Ioannis Boutas

Ulipristal acetate for uterine fibroids: a systematic review and meta-analysis

Abstract Ulipristal acetate (UA), a selective progesterone modulator, has been approved for short-term therapy for symptomatic fibroids. We decided to undertake a systematic review of the best available evidence and draw a more definitive conclusion regarding the efficacy of UA for the management of uterine fibroids. The outcomes included symptomatic relief, quality of life-related parameters, reduction in fibroid size, side effects and recurrence rate. We included four randomised controlled trials which consisted of three trials which compared UA with placebo, and one trial compared it with gonadotropin-releasing hormone analogues for symptomatic relief. The three trials comparing UA with placebo reported significant improvement in symptoms related to excessive uterine bleeding as evidenced by the attainment of amenorrhea or reduction in pictorial blood assessment chart. However, due to the heterogeneity of the available data, a meta-analysis was possible only for one the outcomes – attainment of amenorrhea which indicated improvement in symptoms [57.88 (19.81–169.16); p < 0.00001]. The improved quality of life parameters and reduction in fibroid size was noted in the UA group. With regards to adverse events, even though the three included studies reported increased non-physiological endometrial-related changes following UA, these changes reverted back to normal within 6 months. Short-term use of UA seems to be an effective and safe method of treating uterine fibroids.

Association of endometriosis and breast cancer: mini review of the literature

BackgroundEndometriosis is a common, estrogen-dependent, gynecological disease, which is defined as the presence of endometrial tissue outside the uterine cavity. Current data have associated endometriosis with specific malignancies, including ovarian and breast cancer.PurposeThe purpose of our study is to summarize and present published literature providing evidence regarding the possible relationship between endometriosis and breast cancer.MethodsPubmed and Scopus databases were searched systematically for studies that sought to identify a potential association of endometriosis and breast cancer. 15 relevant articles were retrieved and included in the present review.ResultsA small number of observational studies have shown a correlation of endometriosis and breast cancer. Other studies found that the risk of breast cancer increases with age. The scenario of an early interruption of the inflammatory process, derived from endometriosis, by oophorectomy and a possible consequent decrease in the risk of breast cancer has also been proposed. The hypothesis that both conditions could be related through common mutations on BRAC1 and BRAC2 genes has also been investigated.ConclusionThe available published evidence is inconclusive. Further studies are needed to evaluate the association of endometriosis and breast cancer and the possible pathogenetic pathways that relate the two disorders.

Can anti-Mullerian hormone (AMH) predict the outcome of intrauterine insemination with controlled ovarian stimulation?

Abstract Objective: To assess whether the levels of anti-Mullerian hormone (AMH) are related to outcome of intrauterine insemination (IUI) in patients treated with gonadotropins. Intervention(s): A total of 195 patients underwent controlled ovarian stimulation (COS) with recombinant follicle stimulating hormone (rFSH) (50–150 IU/d). All patients were submitted upto three cycles of IUI. Outcome: Primary outcome was the ability of AMH levels to predict clinical pregnancy at first attempt and the cumulative clinical pregnancy probability of upto three IUI cycles. Secondary outcomes were the relation of AMH, LH, FSH, BMI, age, parity and basic estradiol levels with each other and the outcome of IUI. Results: The area under the receiver operating characteristic (ROC) curve in predicting clinical pregnancy for AMH at first attempt was 0.53 and for cumulative clinical pregnancy was 0.76. AMH levels were positively correlated with clinical pregnancy rate at first attempt and with cumulative clinical pregnancy rate, but negatively correlated with patient’s age and FSH levels. Patient’s FSH, LH levels were negatively correlated with cumulative clinical pregnancy rate. Conclusions: AMH levels seem to have a positive correlation and patient’s age and LH levels had a negative correlation with the outcome of IUI and COS with gonadotropins. AMH concentration was significantly higher and LH was significantly lower in patients with a clinical pregnancy after three cycles of IUI treatment compared with those who did not achieve pregnancy.

Novel Medical Therapy of Cesarean Scar Pregnancy With a Viable Embryo Combining Multidose Methotrexate and Mifepristone: A Case Report.

AbstractAn ectopic pregnancy is defined as cesarean scar pregnancy (CSP) when the products of conception are implanted within the myometrium in the area of a cesarean section scar. CSP can be a life-threatening condition and to date there is no clear consensus for CSP management. A medical approach joining high treatment rates with fertility preservation could be a safer and less invasive method of therapy.We present a case of CSP with a viable embryo that was successfully treated with a novel medical therapy combining multidose methotrexate (MTX) and mifepristone.No further additional invasive procedure was required since pregnancy products were dissolved and no major complications were experienced.Multidose MTX and mifepristone can be considered a safe and effective treatment for CSP.

Undiagnosed vertebral hemangioma causing a lumbar compression fracture and epidural hematoma in a parturient undergoing vaginal delivery under epidural analgesia: a case report.

