Liana Pleș

Therapeutic Approaches of Botulinum Toxin in Gynecology

Botulinum toxins (BoNTs) are produced by several anaerobic species of the genus Clostridium and, although they were originally considered lethal toxins, today they find their usefulness in the treatment of a wide range of pathologies in various medical specialties. Botulinum neurotoxin has been identified in seven different isoforms (BoNT-A, BoNT-B, BoNT-C, BoNT-D, BoNT-E, BoNT-F, and BoNT-G). Neurotoxigenic Clostridia can produce more than 40 different BoNT subtypes and, recently, a new BoNT serotype (BoNT-X) has been reported in some studies. BoNT-X has not been shown to actually be an active neurotoxin despite its catalytically active LC, so it should be described as a putative eighth serotype. The mechanism of action of the serotypes is similar: they inhibit the release of acetylcholine from the nerve endings but their therapeutically potency varies. Botulinum toxin type A (BoNT-A) is the most studied serotype for therapeutic purposes. Regarding the gynecological pathology, a series of studies based on the efficiency of its use in the treatment of refractory myofascial pelvic pain, vaginism, dyspareunia, vulvodynia and overactive bladder or urinary incontinence have been reported. The current study is a review of the literature regarding the efficiency of BoNT-A in the gynecological pathology and on the long and short-term effects of its administration.

Four years of experience in our clinic regarding hysteroscopies for abnormal uterine hemorrhages

Introduction. Abnormal uterine hemorrhages (AUH) are the most common symptom for presentation to gynecologist. Any uterine bleeding other than menstrual bleeding, which concerns the duration, frequency, quality or quantity of the bleeding is considered abnormal. Material and Methods. We realized a retrospective study based on medical records of the patients admitted for abnormal uterine hemorrhage at “Saint John” Emergency Clinical Hospital, “Bucur” Maternity between 2013 and 2016. From the patients with AUH, we focused on those who underwent hysteroscopies. Results. Our study included 146 patients. The age of patients varied from 22 to 71 years. Abnormal uterine bleeding was most prevalent among women of 40-50 years (20%), and the mean age was 42.65%. 82.88% from our patients had obstetrical history and only 17.12% didn’t give birth either as an option, or from primary or secondary infertility. 7.53% of the patients were hypertensive and 5.48% had endocrine pathology. All patients underwent diagnostic hysteroscopy and 4.79% patients therapeutic hysteroscopy. The therapeutic measures that were made are: hysteroscopic resection of the endometrium (47.3%), excision of polyps (36.99%), sinechiolysis (8.22%) and myomectomy (2.71%). The diagnoses were 46.48% endometrial polyp, 13.7% intramural leiomyoma, 13.7% IUD (intrauterine device) and 9.59% intrauterine synechiae, while 15.06% cumulated for uterine septum, endometrial hyperplasia, cervical polyp, foreign intrauterine bodies, secondary infertility, dysfunctional metrorrhagia. Conclusion. In patients with abnormal uterine hemorrhages, hysteroscopy provides the most accurate diagnosis and can reduce the burden of hysterectomy in many cases.

The role of laparoscopic myomectomy in the modern management of uterine fibroids – a literature review

Uterine fibroids are the most common benign tumors of the genital female tract and the leading indication for hysterectomies in the USA. The prevalence rates quoted in literature range from 20-50%, based on postmortem studies. The prevalence varies with age, with an increase in the late reproductive period. Since the beginning of 1990s laparoscopic myomectomy (LM) has provided an alternative to laparotomy when intramural and subserous myomata are to be managed surgically. However, this technique is still the subject of debate. Based on their own experience together with data from literature, the authors report on the situation today regarding the operative technique for LM and the risks and benefits of the technique as compared with myomectomy by laparotomy. The operative technique include four main stage: hysterotomy; enucleation; suture of the myomectomy site and extraction of the myoma. A consensus gradually emerges that the maximal size of myoma must be 8-10 cm and the total number of fibroids should not exceed four. When conducted by experienced surgeons, the risk of perioperative complications is no higher using this technique. The use of laparoscopic approach could reduce the haemorrhagic risk associated with myomectomy. LM could reduce also the risk of postoperative adhesions as compared with laparotomy. Spontaneous uterine rupture seems to be rare after LM but further studies are needed before it can be said whether the strength of the hysterotomy scars after LM is equivalent to that obtained after laparotomy. Some studies showed that the risk of recurrence seems to be higher after LM than after myomectomy performed by laparotomy. Laparoscopic myomectomy cases may become difficult if bleeding problems occur. Extended operative times may be necessary for morcellation and extensive laparoscopic suturing. Gynecologists need to improve their laparoscopic skills, as minimally invasive surgery is becoming the sine qua non condition of a modern surgeon.

Progesterone and neuroprotection at menopause

The neuroprotective effect of progesterone has been demonstrated in numerous experimental cell and animal studies, in traumatic brain/spinal injury, neurodegenerative diseases, storke, demyelinating diseases. Thus progesterone has emerged as a promising candidate for preventing and treating neuronal related disorders leading to a few promising clinical studies.The effects of progesterone in the nervous system involve a variety of signaling actions, therefore we review the evidence that supports the neuroprotective effects of progesterone and recall the mechanisms that mediate these effects. We also discuss the biology of progesterone and the effects of this hormone on myelination and remyelination of the central and peripheral nervous system. Progesterone in the brain is derived from the steroidogenic endocrine glands or from local synthesis by neural cells. Stimulating the formation of endogenous progesterone is currently explored as an alternative strategy for neuroprotection, axonal regeneration, and myelin repair.

Evidence based considerations regarding the new ACOG labor guidelines

Recent guidelines issued jointly by the American College of Obstetrics and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine for assessing labor differ substantially from those described initially by Friedman, who led obstetric practice for decades. The new recommendations are based on results achieved by the analysis of patterns of cervical dilation and fetal descent. They argue that labor models originally described by Friedman are no longer applicable to modern obstetrical practice. The main changes proposed to the Friedman curve are considered to be that the beginning of the active phase is from 6 cm opposed to 4 cm. The diagnosis of dystocia is established for a progression of dilatation under 0.5 cm/h opposed to 1.5-1.2 cm. Accepted duration of the expulsion is amended: over 3 hours for nulliparous and over 2 hours for mulliparous. The new ACOG guidelines revised birth periods favoring a more permissive in terms of time factor.