Diagnostic Accuracy of Ultrasound and MRI in the Mapping of Deep Pelvic Endometriosis Using the International Deep Endometriosis Analysis (IDEA) Consensus

OBJECTIVES

The primary aim was to investigate the diagnostic accuracy of transvaginal ultrasound (TVS) and magnetic resonance imaging (MRI) in the mapping of deep pelvic endometriosis (DE) in a diseased population. The secondary aim was to offer first insights into the clinical applicability of the new International Deep Endometriosis Analysis group (IDEA) consensus for sonographic evaluation, which was also adapted for MRI and surgical reporting in this study.

METHODS

The study was a prospective observational cohort study. In this study, consecutive women planned for surgical treatment for DE underwent preoperative mapping of pelvic disease using TVS and MRI (index tests). The results were compared against the intraoperative findings with histopathological confirmation (reference standard). In case of disagreement between intraoperative and pathology findings, the latter was prioritised. Index tests and surgical findings were reported using a standardised protocol based on the IDEA consensus.

RESULTS

The study ran from 07/2016 to 02/2018. One-hundred and eleven women were approached, but 60 declined participation. Out of the 51 initially recruited women, two were excluded due to the missing reference standard. Both methods (TVS and MRI) had the same sensitivity and specificity in the detection of DE in the upper rectum (UpR) and rectosigmoid (RS) (UpR TVS and MRI sensitivity and specificity 100%; RS TVS and MRI sensitivity 94%; TVS and MRI specificity 84%). In the assessment of DE in the bladder (Bl), uterosacral ligaments (USL), vagina (V), rectovaginal septum (RVS), and overall pelvis (P), TVS had marginally higher specificity but lower sensitivity than MRI (Bl TVS sensitivity 89%, specificity 100%, MRI sensitivity 100%, specificity 95%; USL TVS sensitivity 74%, specificity 67%, MRI sensitivity 94%, specificity 60%; V TVS sensitivity 55%, specificity 100%, MRI sensitivity 73%, specificity 95%; RVS TVS sensitivity 67%, specificity 100%, MRI sensitivity 83%, specificity 93%; P TVS sensitivity 78%, specificity 97%, MRI sensitivity 91%, specificity 91%). No significant differences in diagnostic accuracy between TVS and MRI were observed except USL assessment (p=0.04) where MRI was significantly better and pouch of Douglas obliteration (p=0.04) where MRI was significantly better and pouch of Douglas obliteration (κ) = 0.727 [p=0.04) where MRI was significantly better and pouch of Douglas obliteration (κ) = 0.727 [p=0.04) where MRI was significantly better and pouch of Douglas obliteration (p=0.04) where MRI was significantly better and pouch of Douglas obliteration (.

CONCLUSION

We found that both imaging techniques had overall good agreement with the reference standard in the detection of deep pelvic endometriosis. This is the first study to date involving the IDEA consensus for ultrasound, its modified version for MRI, and intraoperative reporting of deep pelvic endometriosis in clinical practice.

Diagnostic pitfalls in ovarian androgen-secreting (Leydig cell) tumours: case series

Leydig cell tumours of the ovary are rare and represent a diagnostic challenge not only due to their sporadic incidence but also due to the seemingly normal imaging. We present three cases of pre- and postmenopausal women who were presented with severe clinical signs of hyperandogenism where modern imaging modalities (including computed tomography (CT), magnetic resonance imaging (MRI) and positron-emission tomography combined with computed tomography (PET-CT)) failed to identify the tumour. Two patients underwent non-expert ultrasound, CT and MRI examination with uniform conclusion that ovaries are of normal appearance. One of the two patients even had a PET-CT performed, which was inconclusive. Our case reports show the importance of examination by specialists with established skills in gynaecologic ultrasonography in the diagnosis of the Leydig cell tumours. The most useful diagnostic tool seems to be the combination of age (postmenopause), symptoms (onset of hirsutism and virilisation), high total testosterone plasma values and expert sonography. On ultrasound, these tumours are unilateral, usually small, solid intraovarian nodules of a slightly increased echogenicity in contrast to the surrounding ovarian tissue, delineated by abundant perfusion with an enhanced vascularity. The appropriate setting of the sensitive colour Doppler is crucial for the detection of intraovarian Leydig cell tumour. Impact statement What is already known on this subject? A diagnosis of Leydig cell tumours is based on ultrasound performed by a trained examiner or by MRI. CT or PET/CT are not among the primary methods of choice. According to the results of imaging investigations surgical treatment is planned. Because these tumours are usually benign and have a good prognosis the unilateral salpingo-oophorectomy is a standard procedure. What do the results of this study add? Our case series show how difficult it can be to establish the diagnosis of Leydig cell tumours by imaging, including transvaginal ultrasound, the most frequently recommended diagnostic tool. We demonstrate in three cases how easily a small hyperechogenic tumour can be overseen or interchanged for a different gynaecological pathology if transvaginal scan is not performed by an experienced examiner trained in sonographic features of gynaecologic neoplasms. What are the implications of these findings for clinical practice and/or further research? This case series demonstrate how important it is to see the patient in the whole complexity with their medical history, proper clinical symptoms evaluation, laboratory test and not to rely solely just on sophisticated high-end investigations, such as the PET-CT, a CT and an MRI. It also emphasises the importance of specialists with established skills in gynaecologic ultrasonography. Further effort should be made to define the resources for the appropriate training of such sonographers.

Endometriosis in pregnancy - diagnostics and management

OBJECTIVE

Endometriosis in pregnancy predominantly tends to regress or to stay stable but small part of endometriomas and nodules of deep infiltrating endometriosis may undergo the process of decidualization. Therefore, the foci of endometriosis enlarge their volume and change their structure due to cellular hypertrophy and stromal edema associated with higher vascularization caused by the hormonal changes in pregnant women. Consequently, these totally benign lesions may resemble malignant tumors in ultrasound examination.

DESIGN

Review article.

SETTING

Department of Obstetrics and Gynecology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague.

METHODS

A literature review of published data on decidualization of endometriosis.

RESULTS

Majority of decidualized ovarian endometriomas is asymptomatic so it is mostly accidentally found during the routine ultrasound check-ups within the frame of perinatologic screening. The rounded, smooth, highly vascularized solid papillary projections in internal wall of endometroid cysts are the most specific characteristics of decidualization. If ultrasound simple rules are not applicable or show probable malignancy, the pregnant patient should be referred to a tertiary center for expert ultrasound assessment. Magnetic resonance is indicated in cases of uncertain ultrasound findings, because it can clarify the diagnostics due to its high accuracy in detection of products of blood degradation and ability of diffusion-weighted imaging to recognize lower tissue cellularity of benign decidualized endometriomas in comparison to malignant ovarian tumors.

CONCLUSION

If the imaging methods confirm supposed decidualized endometriosis, watch and wait management based on regular ultrasound examinations during the whole pregnancy and after childbed is recommended. The regression of the tumor size and disappearance of the solid portions within endometriomas is expected after delivery. Decidualized endometriosis is rarely a source of gestational or obstetrical complications demanding acute surgical intervention. Elective surgical procedures in pregnant women are indicated only if expert ultrasound or magnetic resonance imaging assess the masses as border-line or invasive tumors (carcinomas) and in cases of suspicious changes of the originally presumed benign cysts during the surveillance.

Diagnosis of endometriosis 3rd part - Ultrasound diagnosis of deep endometriosis

OBJECTIVE

To summarise the current knowledge and trends in the diagnosis of deep endometriosis.

DESIGN

Review article.

SETTING

Centre for diagnostics and treatment of endometriosis and Gynecologic Oncology Centre, Department of Obstetrics and Gynaecology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Department of Gynaecology and Obstetrics, Burton Hospitals NHS, United Kingdom.