IntroductionVertebral hemangiomas are benign vascular tumours of the bony spine which are usually asymptomatic. Pregnancy-related anatomical and hormonal changes may lead to expansion of hemangiomas and development of neurological symptoms. We present an unusual case of vertebral fracture due to an undiagnosed hemangioma presenting as postpartum back pain following epidural analgesia.Case presentationA multiparous female with an unremarkable history developed intense lumbar pain after vaginal delivery under epidural analgesia. The pain was attributed to tissue trauma associated with the epidural technique. The patient had no clinical improvement with analgesics, and her symptoms deteriorated over the following days. A magnetic resonance imaging scan revealed an acute fracture of the second lumbar vertebra (L2) with epidural extension and mild compression of the dural sac, suggesting hemangioma as the underlying cause. The patient underwent successful spinal surgery with pedicle screw fixation to stabilize the fracture.ConclusionVertebral fractures secondary to acute expansion of a vertebral hemangioma rarely occur during vaginal delivery. In such cases, the labour epidural technique and analgesia may challenge the physician in making the diagnosis. Postpartum severe back pain should be thoroughly investigated even in the absence of neurological deficits, and osseous spinal pathology should be considered in the differential diagnosis.RésuméIntroductionLes hémangiomes vertébraux sont des tumeurs vasculaires bénignes de l’épine osseuse et sont généralement asymptomatiques. Les changements anatomiques et hormonaux liés à la grossesse peuvent entraîner l’expansion des hémangiomes et l’apparition de symptômes neurologiques. Nous présentons un cas inhabituel de fracture vertébrale due à un hémangiome non diagnostiqué se présentant sous forme de douleur dorsale postpartum après une analgésie péridurale.Présentation du casUne femme multipare sans antécédents remarquables a manifesté une douleur lombaire intense après un accouchement vaginal sous analgésie péridurale. La douleur a d’abord été attribuée à un traumatisme tissulaire associé à la technique péridurale. La patiente n’a pas ressenti d’amélioration clinique avec l’administration d’analgésiques, et ses symptômes se sont aggravés au cours des jours suivants. Un examen d’imagerie par résonance magnétique a révélé une fracture aiguë de la deuxième vertèbre lombaire (L2) avec extension péridurale et une compression légère du sac dural, suggérant qu’un hémangiome était la cause sous-jacente. La patiente a subi une chirurgie rachidienne avec succès pour fixer une vis pédiculaire afin de stabiliser la fracture.ConclusionLes fractures vertébrales secondaires à l’expansion aiguë d’un hémangiome vertébral surviennent rarement pendant les accouchements vaginaux. Dans de tels cas, la technique et l’analgésie péridurale pour le travail obstétrical pourraient compliquer la formulation d’un diagnostic pour le médecin. Il faut rechercher la cause des douleurs dorsales postpartum graves même en l’absence de déficits neurologiques, et il faut tenir compte des pathologies rachidiennes osseuses dans le diagnostic différentiel.

Assessment of bone metabolism and biomechanical properties of the femur, following treatment with anastrozole and letrozole in an experimental model of menopause

The aim of the present study was to investigate the impact of anastrozole and letrozole supplementation following surgically induced menopause on bone metabolism and biomechanical properties. A total of 45 Wistar rats underwent ovariectomy and were then randomly allocated to receive no treatment, anastrozole or letrozole. At 2 and 4 months following the initiation of the present study, the serum levels of osteoprotegerin (OPG) and receptor activator of nuclear factor-κB ligand (RANKL) were determined, and the animals were sacrificed at the end of the 4-month period to assess the biomechanical properties of the femoral bones. The applied force and the deflection of the central section were recorded during the test. Taking advantage of these quantities, the fracture force, the stiffness of the bone and the energy absorbed until fracture were determined. At 2 months following the initiation of the experimental protocol, the mean OPG levels were significantly increased in the control group compared with the anastrozole-treated group (P<0.01). Similarly, RANKL levels were significantly increased in the control rats compared with the anastrozole-treated animals (P<0.001) and animals that received letrozole (P<0.05). Notably, these trends were not observed at the end of the experiment (4 months). A biomechanical study of the femoral bones revealed significantly decreased stiffness among animals that received anastrozole (P<0.05) and letrozole (P<0.01) compared with their control counterparts. The results of the present study indicate that treatment with anastrozole and letrozole significantly increases the levels of OPG and RANKL in bone, an effect that appears to be directly associated with the biomechanical properties of bones.

The impact of Anastrazole and Letrozole on the metabolic profile in an experimental animal model

Anastrazole and Letrozole are used as endocrine therapy for breast cancer patients. Previous studies suggested a possible association with metabolic and liver adverse effects. Their results are conflicting. Fifty-five 4-week-old female Wistar rats were allocated in 4 groups 1) ovariectomy control (OC), 2) ovariectomy-Anastrazole (OA) 3) ovariectomy -Letrozole (OL), 4) control. Serum glucose, cholesterol, triglycerides, HDL-c and LDL-c were measured at baseline, 2 and 4 months. At the end, the animals‘ liver were dissected for pathology. At 4 months, total cholesterol differed among the OC and OL groups (p = 0.15) and the control and OL groups (p = 0.12). LDL-C differed between the control and OC groups (p = 0.015) as well as between the control and OA (p =0 .015) and OL groups (p = 0.002). OC group triglycerides, differed from those of the OL group (p =0 .002) and the control group (p = 0.007). The OA also significantly differed from the OL (p = 0.50). Liver pathology analysis revealed differences among groups with favored mild steatosis and ballooning. Anastrazole and Letrozole seem to negatively influence the lipid profile in our experimental model. This information should be taken in caution by medical oncologists when addressing patients with altered lipid metabolism.