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Peitsidis P, Tsikouras P, Laganà AS, Laios A, Gkegkes ID, Iavazzo C. A Systematic Review of Systematic Reviews on the Use of Aromatase Inhibitors for the Treatment of Endometriosis: The Evidence to Date. Drug Des Devel Ther 2023; 17:1329-1346. [PMID: 37168488 PMCID: PMC10166210 DOI: 10.2147/dddt.s315726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 04/27/2023] [Indexed: 05/13/2023] Open
Abstract
Endometriosis is a chronic gynecologic condition that affects around 6-10% of reproductive age women. This clinical entity is characterized with pelvic pain, dysmenorrhea, dyspareunia, and infertility which are the most often presenting symptoms. Aromatase P450 is the key enzyme for ovarian estrogen biosynthesis and there is evidence that endometriotic lesions express aromatase and are able to synthesize their own estrogens. Aromatase inhibitors (AIs) are potent drugs that suppress the estrogen synthesis via suppression of aromatase. We performed a systematic review of systematic reviews and narrative reviews on the use of aromatase inhibitors in the medical management of endometriosis. We searched: PubMed (1950-2022), Google Scholar (2004-2022), Cochrane Library (2010-2022) and Researchgate (2010-2022). The search included the following medical subject headings (MeSH) or keywords: "Aromatase Inhibitors" AND "Endometriosis" AND "Systematic reviews" OR "Systematic review" AND "Reviews" OR "Reviews" AND "Endometriosis". The electronic database search yielded initially 12,106 studies from the different databases. Further assessment of the studies resulted in exclusion of (n = 12,015) studies due to duplicates and irrelevance; Finally, 24 studies were selected for inclusion, 5 were Systematic reviews and 19 were Narrative reviews. The 5 systematic reviews were assessed by AMSTAR-2 criteria and were found to have low quality. Narrative reviews were assessed with SANRA criteria and were found to have high-quality aromatase inhibitors are potent drugs that can manage the endometriosis-related symptoms in cases where initial medical management has failed to show positive results. However, their use is limited by the adverse effects that are linked with menopausal symptoms. aromatase inhibitors can be administered as an alternative treatment in patients. Future studies with randomized design are required to reach safer conclusions and further investigation. These studies should define the therapeutic dose, new add-back therapy modalities. Future directions should examine the most-appropriate way of administration and the duration of therapy.
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Affiliation(s)
- Panagiotis Peitsidis
- Department of Obstetrics and Gynecology Helena Venizelou Hospital, Athens, Greece
- Correspondence: Panagiotis Peitsidis, Department of Obstetrics and Gynecology, Helena Venizelou Hospital Athens Greece, Helena Venizelou 2 Street, P.C, Athens, 11521, Greece, Tel +306972221553; +302107473793, Email
| | - Panagiotis Tsikouras
- Department of Obstetrics and Gynecology.The Democritus University of Thrace, Alexandroupolis, Greece
| | - Antonio Simone Laganà
- Unit of Gynecologic Oncology ARNAS “Civico-Di Cristina-Benfratelli”, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, Palermo, Italy
| | - Alexandros Laios
- Department of Gynecological Oncology St James Institute of Oncology, Leeds Teaching Hospitals, Leeds, Uk
| | - Ioannis D Gkegkes
- Department of Colorectal Surgery, Royal Devon and Exeter NHS Foundation, Devon, UK
| | - Christos Iavazzo
- Gynaecological Oncology Department, Metaxa Cancer Hospital, Piraeus, Greece
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Chung JPW, Law TSM, Mak JSM, Sahota DS, Li TC. Ovarian reserve and recurrence 1 year post-operatively after using haemostatic sealant and bipolar diathermy for haemostasis during laparoscopic ovarian cystectomy. Reprod Biomed Online 2021; 43:310-318. [PMID: 34193356 DOI: 10.1016/j.rbmo.2021.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 03/25/2021] [Accepted: 05/05/2021] [Indexed: 11/25/2022]
Abstract
