Advancements and Emerging Therapies in the Medical Management of Uterine Fibroids: A Comprehensive Scoping Review.

Uterine fibroids, benign tumors originating from uterine smooth muscle cells, vary in prevalence depending on patient ethnicity, hormonal exposure, and genetics. Due to their high incidence, these neoplasms pose a significant burden on healthcare systems. Current treatment strategies range from routine monitoring in asymptomatic cases to surgical procedures such as myomectomy or hysterectomy in symptomatic patients, with an increasing trend toward uterus-preserving or non-surgical alternatives. This review examines the existing medical treatments for uterine fibroids and delves into the potential of emerging therapies. A scoping review of the literature was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. Medical therapies are divided into hormonal and non-hormonal treatments; however, long-term, safe, and effective treatments in the treatment of uterine fibroids are limited. In addition to established therapies, there is an increasing number of studies investigating the effect of substances such as vitamin D or green tea extract on uterine fibroids. Some studies investigate acupuncture as a possible alternative therapy. While existing treatments offer symptomatic relief and preparation for surgery, our findings point to a significant need for further research into long-term solutions, especially owing to recent limitations in the use of ulipristal acetate due to risk of liver damage. Initial studies involving vitamin D and epigallocatechin gallate are encouraging; however, additional research is required to establish definitive therapeutic roles.

The effect of adjuvant mitotane therapy of the adrenocortical carcinoma on the endometrium and its clinical consequences in menstruating women. Literature review and authors' own experiences.

Adrenocortical carcinoma (ACC) is a malignant tumour that originates from the adrenal cortex. It is a highly aggressive cancer characterised by a poor prognosis with an annual incidence estimated to be up to 2 cases per million. In the adult population, ACC is diagnosed typically between 40 and 50 years of age, more often in women. Complete surgical resection of the tumour is the primary treatment method for ACC. Unfortunately, despite properly performed adrenalectomy, regional recurrences or distant metastases are detected in up to 90% of the patients. For that reason, adjuvant therapy is recommended. Mitotane is the most effective adrenal-specific agent used in adjuvant and palliative therapy. Two menstruating patients, after adrenalectomy due to ACC, during adjuvant mitotane therapy, have been included in the study. The study aimed to assess the effect of mitotane therapy on the endometrium and its clinical consequences, based on the analysis of these two cases and a review of the literature. It seems that menorrhagia may be expected during adjuvant mitotane therapy of ACC in menstruating women. Heavy uterine bleeding during menstruation may appear several months after the beginning of therapy. The likely mechanism for heavy menstrual bleeding is complex. Menorrhagia can occur due to the toxic effect of mitotane in the form of a haemorrhagic diathesis, while long-term treatment (over ten months) can lead to relative hypoestrogenism resulting in endometrial hyperplasia. Clinical signs of hypoestrogenism during mitotane treatment, have been described (including pre-puberty girls) and should be considered as a side-effect of the therapy. Menorrhagia may lead to severe anaemia, so this should be considered when planning mitotane treatment. Continuous gestagen therapy is helpful in the treatment of the above disorders. After over 60 years of experience with mitotane usage, knowledge about it is still insufficient, and further studies are required.

Noninvasive diagnostic imaging of pelvic venous disorders.

It is estimated that chronic pelvic pain (CPP) may affect up to 24% of women. Unfortunately, very often, despite extensive diagnostics, the cause of CPP remains unknown. The pathophysiology of CPP could be explained to a large extent by the occurrence of pelvic venous disorders (PVD). Although pelvic venography is still considered the gold standard for the diagnosis of PVD, noninvasive diagnostic imaging techniques seem to be instrumental in the initial identification of patients with PVD. This literature review aimed to analyze and evaluate the usefulness of noninvasive diagnostic imaging techniques like transvaginal ultrasonography, transabdominal ultrasonography, magnetic resonance, and computed tomography in the diagnosis and identification of patients with PVD. Forty-one articles published between 1984 and 2023 were included in this literature review. Based on this literature review, we conclude that the clinical application of noninvasive diagnostic techniques in the diagnosis of PVD seems to be very promising. Future studies investigating the role of noninvasive diagnostic imaging techniques in the diagnosis of PVD are required.

A Successful New Case of Twin Pregnancy in a Patient with Swyer Syndrome-An Up-to-Date Review on the Incidence and Outcome of Twin/Multiple Gestations in the Pure 46,XY Gonadal Dysgenesis.

