Continuing education and clinical research for the training of obstetricians and gynecologists in EuropeCreatsas, George; Mastorakos, George
doi: 10.1111/j.1749-6632.2010.05687.xpmid: 20840245
The need for doctors to develop in their profession and in science applies to all ages and at all hierarchical levels. This development can be sustained both via education and research. In this brief paper, we examine certain crucial aspects of education and research in obstetrics and gynecology (OB/GYN) as they are actually observed in Europe. The need for uniform development of continuing professional development (CPD) among all European countries is progressively becoming apparent. There is no single approach to CPD. Junior doctors should benefit from the teaching of senior obstetricians and gynecologists, especially those in a hierarchical system of training that must assure their progress. Hospital visiting organized by EBCOG enables OB/GYN departments of teaching hospitals to unify their teaching and learning approaches. Furthermore, improving the ability of trainees and specialists to conduct clinical research is vital, as this will transform the breakthroughs of basic science into clinical practice. A formal training period in research should be available to most competent trainees in OB/GYN in addition to their basic clinical training.
The role of gonadotropins in the follicular phaseMessinis, Ioannis E.; Messini, Christina I.; Dafopoulos, Konstantinos
doi: 10.1111/j.1749-6632.2010.05660.xpmid: 20840246
Folliculogenesis in humans is a lengthy process that involves several regulators. Pituitary gonadotropins play crucial roles in the late stages, particularly in the last 15 days of follicle maturation. During the intercycle rise of follicle‐stimulating hormone (FSH), selection of the dominant follicle takes place. This is a complex process that also involves locally produced substances. At the same time, luteinizing hormone (LH) stimulates the synthesis of androgens, which serve as the substrate for the production of estrogens. During the second half of the follicular phase, the follicle becomes dependent on LH. Induction of multiple follicular development by exogenous FSH results in a marked suppression of endogenous LH. For normal follicle maturation, both an LH threshold and an LH ceiling have been considered. In the context of an in vitro fertilization program, application of protocols for ovarian stimulation that will prevent the marked suppression of endogenous LH secretion might provide a better approach to treatment optimization.
Bone acquisition during adolescence in athletesMarkou, Kostas B.; Theodoropoulou, Anastasia; Tsekouras, Athanasios; Vagenakis, Apostolos G.; Georgopoulos, Neoklis A.
doi: 10.1111/j.1749-6632.2010.05675.xpmid: 20840247
Bone mass (BM) and skeletal size are similar in prepubertal girls and boys and double between the onset of puberty and early adult life. Sex steroids are responsible for the maturation in human skeleton, as well as for the sexual dimorphism, observed after the onset of puberty. Physical activity in childhood is critical for maximizing bone growth and thus for preventing osteoporosis during older age. Therefore, it constitutes the most effective prevention strategy available. In athletes, high‐impact loading activities have been shown to improve BM, whereas in sports requiring a lean somatotype (therefore leading to a negative energy balance), the delay in skeletal maturation and pubertal development predisposes athletes to osteopenia and osteoporosis. Although the early onset of training, the continuous intensive exercise and its long duration attenuate bone acquisition, the excess mechanical load to which these athletes are exposed from a young age exerts beneficial effects on bone formation that lead to a positive net‐effect on BM.
Umbilical cord blood stem cells: what to expectZhong, Xiao Yan; Zhang, Bei; Asadollahi, Reza; Low, Shyan Huey; Holzgreve, Wolfgang
doi: 10.1111/j.1749-6632.2010.05659.xpmid: 20840248
Umbilical cord blood (UCB) is a valuable alternative source of hematopoietic stem cells (HSCs). It has unique advantages of easy procurement, absence of risk to donors, low risk of transmitting infections, immediate availability, greater tolerance of human leukocyte antigen (HLA) disparity, and lower incidence of inducing severe graft‐versus‐host disease (GVHD). In the last several years, these features of UCB permit the field of UCB transplantation (UCBT) to move at a faster pace for both children and adults with malignancies and nonmalignancies. However, new strategies and novel developments are expected to improve engraftment and reconstitution, and to enable in utero transplantation for early therapy, as well as to allow the therapy for a wide spectrum of human diseases.
Evaluation and management of adolescent amenorrheaDeligeoroglou, Efthimios; Athanasopoulos, Nikolaos; Tsimaris, Pandelis; Dimopoulos, Konstantinos D.; Vrachnis, Nikolaos; Creatsas, G.
doi: 10.1111/j.1749-6632.2010.05669.xpmid: 20840249
During the first years of menstruation it is not rare for a girl to present with an irregular menstrual pattern. The complete absence or cessation of menses, which is defined as amenorrhea, requires careful evaluation and management. It is divided into primary and secondary types that describe the occurrence of amenorrhea before and after menarche, respectively. The list of causes is long and includes anatomical or functional anomalies of the genital tract, hormonal disorders, and multifactorial reasons. The most common causes are hypothalamic amenorrhea, polycystic ovarian syndrome, hyperprolactinemia, and ovarian failure. A thorough medical history and careful clinical examination of the young girl is absolutely essential. The distinction between primary and secondary amenorrhea, together with the presence, or not, of secondary sexual characteristic development will guide the physician to the differential diagnosis of amenorrhea. Essential laboratory examinations include follicle‐stimulating hormone (FSH), luteinizing hormone (LH), thyroid‐stimulating hormone (TSH), and prolactin measurements; while in the presence of acne or hirsutism, androgen levels should also be measured. Management should focus on the restoration of ovulatory cycles and the prevention of short‐ and long‐term consequences of hormonal imbalance.
