Obstetrics and Gynecology

Editorial introductions No abstract available

Impact of obesity on male and female reproductive outcomes Purpose of review The association between obesity and infertility has gained increasing provider and public awareness. The purpose of this review is to outline the recent research into the pathophysiology regarding obesity and its impact of reproductive function in both women and men. Recent findings A BMI more than 25 has a detrimental impact on the hypothalamus-pituitary-gonadal (HPG) axis in both men and women, leading to alterations of HPG hormones, gametogenesis, as well as an increase in inflammation and lipotoxicity from excessive adipose tissue. Additionally, BMI likely impacts assisted reproductive technology (ART) outcomes, with a greater influence on women than men. Studies regarding weight loss interventions are heterogenous in methods and outcomes, and it is difficult to extrapolate from current data if weight loss truly leads to improved outcomes. Summary Elevated BMI induces changes in the HPG axis, hormone levels, gametogenesis, and adverse ART outcomes. Inconsistencies regarding weight loss interventions make it difficult to assess the impact on outcomes after weight loss interventions.

New insights into human prolactin pathophysiology: genomics and beyond Purpose of review To briefly summarize what is known regarding hyperprolactinemia and prolactin-secreting tumors, and review recent findings. Recent findings Prolactin was previously thought to inhibit secretion of gonadotropin-releasing hormone (GnRH) by directly inhibiting the firing of GnRH neurons, resulting in hypogonadotropic hypogonadism and infertility. However, kisspeptin has recently been implicated as the mediator of hyperprolactinemia-induced infertility, by acting upstream of the GnRH neurons as an integrator of endocrine signals. Macroprolactin is generally considered to be inactive and clinically insignificant, but new studies have suggested that patients with macroprolactinemia may have reproductive manifestations as well as sexual dysfunction. Several mutations and polymorphisms in the prolactin receptor have been described, which could describe a genetic cause for prolactinomas and characterize cases of isolated familial hyperprolactinemia. Kisspeptin and tyrosine kinase inhibitors have emerged as potential new therapeutic targets for the treatment of hyperprolactinemia and dopamine-resistant prolactinomas. Summary Molecular studies are shedding light on the pathophysiology of hyperprolactinemia and the effects of excess prolactin production on the reproductive system. Similarly, genetic studies have begun to reveal how differences in prolactin receptor function may account for some of the previously 'idiopathic' cases of hyperprolactinemia and bring to light new causes of prolactinomas. Further elucidation of the transcriptional pathways affected by these genetic changes may help to create new therapeutic targets.

A critical review of recent advances in the diagnosis, classification, and management of uterine adenomyosis Purpose of review The purpose of this review is to summarize and highlight recent critical advances in the diagnosis, classification, and management of adenomyosis. Recent findings Recent studies have clarified the specific mechanism through which adenomyotic lesions invade the underlying myometrium by epithelial–mesenchymal transition. Correlation studies using diagnostic MRI also strongly support the hypothesis of a different pathogenesis between the inner and outer myometrium forms of adenomyosis. Given advances in diagnostic imaging, several international organizations have also highlighted the importance of classification systems for adenomyosis. Finally, selective progesterone receptor modulators and gonadotropin-releasing hormone antagonists have demonstrated significant promise for treating pelvic pain and bleeding associated with adenomyosis, whereas novel fertility-preserving surgical techniques have been introduced to excise diffuse adenomyotic pathology while maintaining adequate uterine integrity. Summary Recent attempts at a uniform and reproducible classification system likely represent the first step for the development of a staging system for adenomyosis that can be correlated with the severity of clinical symptoms and promote an individualized therapeutic approach. Simultaneously, further insights into the etiology and pathogenesis as outlined in this review may also help in the development of targeted medical therapies.

Sleep and female reproduction Purpose of review Sleep disturbances are increasing in prevalence in North America. There is growing evidence that poor sleep quality and short sleep duration may adversely affect circadian rhythms, which in turn may affect female reproduction. The objective of this review is to evaluate recent literature on the association between sleep disturbances and female reproduction. Recent findings There is accumulating evidence that sleep quality and duration are important for female reproduction, but epidemiologic research is limited. Recent studies provide suggestive evidence that sleep disorders are associated with increased menstrual irregularity, subfertility/infertility, and poor pregnancy and birth outcomes. Mechanisms underlying these associations are likely to be multifactorial and complex. In addition to genetics, circadian disruption may impact reproductive outcomes through dysregulation of the hypothalamic-pituitary-adrenal axis, insulin resistance, oxidative stress, and systemic inflammation. Recommendations for future studies include: use of prospective study designs; assessment of populations not already experiencing reproductive disorders; more detailed and accurate assessments of sleep such as validated self-reported measures or objective sleep measures (e.g. actigraphy); comprehensive assessment of potential confounders and mediators; and elucidation of biologic mechanisms. Summary There is a growing body of literature showing evidence that sleep disturbances influence female reproduction, although further epidemiologic research is needed.