BACKGROUND: The aim of the present study is to report a rare occurrence of a successful twin pregnancy in a woman with pure 46,XY gonadal dysgenesis. RESULT(S): A patient with Swyer syndrome (pure 46,XY gonadal dysgenesis) presented with a twin pregnancy after in vitro fertilization. Due to unidentified conditions, the patient developed selective intrauterine growth restriction in one of the fetuses. Twins were born at 33 weeks of pregnancy due to the risk of asphyxia. Nonetheless, the patient did not develop gonadal malignancies before the pregnancy and, despite receiving estrogen, remained amenorrheic. CONCLUSION(S): The aim of this case report is to show the course of twin pregnancy in patients with Swyer syndrome through assisted reproduction. Due to certain disorders in the development of their reproductive organs, such as the less mature uterus, such pregnancies may be associated with an increased risk. The above case report demonstrates the need to systematize methods of pregnancy management in patients with Swyer syndrome, such as: preparation for the pregnancy, assessment of the uterus, medications used, and necessary checkups. Capsule: This case report and review shows clinicians that patients with Swyer syndrome may become pregnant. Twin pregnancies may occur without any major problems through assisted reproduction.

Minimally invasive treatment options for uterine fibroids - state-of-the art 2021.

OBJECTIVES: Uterine leyomyomas are benign, monoclonal tumors that can cause abnormal uterine bleeding, pelvic pain, dyspareunia and/or obstruction of bladder or rectum. Women's growing interest in treatments that avoid surgery and/or preserve the uterus has contributed to the development of minimally invasive methods. Conducting a literature review and assessment of the effectiveness and safety of minimally invasive methods of treating fibroids, with particular emphasis on high intensity focused ultrasound. MATERIAL AND METHODS: Systematic review of MEDLINE, Cochrane and PubMed was performed using the following key words: uterine artery embolization, high-intensity focused ultrasound, microwave ablation, radiofrequency ablation, minimally invasive, leiomyoma, fertility, pregnancy. English abstracts relevant to the topic were selected. Full-text articles were carefully analyzed. RESULTS: Uterine artery embolization is a proven, widely accepted method that is effective in appropriately qualified cases. Although high focused ultrasound is still an experimental procedure, preliminary studies seem to be promising. If its efficacy and safety are confirmed in randomized controlled trials, this method may find its place in clinical practice. Microwave and radiofrequency ablation are interesting minimally invasive methods with the future potential to be recognized as a method of treating fibroids. CONCLUSIONS: Minimally invasive methods are becoming an important treatment option for fibroids. Further research is needed to recognize these procedures as a fully-fledged alternative to surgical treatment.

Ultrasonographic signs of acute ovarian torsion.

Ovarian torsion is defined as partial or complete rotation of the ovarian vascular pedicle and causes obstruction to venous outflow and arterial inflow. Teenage patient was referred to the gynecology ward with pain located in the lower, right abdomen, after an initial misdiagnosis of a dermoid cyst. The patient was diagnosed with a torsion of the right ovarian peduncle. The patient was given diastolic drugs and was discharged in good general condition two days later after the symptoms had resolved. Final USG showed normally vasculated corpus luteum. Among the various treatment options, the wait-and-watch attitude turned out to be the best solution. It is particularly important in the case of young patients, who are planning pregnancy in the future.

The Lublin Protocol of the Uterine Arteries Embolization in the Treatment of Symptomatic Uterine Fibroids.

Uterine fibroids are benign tumors originating from smooth muscle tissue, constituting uterine muscle stroma. Uterine fibroids are the most common benign tumors found in women. In 20%-50% of women, fibroids are asymptomatic and do not require any treatment. The main symptoms of uterine fibroids are profuse menstrual bleeding, abnormal uterine bleeding, and pressure symptoms. Pressure symptoms can cause pelvic pain syndrome, urination disorders, and constipation. The treatment methods that are currently used include surgical treatment, pharmacological therapy, and minimally invasive procedures. The most commonly applied minimally invasive method is the embolization of uterine arteries. This procedure is currently a widely accepted method of treatment for symptomatic uterine fibroids and has been recognized as such by the National Institute for Health and Clinical Excellence in the guidelines for heavy menstrual bleeding. This is a complicated procedure and requires close cooperation between gynecologists and interventional radiologists. We present a protocol applicable to uterine artery embolization in the treatment of symptomatic uterine fibroids. The protocol is divided into five section. The first two section are intended for gynecologists and interventional radiologists, explaining how to qualify and prepare a patient for embolization in a step-by-step manner. Section three, which is directed at interventional radiologists, explains how embolization should be done. Section four is directed at gynecologists or hospital ward doctors who look after the patients after embolization. This section of the protocol offers a method for treating post-embolization pain using the Patient Controlled Analgesia (PCA) pump. Section five completes the procedure with an assessment of the effects and late complications of uterine artery embolization. All five section create a uniform protocol directed at clinicians, experts, and researchers new to the field.

Green urine sign after laparoscopic chromopertubation as an effect of severe contrast intravasation: a report of three cases.

