Relationship and sexual experiences in women with early-onset oestrogen deficiency: Comparison between women with Turner syndrome and premature ovarian insufficiency.

OBJECTIVE: Age at first date and sexual intercourse have been observed to be delayed in women with Turner syndrome (TS), with delayed puberty being the main factor. We sought to assess relationship and sexual experiences comparing women with TS and premature ovarian insufficiency (POI). DESIGN: Cross-sectional observational study. PATIENTS: 302 women with TS and 53 women with karyotypically normal POI (median age 33.0 [15.0-78.4] and 26.3 [17.8-52.3], respectively). MEASUREMENTS: A self-reporting questionnaire was used to collect data on relationship and sexual experiences. RESULTS: Women with TS were older than women with POI (P = .002). Compared to women with POI, a smaller proportion of women with TS had ever had vaginal sexual intercourse (VSI) (40 [78.4%] vs 169 [58.1%], respectively, P = .006) and women with TS exhibited a delay in the median age at first relationship and VSI (POI 19.3 ± 0.4 vs TS 22.2 ± 1.1, P = <.001). Start of oestrogen replacement therapy at ≤ 14 years of age compared with > 14 years did not result in earlier relationship and sexual debut. After adjusting for age and diagnosis, induction of puberty, as opposed to spontaneous puberty, was associated with a delay in the median age at first relationship and VSI and a reduced probability of having VSI (Hazard ratio = 0.44 [95% confidence interval: 0.32-0.60], P = <.001). CONCLUSIONS: Turner syndrome and induction of puberty are associated with a reduced likelihood and a delay in relationship and sexual experiences. Women needing puberty induction and women with TS more than POI have a delayed mean age at first VSI compared to the general population.

Fracture rate in women with oestrogen deficiency - Comparison of Turner syndrome and premature ovarian insufficiency.

OBJECTIVE: Women with early-onset oestrogen deficiency are at risk of reduced bone mineral density (BMD). We sought to assess fracture history and BMD in women with Turner syndrome (TS) and premature ovarian insufficiency (POI). DESIGN: A cross-sectional observational study. PATIENTS: Two hundred and sixty seven women with TS (median age 34.3 years) and 67 women with POI (median age 28.1 years). MEASUREMENTS: A questionnaire was used to collect data on fracture history, co-morbidities and drug history including age at first oestrogen exposure. Clinical data included height, weight, serum vitamin D and hip and spine T-scores, which were adjusted for height and age. Fractures were subdivided into major osteoporotic fractures (MOF) and 'other' fracture types. RESULTS: Overall fracture rate was similar in women with TS and POI (82 [30.5%] vs 22 [32.8%] respectively, P = .74). Compared to women with POI, those with TS had more fractures at MOF sites (30.2% vs 52.7%, P = .012) and fewer phalangeal fractures (27.9% vs 9.8%, P = .005). There was no difference in BMD between women who sustained a fracture compared to those who did not. Women with TS who fractured were more likely to suffer from hearing impairment compared to those with no fracture (62.2% vs 48.1%, P = .045). CONCLUSIONS: TS is not associated with an overall excess risk of bone fracture. The higher rate of fractures at MOF sites in women with TS may be secondary to hearing impairment, thin cortical bone and abnormal bone remodelling.

A 10-year longitudinal study of evaluation of ovarian reserve in women with transfusion-dependent beta thalassaemia major.

OBJECTIVE: Although spontaneous fertility and successful pregnancies have been reported in well-chelated and transfused women with beta thalassaemia major (BTM), majority of women are subfertile due to hypogonadotropic hypogonadism (HH). Little is known about the effect of iron overload on ovarian follicles and whether ovarian reserve is affected by the disease or treatment status. This study compares the markers of ovarian reserve in women with transfusion-dependent BTM over a period of ten years with healthy women from a control population. STUDY DESIGN: We performed a 10-year mixed (retrospective and prospective) longitudinal study in 17 women with transfusion-dependent BTM from our thalassaemia clinic between July 2007 to June 2017. The results were compared with 52 age-matched healthy women without any medical conditions (control population) attending our fertility clinic. Patient demographics, medical history, menstrual history, hormonal parameters (serum levels of FSH, estradiol, TSH and AMH) and antral follicle count were recorded in all women from both groups. Serum levels of ferritin, cardiac T2*, liver iron concentration, thyroid function (TSH) and liver function test results were also recorded at three different time points. RESULTS: Serum AMH levels, estradiol levels and antral follicle count were significantly lower in women with BTM compared with the control group (p < 0.05 for all). Low AMH levels were noted in both groups of women (with and without HH) with a background of BTM. Serum AMH levels positively correlated with AFC in women with BTM. CONCLUSION: Serum AMH level and AFC were significantly lower in women with transfusion dependent BTM as compared to age-matched healthy controls suggesting a direct impact of the disease activity or iron overload on the ovary.

Ulipristal acetate: a novel option for the medical management of symptomatic uterine fibroids.