RESEARCH QUESTION Is there a difference in the ovarian reserve 1 year post-operatively in those who used a haemostatic sealant or bipolar diathermy for haemostasis during laparoscopic ovarian cystectomy for ovarian endometriomas? DESIGN This was an extended follow-up observational study of a previous randomized controlled trial where women aged 18 to 40 years with 3-8 cm unilateral or bilateral endometriomas were randomized to receive haemostasis by a haemostatic sealant or bipolar diathermy following ovarian cystectomy. The primary outcome was the ovarian reserve as assessed by antral follicle count (AFC) 1 year post-operatively. Secondary outcomes included the recurrence rate of ovarian endometrioma, the change in anti-Müllerian hormone (AMH) and FSH concentrations, and reproductive outcomes. RESULTS The significant increase in AFC at 3 months after initial surgery (P = 0.025) in the haemostatic sealant group compared with the diathermy group was sustained at 1 year (P = 0.024) but there was no difference in AMH or FSH concentrations between the groups throughout the follow-up period. The recurrence rate in the FloSeal group was 7.7% (n = 3/39) compared with 22.2% (n = 8/36) in the diathermy group (P = 0.060). The recurrence rate in women who had bilateral lesions was significantly higher than those with unilateral lesions (risk ratio 5.33, interquartile range 1.55-18.38). No difference in reproductive outcomes was found between the two groups. CONCLUSIONS Applying haemostatic sealant after laparoscopic cystectomy of ovarian endometriomas produces a significantly greater improvement in AFC, which was apparent at 3-month follow-up, and was sustained at 1-year follow-up without compromising the recurrence rate.
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Affiliation(s)
- Jacqueline Pui Wah Chung
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin New Territories, Hong Kong SAR.
| | - Tracy Sze Man Law
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin New Territories, Hong Kong SAR
| | - Jennifer Sze Man Mak
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin New Territories, Hong Kong SAR
| | - Daljit Singh Sahota
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin New Territories, Hong Kong SAR
| | - Tin Chiu Li
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin New Territories, Hong Kong SAR
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Romero R. Giants in Obstetrics and Gynecology Series: a profile of Ivo Brosens, MD, PhD, FRCOG (ae). Am J Obstet Gynecol 2020; 223:809-819.e2. [PMID: 33243413 DOI: 10.1016/j.ajog.2020.09.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 09/09/2020] [Indexed: 10/22/2022]
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Gałczyński K, Jóźwik M, Lewkowicz D, Semczuk-Sikora A, Semczuk A. Ovarian endometrioma - a possible finding in adolescent girls and young women: a mini-review. J Ovarian Res 2019; 12:104. [PMID: 31699129 PMCID: PMC6839067 DOI: 10.1186/s13048-019-0582-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 10/15/2019] [Indexed: 12/13/2022] Open
Abstract
Young girls before menarche or menstruating adolescent women may experience long-term drug-resistant chronic pelvic pain, as well as other symptoms associated with pelvic mass. In such cases, it is of great importance to consider ovarian endometrioma in the differential diagnosis. In general, endometrioma is recognized as an ovarian cyst. However, in most cases, the pathology represents pseudocyst with a partial or complete endometrial-like lining with extraovarian adhesions and endometriotic implants which are likely to occur at the sites of ovarian adhesions and at the ceiling of the ovarian fossa. Ovarian endometriomas occur in 17–44% patients with endometriosis and account for 35% of all benign ovarian cysts. The time span from the onset of menarche to the time of endometrioma formation, which requires surgical intervention, has been evaluated to be a minimum of 4 years. The pathogenesis of early-life endometrioma may be different from other types of endometriosis. Diagnosis is often delayed, especially in adolescents, who tend to wait too long before seeking professional help. The three specific aims of treatment in adolescents with endometriosis and endometriomas are control of symptoms, prevention of further progression of the disease as well as preservation of fertility. Increasing evidence demonstrates association between ovarian endometriosis and ovarian cancer. In the present mini-review, we draw the particular attention of clinicians to such a possibility, even if relatively infrequently reported.
