Non-hormonal treatment of vulvo-vaginal atrophy-related symptoms in post-menopausal women

In post-menopausal period vulvo-vaginal atrophy (VVA)-related symptoms may seriously affect women's quality of life. Hormonal replacement therapy effectively relieves these symptoms but it is not always safe or accepted, and a non-hormonal treatment is often needed instead. Over a period of 12 weeks, we tested the effect of a twice-a-week vulvo-vaginal application of a hyaluronic acid, AC collagen, isoflavones and vitamins-based cream (Perilei Pausa(®)) on 35 women in post-menopausal period, reporting VVA-related symptoms. After 12 weeks of treatment with Perilei Pausa(®) a significant improvement in vaginal dryness, vulvo-vaginal itching, dyspareunia (P < 0.001), dysuria (P = 0.02), nocturia (P = 0.009) and pollakiuria (P = 0.005) was reported by the women. Colposcopical score assessing the intensity of atrophic colpitis, cervico-vaginal paleness and petechiae was also reduced (P = 0.037, P = 0.016 and P = 0.032, respectively). No significant difference in terms of maturation value of cervico-vaginal epithelium was observed. In conclusion, Perilei Pausa(®) may represent an effective and safe alternative treatment of symptomatic VVA in post-menopausal women

Effort-related functions of nucleus accumbens dopamine and associated forebrain circuits

Background Over the last several years, it has become apparent that there are critical problems with the hypothesis that brain dopamine (DA) systems, particularly in the nucleus accumbens, directly mediate the rewarding or primary motivational characteristics of natural stimuli such as food. Hypotheses related to DA function are undergoing a substantial restructuring, such that the classic emphasis on hedonia and primary reward is giving way to diverse lines of research that focus on aspects of instrumental learning, reward prediction, incentive motivation, and behavioral activation. Objective The present review discusses dopaminergic involvement in behavioral activation and, in particular, emphasizes the effort-related functions of nucleus accumbens DA and associated forebrain circuitry. Results The effects of accumbens DA depletions on food-seeking behavior are critically dependent upon the work requirements of the task. Lever pressing schedules that have minimal work requirements are largely unaffected by accumbens DA depletions, whereas reinforcement schedules that have high work (e.g., ratio) requirements are substantially impaired by accumbens DA depletions. Moreover, interference with accumbens DA transmission exerts a powerful influence over effort-related decision making. Rats with accumbens DA depletions reallocate their instrumental behavior away from food-reinforced tasks that have high response requirements, and instead, these rats select a less-effortful type of food-seeking behavior. Conclusions Along with prefrontal cortex and the amygdala, nucleus accumbens is a component of the brain circuitry regulating effort-related functions. Studies of the brain systems regulating effort-based processes may have implications for understanding drug abuse, as well as energy-related disorders such as psychomotor slowing, fatigue, or anergia in depression

Twist and re-twist of the ovary in a young woman with ribbon-like contralateral ovary and absence of contralateral tube.

A 24-year-old nulliparous Caucasian woman was referred to our Center for a suspicious right adnexal mass detected at ultrasound examination performed in another hospital (Figure a, e). She complained nausea and recurrent pelvic pain in the last two months. On transvaginal ultrasound examination at our Institution, uterus and right ovary were normal (Figure b), the left ovary appeared reduced in size showing a ribbon-like appearance (Figure f); neither pelvic mass not free fluid in the pelvis was detected. After reviewing the ultrasound images of the previous examination (Figure a,e), a diagnosis of ovarian torsion spontaneously solved in two weeks was hypothesized. Probably, an edematous ovary has been misdiagnosed as an ovarian mass. All tumor markers were negative. After three weeks, she experienced another episode of acute pelvic pain. Transvaginal ultrasound examination showed an enlarged right ovary with stromal edema and peripherally displaced antral follicles, corpus luteum within the parenchyma (Figure c), and free fluid in the pelvis. At color Doppler examination, the ovarian parenchyma appeared normally vascularized and the whirlpool sign 1 was identified. A diagnosis of ovarian torsion was made (Figure g). A laparoscopy was performed confirming an enlarged twisted right ovary and a left ovary reduced in size. The left fallopian tube was absent and several pelvic adhesions were also detected. An untwisting procedure with lysis of adhesions was achieved with no surgical complication. An ultrasound examination was planned to be four weeks after surgery. However, it was postponed to 8 weeks after surgery due to the Covid pandemic, and it showed a normal right ovarian parenchyma. (Figure d, h)

Non-hormonal treatment of vulvo-vaginal atrophy-related symptoms in post-menopausal women