METHODS

Literature review.

RESULTS

Deep endometriosis (DE) in the pelvis is divided into lesions in the anterior and posterior compartment. In the anterior compartment DE infiltrates bladder and ureters, while in the posterior compartment it is mostly uterosacral ligaments, rectum, rectosigmoid and sigmoid colon and rarely rectovaginal septum and posterior fornix. Extrapelvic endometriosis is a rare disease typically located in the proximal bowel segments (jejunum/ileum/appendix), abdominal wall including umbilicus, scars after spontaneus delivery and/or after cesarian section, lungs and diaphragm.

CONCLUSION

Ultrasound diagnosis of pelvic DE has a high accuracy in the hands of an experienced sonographer. Extrapelvic endometriosis is sporadic and imaging of choice depends on the location, such as use of magnetic resonance in retroperitoneal disease (sciatic nerve), computed tomography or endoscopy in thoracic lesions.

Diagnosis of endometriosis 1st part - Overview of diagnostic approaches

Cíl studie: Shrnutí současných poznatků a trendů v oblasti diagnostiky endometriózy. Typ studie: Literární přehled. Název a sídlo pracoviště: Centrum pro komplexní léčbu endometriózy a Onkogynekologické centrum, Gynekologicko-porodnická klinika, 1. lékařská fakulta, Univerzita Karlova a Všeobecná fakultní nemocnice Praha; Department of Gynaecology and Obstetrics, Burton Hospitals NHS, UK. Metodika: Systematický přehledový článek. Výsledky: Diagnóza endometriózy v primární péči je stanovena na podkladě anamnézy, fyzikálního vyšetření a základního ultrazvukového vyšetření, které zobrazí přítomnost endometroidních cyst, adenomyózy a nepřímé známky srůstů. Použití krevních či močových biomarkerů se nedoporučuje. Pacientky s podezřením na přítomnost endometriózy by měly být odeslány do specializovaného centra léčby endometriózy, kde jsou k dispozici zkušení sonografisté anebo radiologové v rámci expertního ultrazvuku anebo magnetické rezonance a specializovaný chirurgický tým. Vysoká diagnostická přesnost obou zobrazovacích metod nepodporuje rutinní využití laparoskopie v diagnostice endometriózy, může však být zvažována k vyloučení povrchové anebo extrapelvické endometriózy u symptomatických pacientek s negativním nálezem při zobrazovacích metodách. Závěr: Během základního ultrazvukového vyšetření by ošetřující gynekolog měl být schopen zobrazit přítomnost endometroidních cyst, adenomyózy a nepřímé známky adhezí a na základě ultrazvukového nálezu anebo typických symptomů odeslat pacientku do centra pro léčbu endometriózy. Expertní ultrazvukové vyšetření pánevní endometriózy je obvykle dostupné ve specia-lizovaných centrech léčby endometriózy. Vzhledem k vysoké diagnostické přesnosti ultrazvuku, jeho běžné dostupnosti v gynekologii, nižší ceně a absenci kontraindikací ve srovnání s magnetickou rezonancí je ultrazvuk metodou volby v zobrazení rozsáhlé pánevní endometriózy, zatímco magnetická rezonance je využívána jako metoda druhé volby v obtížných případech.

Diagnosis of endometriosis 2nd part - Ultrasound diagnosis of endometriosis (adenomyosis, endometriomas, adhesions) in the community

OBJECTIVE

To summarise the current knowledge and trends in the basic ultrasound diagnosis of adenomyosis, endometroid cysts and pelvic adhesions.

DESIGN

Review article.

SETTING

Centre for diagnostics and treatment of endometriosis and Gynecologic Oncology Centre, Department of Obstetrics and Gynaecology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Department of Gynaecology and Obstetrics, Burton Hospitals NHS, United Kingdom.

METHODS

Literature review.

RESULTS

Endometriosis is a relatively common disease, which often escapes timely diagnosis, although sonographic features of adenomyosis, endometriomas and pelvic adhesions can be easily assessed on the basic ultrasound examination. Endometriomas are ovarian cysts in a premenopausal patient with ground glass echogenicity of the cyst fluid, one to four locules and no papilary projections with detectable blood flow. Adenomyosis is characterised by an asymmetrical thickening of the myometrium due to an ill-defined myometrial lesion with fan-shaped shadowing, non-uniform echogenicity with myometrial cysts, hyperechogenic islands, hyperechogenic subendometrial lines and buds with an irregular or interrupted junctional zone, and translesional vascularity containing vessels crossing the leasion perpendicular to the endometrium. Pelvic adhesions can be detected using dynamic aspect of ultrasound examination demonstrating negative sliding sign of the uterus and/or ovaries against surrounding tissue planes and site-specific tenderness. Distorted pelvic anatomy (the presence of uterine ‚question mark sign and/or ‚kissing ovaries) is another sign of adhesions.

CONCLUSION

First step in basic transvaginal ultrasound is visualisation of the uterus and ovaries, assessment of their mobility and tenderness during examination. Knowledge of the characteristic ultrasound features of adenomyosis, endometriomas and adhesions enables timely diagnosis of endometriosis by the community gynecologist and prompt referral to the endometriosis centre.

Domain analysis of PNKP-XRCC1 interactions: Influence of genetic variants of XRCC1

Polynucleotide kinase/phosphatase (PNKP) and X-ray repair cross-complementing 1 (XRCC1) are key proteins in the single-strand DNA break repair pathway. Phosphorylated XRCC1 stimulates PNKP by binding to its forkhead-associated (FHA) domain, whereas nonphosphorylated XRCC1 stimulates PNKP by interacting with the PNKP catalytic domain. Here, we have further studied the interactions between these two proteins, including two variants of XRCC1 (R194W and R280H) arising from single-nucleotide polymorphisms (SNPs) that have been associated with elevated cancer risk in some reports. We observed that interaction of the PNKP FHA domain with phosphorylated XRCC1 extends beyond the immediate, well-characterized phosphorylated region of XRCC1 (residues 515-526). We also found that an XRCC1 fragment, comprising residues 166-436, binds tightly to PNKP and DNA and efficiently activates PNKP's kinase activity. However, interaction of either of the SNP-derived variants of this fragment with PNKP was considerably weaker, and their stimulation of PNKP was severely reduced, although they still could bind DNA effectively. Laser microirradiation revealed reduced recruitment of PNKP to damaged DNA in cells expressing either XRCC1 variant compared with PNKP recruitment in cells expressing WT XRCC1 even though WT and variant XRCC1s were equally efficient at localizing to the damaged DNA. These findings suggest that the elevated risk of cancer associated with these XRCC1 SNPs reported in some studies may be due in part to the reduced ability of these XRCC1 variants to recruit PNKP to damaged DNA.

Persistent 3'-phosphate termini and increased cytotoxicity of radiomimetic DNA double-strand breaks in cells lacking polynucleotide kinase/phosphatase despite presence of an alternative 3'-phosphatase

Polynucleotide kinase/phosphatase (PNKP) has been implicated in non-homologous end joining (NHEJ) of DNA double-strand breaks (DSBs). To assess the consequences of PNKP deficiency for NHEJ of 3'-phosphate-ended DSBs, PNKP-deficient derivatives of HCT116 and of HeLa cells were generated using CRISPR/CAS9. For both cell lines, PNKP deficiency conferred sensitivity to ionizing radiation as well as to neocarzinostatin (NCS), which specifically induces DSBs bearing protruding 3'-phosphate termini. Moreover, NCS-induced DSBs, detected as 53BP1 foci, were more persistent in PNKP ^-/- HCT116 cells compared to their wild-type (WT) counterparts. Surprisingly, PNKP-deficient whole-cell and nuclear extracts were biochemically competent in removing both protruding and recessed 3'-phosphates from synthetic DSB substrates, albeit much less efficiently than WT extracts, suggesting an alternative 3'-phosphatase. Measurements by ligation-mediated PCR showed that PNKP-deficient HeLa cells contained significantly more 3'-phosphate-terminated and fewer 3'-hydroxyl-terminated DSBs than parental cells 5-15 min after NCS treatment, but this difference disappeared by 1 h. These results suggest that, despite presence of an alternative 3'-phosphatase, loss of PNKP significantly sensitizes cells to 3'-phosphate-terminated DSBs, due to a 3'-dephosphorylation defect.