Fibroids, the most common tumor in women of reproductive age, impact negatively on women's health and quality of life, and have significant cost implications for their management. The current mainstay treatments are surgical (myomectomy and hysterectomy) and more recently radiological (UAE and focused ultrasound surgery). Hysterectomy is curative but precludes future fertility, whereas the impact of the other treatments on reproduction is uncertain. With women in Western societies deferring childbearing to their 30s and 40s, when fibroids are most symptomatic, there is a pressing need for a uterus-sparing medical therapy that is cheap, effective, and enhances reproductive potential. Serendipity and meticulous translational research has shown that progesterone augments fibroid proliferation, raising the possibility that progesterone receptor modulators could inhibit fibroid growth; this research has culminated in the emergence of ulipristal acetate (UA), a first-in-class, oral selective progesterone receptor modulator (SPRM) that has successfully completed phase III clinical trials. It has been licensed in Western Europe for short-term clinical use prior to surgery, and has shown efficacy with a significant reduction in uterine bleeding, fibroid volume, and improved quality of life, without the side effects associated with other medications such as gonadotropin-releasing hormone (GnRH) agonists. As with all new medicines, there are concerns surrounding UA, not least its effect on the endometrium and the long-term impact on general health and reproduction. Research to date has tended to be industry led, and therefore, there is a need for researcher/clinician-led studies to address the wider issues concerning SPRMs. UA may not turn out to be the "Holy Grail" of medical therapy in the treatment of symptomatic uterine fibroids, but it has rightly given cause for a huge optimism. Further laboratory and clinical research into PRMs and related compounds will no doubt lead to more refined medications.

Clinical outcomes from a prospective study evaluating the role of ambulation during medical termination of pregnancy.

BACKGROUND: Although induced abortion is one of the most commonly performed gynecological procedures in Great Britain and medical termination of pregnancy is being used more frequently, very little is known about the role of ambulation during the procedure. We sought to compare ambulatory and non-ambulatory groups of patients undergoing medical termination in the hospital setting and determine whether ambulation impacted clinical outcomes. STUDY DESIGN: This was a prospective patient-preference study carried out among 130 women with pregnancies up to 63 days of gestation fulfilling the requirements of the 1967 Abortion Act and undergoing medical termination of pregnancy. The objective was to evaluate the effect of ambulation during medical termination of pregnancy. The women were given the choice to be ambulatory or non-ambulatory throughout the process of medical termination of pregnancy. They received 200 mg oral mifepristone and 800 mcg vaginal misoprostol for the termination procedure. Outcomes measured included time taken to pass the products of conception, first feeling of abdominal cramps, estimated blood loss, time to discharge from the hospital, pain scores and need for analgesia. RESULTS: In both ambulatory and non-ambulatory groups, the mean time taken to pass the products of conception was similar: 230.7 min (118-343.4) and 233.0 min (134.5-331.5) for ambulatory and non-ambulatory patients, respectively. Time to onset of cramps was 75.6 min (29.4-121.8) for ambulatory and 91.7 min (22.2-161.2) for non-ambulatory patients, from administration of misoprostol. Mean estimated blood loss (assessed by weighing the pads as well as blood in bed pan) was less than 100 mL in both groups, and overall, approximately 85% of patients ranked their pain score as 3 or less (on a scale of 0-5). There were no statistically significant differences in the ambulatory versus non-ambulatory groups with regard to clinical outcomes. CONCLUSION: Ambulation during medical termination of pregnancy neither appears to influence the amount of bleeding or pain nor hasten the process of medical termination of pregnancy.

Failed induction of labor: strategies to improve the success rates.

UNLABELLED: The rates of induction of labor (IOL) are rising all over the world. In developed countries, one of every 4 babies is born after IOL at term. The recent World Health Organization guidelines on IOL recommend that failure of induction does not necessitate cesarean delivery [WHO recommendations for induction of labor. World Health Organization, 2011]. These guidelines come when there are concerns that failed primary inductions in nulliparous women, which have led to escalation of the cesarean delivery rates. Obstetricians must recognize the risks associated with IOL (including failure and need for cesarean delivery) and avoid inductions for borderline indications, which are not evidence based. The issue of "failed induction of labor" is topical, and there is a need to define this entity and offer alternatives to cesarean delivery in the management of this group of women. Research is required to develop a test to accurately identify those fetuses most at risk of morbidity or stillbirth who would truly benefit from an early IOL and assess the cost-effectiveness of policies of routine IOL. In this review, we summarized the current recommendations for best practice in the area of IOL, defined "failed induction," and described options to improve the success rate after "failed primary induction of labor." TARGET AUDIENCE: Obstetricians & Gynecologists and Family Physicians. LEARNING OBJECTIVES: After the completing the CME activity, physicians should be better able to classify the factors determining success or failure of induction of labor, counsel women about risks and benefits of various methods of induction of labor, and compare the options of management available after failed primary induction of labor.