Unusual indolent behavior of leiomyosarcoma of the vagina: Is observation a viable option?

•Primary leiomyosarcoma of the vagina is a rare disease.•We identified a case of unanticipated indolent behavior of vaginal leiomyosarcoma.•Observation or hormonal therapy may be viable option for select patients.

Effect of menopause hormone therapy on disease progression in systemic lupus erythematosus: A systematic review.

OBJECTIVE: To review the literature pertaining to the effect of postmenopausal hormone therapy on disease progression in women with systemic lupus erythematosus. METHODS: We performed a systematic review using PubMed, Embase, and the Cochrane Central Register of Controlled Trials from January 1990 to December 2013 for observational studies and randomized clinical trials that study the effect of hormone therapy on the occurrence of flares in menopausal patients with systemic lupus erythematosus. The screenings of titles and abstracts, full text review, and risk of bias assessments were done by two independent reviewers. RESULTS: A total of 12,548 articles were identified. After title and abstract screening and removal of duplicates, 692 articles were retrieved for full text review. Five studies were deemed eligible for inclusion in the analysis, and the methodological quality was assessed. Two of the studies were randomized controlled trials and three were observational studies. One randomized controlled trial found that menopausal women who received hormone therapy were at a higher risk for developing minor to moderate flares of systemic lupus erythematosus. In the other four studies, there was no significant difference in systemic lupus erythematosus disease activity between hormone therapy and non-hormone therapy users. CONCLUSIONS: Hormone therapy in menopausal patients with systemic lupus erythematosus appears to be well tolerated. While there is some evidence supporting an increase in risk of mild to moderate flares among hormone therapy users, no association was identified between hormone therapy use and severe disease flares. In addition, hormone therapy was associated with significant improvement in menopausal symptoms and quality of life. Larger trials are required to assess the long-term effects of hormone therapy on the course of systemic lupus erythematosus in menopausal patients and to identify patient characteristics associated with an increased risk of flares in the setting of hormone therapy exposure.

Predictive Value of Elevated LH/FSH Ratio for Ovulation Induction in Patients with Polycystic Ovary Syndrome.

OBJECTIVE: To assess the value of an elevated luteinizing hormone (LH)-to-follicle-stimulating hormone (FSH) ratio in predicting development of a dominant follicle when ovulation induction is implemented with clomiphene citrate (CC) or letrozole in women with polycystic ovary syndrome (PCOS). STUDY DESIGN: Retrospective review of 312 monitored cycles between 2007 and 2012. All patients met the diagnostic criteria set by the 2006 Androgen Excess-PCOS Society and had baseline LH and FSH levels drawn. Only ovulation induction with CC or letrozole was included. Primary outcome was development of a dominant follicle of ≥ 18 mm. RESULTS: The development of a dominant follicle was significantly associated with clinical pregnancy. The development of a dominant follicle was also higher in the letrozole group as compared to the CC group (87.6% [155/177] vs. 62.2% [84/135], p < 0.001). Furthermore, treatment with letrozole significantly increased the odds of forming a dominant follicle when LH/FSH ratio was ≥ 1 (odds ratio [OR] 7.69, CI 3.69-16.02). When LH/ FSH ratio was < 1, letrozole had no significant effect on dominant follicle development (OR of 3.63, CI 0.92-14.25). CONCLUSION: LH/FSH ratio ≥ 1 could be useful as a predictive tool to identify which subgroup of PCOS patients may be more successful in forming a dominant follicle when using letrozole as compared to CC.

Embryo catheter loading and embryo culture techniques: results of a worldwide Web-based survey.

PURPOSE: To identify trends in embryo catheter loading and embryo culture techniques performed worldwide. METHODS: A retrospective evaluation using the results of a web-based survey, (IVF Worldwide ( www.IVF-worldwide.com ), was performed. RESULTS: Responses from 265 centers in 71 countries were obtained. Most centers (97 %) preferred a catheter with its orifice on top, with only 3 % preferring a catheter with the orifice on its side; 41 % preferred a catheter marked for clear ultrasound view. The most commonly-reported methods of embryo loading were medium-air-embryo-air-medium (42 %), medium in catheter with embryo at end (20 %) and medium-air-embryo (15 %). In 68 % of centers the final volume of the catheter was up to 0.3 ml, with only 19 % using 0.3-0.5 ml and 1 % using 0.5-0.7 ml. Using reduced oxygen concentrations for embryo culture was divided between those who used it in combination with the two-gas system (34 %) and those who did not use it at all (39 %); 24 % reported using a three-gas system. Most clinics using reduced oxygen concentrations used it throughout the entire culture period. Half of centers (51 %) reported using reduced oxygen concentrations for the entire IVF population while 6 % reserved it only for blastocyst transfer. The use of sequential media was highly dominant with 40 % reporting its use.

Menopause education: needs assessment of American obstetrics and gynecology residents.

OBJECTIVE: This study aims to understand the current teaching of menopause medicine in American obstetrics and gynecology residency programs. METHODS: A Web-based survey was e-mailed to all American obstetrics and gynecology residency directors, with a request that they forward it to their residents. RESULTS: Of 258 residency program directors contacted, 79 (30.6%) confirmed forwarding the survey. In all, 1,799 people received the survey, with 510 completions, for a response rate of 28.3%. Most residents reported that they had limited knowledge and needed to learn more about these aspects of menopause medicine: pathophysiology of menopause symptoms (67.1%), hormone therapy (68.1%), nonhormone therapy (79.0%), bone health (66.1%), cardiovascular disease (71.7%), and metabolic syndrome (69.5%). Among fourth-year residents who will be entering clinical practice soon, a large proportion also reported a need to learn more in these areas: pathophysiology of menopause symptoms (45.9%), hormone therapy (54.2%), nonhormone therapy (69.4%), bone health (54.2%), cardiovascular disease (64.3%), and metabolic syndrome (63.8%). When asked to rate the most preferred modalities for learning about menopause, the top choice was supervised clinics (53.2%), followed by case presentations (22.2%), formal lectures (21.3%), small groups (14.7%), Web-based learning (7.8%), and independent reading (5.2%). Only 20.8% of residents reported that their program had a formal menopause medicine learning curriculum, and 16.3% had a defined menopause clinic as part of their residency. CONCLUSIONS: It seems that some American residency programs do not fulfill the educational goals of their residents in menopause medicine. A curriculum would be beneficial for increasing knowledge and clinical experience on menopause issues.