Tubal diseases are responsible for 25% to 35% of female infertility. Laparoscopic chromopertubation is the gold standard for assessing tubal patency when female infertility is suspected. Intravasation is a complication of intrauterine procedures involving the passage of fluid filling the uterine cavity into the bloodstream through endometrial vessels (from the myometrial veins to the uterine venous plexuses). This complication has been described during hysterosalpingography and sonohysterosalpingography. We herein present a report of three cases in which severe intravasation occurred during laparoscopic chromopertubation using methylene blue as a contrast agent. The intravasation manifested as green urine (i.e., the "green urine sign"). The presence of methylene blue in the urine and blood was confirmed by laboratory tests. All three patients had risk factors for intravasation as described in the literature (unilateral or bilateral tubal obstruction, endometriosis, and previous intrauterine procedures for Mullerian duct anomalies and Asherman's syndrome). The green urine sign appeared a few hours after laparoscopic chromopertubation and spontaneously resolved after 24 hours. Cystoscopy was performed to rule out bladder injury. All three patients required only clinical observation.

Psychological aspects of infertility. A systematic review.

OBJECTIVE: Fertility may be defined as a capacity to conceive and produce offspring. Infertility is characterized by failure to establish a clinical pregnancy after 12 months of regular and unprotected sexual intercourse. Infertility concerns an estimated 8-12% of the global population, and is associated with factors including time of unwanted non-conception, age of female partner and number of diseases impacting fertility. Unexplained infertility is described as idiopathic. This study aimed to analyse and evaluate the influence of mental disorders, often considered as reasons for idiopathic infertility, on female and male fertility, including stress, depression, sleep and eating disorders, and addictions. METHODS: This systematic review comprised a search of MEDLINE, Cochrane and PubMed databases for relevant articles that were analysed by two independent reviewers. RESULTS: A total of 106 articles published between 1955-2019 were included. Mental disorders modify endocrine gland and immune system functioning at both the tissue and cellular level, and are negatively associated with female and male fertility. CONCLUSION: Mental disorders may negatively impact female and male fertility. Further studies are required to explain the exact role and contribution of mental disorders to fertility.

The role of the "beret" sign and other markers in ultrasound diagnostic of the acrania-exencephaly-anencephaly sequence stages.

INTRODUCTION: Neural tube defects (NTDs) are a group of heterogeneous congenital anomalies of the central nervous system (CNS). Acrania is a non-NTD congenital disorder related to the CNS. It can transform into anencephaly through the acrania-exencephaly-anencephaly sequence (AEAS). In AEAS, the cerebral tissue is not protected and is gradually destroyed due to exposure to the harmful effect of amniotic fluid and mechanical injuries. These lead to exencephaly and then into anencephaly. In contrast to primary anencephaly (NTDs), this type of anencephaly authors suggests calling secondary anencephaly. OBJECTIVE: Analysis of the known prenatal ultrasonography (US) signs associated with AEAS. Simultaneously, the authors propose a new sign in the differentiation of acrania from exencephaly and anencephaly, called the "beret" sign. METHODS: It is a two-centre retrospective observational study. As part of the study, 4060 US scans were analyzed. RESULTS: In 10 cases, the absence of calvarium was diagnosed, allowing recognition of either AEAS stages or primary anencephaly. In 5 cases, cerebral structures were enclosed by an inertial rippled thin membrane, with a smooth outer contour. Between the described membrane and the brain structures, a thin anechoic space corresponding to cerebrospinal fluid was observed. This sign was defined as the "beret" sign. In these cases, acrania was diagnosed. In three cases calvarium was missing. The brain structures had an irregular appearance, did not wave and remained motionless. The outer contour was unequal as if divided into lobes. Amniotic fluid was anechoic. Exencephaly was diagnosed in these cases. In two cases calvarium, brain structures, and meninges were missing. The "frog eyes" sign and slightly echogenic amniotic fluid were visible. In this case, anencephaly was diagnosed. CONCLUSIONS: The "beret" sign seems to be a promising tool in the diagnosis of acrania. Furthermore, echogenicity of amniotic fluid could be useful during differentiation between primary and secondary anencephaly.

Pituitary-testicular Axis Dysfunction in Methimazole-induced Hypothyroidism in Rats.

