Current Opinion in Obstetrics & Gynecology最新文献

Purpose of review: Endometrial cancer (EC) is rising in incidence, particularly in younger, premenopausal women, due to increasing rates of obesity and delayed childbearing. This review evaluates current and emerging endocrine therapies, with a focus on fertility-preserving approaches for early-stage EC and treatment options for advanced or recurrent disease.

Recent findings: Fertility-sparing endocrine therapies, such as medroxyprogesterone acetate, megestrol acetate, and levonorgestrel-releasing intrauterine devices, achieve high response rates but carry recurrence risks. Biomarkers, including progesterone receptor status and molecular subtyping, are improving patient selection and outcomes. In advanced EC, single-agent and combination endocrine therapies with agents like selective estrogen receptor modulators, selective estrogen receptor down-regulators (SERDs), and aromatase inhibitors show efficacy, especially in hormone receptor-positive disease. Newer agents, including next-generation SERDs and proteolysis-targeting chimeras, hold potential for treating resistant cases.

Summary: Endocrine therapy offers a well tolerated alternative to chemotherapy in selected EC patients, particularly those with hormone-sensitive tumors. Advances in molecular profiling and the development of novel endocrine agents are refining treatment strategies, supporting endocrine therapy's continued role in managing EC across various stages.

Purpose of review: Perimenopausal and menopausal symptoms are common and may significantly impact quality of life. Menopausal hormone therapy is the most effective treatment but may not be appropriate in all cases. Nonhormonal alternatives range from lifestyle changes and dietary supplements to medical interventions and prescription therapies. This review will summarize the newest advancements in nonhormonal therapies for bothersome perimenopausal and menopausal symptoms.

Recent findings: The Menopause Society recently updated their recommendations and guidelines for nonhormonal therapies. Previous recommendations, such as clonidine and pregabalin, are no longer recommended. A new class of medication, neurokinin B antagonists, are now available to target vasomotor symptoms and show promise in addressing sleep and mood issues.

Summary: Well tolerated, effective nonhormonal therapies are available to address perimenopausal and menopausal symptoms for those patients who are not candidates for or chose not to use menopausal hormone therapy.

Purpose of review: A life-limiting fetal diagnosis (LLD) refers to a medical condition identified during pregnancy that is expected to lead to stillbirth, preclude ex utero survival, or significantly reduce neonatal life expectancy. The terms 'lethal' or 'life-limiting' are used to prognosticate early death for various anatomic or physiologic causes, although the expected timeframe is nonspecific. The purpose of this manuscript is to review how the terms 'lethal' or 'life limiting' are used in contemporary perinatal research.

Recent findings: Depending on the study design, 'life-limiting' is defined either prior to data analysis (such as prospective cohort studies), or after outcomes are assessed (such as case series). When 'life-limiting' is defined prior to data analysis, study-specific specific definitions may include timeframes from birth to death, probability of neonatal mortality, or a list of diagnoses based off billing codes.

Summary: Professional societies have guidelines to standardize the reporting of vital statistics, including early death. While these fall short of defining LLDs comprehensively, they present an opportunity for more specific prognostication following prenatal diagnosis, which may improve research standardization to facilitate a clearer understanding of LLDs in clinical practice.

Purpose of review: Despite the availability of Rh(D) immune globulin (RhIg) to prevent alloimmunization in Rh(D)-negative pregnant patients, anti-Rh(D) alloimmunization remains a prevalent cause of hemolytic disease of the fetus and newborn (HDFN). Recent RhIg shortages have caused clinicians and professional societies to identify methods to prioritize RhIg administration. New cell-free DNA (cfDNA) tests to predict fetal red blood cell antigen genotypes have been proposed as an option to prioritize the administration of RhIg to Rh(D)-negative pregnant people.

Recent findings: Commercial laboratories offer fetal Rh(D) genotype testing as part of cfDNA screening for fetal aneuploidy. Studies indicate that these tests have a high sensitivity and specificity for the detection of fetal Rh(D) status. Considering the current RhIg shortage, the American College of Obstetricians & Gynecologists (ACOG) suggests that utilizing cfDNA tests to determine fetal Rh(D) status is a reasonable approach to prioritize RhIg administration when supply is limited.

Summary: cfDNA screening for fetal Rh(D) status is a reasonable approach to triage the administration of RhIg in the setting of the current RhIg shortage. Utilization of cfDNA screening for fetal Rh(D) and other red blood cell antigen status is likely to increase in routine care. Research, professional society guidance, and education are necessary to ensure well tolerated and equitable utilization.

Purpose of review: This review aims to provide a comprehensive overview of the specific challenges, health considerations, and healthcare needs of transgender and gender diverse (TGD) people navigating menopause, highlighting the intersection of gender identity, hormone treatment, and age-related changes.

Recent findings: Research on menopause in TGD individuals is lacking, without guidelines to support clinical management. This is the first review of its type to summarize the described impact of the menopausal transition on TGD individuals, the potential long-term risks associated with both gender-affirming hormone therapy and the intersectionality with aging, and how these risks may impact hormone management and overall comprehensive care.