The Rev1 interacting region (RIR) motif in the scaffold protein XRCC1 mediates a low-affinity interaction with polynucleotide kinase/phosphatase (PNKP) during DNA single-strand break repair

The scaffold protein X-ray repair cross-complementing 1 (XRCC1) interacts with multiple enzymes involved in DNA base excision repair and single-strand break repair (SSBR) and is important for genetic integrity and normal neurological function. One of the most important interactions of XRCC1 is that with polynucleotide kinase/phosphatase (PNKP), a dual-function DNA kinase/phosphatase that processes damaged DNA termini and that, if mutated, results in ataxia with oculomotor apraxia 4 (AOA4) and microcephaly with early-onset seizures and developmental delay (MCSZ). XRCC1 and PNKP interact via a high-affinity phosphorylation-dependent interaction site in XRCC1 and a forkhead-associated domain in PNKP. Here, we identified using biochemical and biophysical approaches a second PNKP interaction site in XRCC1 that binds PNKP with lower affinity and independently of XRCC1 phosphorylation. However, this interaction nevertheless stimulated PNKP activity and promoted SSBR and cell survival. The low-affinity interaction site required the highly conserved Rev1-interacting region (RIR) motif in XRCC1 and included three critical and evolutionarily invariant phenylalanine residues. We propose a bipartite interaction model in which the previously identified high-affinity interaction acts as a molecular tether, holding XRCC1 and PNKP together and thereby promoting the low-affinity interaction identified here, which then stimulates PNKP directly.

[Hirsutism]

OBJECTIVE

Overview of excessive hair growth in women, hirsutism. Although women with hirsutism typically present because of cosmetic concerns, the majority also have an underlying endocrine disorder.

DESIGN

Review article.

SETTING

Department of Gynecology and Obstetrics, General Faculty Hospital and 1st Faculty of Medicine of Charles Universtity, Prague.

MATERIAL AND METHODS

Hirsutism is a clinical diagnosis defined by the presence of excess terminal hair growth (dark, coarse hairs) in androgen-sensitive areas. It affects between five and ten percent of women of reproductive age. It may be the initial, and possibly only, sign of an underlying androgen disorder.

CONCLUSIONS

The most common cause of hirsutism is polycystic ovary syndrome (PCOS). In some cases, hirsutism is mild and requires only reassurance and local (nonsystemic) therapy, while in others it causes significant psychological distress and requires more extensive therapy. In case of rapid progressive hair growth should be first exclude androgen-secerning tumour (ovarian, adrenal) as the most serious condition.

[Management of Medical Termination of Pregnancy (MToP) up until the 7th week of gestation in the Czech Republic]

OBJECTIVE

In the Czech Republic (CR), it is possible, to carry out Medical Termination of Pregnancy (MToP) in the 1st trimester since June 2014, in case a woman submits a written request for it and in case the ultrasound examination confirms an intrauterine singleton prosperous pregnancy, between day 42 and 49 of gestation, crown-rump length (CRL) of the embryo 2-9 mm. The aim of the study is to analyze the management of MToP up until the 7th week of gestation in five centres in the CR.

DESIGN

Multicenter cohort (prospective) study.

SETTING

Department of Obstetrics and Gynecology, Palacky University Olomouc, Faculty of Medicine and Dentistry, University Hospital Olomouc; The Institute for the Care of Mother and Child, Charles University in Prague, Third faculty of Medicine; Department of Gynecology and Obstetrics, Charles University in Prague, First faculty of Medicine, General University Hospital in Prague; Department of Gynecology and Obstetrics, Charles University in Prague, First faculty of Medicine, Hospital Na Bulovce, Prague; Department of Gynecology and Obstetrics, Masaryk University, Faculty of Medicine, University Hospital Brno.

METHODS

In 2014-2016, a total of 1820 pregnant women requested MToP. The diagnosis of an intrauterine singleton prosperous pregnancy was set by transvaginal ultrasound, CRL 2-9 mm. MToP was carried out by combination of mifepristone (600 mg orally) and misoprostol (400 mcg orally) within 48 hours. MToP follow up (exclusion of ongoing pregnancy) after 2-3 weeks was carried out by transvaginal ultrasound as well.

RESULTS

In 11.0% of women (201/1820) who requested MToP, CRL > 9 mm, unprosperous, multiple or ectopic pregnancy was diagnosed. In the remaining 1619 women MToP was carried out, but in 221 cases (13.7%) at least one additional pre-first visit was needed before the diagnosis of intrauterine singleton prosperous pregnancy CRL 2-9 mm could be established, in 19 cases (1.2%) two pre-first visits and in 5 cases (0.3%) even three. Gestational age was 42-49 days (average 47.1, median 47), the women were 14-47 years of age (average 30.7, median 30). In 20.8% of women (336/1619) MToP follow up was missed and of the remaining 1283 women, ongoing pregnancy (MToP failure) was diagnosed in 1.6% (24/1283), incomplete abortion in 6.5% (83/1283) and complete abortion in 91.9% (1179/1283). A subsequent surgical intervention was carried out in 7.1 % of women (91/1283).

CONCLUSION

A medical facility performing MToP in the 1st trimester should develop its own methodology in accordance with the legislation in force, Summaries of Product Characteristics, and recommendations of professional associations. The methodology should also include a method of evaluation of the result and management. The subsequent surgical intervention should only be performed in indicated cases. The main goal of MToP follow up is to exclude ongoing pregnancy (MToP failure), and the patient should be informed in detail about the risks involved and possibilities of their solution, it is necessary to obtain an informed consent.

Management of Medical Termination of Pregnancy (MToP) up until the 7th week of gestation in the Czech Republic

OBJECTIVE

In the Czech Republic (CR), it is possible, to carry out Medical Termination of Pregnancy (MToP) in the 1st trimester since June 2014, in case a woman submits a written request for it and in case the ultrasound examination confirms an intrauterine singleton prosperous pregnancy, between day 42 and 49 of gestation, crown-rump length (CRL) of the embryo 2-9 mm. The aim of the study is to analyze the management of MToP up until the 7th week of gestation in five centres in the CR.

DESIGN

Multicenter cohort (prospective) study.

SETTING

Department of Obstetrics and Gynecology, Palacky University Olomouc, Faculty of Medicine and Dentistry, University Hospital Olomouc; The Institute for the Care of Mother and Child, Charles University in Prague, Third faculty of Medicine; Department of Gynecology and Obstetrics, Charles University in Prague, First faculty of Medicine, General University Hospital in Prague; Department of Gynecology and Obstetrics, Charles University in Prague, First faculty of Medicine, Hospital Na Bulovce, Prague; Department of Gynecology and Obstetrics, Masaryk University, Faculty of Medicine, University Hospital Brno.

METHODS

In 2014-2016, a total of 1820 pregnant women requested MToP. The diagnosis of an intrauterine singleton prosperous pregnancy was set by transvaginal ultrasound, CRL 2-9 mm. MToP was carried out by combination of mifepristone (600 mg orally) and misoprostol (400 mcg orally) within 48 hours. MToP follow up (exclusion of ongoing pregnancy) after 2-3 weeks was carried out by transvaginal ultrasound as well.

