48.5% spontaneous), 76.19% in the isolated BE group (56.3% spontaneous). Among the 94 patients with previous infertility, 74.5% conceived, 50% spontaneously. No statistical difference was found in PR and need for in vitro fertilization between isolated and nonisolated BE groups. BE recurrence rate was 3.4%. No difference was observed between groups with full-thickness bladder resection (4/88) and shaving (2/88) (p = .406). Age at surgery (hazard ratio 0.91 [0.84–0.98], p = .016) and postoperative pregnancy (hazard ratio 0.07 [0.01–0.91], p = .042) showed influence on disease recurrence.ConclusionsThe study demonstrates that laparoscopic BE removal is feasible with very low complications rates and was associated with high PR (both spontaneous and in vitro fertilization), even in patients with previous infertility. BE recurrence is lower than for other endometriosis locations. Bladder endometriosis; Laparoscopy; Deep infiltrating endometriosis; Fertility; Partial bladder resection     

The medium-term effects of diadynamic currents in chronic low back pain; TENS versus diadynamic currents: A randomised,follow-up study

ObjectiveThe aims of the study were to evaluate the medium-term effects of diadynamic (DD) currents on relieving symptoms/improving physical functionality in patients with chronic low back pain (LBP) and to compare the efficacy of DD versus TENS.MethodsThe patients were divided into two groups as the TENS group (n = 26) and the DD group (n = 29). Additional treatment of hot pack + therapeutic ultrasound was applied to all patients. The therapy programs were administered as a total of 10 sessions over a period of 2 weeks. Roland Morris Disability Questionnaire (RDQ), Oswestry Disability Index and Visual Analog Scale (VAS) values were recorded.ResultsBoth groups showed significant improvements in VAS and RDQ scores after one month of the therapies (all p < 0.05).ConclusionUsing TENS and DD currents in chronic LBP can lead to reduced pain, and improved physical functions. Hence, DD currents can be used as an adjuvant therapy for rehabilitation of chronic LBP.     

The association between maternal pre-pregnancy body mass index and pregnancy outcomes of preeclampsia

ObjectiveTo evaluate the effects of pre-pregnancy maternal body mass index (BMI) to pregnancy outcomes in patients diagnosed as preeclampsia.Materials and methodsThis was a retrospectively study on women who had been diagnosed as preeclampsia and delivered at Seoul National University Bundang Hospital between June 2017 and March 2020. Multifetal gestation, major fetal anomaly, and fetal death in utero were excluded. A total of 150 singleton pregnancies were included and divided into four groups according to the pre-pregnancy BMI classification: underweight (<18.5 kg/m², n = 6), normal (18.5–22.9 kg/m², n = 66), overweight (23.0–24.9 kg/m², n = 26), and obese (≥25.0 kg/m², n = 52). Pregnancy outcomes including gestational age at delivery, birthweight, and delivery modes were reviewed.ResultsThe rates of preterm birth before 34 weeks of gestation were 67%, 49%, 35%, and 27% for underweight group, normal BMI group, overweight group, and obese group, respectively (p-trend = 0.006). The birthweight of newborn increased significantly as pre-pregnancy BMI increased (p-trend<0.001). The proportions of small for gestational age (SGA) were highest in underweight group and decreased as pre-pregnancy BMI increased (67%, 41%, 42%, and 10% for each group, respectively, p-trend<0.001).ConclusionThe rates of preterm birth before 34 weeks and SGA increased as pre-pregnancy BMI decreased in patients with preeclampsia.Implications for practiceWomen with underweight before pregnancy are at the highest risk for preterm birth and SGA, therefore they need to be monitored more intensively when diagnosed as preeclampsia.     

Olaparib as maintenance therapy and salvage therapy in recurrent ovarian cancer: The early experience in Taiwan

ObjectiveThe first Poly (adenosine diphosphate [ADP]-ribose) polymerase inhibitor, olaparib, was approved by Taiwan Food and Drug Administration in June 2018, which was available under a compassionate use program since 2015. This study aims to report the early experience of the effectiveness and adverse effects of olaparib in recurrent ovarian cancer patients in Taiwan.Materials and methodsThis retrospective study enrolled patients with recurrent epithelial ovarian and peritoneal cancer who received olaparib as maintenance therapy or salvage therapy between December, 2015 and October, 2019. We observed response rates in the salvage therapy group, and progression-free interval (PFI) in both groups.ResultsA total of 20 patients (10 in maintenance and 10 in salvage groups) were enrolled. BRCA status was checked in 18 patients by blood or tumor samples, and 83.3% were mutated (n = 15), including pathological/probable pathological variants in BRCA1 (n = 11), BRCA2 (n = 2), or both BRCA1/BRCA2 (n = 2). In the salvage group, there were two partial responses and two stable diseases, adding up to a clinical benefit rate at 40%. In the maintenance group, median PFI was 20.1 months (range, 1.0–33.1). The median PFI of those with chemotherapy-free interval >12 months was not reached, which was significantly better than those ≤12 months, with median PFI 3.1 months (p = 0.022). The most common grade 3/4 adverse effects in patient with olaparib as monotherapy were neutropenia (30.8%) and fatigue (7.7%). Anemia of grade 1/2 was noted in 76.9%.ConclusionThis real-world experience of olaparib for recurrent ovarian cancer in Taiwan showed efficacy and safety similar to the results of previous clinical trial.