Summary: By drawing on the shared principles of cisgender menopausal hormone therapy and gender-affirming hormone therapy, providers are well positioned to apply their expertise to support the TGD population during menopause. We recommend using shared decision-making, culturally competent care, and a strong understanding of the biological, personal, and social experiences of TGD people that do not necessarily conform to stereotypically ciswoman experiences.

Purpose of review: Sleep problems are among the most prevalent and bothersome symptoms of menopause. This review characterizes menopausal sleep disturbances, describes biopsychosocial predictors, and summarizes the evidence supporting pharmacological and nonpharmacological treatment options.

Recent findings: Recent studies found that sleep changes are early indicators of perimenopause and sought to disentangle the respective impacts of menopausal status, hot flashes (HFs), and changes in reproductive hormones on peri-/postmenopausal sleep problems. Both HFs and reproductive hormones predicted sleep problems, but neither solely accounted for the myriad changes in sleep, thus highlighting the contribution of additional biopsychosocial risk factors. Inconsistencies across studies were likely due to differences in study design and methodology, participants' menopausal stage, and the presence of sleep complaints. Recent studies support the use of psychological (cognitive-behavioral therapy for insomnia) and pharmacological (e.g., neurokinin B antagonists) treatments in addition to hormone therapy.

Summary: Sleep problems are common and of critical import to women during the menopausal transition, significantly influencing treatment preferences and satisfaction. Thus, sleep problems should be routinely assessed from a biopsychosocial perspective and treated with evidence-based interventions throughout menopause. Treatment selection should be based on diagnosis and careful assessment.

Purpose of review: This review discusses mental health changes commonly experienced by individuals during the menopause transition (MT). The pathophysiology of the MT, the chronology and type of mental health symptoms arising from this pathophysiology, and evidence-based options for treating midlife patients are discussed. This review concludes with treatment options to enable clinicians to more effectively counsel, recognize and treat symptoms during the MT.

Recent findings: The MT begins earlier than previously understood with mood and cognitive issues as common initial mental health symptoms significantly impacting quality of life. These symptoms are due to profound changes in the brain's structure, connectivity, energy metabolism, and inflammation linked to perimenopausal hormone shifts. Hormone therapy, psychiatric medication, psychotherapy, and lifestyle adjustments all play a role in the management of mental health symptoms arising during the MT. Lack of both obstetrician and gynecologist and mental health clinician awareness can leave patients undertreated and vulnerable to nonevidence-based approaches.

Summary: Patients in the MT are at increased risk for mental health issues, both preexisting and new onset. The OB/GYN clinician plays a key role in recognizing and addressing these conditions to improve health outcomes in midlife women.

Purpose of review: This review aims to elucidate the developments in subclinical hypothyroidism (SCH) in pregnancy effects, management, and treatment. While mostly focusing on recent research, landmark studies are briefly reviewed to highlight major developments since their publication.

Recent findings: Research has continued to show an increased risk of adverse outcomes in pregnant women with SCH, with recent research showing an increased risk of both impaired glucose tolerance and hypertensive disorders of pregnancy. Research has continued to show unclear effects of SCH on neonatal outcomes, specifically in offsprings' intellectual development and ability. The benefit of treatment of SCH continues to be unclear; however, data suggest that treatment for thyroid stimulating hormone (TSH) 2.5-4 mU/l regardless of thyroid peroxidase antibodies status and TSH 4-10 mU/l in later pregnancy has not shown maternal or neonatal benefit.

Summary: With varying guidelines and inconsistent research outcomes, it is not surprising that SCH practices differ widely. Further research, with uniform definitions and criteria of SCH, is needed to elucidate the optimal management and treatment of this common pregnancy condition. Additionally, further research specifically aimed at optimizing TSH in preconception and early pregnancy is needed.

Purpose of review: Provide the most up-to-date information on the dynamic landscape of antibody-drug conjugates (ADCs) in gynecologic cancers. We discuss the latest research that supports the approved ADCs and outline the ongoing trials and preliminary results that may lead to ADC approvals in the future. Current gaps in knowledge and areas for future research are discussed.

Recent findings: ADCs are rapidly changing the landscape of gynecologic cancer care. Three ADCs are currently FDA approved and used routinely in clinical practice, with many more currently in clinical development. The most common ADC target is folate receptor alpha of which there are 8 different folate receptor targeting ADCs in development. Other targets under investigation include trophoblast cell surface antigen-2 (Trop-2), claudin-6 (CLDN6), cadherin-6 (CDH6), nectin-4, HER-2 and B7-H4. ADCs can cause new and unique adverse effects, including ocular toxicities and interstitial lung disease.

Summary: ADCs offer the opportunity for a more effective and personalized treatment approach for gynecologic cancer patients. Side effects must be closely monitored, and preventive measures must be followed to maximize benefit and minimize toxicity. A better understanding of the role of target proteins as biomarkers to predict response to ADCs will be critical for successful clinical implementation of ADCs and further research in this area is necessary.