RESULTS

In 11.0% of women (201/1820) who requested MToP, CRL > 9 mm, unprosperous, multiple or ectopic pregnancy was diagnosed. In the remaining 1619 women MToP was carried out, but in 221 cases (13.7%) at least one additional pre-first visit was needed before the diagnosis of intrauterine singleton prosperous pregnancy CRL 2-9 mm could be established, in 19 cases (1.2%) two pre-first visits and in 5 cases (0.3%) even three. Gestational age was 42-49 days (average 47.1, median 47), the women were 14-47 years of age (average 30.7, median 30). In 20.8% of women (336/1619) MToP follow up was missed and of the remaining 1283 women, ongoing pregnancy (MToP failure) was diagnosed in 1.6% (24/1283), incomplete abortion in 6.5% (83/1283) and complete abortion in 91.9% (1179/1283). A subsequent surgical intervention was carried out in 7.1 % of women (91/1283).

CONCLUSION

A medical facility performing MToP in the 1st trimester should develop its own methodology in accordance with the legislation in force, Summaries of Product Characteristics, and recommendations of professional associations. The methodology should also include a method of evaluation of the result and management. The subsequent surgical intervention should only be performed in indicated cases. The main goal of MToP follow up is to exclude ongoing pregnancy (MToP failure), and the patient should be informed in detail about the risks involved and possibilities of their solution, it is necessary to obtain an informed consent.

[Endometriosis and quality of life]

OBJECTIVE

This article aims to provide a comprehensive overview of the possibilities of evaluating the impact of symptoms of endometriosis on quality of life of affected women and to overview the effect of treatment modalities in improving of the quality of their life.

DESIGN

Review article.

SETTING

Department of Obstetrics and Gynecology, First Faculty of Medicine, Charles University and General University Hospital in Prague.

METHODS

Review of results of published studies evaluating quality of life in patients with endometriosis.

CONCLUSION

Symptoms of endometriosis decrease the quality of life of affected women, which has significant impact on society. Since the extent of endometriosis does not correlate with subjective complaints, it is suitable to evaluate the quality of life of patients in addition to assessment of the extent and classification of the disease (according to internationally accepted classification). The quality of life could be measured and compared by structured interviews or by validated questionnaires. Pharmacological as well as surgical treatment significantly improve quality of life of patients with endometriosis. Routine use of validated questionnaires of quality of life in patients with endometriosis might improve the assessment of severity of the disease and evaluation of effectiveness of the treatment in the future.

[Laparoscopic lymph-node dissection in gynecological surgery]

OBJECTIVE

To analyze our experience with transperitoneal laparoscopic dissection of lymphatic nodes in women with gynecologic malignancies.

STUDY DESIGN

Retrospective clinical study.

SETTING

Center of gynecologic endoscopy and minimally invasive surgery; Department of Obstetrics and Gynecology, General Faculty Hospital and 1st Medical Faculty in Prague.

METHODS

Analysis of data from our laparoscopic procedures in the years 2006-2011. The following procedures have been included: systematic pelvic lymphadenectomy (PLN), paraaortic lymphadenectomy (PALN), pelvic sentinel node excision, focused dissection of bulky lymphatic nodes from pelvis or paraaortic area.

RESULTS

We performed 177 primarily laparoscopic procedures pointed at dissection of pelvic and/or paraaortic lymph-nodes. The mean operating time and the mean number of lymph-nodes was 82 minutes and 26.5 nodes in patients with PLN, and 75 minutes and 12.5 nodes in patients with PALN. The overall rate of laparo-conversions was 4.5%; the incidence of major complications was 6.8% and of serious bleeding 5.6%. Laparoscopic lymphadenectomy could not be performed or completed in 2.3% of cases. Complications were more frequently associated with PALN than with PLN.

SUMMARY

Laparoscopic approach to PLN and PALN is feasible in vast majority of patients. It provides adequate earnings of the lymphatic nodes, tolerable operative time, and relatively low complication rate. The highly experienced operation team for especially high infrarenal PALN is necessary.

[Endometriosis]

OBJECTIVE

To summarize current knowledge of pathogenesis, diagnostics and treatment of endometriosis.

DESIGN

Review article.

SETTING

Centre for diagnostics and treatment of endometriosis, Department of Gynecology and Obstetrics, General Faculty Hospital and 1st Faculty of Medicine of Charles University, Prague.

METHODS AND RESULTS

Endometriosis is defined as the presence of endometrial-like tissue outside the uterus, which induces a chronic, inflammatory reaction. The condition is predominantly found in women of reproductive age, from all ethnic and social groups. The associated symptoms - pain, infertility - can impact on general physical, mental and social well being. Treatment must be individualised, taking the clinical problem in its entirety into account, including the impact of the disease and the effect of its treatment on quality of life. Pain symptoms may persist despite seemingly adequate medical and/or surgical treatment of the disease. In such circumstances, a multi-disciplinary approach involving a pain clinic and counselling should be considered early in the treatment plan.

CONCLUSION

Endometriosis is a medical condition with high recurrence rate and especially those patients with deep infiltrating endometriosis should be centralized to the centres experienced in diagnostics, complicated surgical treatment and providing multi-disciplinary approach with adequate postoperative care.

[Office hysteroscopy - management and results]

OBJECTIVE

Sum up the knowledge about office hysteroscopy.

TYPE OF STUDY

Review of literature and our own experience.

SETTING

Department of Gynaecology and Obstetrics, First Faculty of Medicine, Charles University Prague and General Teaching Hospital Prague.

METHODS

Data from scientific literature and 10 years of our own experience with office hysteroscopy.

CONCLUSIONS

Hysteroscopy provides optical evaluation of uterine cavity. Most of the benign intrauterine organics pathologies could be managed in a outpatient setting with a vaginoscopic approach without any anaesthesia and analgesia. Using that approach we can recommend to perform endometrial target biopsy, resection of endometrial polyps up to 1.5 cm and pedunculated submucous myomas up to 1 cm as well as resection of filmy intrauterine adhesions. Method is comfortable for well managed patients and practically complication-free.

[A recommended approach to evaluate cardiovascular risk and to prevent cardiovascular diseases and type 2 diabetes mellitus in women with polycystic ovary syndrome]

Polycystic ovary syndrome is one of the most common endocrinopathy in women of fertile age. It is commnoly accompanied by an increased occurence of cardiovascular risk factors. This association led to a consensus statement of Androgen Excess Society for screening of cardiovascular risk factors. We present the recommendations of Czech Endocrine and Czech Diabetological Societies for the screening and primary prevention of cardiovascular diseases and diabetes mellitus.

Phosphorylation of polynucleotide kinase/ phosphatase by DNA-dependent protein kinase and ataxia-telangiectasia mutated regulates its association with sites of DNA damage

Human polynucleotide kinase/phosphatase (PNKP) is a dual specificity 5'-DNA kinase/3'-DNA phosphatase, with roles in base excision repair, DNA single-strand break repair and non-homologous end joining (NHEJ); yet precisely how PNKP functions in the repair of DNA double strand breaks (DSBs) remains unclear. We demonstrate that PNKP is phosphorylated by the DNA-dependent protein kinase (DNA-PK) and ataxia-telangiectasia mutated (ATM) in vitro. The major phosphorylation site for both kinases was serine 114, with serine 126 being a minor site. Ionizing radiation (IR)-induced phosphorylation of cellular PNKP on S114 was ATM dependent, whereas phosphorylation of PNKP on S126 required both ATM and DNA-PK. Inactivation of DNA-PK and/or ATM led to reduced PNKP at DNA damage sites in vivo. Cells expressing PNKP with alanine or aspartic acid at serines 114 and 126 were modestly radiosensitive and IR enhanced the association of PNKP with XRCC4 and DNA ligase IV; however, this interaction was not affected by mutation of PNKP phosphorylation sites. Purified PNKP protein with mutation of serines 114 and 126 had decreased DNA kinase and DNA phosphatase activities and reduced affinity for DNA in vitro. Together, our results reveal that IR-induced phosphorylation of PNKP by ATM and DNA-PK regulates PNKP function at DSBs.

