Introduction

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The Endometrium in Adenomyosis

The observation has long been reported of direct continuity between the eutopic and the ectopic endometrial glands in adenomyosis. Recent evidence point to the existence of differences between the endometrium in adenomyosis compared to control endometrium including increased 'invasiveness' in adenomyosis. Differences were also reported between the eutopic endometrium in adenomyosis and endometriosis. However, almost all published literature suffers from methodological weaknesses including inadequate control for cycle phase and symptoms. This calls for caution when interpreting the findings or drawing conclusions relevant to the pathophysiology of adenomyosis

Menstrual preconditioning for the prevention of major obstetrical syndromes in polycystic ovary syndrome

The presence of multiple ovarian cysts, anovulation, and endometrial progesterone resistance in the neonate seems remarkably similar to ovarian and endometrial features of the polycystic ovary syndrome (PCOS) of adolescent and adult women. In fact, in the absence of cyclic menstruations after menarche, the neonatal progesterone resistance is likely to persist and adversely affect young women with PCOS at the time of pregnancy after induction of ovulation, because any persisting defect in progesterone response can interfere with the process of decidualization and trophoblast invasion. The primigravid woman with PCOS therefore is likely to be at risk of defective deep placentation as manifested by the increased risk of major obstetric syndromes. A recent, large epidemiologic study has demonstrated that the risk of preeclampsia and preterm delivery is elevated in the 13- to 15-year old group, although it does not persist in the 16- to 17-year old group. It is proposed therefore that induction of ovulation in the infertile nulligravid woman with PCOS should be preceded by a period of progesterone withdrawal bleedings to achieve full endometrial progesterone response by the time of pregnancy. The cyclic administration of clomiphene citrate for a period to be determined by vascular response may be an appropriate tool to reduce the risk of major obstetric syndromes by menstrual preconditioning

Safety, efficacy and patient satisfaction with continuous daily administration of levonorgestrel/ethinylestradiol oral contraceptives

The progestational steroid norgestrel was synthesized and tested between 1960 and 1965 through an international cooperation between Wyeth, USA and Schering, Berlin. It is a mixture of two “enantiomers,” with only one form (designated as levonorgestrel) biologically active. When taken orally, it is rapidly absorbed, not subjected to a “first-pass” effect and is approximately 90% bioavailable, with a circulating half-life around 15 hours. Its contraceptive action is exerted at the central (hypothalamic) and peripheral (cervical mucus and endometrium) levels. Levonorgestrel (LNG), alone or in combination with ethinyl estradiol (EE), is the most widely employed contraceptive progestin: it is used in combined oral contraceptives, progestogen-only pills, long-acting contraceptive implants, intrauterine contraceptive systems and in emergency contraception. It is also the steroid of choice for new oral contraceptive regimens aimed at reducing the frequency of bleeding episodes. This novel approach, already tried more than 30 years ago, gained interest around the year 2000 when surveys of women’s attitudes toward monthly menstrual bleeding started to show a major change: more and more women declared that they would welcome a hormonal contraceptive method that reduced bleeding episodes to 4, 2 or even 1 per year. At this point, while the debate on the significance and “usefulness” of menstruation went on, attention focused on new regimens. The first new modality consisted of changing the 7-day medication-free interval, either shortening it to fewer than 7 days, or by the administration of low-dose estrogens during the interval between packages. Then, continuous administration regimens started to be investigated. This, however, did not happen suddenly, since, in specific situations, doctors had for years empirically utilized various continuous administration regimens. The first extended-cycle oral contraceptive regimen introduced in clinical practice is an 84-day regimen that results in bleeding only 4 times a year. A commercial product specifically packed for continuous use is now available in Europe and contains 30 μg EE and 150 μg LNG. In a variation of this regimen, after administration of the same combination for 84 days, women are given 7 pills containing 10 μg EE. A 6-monthly regimen has also been tested in a small study using EE 20 μg plus LNG 100 μg taken with and without a hormone-free interval. Women in the continuous group reported significantly fewer bleeding days requiring protection and were more likely to have amenorrhea; in addition they also reported significantly fewer days of bloating and menstrual pain. A yearly regimen is now being developed. Each pill of this novel formulation contains EE 20 μg and LNG 90 μg to be taken continuously for 364 days (13 cycles) per year. A phase III trial has now evaluated safety, efficacy and menses inhibition. At the end of the 1-year trial amenorrhea was present in 58.7% of the women and a complete absence of bleeding in 79.0%. Overall, the number of bleeding and spotting days per pill pack declined with time and adverse events and discontinuations were comparable to those reported for cyclic oral contraceptive regimens