INTRODUCTION: Thyroid hormones play a major role in the regulation of testicular maturation and growth and in the control of Sertoli and Leydig cell functions in adulthood. When naturally occurring, hypothyroidism causes male hypogonadotropic hypogonadism and Sertoli cell function disorders, but when iatrogenic and methimazole-induced its influence on the pituitary-testicular axis function with respect to Sertoli cells is poorly known. MATERIAL AND METHODS: Male adult Wistar rats (n = 14) were divided into two groups: E - taking methimazole orally for 60 days, and C - control animals. After 60 d, the concentrations in serum of testosterone, follicle-stimulating and luteinising hormones, and inhibins A and B were measured. Testicles were examined morphologically: the apoptotic Sertoli cell percentage (ASC%) and number of these cells functional per tubular mm2 (FSCN/Tmm2) were calculated. RESULTS: In group E, inhibin A was higher while inhibin B was lower than in group C. ASC% was higher and FSCN/Tmm2 lower in group E than in group C. CONCLUSION: A specific modulation of Sertoli cell function in the course of methimazole-induced hypothyroidism leads to a simultaneous concentration increase in inhibin A and decrease in B. Inhibin A might share responsibility for pituitary-testicular axis dysfunction and hypogonadotropic hypogonadism in this model of hypothyroidism.

Is it necessary to correct a caesarean scar defect before a subsequent pregnancy? A report of three cases.

Rates of caesarean section have increased over recent years and so too have associated complications, one of which is a caesarean scar defect (CSD). The defect may cause gynaecological symptoms, such as menometrorrhagia, infertility, chronic abdominal/pelvic pain or it may be asymptomatic. The presence of CSD may lead to obstetrical sequalae such as preterm delivery, uterine rupture, caesarean scar pregnancy or abnormal placenta implantation. Three cases of CSD are described here. In one case, surgical correction of the CSD was performed before a subsequent pregnancy with an uncomplicated obstetric outcome. In the other two cases, surgical correction of the CSD was not performed and the pregnancies were complicated by caesarean scar dehiscence and caesarean scar pregnancy. We suggest that women with a CSD may benefit from surgical correction of the defect before becoming pregnant to reduce the likelihood of serious complications.

Elastographic and Morphological Testicular Changes in Hypothyroidism - An Experimental Study.

INTRODUCTION: Methimazole-induced hypothyroidism is a clinical problem in the treatment of hyperthyroidism in people and animals and is an example of metabolic disease that can lead to fertility disorders and can give elastographic testicular changes. MATERIAL AND METHODS: Ultrasound elastography using the Esaote MyLab Twice ultrasound system and a morphological examination of testes were performed in seven methimazole-administered (group E) and seven healthy rats (group C). RESULTS: The elasticity ratio of strains in the scrotal wall of the near-field test area to testicular tissue (ELX-T-RAT) and hardness percentage of strained tissues in the defined area of a testicle (ELX-T%HRD) in group E were statistically significantly lower than in group C. The degree of spermatogenesis was statistically significantly higher in group E than in group C and similarly seminiferous tubule diameters in group E were statistically significantly higher than in group C. Body weight and testicular weight in group E were statistically significantly lower than in group C. CONCLUSION: Changes in the elastographical parameters of testes may result from disorders secondary to hypothyroidism. The usefulness of elastography is noteworthy in the case of evaluation of testis function in patients with some metabolic disorders.

Ultrasound screening for pyelectasis in pregnant women. Clinical necessity or "art for art's sake"?

Renal pelvicalyceal dilatation is caused by urine retention in the upper urinary tract. It is referred to as pyelectasis in medical literature. This term does not indicate the cause that leads to the dilatation of and urine retention in the renal pelvicalyceal system. Mild pelvicalyceal dilatation during pregnancy is usually considered to be physiological in nature - it can occur in up to 90% of pregnant women. Retention is more common in the right kidney, in primigravidae, in the second half of pregnancy and in multiple pregnancies. Pyelectasis during pregnancy rarely causes clinical symptoms and often does not require treatment. Nevertheless, urine retention in the renal pelvicalyceal system is conducive to the development of asymptomatic bacteriuria and may be a risk factor for recurrent urinary tract infections, pyelonephritis and acute kidney failure; it may also cause renal colic. In consequence, this condition can lead to intrauterine infection and premature labor in the pregnant woman and to prematurity, anemia, congenital pneumonia or sepsis in the child. In a study conducted at the 3 rd Department of Gynecology of the Medical University of Lublin it was concluded that unilateral pyelectasis of more than 20 cm 3 is associated with a significant increase in the risk of asymptomatic bacteriuria. This volume corresponds to grade 3 and/or 4 pelvicalyceal dilatation according to the Society for Fetal Urology/European Federation of Societies for Ultrasound in Medicine and Biology classification. The pyelectasis volume measuring method using three-dimensional ultrasound scanning included in the criteria for the assessment of asymptomatic bacteriuria was assessed as sensitive and specific. The ultrasound-based evaluation of the kidneys for the presence of pyelectasis and its grade in pregnant women has some clinical implications. It allows for identifying cases with an increased risk of asymptomatic bacteriuria, which requires treatment in pregnant women. Screening during pregnancy for pyelectasis seems to be important in preventing asymptomatic bacteriuria from progressing to symptomatic urinary tract infection.