Dual modes of interaction between XRCC4 and polynucleotide kinase/phosphatase: implications for nonhomologous end joining

XRCC4 plays a crucial role in the nonhomologous end joining (NHEJ) pathway of DNA double-strand break repair acting as a scaffold protein that recruits other NHEJ proteins to double-strand breaks. Phosphorylation of XRCC4 by protein kinase CK2 promotes a high affinity interaction with the forkhead-associated domain of the end-processing enzyme polynucleotide kinase/phosphatase (PNKP). Here we reveal that unphosphorylated XRCC4 also interacts with PNKP through a lower affinity interaction site within the catalytic domain and that this interaction stimulates the turnover of PNKP. Unexpectedly, CK2-phosphorylated XRCC4 inhibited PNKP activity. Moreover, the XRCC4·DNA ligase IV complex also stimulated PNKP enzyme turnover, and this effect was independent of the phosphorylation of XRCC4 at threonine 233. Our results reveal that CK2-mediated phosphorylation of XRCC4 can have different effects on PNKP activity, with implications for the roles of XRCC4 and PNKP in NHEJ.

Mechanism of action of an imidopiperidine inhibitor of human polynucleotide kinase/phosphatase

The small molecule, 2-(1-hydroxyundecyl)-1-(4-nitrophenylamino)-6-phenyl-6,7a-dihydro-1H-pyrrolo[3,4-b]pyridine-5,7(2H,4aH)-dione (A12B4C3), is a potent inhibitor of the phosphatase activity of human polynucleotide kinase/phosphatase (PNKP) in vitro. Kinetic analysis revealed that A12B4C3 acts as a noncompetitive inhibitor, and this was confirmed by fluorescence quenching, which showed that the inhibitor can form a ternary complex with PNKP and a DNA substrate, i.e. A12B4C3 does not prevent DNA from binding to the phosphatase DNA binding site. Conformational analysis using circular dichroism, UV difference spectroscopy, and fluorescence resonance energy transfer all indicate that A12B4C3 disrupts the secondary structure of PNKP. Investigation of the potential site of binding of A12B4C3 to PNKP using site-directed mutagenesis pointed to interaction between Trp(402) of PNKP and the inhibitor. Cellular studies revealed that A12B4C3 sensitizes A549 human lung cancer cells to the topoisomerase I poison, camptothecin, but not the topoisomerase II poison, etoposide, in a manner similar to small interfering RNA against PNKP. A12B4C3 also inhibits the repair of DNA single and double strand breaks following exposure of cells to ionizing radiation, but does not inhibit two other key strand-break repair enzymes, DNA polymerase beta or DNA ligase III, providing additional evidence that PNKP is the cellular target of the inhibitor.

Independent mechanisms of stimulation of polynucleotide kinase/phosphatase by phosphorylated and non-phosphorylated XRCC1

XRCC1 plays a central role in mammalian single-strand break repair. Although it has no enzymatic activity of its own, it stimulates the activities of polynucleotide kinase/phosphatase (PNKP), and this function is enhanced by protein kinase CK2 mediated phosphorylation of XRCC1. We have previously shown that non-phosphorylated XRCC1 stimulates the kinase activity of PNKP by increasing the turnover of PNKP. Here we extend our analysis of the XRCC1-PNKP interaction taking into account the phosphorylation of XRCC1. We demonstrate that phosphorylated and non-phosphorylated XRCC1 interact with different regions of PNKP. Phosphorylated XRCC1 binds with high affinity (K_d = 3.5 nM and 1 : 1 stoichiometry) to the forkhead associated (FHA) domain, while non-phosphorylated XRCC1 binds to the catalytic domain of PNKP with lower affinity (K_d = 43.0 nM and 1 : 1 stoichiometry). Under conditions of limited enzyme concentration both forms of XRCC1 enhance the activities of PNKP, but the effect is more pronounced with phosphorylated XRCC1, particularly for the kinase activity of PNKP. The stimulatory effect of phosphorylated XRCC1 on PNKP can be totally inhibited by the presence of excess FHA domain polypeptide, but non-phosphorylated XRCC1 is not susceptible to competition by the FHA domain. Thus, XRCC1 can stimulate PNKP by two independent mechanisms.

[Sexual functions after laparoscopically assisted vaginal hysterectomy (LAVH) and total laparoscopic hysterectomy (TLH) in preoperatively asymptomatic women]

OBJECTIVE

To find the consequences of laparoscopically assisted vaginal hysterectomy (LAVH) and total laparoscopic hysterectomy (TLH) for sexual functions in preoperatively asymptomatic women.

DESIGN

Prospective study.

SETTING

Department of Obstetrics and Gynecology, 1st Faculty of Medicine, Charles University and General Teaching Hospital in Prague.

MATERIAL AND METHODS

In 100 women without subjective complaints hysterectomy was performed for benign uterine pathology. In all the women the uterus weighted less than 250 g, there were no salpingooophorectomies and no perioperative complications. Women were alternativelly assigned for LAVH (n = 50) or TLH (n = 50). Clinical documentation and questionnaires about sexual functions were evaluated in 87 women (in 40 women after LAVH and in 47 after TLH) 18 months after surgery or later.

RESULTS

According to our findings the type of surgery did not influence the frequency of sexual activity after surgery, there was no change in sexual manners using during coitus as well as no change in preferred way how to reach the sexual arousal (clitoridally, vaginally or combined). The type of surgery did not influence frequency, quality and duration of orgasm. From all the evaluated parameters there were only two significantly different: the presence of postoperative sexual activity (positive answer in all women from LAVH group and only in 85% women from TLH group, F test, p = 0.009) and the frequency of sexual satisfaction (in terms of both increase and also decrease in TLH group chi2 8,376, p = 0.015).

CONCLUSION

The type of laparoscopic hysterectomy (LAVH or TLH) does not significantly affect the sexual functions (frequency of sexual satisfaction, type of sexual arousability, intensity and duration of orgasm) in preoperatively asymptomatic women.

Uterine arteries doppler velocimetry provides 3-years follow up endometrial ablation outcome

The aim of this study was to assess whether uterine artery Doppler velocimetry [pulsatility index (PI) and resistance index (RI)] and thickness of the endometrium (TE) are able to predict 3-year clinical outcome after endometrial ablation (EA) for dysfunctional uterine bleeding (DUB). This was a prospective, observational study of 29 women of whom 22 were amenorrhoeic (A) and 7 eumenorrhoeic (E) at the end of the first postoperative year. The PI, RI and TE were measured prior to and 1, 6 and 12 months after EA. Statistical analyses were performed using BMDP statistical software, discriminant analysis, ANOVA and T test. Using the calculated classification function (CF) with the three parameters PI, RI and TE measured 12 months after FEAT, we were able to accurately (100%) specify which of the women will have A or E in 3 years. The predictive value of PI, RI and TE has been confirmed clinically in a minimum 3-year follow-up of outcome (ranging from 36 to 72 months [mean 55]). All A and E women have stayed in the same group (A or E) during the minimum of 3 years. In conclusion we found that PI, RI and TE measured prior to EA cannot predict the outcome, however these measurements performed 1 year after FEAT can predict the duration of A or E in the 3-year follow up.

