Current Opinion in Obstetrics & Gynecology最新文献

Purpose of review: Hysterectomy remains one of the most performed gynecologic procedures, yet its application in young and nulliparous individuals raises complex ethical, medical, and psychosocial considerations. As early detection of gynecologic conditions improves, requests for hysterectomy at younger ages may increase. This review examines the current literature on the morbidity, quality of life, psychological impact, and social implications of hysterectomy in younger patients.

Recent findings: Research indicates both benefits and risks associated with early-age hysterectomy. While it provides significant symptom relief for conditions such as chronic pelvic pain, endometriosis, and fibroids, studies also suggest an increased risk of cardiovascular disease, metabolic disorders, and psychological distress. Younger patients may experience residual symptoms and identity disruption, particularly in relation to fertility loss. While regret appears to be low in the short term, long-term data on patient satisfaction remain limited. In addition, hysterectomy plays a critical role in gender-affirming care, highlighting the need for individualized counseling.

Summary: Gynecology providers must engage in shared decision-making, providing evidence-based counseling on the benefits, risks, and alternatives to hysterectomy. Future research should focus on long-term outcomes, particularly in younger and nulliparous patients, to guide best practices and optimize patient-centered care.

Purpose of the review: Among patients with hereditary breast and ovarian cancer, risk reduction strategies have a direct impact on fertility. In this review, we highlight the importance of early referral of those patients to fertility specialists for fertility planning, as the consideration for these risk-reducing procedures is overlaid with thoughts on childbearing.

Recent findings: Increased utilization of genetic testing has identified individuals with inherited pathogenic variants increasing risks of breast and ovarian cancer. For those patients, studies have identified potential areas for improvement including counseling on reproductive potential, fertility preservation, and the option for preimplantation genetic testing. Recent guidelines have emphasized the importance of consultation with a reproductive endocrinologist in the care of those patients.

Summary: Early referral to fertility specialists would ensure that reproductive concerns are met in a timely fashion and would facilitate future fertility planning, reviewing options for IVF, oocyte and embryo cryopreservation, and consideration of preimplantation genetic testing.

Purpose of review: Social media has transformed how patients access and interpret gynecological health information, significantly influencing their expectations and medical decision-making. This comprehensive review examines how social media impacts patients' understanding of diagnoses, pursuit of treatment options, and interactions with healthcare providers. The increasing reliance on online content presents challenges, particularly when patients prioritize social media content over evidence-based recommendations. Given the rapid evolution of digital platforms, it is essential to understand the current trends and their impact on clinical practice.

Recent findings: Recent studies demonstrate that while social media offers unprecedented access to health information and community support, it simultaneously propagates misinformation that can adversely affect clinical encounters. Patients frequently turn to platforms such as TikTok, Instagram, X (formerly Twitter), and YouTube for gynecologic health information, though much of this content is anecdotal and lacks scientific validity. Research shows that while these platforms offer a wealth of information, the quality of this information is inconsistent, often leading to misconceptions about medical conditions and treatments. Healthcare providers face the dual challenge of addressing misconceptions while leveraging these platforms to enhance patient education and shared decision-making.

Summary: Understanding the influence of social media can help improve the accuracy of online health information and reduce stigma and social barriers surrounding gynecologic issues. Strengthening digital literacy and integrating reliable online resources into clinical practice can enhance patient education and promote informed decision-making in gynecology and gynecologic surgery.

Purpose of review: Intrauterine adhesions (IUA) are fibrous bands of scar tissue within the uterine cavity resulting from trauma to the endometrium. Despite treatment with hysteroscopic lysis of IUA, recurrence rates are substantial, ranging from 3 to 25%. Practice patterns can differ widely regarding intraoperative and postoperative interventions. Our goal is to review current literature that explores strategies to decrease recurrence of IUA.

Recent findings: This literature review examines intraoperative recommendations regarding surgical technique for lysis of IUA, intrauterine placement of mechanical barriers like a balloon or an intrauterine device, and use of substances like hyaluronic acid, platelet-rich plasma, and amnion graft. Postoperative techniques including hormonal medications after lysis of IUA, medications that increase vascular flow to the uterus, and second-look hysteroscopy are also explored.

Summary: Various intraoperative and postoperative interventions show promise in reducing IUA reformation after hysteroscopic lysis of adhesions. What remains to be explored are implications of preventive therapy on pregnancy rate and live birth rate. Additionally, the optimal combination of therapy for preventing IUA recurrence has yet to be established. Further research is essential to determine the most effective strategies for preventing IUA reformation and optimizing long-term reproductive health.