Surgical management and gynecologic care of the transgender patient Purpose of review Over 1.4 million adults are identified as transgender in 2014. Many of these individuals have undergone, or plan to undergo, gender-affirming surgery. This review summarizes the medical and surgical options available for the transgender population and reviews screening guidelines and fertility preservation options. In addition, it highlights the role gynecologists have in caring for this population. Recent findings Gynecologists perform certain gender-affirming surgeries, such as hysterectomies and bilateral salpingooophorectomies. They also can play an important role in providing hormone therapy, anatomy specific cancer screening, and discussion of and/or referral for fertility preservation. Summary Gynecologists are skilled to perform certain gender-affirming surgeries and play an important role in gender-affirming care.

Applications of Tranexamic acid in benign gynecology Purpose of review Bleeding at the time of benign gynecologic surgery, as well as from benign gynecologic conditions, is a major source of morbidity for many women. Few nonhormonal medical options exist for the treatment of heavy menstrual bleeding, and to reduce surgical bleeding during major gynecologic surgery. Interest in Tranexamic acid (TXA) as a means to reduce surgical blood loss has been growing across many surgical specialties. This review focuses on applications for TXA as a means to reduce heavy menstrual bleeding (HMB) as well as to reduce surgical bleeding during benign gynecologic surgery. Recent findings Tranexamic acid is an effective treatment to reduce the volume of bleeding during menstruation. Tranexamic acid was found to be superior to both placebo and oral progestins, and as good as combined oral contraceptives at reducing menstrual blood volume. Tranexamic acid has also been show to reduce the volume of bleeding during abdominal myomectomy as well as hysterectomy. There is a major need for prospective studies evaluating the utility of TXA for reducing blood loss during benign gynecologic surgery. Summary Tranexamic acid has been found to be an excellent affordable nonhormonal treatment option for women with HMB and should be considered during major gynecologic surgery.

Informed consent in gynecologic surgery Purpose of review Informed consent is frequently used interchangeably with obtaining a signature on a form. This oversimplification shifts the value from the process of informed consent to the documentation. This review focuses on the recommended components of the consent process, barriers encountered, factors influencing patient satisfaction, attempts to improve the consent practice, and considerations in special populations. Recent findings The process of informed consent is key to promoting shared decision-making and patient autonomy. Several barriers exist to providing optimal consent including time constraints as well as educational, cultural, and language barriers. Innovative approaches such as audiovisual aids show promise in overcoming barriers and improving the consent process. Summary Patients seek expertise and knowledge to aid in making decisions that align with their care goals. Providers have an obligation to provide individualized and accessible counseling. Ongoing research is needed to optimize this process.

Prevention and management of bowel injury during gynecologic laparoscopy: an update Purpose of review The current article aims to briefly review recent literature on bowel injury in gynecologic surgery with a focus on minimally invasive techniques, strategies for prevention, and management of injury. Recent findings Recent reviews describe a low incidence of bowel injury that is likely affected by low rates of reporting and inconsistent definitions. The major risk factor for bowel injury is adhesive disease, and assessment and prevention techniques for the presence of adhesive disease are evolving. When bowel injury occurs, prompt diagnosis and intraoperative repair yields more favorable outcomes than delayed diagnosis. Repair can be performed by a gynecologic surgeon, with or without the help of a consultant depending on the extent of the injury and surgeon comfort. Summary Bowel injury is a potentially catastrophic complication in gynecologic surgery, but its rarity presents a challenge in research. A high index of suspicion and meticulous surgical technique are the cornerstones of managing a bowel injury.

Optimizing surgical management of patients who decline blood transfusion Purpose of review This review highlights the complexity of caring for gynecologic patients who refuse blood transfusion and discusses the importance of early, targeted perioperative and intraoperative medical optimization. We review alternative interventions and the importance of medical management to minimize blood loss and maximize hematopoiesis, particularly in gynecologic patients who may have significant uterine bleeding. The review also focuses on intraoperative interventions and surgical techniques to prevent and control surgical blood loss. Recent findings With improvements in surgical technique, greater availability of minimally invasive surgery, and increased use of preop UAE and cell salvage, definitive surgical management can be safely performed. New technologies have been developed that allow for safer surgeries or alternatives to traditional surgical procedures. Many medical therapies have been shown to decrease blood loss and improve surgical outcomes. Nonsurgical interventions have also been developed for use as adjuncts or alternatives to surgery. Summary The care of a patient who declines blood transfusion may be complex, but gynecologic surgeons can safely and successfully offer a wide variety of therapies depending on the patient's goals and needs. Medical management should be implemented early. A multidisciplinary team should be mobilized to provide comprehensive and patient-centered care.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com