XRCC1 Stimulates Polynucleotide Kinase by Enhancing Its Damage Discrimination and Displacement from DNA Repair Intermediates

Human polynucleotide kinase (hPNK) is required for processing and rejoining DNA strand break termini. The 5'-DNA kinase and 3'-phosphatase activities of hPNK can be stimulated by the "scaffold" protein XRCC1, but the mechanism remains to be fully elucidated. Using a variety of fluorescence techniques, we examined the interaction of hPNK with XRCC1 and substrates that model DNA single-strand breaks. hPNK binding to substrates with 5'-OH termini was only approximately 5-fold tighter than that to identical DNA molecules with 5'-phosphate termini, suggesting that hPNK remains bound to the product of its enzymatic activity. The presence of XRCC1 did not influence the binding of hPNK to substrates with 5'-OH termini, but sharply reduced the interaction of hPNK with DNA bearing a 5'-phosphate terminus. These data, together with kinetic data obtained at limiting enzyme concentration, indicate a dual function for the interaction of XRCC1 with hPNK. First, XRCC1 enhances the capacity of hPNK to discriminate between strand breaks with 5'-OH termini and those with 5'-phosphate termini; and second, XRCC1 stimulates hPNK activity by displacing hPNK from the phosphorylated DNA product.

[Late (non-classic) adrenal hyperplasia]

OBJECTIVE

To summarize available data concerning adrenal hyperandrogenemia caused by 21-hydroxylase deficiency, non-classic adrenal hyperplasia (NCAH).

DESIGN

Review article.

SETTING

Department of Gynecology and Obstetrics, General Faculty Hospital and 1st Medical Faculty, Prague.

METHODS

Compilation of published data from scientific literature.

CONCLUSION

Although 21-hydroxylase deficiency is one of the most frequent autosomal recessive genetic disorders, prevalence of NCAH in the whole population and among hyperandrogenic women is very low. The measurement of 17OH-progesterone should be incorporated into the standard evaluation of all hyperandrogenic patients to establish or exclude the diagnosis of NCAH. There is no typical clinical sign of NCAH, and clinical symptoms are to similar to patients with PCOS. Corticoid substitution as a treatment modality of NCAH is derived from therapy of classic congenital adrenal hyperplasia (CAH). Anti-androgen therapy is effective in skin disorders (hirsutism). Due to normal cortisol value there is to use of combined oral contraceptives in the treatment of choice. An improvement of clinical symptoms is a key parameter for the evaluation of treatment effectiveness. There are no data about risk of late metabolic complications in NCAH patients.

Biophysical characterization of human XRCC1 and its binding to damaged and undamaged DNA

The human DNA repair protein, hXRCC1, which is required for DNA single-strand break repair and genetic stability was produced as a histidine-tagged polypeptide in Escherichia coli, purified by affinity chromatography, and subjected to sedimentation and spectroscopic analyses. This study represents the first biophysical examination of full-length XRCC1. Sedimentation equilibrium measurements indicated that hXRCC1 exists as a monomer at lower protein concentrations but forms a dimer at higher protein concentrations with a K(d) of 5.7 x 10(-)(7) M. The size and shape of hXRCC1 in solution were determined by analytical ultracentrifugation studies. The protein exhibited an intrinsic sedimentation coefficient, s(0)(20,w), of 3.56 S and a Stokes radius, R(s), of 44.5 A, which together with the M(r) of 68000 suggested that hXRCC1 is a moderately asymmetric protein with an axial ratio of 7.2. Binding of model ligands, representing single-strand breaks with either a nick or a single nucleotide gap, quenched protein fluorescence, and binding affinities and stoichiometries were determined by carrying out fluorescence titrations as a function of ligand concentration. XRCC1 bound both nicked and 1 nucleotide-gapped DNA substrates tightly in a stoichiometric manner (1:1) with K(d) values of 65 and 34 nM, respectively. However, hXRCC1 exhibited lower affinities for a duplex with a 5 nucleotide gap, the intact duplex with no break, and a single-stranded oligonucleotide with K(d) values of 215, 230, and 260 nM, respectively. Our results suggest that hXRCC1 exhibits preferential binding to DNA with single-strand breaks with a gap size of <5 nucleotides.

[Benefits and risk of the modern combined hormonal contraception]

The combined hormonal contraception is the most efficient reversible variety of family planning. The modern low doses combined hormonal contraception have a high efficacy with minimal risks. Users are still in risks of cardiovascular complications. The combined hormone contraception also has positive noncontraceptive effects on menstrual disorders, hyperandrogenism, cysts of ovary, pelipathy etc. The benefits are higher than the risks only when respecting the basic rules of the combined hormonal contraception prescription.

The effect of combination therapy with metformin and combined oral contraceptives (COC) versus COC alone on insulin sensitivity, hyperandrogenaemia, SHBG and lipids in PCOS patients

BACKGROUND

Neither oral contraceptives (COC) nor metformin are an optimal modality for the long-term treatment of polycystic ovary syndrome (PCOS). The aim of this study was to evaluate whether a combination of both is beneficial over COC monotherapy.

METHODS

Altogether, 30 women were included in the study and 28 finished the protocol. The patients were randomly assigned to two groups treated with either COC (COC group) or COC and metformin (1500 mg/day) (METOC group) for 6 months. Anthropometric parameters, androgens, lipids, fasting insulin, glucose and sex hormone binding globulin (SHBG) concentrations were measured before and at the end of the sixth cycle of treatment. The insulin sensitivity index was evaluated using the euglycaemic clamp.

RESULTS

There were no significant changes in anthropometric parameters, fasting glucose or insulin sensitivity in either group. Total testosterone, free androgen index, androstenedione and dehydroepiandrosterone decreased and SHBG increased significantly in both groups. When comparing the effect of both treatments, only a more pronounced decrease in free androgen index was found in the METOC group.

CONCLUSIONS

Adding metformin slightly modified the treatment effect of COC, causing a more significant decrease in the free androgen index but having no additional positive impact on lipids, insulin sensitivity, SHBG or testosterone. The available data do not offer enough evidence to advocate the standard use of combined treatment in PCOS. Whether the combination might be beneficial for specific subgroups of patients is of further interest.

Spectroscopic studies of DNA and ATP binding to human polynucleotide kinase: evidence for a ternary complex

Human polynucleotide kinase (hPNK), which possesses both 5'-DNA kinase and 3'-DNA phosphatase activities, is a DNA repair enzyme required for processing and rejoining of single- and double-strand-break termini. Full-length hPNK was subjected to sedimentation and spectroscopic analyses in association with its ligands, a 20-mer oligonucleotide, ATP, and AMP-PNP (a nonhydrolyzable analogue of ATP). Sedimentation equilibrium measurements indicated that hPNK was a monomer in the presence and absence of the ligands. Circular dichroism measurements revealed that the ligands induced different conformational changes in hPNK, although AMP-PNP induced the same conformational changes as ATP. CD also indicated that the oligonucleotide could bind to the protein-AMP-PNP complex. Protein-ligand binding affinities and stoichiometries were determined by measuring changes in protein intrinsic fluorescence. Titrating hPNK with the oligonucleotide indicated tight binding with a K(d) value of 1.3 microM and with 1:1 stoichiometry. A 5'-phosphorylated oligonucleotide with the same sequence exhibited an almost 6-fold lower affinity (K(d) value, 7.2 microM). ATP and AMP-PNP bound with high affinity (K(d) values, respectively, of 1.4 and 1.6 microM), and the observed binding stoichiometries were 1:1. Furthermore, the nonphosphorylated oligonucleotide was able to bind to hPNK in the presence of AMP-PNP with a K(d) value of 2.5 microM, confirming the formation of a ternary complex. This study provides the first direct physical evidence for such a ternary complex involving a polynucleotide kinase, AMP-PNP, and an oligonucleotide, and supports a reaction mechanism in which ATP and DNA bind simultaneously to the enzyme.

[A transdermal form of combined hormonal contraceptives (EVRA)]

OBJECTIVE

To present a review of a novel transdermal contraceptive patch containing norelgestromin (150 micrograms/d) and ethinylestradiol (20 micrograms/d).

