Paolo Maniglio

Inositol’s and other nutraceuticals’ synergistic actions counteract insulin resistance in polycystic ovarian syndrome and metabolic syndrome: state-of-the-art and future perspectives

Abstract The incidence of metabolic syndrome (MetS), type II diabetes (T2D) and polycystic ovarian syndrome (PCOS) has been progressively increasing. Insulin resistance (InsR) seems to play a key role in a majority of phenotypes of these conditions, altering metabolic homeostasis, within muscle, liver, adipose and other tissues. Hyperinsulinemia is often associated with InsR and causes hormonal imbalances especially within ovaries and adrenals. Inositol is a polyalcohol, naturally occurring as nine stereoisomers, including D-chiro-inositol (DCI) and myo-inositol (MI), which have prominent roles in the metabolism of glucose and free fatty acids. MI and DCI have been classified as insulin-sensitizers and seem to adequately counteract several InsR-related metabolic alterations with a safe nutraceutical profile. Based on our analysis of selected studies that investigated MI and/or DCI, we conclude that supplementation with MI and/or DCI complement each other in their metabolic actions and act in synergy with other insulin sensitizing drugs and/or nutraceuticals. Nevertheless, considering the possible severe bias due to different methodologies across published studies, we conclude that there is a need for further studies on larger cohorts and with greater statistical power. These should further clarify outcomes and suitable therapeutic dosages of MI and DCI, possibly based on each patient’s clinical status.

Obstetric and neonatal outcomes of women with FGM I and II in San Camillo Hospital, Burkina Faso

PurposeFemale genital mutilation (FGM) is still performed in the world. Women who underwent FGM have marked psychological, gynecological and obstetric consequences. This article contributes to the spread of knowledge about obstetric and neonatal outcomes in women with FGM I and II.MethodsOur observational study compared the obstetric outcomes of 85 women with FGM I and II (case group) and 95 women without it (control group). We evaluated age, need of oxytocin during labor, duration of the expulsion phase, need of episiotomy, weight of the newborn, Apgar score at birth, resuscitation of the newborn, stillbirth. We observed the rate of cesarean sections and their main indications. We compared the rate of cesarean sections among the cases and the controls.ResultsControls were younger than women who underwent FGM. Intravenous oxytocin injection was higher in cases. The expulsion phase was longer in women with FGM than in the controls. FGM is related to a higher risk of episiotomy. Apgar score 9/10 was more frequently assigned to babies from mothers without FGM. There were more resuscitated babies and more stillbirth in the group of cases. Ten percent of all women underwent cesarean section. FGM is related to a higher incidence of cesarean section.ConclusionFGM is associated with a higher risk of gynecological and obstetrical consequences, acting on women’s health and also on the economy of resource limited countries. Because of migration, health professionals could interface with women who underwent FGM and have to know their related complications.

Epigenetic modifications of primordial reproductive tract: A common etiologic pathway for Mayer-Rokitansky-Kuster-Hauser Syndrome and endometriosis?

http://dx.doi.org/10.1016/j.mehy.2016.02.015 0306-9877/ 2016 Published by Elsevier Ltd. Dear Editor, we read with great interest the paper by Alcolado [1], published in your prestigious Journal. This work conforms ‘‘the fetal basis of adult disease’’ hypothesis, which proposes that prenatal exposure to certain forms of environmental stress can cause increased susceptibility to clinical disorders, modulating the gene expression later in life (the so-called ‘‘epigenetic imprinting”). During embryogenesis, it was already shown that homeobox (Hox) genes are strictly involved in the differentiation of the paramesonephric duct into the mature female reproductive system [2]. Two weeks after birth, Hoxa9, Hoxa10, Hoxa11 and Hoxa13 develop their characteristic spatial distribution throughout the Müllerian ducts [3]. Moreover, it was demonstrated that the loss of Hoxa10 function provokes dysregulation during decidualization and implantation, resulting in female infertility [4]. Although clear data about the role of Hoxa gene clusters in infertility remain to be elucidated, we know that Hoxa10 specifically mediates the progesterone regulation of two prostaglandin E2 receptors (EP3 and EP4) in uterine stroma [5]. Moreover, another well-known family of genes that influence remarkably the organogenesis of the Müllerian reproductive tract is Wnt (wingless-type MMTV integration site family). Failures in Wnt signaling are associated with infertility, endometriosis, endometrial cancer and gestational trophoblastic disease such as choriocarcinomas [6]. Basing on these data, it is possible that epigenetic disturbance(s) during the Müllerian reproductive tract development may lead to modified intercellular communications, dysregulation of common downstream targets and, finally, to defect of organogenesis. Considering that the dysregulation of Wnt and/or Hox genes may affect cell migration during organogenesis and differentiation of Müllerian structures of the female reproductive tract, these altered pathways can underlie the well-known Mayer-Rokitansky-Kuster-Hauser Syndrome [7], clinically characterized by a physiological development of the secondary sexual characters and by a normal female karyotype 46 XX, with a congenital aplasia of the uterus and of 2/3 superior parts of vagina. A similar etiologic machinery was already hypothesized for endometriosis [8], a gynecological condition characterized by the breakdown of peritoneal immune homeostasis [9–11] and related symptoms and signs [12–14] due to the pro-inflammatory profile of pelvic as well as intrauterine microenvironment. Conflict of interest statement

