Current Women's Health Reviews - Volume 1, Issue 2, 2005

Endometrial cancer, cancer of the epithelial lining of the uterine corpus, is the most common gynecological malignancy in the United States and is the eighth leading cause of cancer death in U.S. women. The endometrium is highly responsive to hormonal stimuli; cyclic production of estrogen and progesterone during the menstrual cycle, and declining sex steroid levels after menopause are correlated with endometrial proliferation and/or atrophic morphological changes. Excess exposure to endogenous and exogenous estrogens, unopposed by progesterone, increases endometrial cell division and is suggested to be the mechanism through which established risk factors for endometrial cancer influence risk. In searching for endometrial cancer susceptibility genes, components of the sex steroid hormone pathway are likely candidates. Data suggest that sequence variations within genes involved in the sex steroid hormone pathway may be responsible for altered levels of steroid hormones and hormone metabolites, and hence, associated with an increased risk of endometrial cancer. A number of molecular epidemiological studies have been conducted to evaluate associations between variations within genes involved in the steroid hormone pathway and endometrial cancer risk. In this report, we review the role of sequence variations within the genes encoding for proteins involved in sex steroid biosynthesis, metabolism, and transport in modulating individual susceptibility to endometrial cancer.

Radical vaginal trachelectomy (RVT) is a relatively new procedure in Gynecologic Oncology. It is gaining acceptance worldwide as a safe management option that allows fertility preservation in women with early cervical carcinoma who are unlikely to require adjuvant therapy. This review of 319 cases reported in the literature includes patient/tumour demographics, operative details, recurrence and fertility rates, and obstetrical outcomes. Reports to date indicate that the recurrence rates are similar to that after radical hysterectomy, yet with the advantages of deceased blood loss and a shorter hospital stay. Importantly, experienced surgeons have been able to offer RVT to young women and thus provide them a reasonable likelihood of achieving pregnancy and obtaining a healthy newborn. Patients should be counseled regarding potential obstetrical complications and the importance of close follow-up for possible recurrence. A randomized study is unlikely ever to be feasible, and therefore, as more data is published, a more accurate analysis of recurrence and pregnancy outcomes will become available.

The concept of hormonal contraception is believed to have begun in the early 1900s, with the first oral contraceptive coming onto the market in 1960. The contraceptive pill revolutionized society and in recent years, there has been an escalation in the range of hormonal contraceptive options available. Long-term contraceptives have been designed to deliver hormones via injections, implants, intrauterine devices, vaginal rings, and transdermal patches as alternatives to the traditional short-term oral contraceptives (OCs). The overall effect has been an increase in compliance, greater usercontrol and a decrease in side-effects. This review will examine the range of products that are available commercially and compare their efficacy, health risks, side-effects and non-contraceptive benefits. There is a continuing demand for new products that protect the health of the user as well as preventing pregnancy. Potential areas where new products may arise in the future are considered.

Accurate estimates of the effectiveness of hormonal emergency contraception (EC) are important for public policy and clinical application. Because there are no randomized trials of emergency contraception, observational studies with historical controls are employed to estimate effectiveness. There are many methodologic issues that can influence estimates of effectiveness, with multiple opportunities for bias. These include issues around use of EC and follow-up, selection of women for study, the historical reference population used for estimates of expected pregnancies, and the statistical approaches used to derive estimates of expected pregnancies. We discuss how the different sources of bias, including previously unrecognized sources, may affect existing estimates and make suggestions for future methodologic improvements to estimate effectiveness.

Excess body weight can influence the hormone production and consequently the chance of achieving pregnancy of patient undergoing ovarian hyperstimulation for in vitro fertilization embryo transfer, could be reduced. Besides, maternal obesity leads to major maternal and fetal complications. Even moderate obesity has a significant deleterious effect on pregnancy outcome. In addition, obesity is also a risk factor for breast and endometrial cancer. However, the morbidity and mortality of obesity could be minimized through appropriate obesity management.Therefore, the aim of this review was to find out the association between overweight, obesity and the reproduction outcome especially of patients undergoing controlled ovarian hyperstimulation for assisted reproduction therapy.

Loss of sexual desire is a common problem among surgically menopausal women that often results in personal distress and diminished quality of life. Various physiological, psychosocial, and interpersonal factors may contribute, but the hormonal changes induced by the removal of the ovaries should not be overlooked. Postoperative declines in testosterone often result in loss of sexual desire, and estrogen deficiency may aggravate the situation, leading to vaginal atrophy, dryness, and pain during intercourse. Physicians' direct questioning about sexual function is an essential step in establishing a dialogue before and after surgery. When complaints of low sexual desire are present, a thorough sexual, medical, and psychosocial history is needed to help delineate underlying causes and establish a diagnosis. Hypoactive sexual desire disorder (HSDD) may be diagnosed in women with a persistent lack of interest in, desire for, or receptivity to sexual activity that causes personal distress. An integrated treatment approach may be most successful. Recent evidence suggests that testosterone therapy is effective in restoring sexual desire in surgically menopausal women with HSDD. Additional clinical trials are needed to define the efficacy and tolerability of the different testosterone therapies and establish long-term safety, ensuring appropriate use in clinical practice.