Purpose of review: This review explores the medical management of abnormal uterine bleeding (AUB) in women at risk for venous thromboembolism (VTE), with a focus on six key principles to consider when initiating hormonal therapies for this patient population. Case studies are used to illustrate these principles in practice, emphasizing the importance of assessing the patient's thrombotic risk and selecting appropriate therapies to effectively manage AUB while minimizing the risk of VTE.

Recent findings: While estrogen and certain high-dose progestins are known to elevate VTE risk, evidence suggests that progestin-only formulations and lower-dose hormonal therapies may not significantly increase this risk, even in vulnerable populations. Antifibrinolytic agents such as tranexamic acid are effective in reducing menstrual blood loss without the risk of thromboembolic complications.

Summary: There is wide variability in the thrombotic risks associated with the various hormonal and nonhormonal therapies available for managing AUB. A thorough evaluation of a patient's VTE risk factors and preferences is essential for effectively managing AUB in women at risk for thrombotic events.

Purpose of review: Hot flashes are a prevalent and bothersome symptom associated with menopause. Beyond the fact that they cause discomfort, hot flashes are responsible for significant healthcare costs and lost productivity among midlife women. They may also be a harbinger for future disease risk. While hormone therapy is a mainstay of treatment, many women cannot or do not wish to take hormones to mitigate their hot flashes.

Recent findings: The discovery of the linkage of the neurokinin (NK) receptor to hot flashes has resulted in a rapid bench-to-bedside development of a new class of compounds targeting the NK3 receptor and its related pathways. Fezolinetant is the first FDA-approved medication in this class, and elinzanetant is awaiting FDA approval. Both agents are effective against hot flashes and represent exciting new nonhormonal treatments that are free of untoward off-target effects. Both have demonstrated improvements in patient self-reported sleep outcomes.

Summary: Targeting of the NK receptor in the hypothalamus has led to the availability of nonhormonal options for menopausal women suffering from hot flashes.

Purpose of review: Atypical endometriosis is a distinct subtype of endometriosis, characterized by specific histopathologic findings. It is thought to be a precursor lesion to endometriosis-associated ovarian cancers, particularly clear-cell and endometrioid subtypes, analogous to endometrial intraepithelial neoplasia as a precursor lesion to endometrial cancer. This review summarizes recent evidence regarding the pathogenesis of atypical endometriosis and progression to endometriosis-associated ovarian cancer and the diagnosis and management of atypical endometriosis.

Recent findings: (a) Pathogenesis: Deep infiltrating endometriosis and ovarian endometriomas are associated with an increased risk of ovarian cancer. Genomic alterations in endometriosis potentiate progression from benign to malignant disease. Dysregulation in the mechanistic target of the rapamycin pathway is noted throughout endometriosis and endometriosis-associated ovarian cancer. (b) Diagnosis: Glandular crowding is emphasized as an important pathologic characteristic in atypical endometriosis and appears to increase the risk of development of ovarian cancer. (c) Management: Management strategies for atypical endometriosis are guided by clinical history and imaging characteristics.

Summary: A strong association exists between ovarian endometriomas and deep infiltrating endometriosis and ovarian cancer. While new genomic alterations have been implicated in the progression from endometriosis to endometriosis-associated ovarian cancer, there remains no established molecular mechanism to predict cancer progression. Accurate pathologic diagnosis of atypical endometriosis is critical to characterizing ovarian cancer risk. Appropriate patient selection for salpingo-oophorectomy is the foundation of management for atypical endometriosis.

Purpose of review: The use of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) is on the rise and their impact on reproductive health in healthy women without polycystic ovary syndrome (PCOS) remains unclear. This review provides a critical analysis of existing data about their impact on reproduction in non-PCOS state.

Recent findings: To date, studies in animal models have been very heterogeneous using different models (rats versus mice) and different types of GLP-1 RAs (liraglutide versus exendin-4 versus dulaglutide), with variable modes of administration (subcutaneous versus intracerebral) and variable duration/dose of administration. In the ovaries, GLP-1 RA caused lower ovarian weights, more follicular atresia, and a drop in serum steroid levels. In the hypothalamus, GLP-1 RA caused downregulation in kiss-1 and kiss-1r expression leading to lower serum luteinizing hormone levels and delay in puberty. In the uterus, GLP-1 RAs caused a negative impact on the epithelium, however, in the intrauterine adhesion mouse model, they lowered uterine fibrosis. No human studies to examine the effect of GLP-1 RAs on fertility in women without PCOS have been published.

Summary: Further research is essential to understand the impact of GLP-1 RA in non-PCOS women, especially because many reproductive-aged women without PCOS are using these medications for weight loss.