Long-Acting Hormonal Contraception:

For 30 years the combined oral contraceptive pill has been an almost automatic choice for effective contraception in sexually active adolescent women. Nevertheless consideration of the criteria of a hypothetical "ideal" contraceptive suggests that long-acting progestogen-only methods may have considerable advantages for some adolescents. These would include greater efficacy easier compliance avoidance of estrogenic side effects and potentially greater privacy. The disadvantages of menstrual irregularity progestogenic side effects including weight gain and the initial greater medicalization of the method particularly implants must be weighed against the wishes and preferences of the adolescent. A number of studies of the uptake and utilization of these methods in adolescence have arisen particularly from the US. These are reviewed together with experience from programs in the United Kingdom. (authors

Italian Constitutional Court removes the prohibition on gamete donation in Italy

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La legge sull’interruzione volontaria di gravidanza e l’aborto tardivo

Law 194/78 regulates the practice of voluntary abortion in Italy. This law identifies two different kinds of abortive procedures: the first one, the therapeutic abortion sensu strictu, can be performed only if the woman’s life is at serious risk. The second one, the indirect eugenic abortion, is allowed only if the foetus has “relevant anomalies or malformations”, and it is aimed at preserving the physical and mental health of the mother. On this point the law is not clear, therefore leading to possible misunderstanding, and subsequent risks for the mother and the physicians. The article provides an overview of the law, explaining its meaning, and underlining its limits and possible interpretative errors

La legislazione italiana sulla fecondazione assistita: tra norme restrittive e interpretazioni giuridiche

The Italian Law 40/2004 regulates assisted reproduction technology; it states that no more than three embryos must be created at any one time; that all the embryos created must be transferred together, and that embryo cryopreservation is forbidden. Six years after its promulgation, the debate over this issue is still heated. On 8 May 2009, the Italian Constitutional Court declared that some parts of the law are unconstitutional. The article highlights the key points of the law and their implications, underlining the importance of coming to an agreement between the parties to the case, with the final aim of protecting both women’s and children’s health

Improving sexual and reproductive health of migrant girls and women living with female genital mutilations providing them with specific maternity care

Background: Worldwide, 200 million girls and women have been estimated as living with female genital mutilation/cutting. Today, this phenomenon does not only concern the countries where this practice is widespread, but also in many other nations where the immigrant female population comes from the countries with high prevalence, or is clandestinely practiced in the countries of destination of immigrant girls and women. It has been estimated that 50 to 80% of all African women who migrated to Italy more than 5 years ago, underwent some form of FGM. Two-third of these have been found to be afraid of seeking gynecological care. Only a small proportion of the 60% who have a vaginal delivery receive appropriate care (anesthesia and de-infibulation). FGM is responsible for specific short and long-term complications that include uro-gynaecological, obstetric, infectious, psychological and sexual consequences requiring appropriate care. The Department of Reproductive Health and Research (RHR) of the WHO has recently published new guidelines on the management of health complications from FGM with up-to-date, evidence-based recommendations. The European Union has also recently launched an E-learning tool to improve knowledge of healthcare for asylum-seekers among professionals. Its aims are to provide easily accessible information and support to professionals dealing with FGM Aim: The main scope of the project proposed is: to map existing referral centres and centres with expertise on women and girls living with FGM in Italy and make this information available for professionals and the women concerned (website, professional boards). In addition we aim to define the scientific, clinical and organisational requirements for such centres and to implement updated and evidence-based training courses in obstetric and gynaecological diagnosis and management of FGM (in particular defibulation) and its complications at a national level. Training courses will also provide useful information on further subjects, such as asylum-seekers and FGM and the legal situation concerning FGM. Finally we hope to promote research on the economical impact of FGM