There is controversy about the protective effect of condoms in preventing sexually transmitted diseases (STDs). This paper summarizes recent studies that assess the association between condom use and the prevalence of various STDs. Because condom use is considered a marker for sexual partnerships with greater risk of STD transmission, limited evidence of protection has been found among those reporting condom use compared to non-users. Previously, methodological issues have impacted the performance of valid studies on condom effectiveness including inability to determine consistency and correctness of use or the infection status of partners. These assessments are critical to interpreting data from condom studies since they tend to confound effectiveness and underestimate the protective effect of condom use. Recent studies have assessed these issues and found that consistent condom use is associated with lower rates of gonorrhea, chlamydia, syphilis, trichomonas (women) and genital herpes than inconsistent use. Pelvic inflammatory disease may be decreased and HPV-associated lesions may regress faster. While consistent use has been found to reduce STD, incorrect use undermines this benefit, especially for heterosexual men. Thus, while non-use is a significant factor affecting condom use failure, consistent and correct use of condoms is an important strategy in reducing STD risk.

Trophoblast cell differentiation and fusion during human placentogenesis are controlled by a variety of regulatory genes and key molecules. In this review, we focus on the fusogenic protein syncytin, which originally derived from a human endogenous retrovirus and was discovered in 2000, and discuss its possible role in pre-eclampsia and HELLP syndrome. Secondly, we define a further regulator of placental syncytium formation, the transcription factor GCMa (or Gcm1, glial cells missing a). GCMa is the first transcription factor capable of initiating syncytiotrophoblast formation, and has been shown to activate syncytin gene expression as a possible underlying cell fusion event. GCMa is also thought to play a role in human placental diseases such as pre-eclampsia or intrauterine growth restriction (IUGR). Additionally, we discuss studies on the effects of hypoxia on trophoblastic cells. Since placental effectors stimulating cell differentiation also depend on local oxygen tension, oxygen availability or sensing, alterations of these conditions contribute to abnormal placental development. Pre-eclampsia is unique to human pregnancy, and its pathogenesis, certainly multifactorial, is still obscure. In conclusion, we propose that syncytin and GCMa are promising candidates for research into altered placenta formation and also for acquiring a basic knowledge of placental syncytialization processes.

Vaginal birth after prior cesarean has become a part of routine obstetric care over the past three decades. Recently, however, the pendulum has swung in the other direction with a decreasing proportion of women choosing to undergo a trial of labor after prior cesarean. Since more than one-fourth of all deliveries are via cesarean, counseling patients regarding the risks and benefits of undergoing a trial of labor in a subsequent pregnancy is a skill all clinicians who care for obstetric patients should have. In particular, there is good evidence regarding risk factors that change the chance of success in a subsequent trial of labor as well as that of a uterine rupture. For example, women with a prior indication for cesarean that is nonrecurring (e.g. breech, previa, herpes), women with a prior vaginal delivery, and those who present in spontaneous labor all have an increased chance of success in a subsequent trial of labor. Women with more than one prior cesarean, who undergo induction of labor, are treated with prostaglandins, and who have prior classical cesareans are at increased risk for uterine rupture. Using this evidence to counsel women regarding their risks and chances of success in a subsequent trial of labor is paramount to ensuring that a well-informed decision has been made.

Prostaglandin preparations have been the traditional approach to second trimester abortions for at least 40 years, and misoprostol recently has gained an almost “standard of practice role in obstetrics. Although many applications of misoprostol are still off-label, after more than 1,000,000 women have been treated with misoprostol all over the world, a broad base of knowledge has accumulated on the efficacy and safety of this medication. The purpose of this paper was to review the evidence supporting the different applications of misoprostol in obstetrics. The update includes a short incursion in the pharmacokinetics of misoprostol, connecting the biological plausibility with the evidence generated by clinical trials. The experience with misoprostol indicates that efficacy and side-effects are dosedependent, the practitioner having to navigate the tightrope between ineffective action and hyperstimulation. Variables relative to the technique of administration of misoprostol are also discussed. The reader will derive the benefit of an organized overview on the subject, and more importantly, of practical recommendations for a safe and efficacious use of misoprostol for at least 8 indications: labor induction, cervical ripening, 1st and 2nd trimester induced abortion, missed abortion, incomplete abortion, and control of postpartum and postabortum bleeding.