In post-menopausal period vulvo-vaginal atrophy (VVA)-related symptoms may seriously affect women's quality of life. Hormonal replacement therapy effectively relieves these symptoms but it is not always safe or accepted, and a non-hormonal treatment is often needed instead. Over a period of 12 weeks, we tested the effect of a twice-a-week vulvo-vaginal application of a hyaluronic acid, AC collagen, isoflavones and vitamins-based cream (Perilei Pausa()) on 35 women in post-menopausal period, reporting VVA-related symptoms. After 12 weeks of treatment with Perilei Pausa() a significant improvement in vaginal dryness, vulvo-vaginal itching, dyspareunia (P < 0.001), dysuria (P = 0.02), nocturia (P = 0.009) and pollakiuria (P = 0.005) was reported by the women. Colposcopical score assessing the intensity of atrophic colpitis, cervico-vaginal paleness and petechiae was also reduced (P = 0.037, P = 0.016 and P = 0.032, respectively). No significant difference in terms of maturation value of cervico-vaginal epithelium was observed. In conclusion, Perilei Pausa() may represent an effective and safe alternative treatment of symptomatic VVA in post-menopausal women

Imaging techniques for the evaluation of cervical cancer

Improvements in the treatment of cervical carcinoma have made it possible to offer optimal and personalised treatment. Cervical cancer staging is based on clinical examination and histological findings. Many diagnostic methods are used in clinical practice. Magnetic resonance imaging is considered the optimal method for staging cervical carcinoma because of its high accuracy in assessing local extension of disease and distant metastases. Ultrasound has gained increased attention in recent years; it is faster, cheaper, and more widely available than other imaging techniques, and is highly accurate in detecting tumour presence and evaluating local extension of disease. Magnetic resonance imaging and ultrasound are often used together with computed tomography or positron emission tomography combined with computed tomography to assess the whole body, a more accurate detection of pathological lymph nodes and metabolic information of the disease

Transvaginal ultrasound assessment of urinary tract in gynecological oncology patients: A multicenter prospective study

Introduction: The aim of this study was to assess the prevalence of urinary tract involvement diagnosed on transvaginal ultrasound examination in women gynecological cancers. The diagnostic performance of transvaginal ultrasound in detecting ureteral and bladder involvement was also evaluated. Methods: This is a multicenter prospective study. Women with gynecological cancers or recurrence undergoing ultrasound examination were included. Transvaginal ultrasound is simple and non-invasive method. Ureters, vesico-uterine septum, bladder involvement were evaluated. Sensitivity, specificity, positive predictive values (PPV), negative predictive value (NPV) of ultrasound were calculated. Surgery or imaging methods (MRI or CT scan) were considered as reference standard. Results: A total of 569 patients were enrolled and 547 of them had diagnosis of malignancy. 56/547 (10.2%) had a diagnosis of urinary tract infiltration at ultrasound examination. On ultrasound examination, both ureters were clearly visualized in the vast majority of cases (507/547, 92.7%), whereas only one ureter was identified in 21/547 (3.8%) patients and both ureters were not visualized in 19/547 (3.5%). Ultrasound examination demonstrated high specificity (&gt;99.0%) and high NPV (&gt;97.0%) for all ultrasound parameters; sensitivity was good for bladder wall infiltration (83.3%) and for vesico-uterine septum infiltration (80.8%), and low for right (69.23%) and left (65.4%) ureter infiltration. Conclusions: The prevalence of pelvic urinary tract infiltration on transvaginal ultrasound examination in women with gynecologic malignancy was 10%. We believe that pelvic urinary tract assessment plays a key role during transvaginal ultrasound examination, in order to plan the management of patients with gynecologic cancers

Management of Unusual Not Scar Ectopic Pregnancy: A Multicentre Retrospective Case Series