Athletic amenorrhea: energy deficit or psychogenic challenge?Pauli, Samuel A.; Berga, Sarah L.
doi: 10.1111/j.1749-6632.2010.05663.xpmid: 20840250
Athletic women are at risk for developing ovulatory dysfunction, which presents variably as menstrual irregularity or absence. Initially characterized as an isolated disruption of hypothalamic gonadotropin–releasing hormone (GnRH) release, athletic amenorrhea, a form of hypogonadotropic hypogonadism, is invariably accompanied by additional neuroendocrine aberrations, including activation of adrenal and suppression of thyroidal axes. Exercise may elicit intermittent or chronic metabolic stress owing to increased energy expenditure and/or insufficient or imbalanced nutrient intake. In addition, athletic activities are motivated by or serve as psychogenic stressors. Prior studies dichotomized stressors as metabolic or psychogenic. Not only is this a false dichotomy because all stressors have both a metabolic and a psychogenic component, but also stressors act synergistically rather than in isolation to compromise GnRH drive and endocrine homeostasis. To ameliorate reproductive and endocrine consequences of stress, then, requires identification and amelioration of all relevant stressors. Formal psychosocial support helps individuals to develop better coping strategies and make appropriate lifestyle changes. Our research has shown that cognitive behavior therapy restores reproductive and endocrine balance.
The influence of intensive physical training on growth and pubertal development in athletesGeorgopoulos, Neoklis A.; Roupas, Nikolaos D.; Theodoropoulou, Anastasia; Tsekouras, Athanasios; Vagenakis, Apostolos G.; Markou, Kostas B.
doi: 10.1111/j.1749-6632.2010.05677.xpmid: 20840251
Genetic potential for growth can be fully expressed only under favorable environmental conditions. Although moderate physical activity has beneficial effects on growth, excessive physical training may negatively affect it. Sports favoring restricted energy availability, in the presence of high energy expenditure, are of particular concern. In gymnastics, a different pattern in skeletal maturation and linear growth was observed, resulting in an attenuation of growth potential in artistic gymnasts (AG), more pronounced in males than in females. In female rhythmic gymnasts (RG), the genetic predisposition to growth was preserved owing to a late catchup growth phenomenon. In all other sports not requiring strict dietary restrictions, no deterioration of growth has been documented so far. Intensive physical training and negative energy balance alter the hypothalamic pituitary set point at puberty, prolong the prepubertal stage, and delay pubertal development and menarche in a variety of sports. In elite RG and AG, prepubertal stage is prolonged and pubertal development is entirely shifted to a later age, following the bone maturation rather than the chronological age.
Pathophysiology of bone loss in the female athleteLambrinoudaki, Irene; Papadimitriou, Dimitra
doi: 10.1111/j.1749-6632.2010.05681.xpmid: 20840252
Low bone mass is frequent among female athletes. The “female athlete triad” is a term that describes the interaction among energy availability, menstrual function, and bone metabolism that may lead to amenorrhea and osteopenia or osteoporosis. The main pathophysiologic mechanisms that lead to low bone mass in female athletes are low energy availability and functional hypothalamic amenorrhea. Increased energy expenditure and/or decreased energy intake, as well as the presence of eating disorders, are associated with low bone mass. In addition, menstrual dysfunction is quite common, especially among athletes competing in sports favoring leanness, and also associates with low bone mass. Screening for bone loss in female athletes should take place in the presence of amenorrhea or body mass index <18 kg/m2. Management of low bone mass aims to restore normal energy availability and nutritional habits. Hormone replacement therapy has no effect in abnormally underweight patients unless normal eating behaviors are restored.
Can HPV testing replace the pap smear?Agorastos, Theodoros; Sotiriadis, Alexandros; Chatzigeorgiou, Konstantinos
doi: 10.1111/j.1749-6632.2010.05661.xpmid: 20840253
The most compelling question in evaluating the possible replacement of the conventional Papanicolaou smear from a high‐risk HPV testing method is the balance between specificity and sensitivity for detection of cervical intraepithelial neoplasia grade ≥CIN 2 (CIN 2+). Multiple studies have shown that HPV testing has higher sensitivity than cytology for the detection of high‐grade CIN. Positivity increases the test cut‐off for HPV and may reduce false positive results without significantly compromising the sensitivity, potentially alleviating the concern of low specificity. Overall, available evidence convincingly shows that HPV testing is superior to traditional screening for the detection of high‐grade cervical lesions, and efforts are focused on improving its sensitivity, either by increasing its cut‐off for positivity or by selecting those subgroups where HPV testing is expected to have higher positive predictive value for cervical disease, or by seeking to optimize triage tests after a positive HPV result.
Clinical management of HPV‐related disease of the lower genital tractKyrgiou, M; Valasoulis, G.; Founta, C.; Koliopoulos, G.; Karakitsos, P.; Nasioutziki, M.; Navrozoglou, I.; Dalkalitsis, N.; Paraskevaidis, E.
doi: 10.1111/j.1749-6632.2010.05676.xpmid: 20840254
Cytology remains the mainstay for cervical screening. The need to achieve effective management, limit complications, and preserve reproductive function led to the popularity of local treatment. Although the cure rates for ablative and excisional methods are similar, the excisional method provides a more reliable histopathological diagnosis. Recent evidence revealed increased perinatal morbidity after treatment that appears to be related to the proportion of cervix removed. The human papillomavirus (HPV) DNA test appears to enhance the detection of disease in primary screening, in the triage of minor cytological abnormalities, and in follow‐up. Further research on the clinical application of a scoring system is ongoing. The vaccines are now available and appear to be safe, well tolerated, and highly efficacious in HPV naive women. A synergy of vaccination and screening will be required. Treatment for early cervical cancer is increasingly shifting toward more fertility‐sparing surgical techniques. Careful selection of patients is essential.