Current Opinion in Obstetrics & Gynecology最新文献

Purpose of review: The vaginal microbiome plays an important role in protecting the vagina and bladder from infection. There is significant interest in understanding whether probiotics can normalize the vaginal microbiome and lead to decreased incidence of vulvovaginal-associated infections. Probiotics are an appealing treatment option as they are well tolerated, have a low risk profile, and potentially can reduce antibiotic usage.

Recent findings: Recent research suggests that probiotics may play a role in preventing recurrent bacterial vaginosis (BV) when administered with or after antibiotic treatment. Probiotics do not seem to be helpful for preventing recurrent vulvovaginal candidiasis. Probiotics prevent vaginal colonization with uropathogens from the gastrointestinal tract, and decrease recurrent urinary tract infections (UTIs) 76% when administered as part of a nonantibiotic recurrent UTI treatment bundle, which includes D-mannose, cranberry supplementation, and probiotics. Probiotics are a hopeful treatment for human papillomavirus (HPV), and evidence suggests that probiotic administration increases clearance of HPV and results in the resolution of abnormal papanicolaou test results.

Summary: Evidence shows that probiotics are useful treatments for BV, recurrent UTIs, and HPV. More research is necessary to recommend specific bacterial strains or products for each indication.

Purpose of review: Abnormal uterine bleeding (AUB) is a common complaint in adolescents and is mostly treated with hormonal medication. This review provides an update on adolescent AUB evaluation and treatment.

Recent findings: Anovulatory cycles and coagulopathies remain the most common reasons for AUB. Structural causes of AUB are still overall rare in adolescents, but recent advances in imaging techniques show they are more prevalent than previously thought. Since hormonal medication is the main treatment for AUB, acknowledging updates about their safety in certain populations is necessary. Investigations on nonhormonal medications for AUB and conservative surgical approaches are promising.

Summary: Recent updates to the safety of hormonal interventions impact management of AUB in adolescents. More research is needed to identify novel methods for managing AUB, as this can have negative impacts on both physical and mental health.

Purpose of review: Uterine fibroids are benign smooth muscle growths that can cause abnormal uterine bleeding, bulk symptoms, and infertility. Traditional treatments include medical therapy and surgical interventions such as hysterectomy and myomectomy. In the past three decades, minimally invasive, uterus-sparing alternatives - namely, high-intensity focused ultrasound (HIFU), uterine artery embolization (UAE), and radiofrequency ablation (RFA) - have revolutionized the management of symptomatic fibroids. Although early studies suggest these modalities are effective, high-quality data on their long-term efficacy, safety profiles, and reproductive outcomes are limited.

Recent findings: This paper presents a literature review on HIFU, UAE, and RFA for the treatment of symptomatic uterine fibroids. Studies report improvements in symptom severity and quality of life, with low complication rates. Optimal outcomes depend on careful patient selection, as certain factors increase the risk of treatment failure and the need for reintervention. Furthermore, little is known about pregnancy outcomes following these interventions, as studies are sparse and heterogenous.

Summary: HIFU, UAE, and RFA are safe and effective options for the treatment of symptomatic uterine fibroids. Further research is needed to evaluate long-term effectiveness, fertility and pregnancy outcomes, and comparisons between treatment modalities.

Purpose of review: The aim is to summarize the role of sentinel lymph node biopsy (SLN) in surgical staging for endometrial cancer (EC).

Recent findings: The value of SLN in EC staging continues to be demonstrated in all clinically uterine-confined disease, as SLN matches or improves the diagnostic accuracy of pelvic±para-aortic lymphadenectomy (PLD ± PALD) while reducing recovery time, surgical complications, and risk of lower extremity lymphedema. High diagnostic accuracy allows recommendation of appropriate adjuvant therapy, and recent studies have shown that even patients with high-risk histology may undergo SLN as opposed to PLD ± PALD provided this is combined with appropriate imaging. Debate about the necessity of any lymph node assessment in patients with certain low-risk features continues, with a preponderance of evidence pointing toward universal SLN in patients undergoing surgical staging for EC. In patients with negative SLN and intermediate risk uterine factors, molecular profiling is recommended to augment information gained through surgical assessment.

Summary: EC surgical staging with SLN is considered standard practice in clinically uterine-confined disease. This approach allows precise treatment recommendations without PLD ± PALD related side effects. The integration of molecular profiling with EC surgical staging will accelerate the benefits of therapeutic advances in EC.

Purpose of review: Chronic endometritis is a condition that may affect reproductive outcomes, particularly in patients with unexplained infertility, recurrent implantation failure, or recurrent pregnancy loss. This review concisely summarizes the available literature, highlighting some of the controversies on this topic.

Recent findings: Although embryo selection through preimplantation genetic testing for aneuploidy has improved, many euploid embryo transfers still fail, prompting interest in endometrial factors such as chronic endometritis. Chronic endometritis is typically asymptomatic and diagnosed by identifying plasma cells in endometrial biopsy specimens; however, diagnostic criteria vary widely regarding biopsy timing, staining techniques, and threshold definitions, contributing to inconsistent prevalence and outcomes across studies. It is often attributed to chronic infection and is treated with empirical or culture-guided antibiotics, though reported cure rates vary significantly. While some studies suggest that treating chronic endometritis improves reproductive outcomes, evidence is limited by methodological heterogeneity. Meta-analyses support treatment, yet diagnostic inconsistencies and potential effects of antibiotics on the microbiome remain concerns.

Summary: While frequently diagnosed in the infertility setting, the true prevalence and impact of chronic endometritis remain unclear. The heterogeneity of the existing literature and the lack of large prospective cohort studies remain challenges to fully understanding the condition, particularly regarding the general infertile population.