Clinical factors and malignancy in endometrial polyps. Analysis of 1027 cases

STUDY OBJECTIVE To assess the prevalence of polyps carrying a malignancy and match association between clinical factors and oncologic progression. STUDY DESIGN A retrospective study (Canadian Task Force classification II-3) at a university hospital in Rome, Italy. We retrospectively analyzed data from 1027 women consecutively treated for endometrial polyps at our center in the period 2002-2011. The association of malignancy with hormonal status, tamoxifen, hypertension, symptoms, diabetes mellitus, obesity, and hormonal replacement therapy in pre- and post-menopausal women was assessed. RESULTS Mean age was 45.8±10.8 years. Benign polyps accounted for 95.8% of the total, pre-malignant for 2.67%, malignant for 1.54%. Our data showed that post-menopausal and older women (>60y) with endometrial polyps have a higher risk of developing a related endometrial cancer (OR: 3.05, 95% CI [1.54, 6.19], p<0.001 and OR: 2.8, 95% CI [1.38, 5.56], p≤0.003. Also we observed that women with AUB in the post-menopausal period displayed a risk of malignancy (OR: 31.1, 95% CI [10.3,111], p value <0.001). CONCLUSION Special attention should be drawn to symptomatic post-menopausal patients that appear to be at higher risk of malignancy. Symptomatic pre-menopausal women and asymptomatic post-menopausal women with polyps may be a group with intermediate-risk. These patients should undergo an individualized management plan, balancing both risks and benefits of surgical intervention after discussion with the patient.

Life-threatening bleeding after pelvic lymphadenectomy for cervical cancer: endovascular management of ruptured false aneurysm of the external iliac artery.

Late rupture of external iliac artery pseudo-aneurysm is an uncommon complication in patients who undergo extensive gynecologic radical surgeries. A 28-year-old woman with stage IB cervical cancer underwent pelvic lymphadenectomy and extrafascial trachelectomy. Two months after surgery, massive bleeding from ruptured pseudo-aneurysm of the external iliac artery occurred. Endovascular management with covered stent placement was feasible and safe to stop bleeding.

A case of high-grade leiomyosarcoma of the bladder with delayed onset and very poor prognosis

Mesenchymal tumors represent a small number of bladder cancer cases. Leiomyosarcoma is the most common histology with over 100 cases reported in the whole literature. This tumor is been historically considered as highly aggressive and showing a poor prognosis. Despite very low survival rates showed in older reports, some authors indicate that some patients could have a better outcome. We report a review of the literature and a case of high-grade LMS of the bladder in a 68 years old woman. Diagnosis was delayed and disease was locally advanced. Symptoms and imaging of our case first oriented to a gynecologic condition with an adnexal or uterine origin of the mass, and, a genitourinary origin could be unveiled only intra-operatively.

Vaginal treatment of endometrial cancer: role in the elderly

BackgroundTo compare abdominal hysterectomy, the most currently used for treating cancer of the endometrium, to the vaginal hysterectomy in term of survival, morbidity and failure rates.MethodsWe retrospectively analyzed 68 cases divided into two sub-groups. A study group of 31 cases received vaginal surgery; a control group of 37 cases was treated with a laparotomy. Mean operative time, median hospital stay, intra- and post-operative complications, DFS and OS time as well as occurrence of local or distant recurrences have been evaluated and reported. Cases included patients with a higher rate of medical morbidities (p = 0.01) than controls.ResultsMean age was 76.2 and 70.4 years in the vaginal (V) group and abdominal (A) group respectively. Mean operative time was longer for the group A. Group V patients had a lower mean post-operative hospital stay (p < 0.05). Differences in the two groups regarding intra- and post-operative complications, occurrence of local or distant recurrences and DFS time were not statistically significant. Disease specific survival time at 5 years scored 97% for group V, and 97% for group A.ConclusionsResults show how vaginal approach had a similar outcome in selected patients. Vaginal surgery could therefore be the proper choice in patients with early stages and lower surgical risk, in addition to elderly patients exposed to a higher surgical risk.

Laparoscopic injury of the obturator nerve during fertility-sparing procedure for cervical cancer

BackgroundIntraoperative injury of the obturator nerve has rarely been reported in patients with gynecological malignancies undergoing extensive radical surgeries. Irreversible damage of this nerve causes thigh paresthesia and claudication. Intraoperative repair may be done by end-to-end anastomosis or grafting when achieving tension-free anastomosis is not possible.Case presentationA 28-year-old woman with stage IB cervical cancer underwent fertility–sparing surgery, including conization and bilateral pelvic lymphadenectomy. The left obturator nerve was damaged intraoperatively during pelvic dissection.ConclusionImmediate laparoscopic repair was successful and there was no functional deficit in the left thigh for six months postoperatively.

Catamenial pneumothorax caused by thoracic endometriosis

Background Thoracic endometriosis syndrome is a rare form of extrapelvic endometriosis characterized by the presence of functioning endometrial tissue in pleura, lung parenchyma, and airways, associated with a high rate of infertility. Case Report We have reported a case of successful management and treatment of thoracic endometriosis syndrome that occurred in a 37-year-old female patient. She underwent thoracoscopic resection of the lesion. During follow-up, we revealed the recurrence of a previously surgically treated thoracic endometriosis. She was initially treated with a gonadotropin-releasing hormone agonist; subsequently this was replaced by a prophylactic treatment with Dienogest. Conclusion The diagnosis of thoracic endometriosis is challenging. The first line of treatment is medical, whereas the surgical treatment is performed secondly. Moreover, surgical treatment can lead to a significant rate of recurrence, often reduced by a coadjutant medical treatment.

Complete remission of cerebral endometriosis with dienogest: a case report

Abstract The most recent evidences suggest the use of progesterone mimicking drugs for the treatment of endometriosis. Particularly, dienogest has been largely tested. However, the standard treatment of extra-pelvic endometriosis is debated. Particularly, cerebral localization of endometriosis is a very rare clinical condition. The surgical approach for such a particular disorder would consist in difficult procedures, thus leading to prefer the medical treatment. We hereby report the clinical case of a cerebral localization of endometriosis treated with dienogest who experienced a complete remission of the disease.