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Affiliation(s)
- Krzysztof Gałczyński
- Siedlce University of Natural Sciences and Humanities, Faculty of Natural Sciences, Konarskiego str. 2, 08-110, Siedlce, Poland.,Second Department of Gynecological Oncology, St. John's of Dukla Cancer Center of Lublin, Jaczewskiego str. 7, 20-090, Lublin, Poland
| | - Maciej Jóźwik
- Department of Gynecology and Gynecologic Oncology, Białystok Medical University, Kilińskiego str. 1, 15-089, Białystok, Poland
| | - Dorota Lewkowicz
- Department of Clinical Pathology, Lublin Medical University, Jaczewskiego str. 8b, 20-090, Lublin, Poland
| | - Anna Semczuk-Sikora
- Department of Pathology of Pregnancy, Lublin Medical University, Staszica str. 16, 20-081, Lublin, Poland
| | - Andrzej Semczuk
- IIND Department of Gynecology, Lublin Medical University, Jaczewskiego str. 8, 20-954, Lublin, Poland.
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Zhang NN, Sun TS, Yang Q. An effective "water injection"-assisted method for excision of ovarian endometrioma by laparoscopy. Fertil Steril 2019; 112:608-609. [PMID: 31280960 DOI: 10.1016/j.fertnstert.2019.05.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 05/08/2019] [Accepted: 05/09/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To introduce an effective approach for excision of ovarian endometrioma by "water injection"-assisted laparoscopy treatment. DESIGN Step-by-step video explanation of the surgical procedure with still pictures and surgical video clips to demonstrate the detailed technique, approved by the Shengjing Hospital of China Medical University. SETTING Hospital. PATIENTS A 26-year-old young woman diagnosed with a 6 cm in diameter right ovarian cyst, who endured 5 years of dysmenorrhea. INTERVENTIONS The "water injection"-assisted laparoscopic excision of ovarian endometrioma consists of five steps: rupture the ovarian endometrial cyst and remove the "chocolate fluid;" inject the "water" (diluted vasopressin solution) into the interface between endometrioma and ovarian parenchyma; stop injecting until the solution overflow; separate the endometrioma away from the ovarian parenchyma; and suture the ovary. MAIN OUTCOME MEASURES Value and feasibility of "water injection"-assisted laparoscopic excision of ovarian endometrioma. RESULTS The "water injection"-assisted laparoscopic excision of ovarian endometrioma was feasible and effective. In the follow-up period, the patient did not report any symptom of dysmenorrhea; and the sex hormone and antimüllerian hormone tests reached to normal levels. CONCLUSION Our surgical approach demonstrated several noteworthy advantages. After "water injection", the endometrioma and ovarian parenchyma was easily distinguished and separated. The approach avoided normal ovarian tissue destruction during endometrioma separation. The utilization of diluted vasopressin solution might decrease bleeding of ovarian wound. Considering its simplicity of realization, our surgical approach should be promoted to more reproductive-age patients.
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Affiliation(s)
- Ning-Ning Zhang
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, People's Republic of China
| | - Tian-Shui Sun
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, People's Republic of China
| | - Qing Yang
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, People's Republic of China.
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Atılgan R, Pala Ş, Kuloğlu T. Investigation of treatment efficacy of 10% povidone–iodine sclerotherapy on ovarian cyst diameter: an experimental study. Turk J Med Sci 2019; 49:795-801. [PMID: 31072075 PMCID: PMC7018216 DOI: 10.3906/sag-1810-27] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Background/aim The purpose of this study was toinvestigate the effects of 10% povidone–iodine (PI) sclerotherapyon ovarian cyst diameter through an experimental study. Materials and methods To be able to create ovarian cysts, right unilateral salpingectomy was performed on 20 Wistar albino rats. One month after the operation, the abdomens of all rats were reopened. Sixteen rats with macroscopic ovarian cysts were divided randomly into 2 groups consisting of 8 rats. Group 1 (G1): the cyst content was only aspirated. Group 2 (G2): the ovarian cyst was aspirated and then the cystic cavity was irrigated with PI. Abdomens of all rats were closed and 1 month later they were reopened. Tissues of the right ovaries of the rats were embedded in paraffin blocks for histopathological examination. Follicle count, fibrosis, and congestion were evaluated under a light microscope. Results For G1, there was no difference in cyst diameters before and after aspiration. In G2, a decrease was observed in cyst diameter. There was no difference in ovarian reserve between the 2 groups. When compared with G1, an increase in fibrosis and congestion was determined in G2. Conclusion Sclerotherapyinto the ovarian cyst for a 5-min period using 10% PI reduces cyst diameter without any change in ovarian reserve.