Purpose of review: The vulva is part of the skin. A wide spectrum of dermatological diseases affects the vulva, including infections, dermatoses, manifestations of hormonal and systemic conditions, and neoplasia. Vulval diseases are typically associated with significant delay in diagnosis due to limited healthcare practitioner knowledge amongst primary care physicians and specialists alike. This review article provides an update on the diagnosis and management of common vulval lesions.

Recent findings: This article reviews the literature on vulval lesions and vulval dermatoses and was conducted through searching PubMed. Common causes of vulval lesions are presented, including vulval cancer, vulval squamous intraepithelial lesions, dermatitis, psoriasis, lichen simplex chronicus, acute and chronic candida vulvovaginitis, lichen sclerosus, lichen planus, and nonsexually acquired genital ulceration.

Summary: Vulval complaints are common. It is important to not only be able to differentiate between benign findings and potentially premalignant or malignant lesions but also recognise and manage common causes of vulval lesions such as dermatitis, psoriasis, lichen sclerosus, infectious causes of disease, and nonsexually acquired genital ulceration.

Purpose of the review: Vasomotor symptoms or hot flashes are reported by 80% of women and have a median duration of 7 years. About 25-30% of women have severe enough symptoms that activities of daily living and workplace productivity are compromised. Although hormone therapy is the 'gold standard' for hot flash treatment, many women are unable or unwilling to use it.

Recent findings: A number of nonhormone treatments for hot flashes are supported by medical evidence, but only two (paroxetine mesylate and fezolinetant) are currently Food and Drug Administration approved. Selective serotonin reuptake inhibitors and selective serotonin reuptake inhibitor-norepinephrine reuptake inhibitors, gabapentin, oxybutynin, clonidine, and fezolinetant are described. The new class of neurokinin-3 receptor antagonists includes both fezolinetant and elinzanetant and acts directly on the hypothalamic neurons that control body temperature regulation. These latter agents have an efficacy profile that approaches that of hormone therapy and lack the off-target side effects seen with other nonhormonal treatments.

Summary: Women who cannot use or wish to avoid hormones have a number of nonhormonal options to choose from to treat hot flashes. New science elucidating the biology of hot flashes holds great promise for highly effective treatments that do not have off-target effects.

Purpose of review: This review sets out to document some of the recent developments in the field of preconception care (PCC).

Recent findings: Recent advances in PCC reflect a growing understanding of the complex interplay between medical, behavioral, environmental, and social factors that influence reproductive health. Innovations in genetic carrier screening have led to an expansion in the availability of testing, and the preconception period being recognized as the ideal time. Other studies have highlighted the rise in chronic diseases amongst reproductive age women and their partners, with the common ones being diabetes and overweight and obesity. The health of people with these conditions often remains poorly optimized before pregnancy leading to adverse perinatal outcomes. Those attempting weight loss with the use of glucagon-like peptide-1 receptor agonists need to be aware that the medications should be ceased 2 months before pregnancy and their use is contraindicated in pregnancy. There remains an emphasis on health equity and the integration of PCC into broader public health initiatives to broaden its reach and impact.

Summary: This article explores the latest research in PCC, highlighting evidence-based practices, and public health implications that collectively aim to enhance reproductive health across populations.

Purpose of review: Ovarian cancer remains the most lethal gynaecological cancer. Early detection and treatment options are limited, so prevention is key. This article reviews the current opinion on opportunistic salpingectomy for ovarian cancer prevention within the general population.

Recent findings: Salpingectomy (the removal of the fimbriated ends of the fallopian tubes) reduces ovarian cancer risk without inducing early menopause or depleting ovarian reserves. The International Federation of Gynecology and Obstetrics firmly supports the use of salpingectomy opportunistically (in addition to planned abdominal surgery) for ovarian cancer risk reduction. When salpingectomy should be provided as an elective surgery, and what nongynecological surgeries can be used as opportunities for salpingectomy, is an ongoing discussion.

Summary: As understanding of the safety and efficacy of opportunistic salpingectomy has solidified into guidelines, its use for ovarian cancer risk reduction has increased. However, the uptake of opportunistic salpingectomy has varied between geographic regions and across institutions. In the US, roughly a third of women undergo a hysterectomy during their lifetime, each of these women should have a chance to consider opportunistic salpingectomy for ovarian cancer prevention. Education about the benefits and harms of opportunistic salpingectomy is both necessary and effective in reducing inequities in access to this risk-reducing surgery.

Purpose of review: Congenital syphilis continues to result in devastating adverse pregnancy and infant outcomes globally, with significant rises noted in recent years in high-income countries (HIC). Prenatal screening and prompt treatment for syphilis in pregnant persons are important in contributing to healthy pregnancy outcomes, particularly in equity-denied populations. However, the implementation of these recommendations remains challenging, even in HIC.

Recent findings: Although antenatal screening guidelines for syphilis universally recommend screening in pregnancy, the implementation of these recommendations has been challenging. In HIC, individuals grappling with poverty, unstable housing, addictions, and mental health concerns often encounter significant barriers to accessing essential healthcare services. Innovative approaches, such as the use of rapid/point-of-care tests, opportunistic screening, and community-based or outreach testing, are essential to reach key equity-denied populations. It is crucial to include members of key populations and community-based organizations in the design of interventions to effectively reach these populations.

Summary: Given the resurgence of congenital syphilis in some regions, especially in HIC, we must address this preventable cause of maternal and fetal morbidity and mortality effectively. Collaboration between all levels of government and health services and the inclusion of key equity-denied populations is crucial.