DESIGN

Review article.

SETTING

Department of Gynecology and Obstetric, 1st Medical Faculty and General Faculty Hospital, Prague.

RESULTS

The contraceptive patch exhibits favourable pharmakokinetic profile, maintaining efficacious serum hormone concentrations under varying conditions and without peaks and through characteristic of oral dosing. Efficacy, cycle control, tolerability and side effect profile were comparable to an established oral contraceptive. Compliance with the weekly administered contraceptive patch was significantly better than with an oral contraceptive. The reliability of adhesion of the patch is very high and consistent even under varying conditions (heat, humidity, exercise).

Pregnancy outcome in women with PCOS and in controls matched by age and weight

BACKGROUND

The aim of this study was to compare the pregnancy outcome, especially the prevalence of gestational diabetes mellitus (GDM), in a group of patients with polycystic ovary syndrome (PCOS), with a group of healthy weight-matched women.

METHODS

Retrospectively, we evaluated the pregnancies of 66 women with PCOS, who had been treated for infertility and who delivered at our department. These were compared with a group of 66 age- and weight-matched controls.

RESULTS

We did not find any significant differences in the prevalence of pregnancy complications such as gestational diabetes mellitus, pregnancy-induced hypertension (PIH) and premature deliveries between the group of PCOS patients and the controls.

CONCLUSION

When differences in age and weight between PCOS patients and controls are negligible, PCOS is not associated with a higher risk of pregnancy complications.

[Long-term follow-up after complete treatment of peritoneal endometriosis with the CO2 laser]

OBJECTIVE

To evaluate the effect of laparoscopic CO2 laser ablation of peritoneal endometriosis in the treatment of pelvic pain with a long-term follow-up. To differentiate the effect of surgery on different types of pelvic pain.

DESIGN

Prospective observational study.

SETTING

Department of Obstetrics and Gynecology, 1st Medical Faculty, Charles University and General Faculty Hospital, Prague.

METHODS

Patients with 1st to 3rd stage endometriosis, with manifestation of pelvic pain, and with complete excision of peritoneal endometriosis lesions, were included in the study. All visible lesions were vaporized by CO2 laser following adhesiolysis and complete visualization of the pelvis. After the procedure, patients were followed up at 6-month intervals. The severity of pelipathia, dyspareunia, dysmenorrhea, pain during micturition, and pain during defecation were monitored using a visual analog score of 10 points.

RESULTS

A total of 31 patients were included in the study. After 6, 12, and 18 months after surgery, the recurrence of pelvic pain was found in 12 (39%), 15 (48%), and 19 (61%) patients, respectively. Improvement or disappearance of complaints was documented 18 months after the surgery in 11 cases of dysmenorrhea (50%), 9 cases of dyspareunia (50%), 14 cases of pelipathia (58%), 12 cases of pain during micturition (71%), and in 14 cases of pain during defecation (87.5%). The proportion of recurrences increases with the length of the interval after the procedure, mainly in dysmenorrhea and dyspareunia.

CONCLUSIONS

The effect (improvement or disappearance of pelvic pain) of a complete CO2 laser ablation of peritoneal endometriosis continues 18 months after the surgery in about 40% of patients. A graduated increase in the number of recurrences is apparent during follow-up, most significantly in dysmenorrhea and dyspareunia. The effect of surgery on different types of pelvic pain varies. A small number of recurrences was found in pain during micturition and pain during defecation, on the other hand, less success was apparent in the treatment of dysmenorrhea.

Prediction of insulin sensitivity in nonobese women with polycystic ovary syndrome

Insulin resistance is a frequent (although not constant) abnormality in both obese and nonobese women with polycystic ovary syndrome (PCOS). It plays a key role in the predisposition to type 2 diabetes, which is the most important health consequence of the syndrome. Identification of patients with insulin resistance is significant both for follow-up and for therapeutic reasons. The aim of the study was to evaluate the relationships between insulin sensitivity, measured by euglycemic clamp, and both endocrine and metabolic indices and to identify the best model for predicting insulin sensitivity. A total of 41 nonobese women fulfilling the diagnostic criteria for PCOS were enrolled in the study. None of the androgens correlated with the insulin sensitivity index. All clamp parameters correlated with SHBG, triglycerides, and body mass index, although no correlation was found with waist to hip ratio or waist circumference. The close relationship between insulin sensitivity and SHBG was documented by factor analysis and by its presence in all prediction models as the most significant (or even the single) predictor of the insulin sensitivity index.

IN CONCLUSION

1) a decreased level of SHBG can be used as a single reliable parameter in the prediction of insulin sensitivity in nonobese women with PCOS; and 2) waist to hip ratio, waist circumference, and androgen concentrations have no predictive value.

Insulin sensitivity in non-obese women with polycystic ovary syndrome during treatment with oral contraceptives containing low-androgenic progestin

BACKGROUND

Combined oral contraceptives (COC) effectively suppress hyperandrogenism in women with polycystic ovary syndrome (PCOS), though deterioration of insulin sensitivity during treatment is assumed. The study aim was to investigate insulin action and androgen production during treatment with COC containing low-androgenic progestin.

METHODS

A total of 13 PCOS women and nine controls was enrolled into the study. Only non-obese women with a body mass index (BMI) <or=30 kg/m(2) were included. Hyperinsulinaemic euglycaemic clamp techniques were performed before and after 6 months of treatment with a monophasic COC containing norgestimate.

RESULTS

Anthropometric parameters [BMI, waist:hip ratio (WHR)] remained unaltered during the study in both groups. No deterioration in glucose disposal rate (M), insulin sensitivity index (ISI) or metabolic clearance rate of glucose (MCRG) was observed during treatment in PCOS subjects. Fasting glucose decreased significantly (P < 0.01), but fasting insulin remained unchanged. Significant decreases in concentrations of testosterone (P < 0.001), androstenedione (P < 0.01) and dihydroepiandrosterone (DHEA) (P < 0.001), a decrease in the free androgen index, and an increase in concentrations of sex hormone-binding globulin were found in PCOS subjects.

CONCLUSIONS

The norgestimate-containing COC significantly decreased androgen production and concentrations of free androgens, without reducing insulin sensitivity in non-obese PCOS subjects.

[Can hormonal contraceptives affect plasma levels of IGF-1 and IGFBP-1 in slim women with polycystic ovary syndrome?]

BACKGROUND

Polycystic ovary syndrome (PCOS) represents a frequent endocrinopathy among fertile women. Ethiopathogenesis of the syndrome is multifactorial and it is a subject of scientific discussions. Considered is the possibility of intraovarial IGF system disorder affecting maturation of ovarial folicles. The aim of our work was to determine effects of peroral contraceptives with low-androgen progestin on IGF system in PCOS patients and healthy woman controls.

METHODS AND RESULTS

14 patients fulfilling diagnostic criteria of PCOS and 7 healthy controls were included into the study. All persons were examined before and after six months lasting administration of monophasic estrogen-progesteron contraceptive therapy with 35 micrograms of ethinylestradiol per day and 250 micrograms of low-androgen progestin norgestimate per day. In PCOS patients low increase of basal insulinemia levels occurred (16.3 +/- 4.8 vs. 20.8 +/- 4.8 mU.l-1, p < 0.05). IGF-1 serum levels were not influenced (230 +/- 70 vs. 235 +/- 112 pg.ml-1, n.s.), IGFBP-1 serum concentration significantly increased (46.3 +/- 24.1 vs. 75.6 +/- 24.0 pg.ml-1, p < 0.001). Insulinemia in healthy women also slightly increased (15.9 +/- 4.0 vs. 18.4 +/- 4.0 pg.ml-1, p < 0.05). IGF-1 serum concentration significantly increased (140 +/- 65 vs. 241 +/- 89 pg.ml-1, p < 0.001). IGFBP-1 was also higher (45.0 +/- 19.19 vs. 80.0 +/- 15.6 pg.ml-1, p < 0.001). Influence of the hormonal contraception on the followed parameters was estimated using Wilcoxon's test. While BP-1 increase was significant in both groups, the increase of IGF-1 was significant only in healthy controls.