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Affiliation(s)
- Remzi Atılgan
- Department of Obstetrics and Gynecology, School of Medicine, Fırat University, Elazığ, Turkey
| | - Şehmus Pala
- Department of Obstetrics and Gynecology, School of Medicine, Fırat University, Elazığ, Turkey
| | - Tuncay Kuloğlu
- Department of Histology and Embryology, School of Medicine, Fırat University, Elazığ, Turkey
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Artaş G, Pala Ş, Kuloğlu T, Atilgan R, Yavuzkir Ş, Akyol A. The effects of sclerotherapy with 5% trichloroacetic acid on the cyst diameter and ovarian tissue in the rat ovarian cyst model. J OBSTET GYNAECOL 2018; 38:686-692. [PMID: 29564948 DOI: 10.1080/01443615.2017.1399991] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
The aim of this study was to compare the effects of only aspiration with aspiration and 5% trichloroacetic acid (TCA) application on ovarian cyst size and ovarian reserve. The ovarian cysts of 14 rats that were divided into two groups randomly were investigated after total salpingectomy procedure. G1 was the group of saline application after cyst aspiration, while in G2, after aspiration 5% TCA at half amount of aspiration volume was injected into the cyst and re-aspirated after five minutes. The abdomens of the rats were closed and re-explored after 1 month. The cyst diameters of the rats in each group were measured. Ovaries were removed for histopathological examination. There was no significant difference in cyst diameter in G1 before and after aspiration. In G2, there was a significant decrease in cyst size after TCA application. Ovarian follicle counts were not significantly different between the two groups. In conclusion, application of 5% TCA to the ovarian cysts for five minutes significantly reduces the cyst size. Impact Statement What is already known on this subject: Minimally invasive therapies come into prominence to avoid surgical complications and diminished fertility in the treatment of ovarian cysts. USG-guided aspiration and sclerosis has been reported as cost-efficient and effective treatment methods for localised benign cysts in other organs such as the thyroid, parathyroid, liver, kidney and spleen. It has been shown that sclerotherapy applied to infertile women with ovarian cysts reduces pelvic pain without affecting the number of follicles, term pregnancy and abortion rates, extracted oocytes, embryo quality or hormonal levels when compared to non-ovarian cystic infertile women. TCA is a chemical agent that is topically applied, not systemically absorptive, which causes denaturation of proteins and structural cell death, resulting in coagulation necrosis after chemical cauterisation. For this reason, we used 5% TCA to treat simple ovarian cysts on a rat model. What the results of this study add: In this experimental study, we showed that the application of 5% TCA into the cyst for five minutes - then aspirated - significantly reduced the size of the ovarian cysts. Five percent TCA application did not affect the ovarian reserve. What the implications are of these findings for clinical practice and/or further research: Our study is original because of the fact that to the best of our knowledge, this is the first study about the use of 5% TCA in treatment of ovarian cysts in the literature.