Background: Management of unusual not scar ectopic pregnancies (UNSEPs) is an unexplored clinical field because of their low incidence and lack of guidelines.Objective: To report the clinical presentation, the first- and second-line treatment and outcomes of UNSEPs.Methods: We retrospectively collected patients treated for UNSEP (namely cervical, interstitial, ovarian, angular, abdominal, cornual and intramural), their baseline characteristics, risk factors, symptoms, diagnostic pathway and the type of first-line treatment (medical, surgical or combined). We further collected treatment failures and the type of second-line treatment. We assessed treatment outcomes, time to serum beta human chorionic gonadotropin (beta-hCG) level negativity, length of recovery, follow up and return to a normal menstrual cycle.Results: From 2009 to 2019, we collected 79 cases. Of them, 27 (34%), 23 (29%), 12 (15%), 8 (10%), 6 (8%) and 3 (4%) were cervical, interstitial, ovarian, angular, abdominal and cornual, respectively. Forty women (50.6%) were submitted to medical treatment, mostly methotrexate based; conversely, 36 patients (45.6%) underwent surgery and only 3 women (3.8%) received a combined treatment. The success of first-line treatment rate, regardless of UNSEP location, was 53% and 89% for medical and surgical treatment, respectively. Treatment failures (21 patients) were submitted to second-line treatment, respectively 47.6% and 52.4% to medical and surgical approach. Of interest, cervical pregnancies achieved the lowest rate of first-line medical treatment success (22%) and received more frequently (69%) a subsequent surgical approach with no hysterectomy. Interstitial pregnancies were submitted to surgery mostly for a matter of urgency (71%), otherwise, they were treated with a medical approach both at first- and second-line treatment. Ovarian pregnancies were treated with ovariectomy in 44% of the cases submitted to surgery. Angular pregnancies underwent surgery more often, while all the abdominal pregnancies underwent endoscopic or open surgery. Cornual pregnancies received cornuostomy in 75% of the cases. Overall, the need for blood transfusion was 23.1% among the patients submitted to surgery. The median length of hospitalisation was shorter for women submitted to surgical first-line treatment (5 vs. 10 days; p = 0.002). In case of first-line medical treatment and in case of failure, we found an increase of 3 days (CI95% 0.6-5.5; p = 0.01) and of 3.6 days (CI95% 0.89-6.30; p = 0.01) in the length of hospitalisation, respectively. Negative beta-HCG levels were obtained earlier in the surgical group (median 25 vs. 51 days; p = 0.001), as well as the return to normal menstrual cycle (median 31 vs. 67 days; p &lt; 0.000). Post-treatment follow-up, regardless of the failure of first-line treatment was shorter in the surgical group (median 32 versus 68 days; p= 0.003).Conclusion: Cervical pregnancies were successfully managed with a surgical approach without hysterectomy, and hence, we suggest avoiding medical treatment. No consensus emerged for other UNSEPs. Ovarian, angular and interstitial pregnancies are burdened by a non-conservative approach on the utero-ovarian structures. The surgical approach led to shorter recovery, earlier beta-hCG negativity and shorter follow-up, even though there is an increased risk for blood transfusion

Imaging of gynecological disease: clinical and ultrasound characteristics of uterine sarcomas

OBJECTIVE: To describe the clinical and ultrasound characteristics of uterine sarcomas. METHODS: This is a retrospective multicenter study. From the databases of 13 ultrasound centers, we identified patients with a histological diagnosis of uterine sarcoma with available ultrasound reports and ultrasound images who had undergone preoperative ultrasound examination between 1996 and 2016. As a first step, each author collected information from the original ultrasound reports on predefined ultrasound features of the tumors from his/her own center and by checking the ultrasound images to find information on variables not described in the original report. As a second step, 16 ultrasound examiners reviewed electronic ultrasound images in a consensus meeting and described them using a predetermined terminology. RESULTS: We identified 116 patients with a leiomyosarcoma, 48 with endometrial stromal sarcoma, and 31 with undifferentiated endometrial sarcoma. Median age of the patients was 56 (range, 26-86) years. Most patients were symptomatic at diagnosis (164/183, 89.6%), the most frequent presenting symptom being abnormal vaginal bleeding (91/183, 49.7%). Patients with endometrial stromal sarcoma were younger than patients with leiomyosarcoma or undifferentiated endometrial sarcoma (median age 46 years vs 57 vs 60). The results of the first and second step of analysis were similar. According to the assessment by the original ultrasound examiners, the median largest tumor diameter was 91 (range 7-321) mm. Visible normal myometrium was reported in 149/195 (76.4%) cases, and 80% (156/195) of lesions were solitary. Most sarcomas were solid masses (>80% solid tissue) (155/195, 79.5%) and most manifested inhomogeneous echogenicity of the solid tissue (151/195, 77.4%), one sarcoma was multicystic without solid components. Cystic areas were described in 87/195 (44.6%) tumors and most cyst cavities had irregular walls (67/87, 77.0%). Internal shadowing was observed in 42/192 (21.9%) sarcomas and fan shaped shadowing in 4/192 (2.1%). Moderate or rich vascularization was found on color Doppler in 127/187 (67.9%) cases. In 153/195 (78.5%) sarcomas the original ultrasound examiner suspected malignancy. CONCLUSIONS: Uterine sarcomas typically appear as solid masses with inhomogeneous echogenicity, sometimes with irregular cystic areas but rarely with fan shaped shadowing. Most are moderately or very well vascularized. This article is protected by copyright. All rights reserved