CONCLUSIONS

Increased levels of IGFBP-1 were found in both studied groups of women. Women with PCOS had higher serum levels of IGF-1 before the therapy and the treatment did not influence it. Contrary to it, in healthy women the increased value was observed. Explanation of that finding will become the aim of our next study.

Production, characterization, and epitope mapping of monoclonal antibodies against human polydeoxyribonucleotide kinase

Polydeoxyribonucleotide kinase (PNK) is a mammalian DNA repair enzyme that has the capacity to phosphorylate 5' DNA termini and dephosphorylate 3' DNA termini. A series of murine monoclonal antibodies (MAbs) was raised against the full-length recombinant human PNK. Seven of these antibodies were selected and characterized by enzyme immunoassay, Western blot analysis, and their capacity to immunoprecipitate PNK. The epitope location was defined by cyanogen bromide digestion and by using a truncated PNK for Western blot analysis. All of the MAbs recognize a single 60-kDa protein in human cell extracts. PNKs from calf, monkey, and Chinese hamster cell and tissue extracts were also detected by some or all of the MAbs. These antibodies can be successfully used for the cellular, biochemical, and functional analysis of PNK in different mammalian cell lines.

Does obesity diminish the positive effect of oral contraceptive treatment on hyperandrogenism in women with polycystic ovarian syndrome?

Polycystic ovarian syndrome (PCOS) is an obvious indication for long-term treatment. Combined oral contraceptives (COC) remain the first choice for the treatment of hyperandrogenism in most patients. However, differences in endocrine and metabolic parameters between obese and lean patients have been postulated. This is the first study evaluating the effect of COC treatment in obese versus non-obese PCOS patients. In total, 28 lean [body mass index (BMI) <25 kg/m(2))] and 15 obese (BMI >30 kg/m(2)) women patients were enrolled in the study. The concentrations of androgens, sex hormone-binding globulin (SHBG) and lipids were measured before and after 6 months of treatment with COC containing low-androgenic progestins. Clinical androgenic symptoms were monitored. There was a lower concentration of SHBG in obese patients, but there were no differences in androgen concentrations between both groups before the study. Highly significant changes in concentrations of testosterone (P < 0.001), androstenedione (P < 0.0001), SHBG (P < 0.001) and LH (P = 0.01) were demonstrated in lean patients, with only less significant changes in SHBG (P < 0.01) and testosterone (P < 0.05) in obese patients during the study. Clinical androgenic symptoms improved significantly (P = 0.05) only in the group of lean women. No reduction in low-density lipoprotein-cholesterol/high-density lipoprotein-cholesterol ratio was observed in either group. In conclusion, the positive effect of COC treatment on androgen production, serum androgen binding capacity, and clinical androgenic symptoms was negatively influenced by an increased BMI.

The role of androgens in determining acne severity in adult women

BACKGROUND

Although many arguments have been put forth supporting the role of androgens in the aetiology of acne, their part in determining the severity of the disease is not well established.

OBJECTIVES

The aim of our study was to evaluate the relationship between acne severity and the clinical and laboratory markers of androgenicity in a large group of patients.

METHODS

Ninety women over 17 years of age with acne were enrolled into the study. The levels of testosterone, androstenedione, dehydroepiandrosterone, dehydroepiandrosterone sulphate and sex hormone binding globulin (SHBG) were measured. Menstrual cycle regularity, hirsutism score, acne severity and ultrasound evaluation of polycystic ovaries were recorded. One-way analysis of variance, chi(2)-test and correlation analysis were used for data processing.

RESULTS

Hirsutism was documented in 19 (21%) subjects, elevated levels of at least one androgen in 73 (81%) subjects, an irregular cycle was reported by 43 (48%) women, and polycystic ovaries were found in 45 (50%) women. The patients were divided into three groups according to acne severity. Acne was graded using the Leeds technique as minor in 43 (48%) cases, mild in 27 (30%) and moderate in 20 (22%). We did not demonstrate a positive correlation between the grade of acne severity and any of the clinical or laboratory markers of androgenicity assessed. On the contrary, women with a higher grade of acne severity showed lower values of the index of free testosterone, a lower hirsutism score and higher SHBG levels.

CONCLUSIONS

Our study suggests that the severity of acne manifestation in adult women is not determined by androgen production.

Increased risk of non-insulin dependent diabetes mellitus, arterial hypertension and coronary artery disease in perimenopausal women with a history of the polycystic ovary syndrome

The aim of the study was to determine the prevalence of non-insulin dependent diabetes mellitus (NIDDM), arterial hypertension, coronary artery disease and the risk factors for these diseases in perimenopausal women with a history of polycystic ovary syndrome (PCOS) treatment. A group of 28 women was selected from a large group of patients who had undergone wedge ovarian resection. A total of 752 controls was selected by age (45-59 years) from a random female population sample. There was no difference between the two groups in body mass index, waist circumference or waist-hip ratio. Both groups were found to have identical family histories of NIDDM, hypertension, and coronary artery disease and identical smoking habits. We did not find a difference between the mean concentrations of lipids and fasting glucose. The two groups did not differ in the proportions of women with elevated lipid concentrations. The prevalence of NIDDM and coronary artery disease was significantly higher in PCOS women. In conclusion, women in the general population have the same level of risk factors at perimenopausal age as PCOS women. Patients with markedly expressed clinical symptoms of PCOS made up a subgroup in the general population at high risk for developing NIDDM and coronary artery disease.

[Prediction of increased levels of androgen in women with acne vulgaris using ultrasound and clinical parameters]

OBJECTIVE

The aim of our study was to identify clinical parameters characterizing women with acne whose dermatological problems are due to increased androgen production. Identification of these parameters would allow to indicate endocrinological examination in only a proportion of women with acne vulgaris.

PATIENTS AND METHODS

A total of 54 women with acne vulgaris resistant to local treatment were enrolled in the study. The following clinical parameters were monitored: hirsutism (Ferriman-Gallway score), severity of acne, association of the severity of acne with the menstrual cycle, beginning of manifestations of acne, regularity of the menstrual cycle, presence of alopecia, age at menarche, body weight, BMI and ultrasound investigation of the ovaries. In the standard phase of the cycle, blood was collected to determine the levels of the following hormones: LH, FSH, PRL, TSH, testosterone, androstenedione, DHEA, DHEAS, SHGB. Wilcoxon's robust non-parametric paired test was employed for statistical data analysis.

RESULTS

Overall, 33 (61%) women showed increased levels of at least one androgen. An irregular cycle was found in 21 (39%) women, acne severity was associated with the menstrual cycle in 16 (30%) women, 48 (89%) women had acne from menarche, 19 (35%) women had hirsutism; an ultrasound finding of polycystic ovaries was revealed in 32 (59%) women. No significant differences were found between a sub-group of women with levels of at least one androgen above the upper reference limit and the other women in the following variables: age, weight, BMI, age at menarche, ultrasound finding of polycystic ovaries, manifestation of acne from menarche, irregular cycle, hirsutism. The two groups were not different in the severity of acne. Deterioration of acne depending on the menstrual cycle was more often present in women with normal androgen levels. By contrast, a regular menstrual cycle was found to be more frequent in women with raised androgen levels, although the difference was not statistically significant.

CONCLUSIONS

Clinical parameters had no association with androgen overproduction. Evaluation of clinical parameters, including severity of acne, does not allow to refer only a proportion of women with acne resistant to local treatment for endocrinological examination.