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Affiliation(s)
- Gökhan Artaş
- a Department of Pathology , Firat University School of Medicine , Elazig , Turkey
| | - Şehmus Pala
- b Department of Obstetrics and Gynecology , Firat University School of Medicine , Elazig , Turkey
| | - Tuncay Kuloğlu
- c Department of Histology and Embriology , Firat University School of Medicine , Elazig , Turkey
| | - Remzi Atilgan
- b Department of Obstetrics and Gynecology , Firat University School of Medicine , Elazig , Turkey
| | - Şeyda Yavuzkir
- b Department of Obstetrics and Gynecology , Firat University School of Medicine , Elazig , Turkey
| | - Alparslan Akyol
- b Department of Obstetrics and Gynecology , Firat University School of Medicine , Elazig , Turkey
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Endometrioma in Adolescents and Future Reproductive Health. JOURNAL OF ENDOMETRIOSIS AND PELVIC PAIN DISORDERS 2017. [DOI: 10.5301/je.5000267] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
There continues to be debate over the nature and progression of ovarian endometriomas in adolescence due to the possibility that they may have a different origin and to the impossibility to be able to predict progress. The hypothesis of a different origin traces its roots in the phenomenon called “neonatal menstruation” (NUB), occurring in approximately 5% of newborn. The retrograde shedding of neonatal endometrium may contain progenitor cells and stroma that may lie dormant under the peritoneal surface until being activated when estrogens begin to rise. In teenagers, ovarian endometriomas are often preceded by highly angiogenic implants in the fossa ovarica, with adhesion formation resulting in the invagination of the ovarian cortex and the creation of a pseudocyst. Use of imaging techniques makes it possible to diagnose even small endometriomas. This is vital to their management, since there is evidence that the disease in an adolescent represents a severe condition, with tendency to progression. In addition, if intervention is decided, the first surgical procedure can determine the ultimate outcome of her reproductive life, because there is a significantly higher risk of inadvertently removing ovarian tissue in the presence of an endometrioma than of other ovarian pathologies. For this reason, techniques avoiding additional trauma to the ovary should be preferred and those who wish to become pregnant should attempt conception as soon as possible; if pregnancy is not sought, hormonal therapy is strongly advised. Finally, young age at diagnosis may constitute a pivotal factor in considering fertility preservation.
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Benagiano G, Guo SW, Bianchi P, Puttemans P, Gordts S, Petraglia F, Brosens I. Pharmacologic treatment of the ovarian endometrioma. Expert Opin Pharmacother 2016; 17:2019-31. [PMID: 27615386 DOI: 10.1080/14656566.2016.1229305] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Treatment of ovarian endometriomas is commonly achieved through laparoscopic surgery and this can be effective in eliminating the disease, although a majority of recent trials documented an adverse effect of surgery on ovarian reserve markers. With the advancement in imaging techniques, ovarian endometriomas are increasingly diagnosed at an earlier stage when the endometrioma may be smaller, less fibrotic and more responsive to medical treatment, making an evaluation of medical options critically important. AREAS COVERED The review focuses on currently utilized pharmacologic therapies for endometrioma (oral contraceptives, the levonorgestrel-releasing IUS, the hormone-releasing subdermal implant, Implanon); experimental and future treatments are also mentioned (GnRH antagonists, progesterone receptor modulators, antioestrogens, newer subdermal implants and intracystic administration of pharmacologic agents). Finally, the usefulness of post-operative adjuvant medical treatments is discussed Expert opinion: Today, reliable, non-invasive diagnostic procedures of an ovarian endometrioma are available and should be utilized to identify its presence and type of pathology. In a young patient, classic medical therapies such as oral contraceptives and synthetic progestins should be tried first to alleviate symptoms. Only when these regimens fail, should a minimally invasive surgery be envisaged. Following endoscopic surgery, adjuvant medical treatment may reduce recurrence of both symptoms and the lesion.
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Affiliation(s)
- Giuseppe Benagiano
- a Department of Gynaecology, Obstetrics and Urology , Sapienza University of Rome , Rome , Italy
| | - Sun-Wei Guo
- b Department of Gynecology, Shanghai Obstetrics and Gynecology Hospital , Fudan University , Shanghai , People's Republic of China
| | - Paola Bianchi
- c Department of Surgical and Medical Sciences and Traslational Medicine, Sant'Andrea Hospital, Faculty of Medicine and Psychology , Sapienza University of Rome , Rome , Italy
| | | | - Stephan Gordts
- d Leuven Institute for Fertility and Embryology , Leuven , Belgium
| | - Felice Petraglia
- e Department of Molecular and Developmental Medicine, Obstetrics and Gynecology , University of Siena , Siena , Italy
| | - Ivo Brosens
- f Department of Obstetrics and Gynaecology , Catholic University of Leuven , Leuven , Belgium
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Wildemeersch D. Response to "A new approach to the management of ovarian endometrioma to prevent tissue damage and recurrence". Reprod Biomed Online 2016; 33:214. [PMID: 27260698 DOI: 10.1016/j.rbmo.2016.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 04/26/2016] [Indexed: 11/17/2022]
Affiliation(s)
- Dirk Wildemeersch
- Gynecological Outpatient Clinic and IUD Training Centre, Ghent, Belgium.
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