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What's new in obstetrics and gynecology
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What's new in obstetrics and gynecology
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Nov 2016. | This topic last updated: Nov 29, 2016.

The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection.

OBSTETRICS

Pattern of anomalies in congenital Zika syndrome (November 2016)

The clinical spectrum of congenital Zika syndrome (CZS) is evolving as more cases are described. A comprehensive review of the available published data identified five unique features of CZS that are rarely seen with other congenital infections: (1) severe microcephaly with partially collapsed skull, (2) thin cerebral cortices with subcortical calcifications, (3) macular scarring and focal pigmentary retinal mottling, (4) congenital contractures (arthrogryposis), and (5) marked early hypertonia [1]. Recognition of this distinctive phenotype can help clinicians identify infants with CZS and ensure appropriate etiologic evaluation and comprehensive clinical investigation. (See "Congenital Zika virus infection: Clinical features, evaluation, and management of the neonate", section on 'Clinical findings'.)

Extended versus narrow spectrum antibiotic prophylaxis for cesarean delivery (November 2016)

Use of extended versus narrow spectrum antibiotic prophylaxis for cesarean delivery is controversial. In the largest randomized trial, which was limited to women in labor or with ruptured membranes for at least four hours, the combination of azithromycin and cefazolin resulted in a 50 percent reduction in postcesarean infection compared with cefazolin alone [2]. This trial had a high proportion of obese patients and lacked comparative data on the efficacy of weight-based cefazolin dosing, which may have accounted, at least in part, for the findings. We continue to use single-dose narrow-spectrum antibiotic prophylaxis for all patients before cesarean delivery; however, others may reasonably choose to use an extended spectrum regimen in the high-risk patient population targeted by the trial. (See "Cesarean delivery: Preoperative issues".)

Closed-loop insulin pump in pregnant women with type 1 diabetes (October 2016)

A recent crossover trial in 16 pregnant women with type 1 diabetes compared use of a closed-loop insulin pump (automatic adjustment of basal insulin dose) with manual adjustment of the basal insulin [3]. The closed loop pump improved glycemic control with no difference in hypoglycemia rate, but the incidence of large for gestational age infants remained high. This technology is not readily available and, in this small trial, provided no clear pregnancy benefit. (See "Pregestational diabetes mellitus: Glycemic control during pregnancy", section on 'Types of insulin pumps'.)

Duration of passive protection of the infant from maternal influenza vaccination (September 2016, Modified September 2016)

A randomized trial of trivalent inactivated influenza vaccination of pregnant women reported 86 percent efficacy against laboratory confirmed influenza among infants ≤8 weeks of age and 25 to 30 percent efficacy among infants 8 to 24 weeks of age, compared with placebo vaccination [4]. These data suggest that the passive protection afforded by maternal influenza vaccination declines significantly before the infant is eligible for influenza vaccination at six months of age. (See "Influenza and pregnancy", section on 'Infant protection'.)

Safety of magnetic resonance imaging and gadolinium in pregnancy (September 2016)

Magnetic resonance imaging (MRI) may be used for diagnostic imaging in pregnancy when ultrasound examination is inadequate; however, fetal safety has not been conclusively established. Recently, the largest study of MRI in pregnancy (over 1700 exposed and 1.4 million unexposed births) reported that first-trimester MRI was not associated with significantly increased risks for stillbirth, neonatal death, congenital anomaly, neoplasm, or vision or hearing loss in children followed up to age four years, when adjustments were made for differences between exposure groups [5]. The study also found that gadolinium exposure at any time during pregnancy was associated with an increased risk for stillbirth and neonatal death. Children exposed in utero were at increased risk for rheumatological, inflammatory, or infiltrative skin conditions, but not congenital anomalies or nephrogenic systemic fibrosis (NSF). This study is a major addition to the body of evidence supporting the safety of MRI in pregnancy when medically indicated. It also provides the first data supporting existing recommendations to avoid use of gadolinium-based contrast agents in pregnant women, when possible. (See "Diagnostic imaging procedures during pregnancy", section on 'Magnetic resonance imaging'.)

Oxytocin induction not associated with autism (August 2016)

A possible association between oxytocin induction of labor and development of autism in offspring has been widely publicized in the lay press, based on findings from a single epidemiological study. Recently, a nationwide epidemiologic study in Sweden found no association between labor induction and autism in offspring when adjustments were made for environmental and genetic factors shared by siblings [6]. A strength of this study was that comparison of exposure-discordant births to the same woman allowed control for all unmeasured factors shared by siblings. We believe an association between oxytocin induction and autism is unlikely. (See "Induction of labor", section on 'Other'.)

Low-dose aspirin for preeclampsia prophylaxis (August 2016)

In July 2016, the American College of Obstetricians and Gynecologists (ACOG) endorsed the United States Preventive Services Task Force (USPSTF) recommendation for use of low-dose aspirin prophylaxis in women at high risk of developing preeclampsia, and identified these women based on the same criteria designated by the USPSTF [7]. Prior to July 2016, ACOG defined high risk more narrowly: history of early-onset preeclampsia and preterm delivery <34 weeks of gestation or more than one prior pregnancy complicated by preeclampsia. The broader USPSTF criteria included multifetal gestation, chronic hypertension, pregestational diabetes, renal disease, and some autoimmune diseases. We continue to suggest low-dose aspirin prophylaxis for women included under the broader criteria, as well as some women with multiple moderate risk factors for preeclampsia. (See "Preeclampsia: Prevention", section on 'Guidelines from selected organizations'.)

Mosquito-borne transmission of Zika virus in the continental United States (August 2016)

Zika virus is a mosquito-borne infection associated with congenital microcephaly and other birth defects among babies born to women infected during pregnancy. Mosquito-borne transmission of Zika virus was detected in Florida in July 2016, and in August 2016 the United States Centers for Disease Control and Prevention (CDC) issued an advisory recommending that pregnant women avoid travel to affected areas [8]. Updates regarding areas with Zika may be found on the CDC website (http://www.cdc.gov/zika/). (See "Zika virus infection: An overview", section on 'Travel advisories for pregnant women'.)

Testing for Zika virus infection in pregnant women (July 2016)

The approach to testing for Zika virus infection is different for pregnant versus nonpregnant individuals because Zika virus RNA persists longer in pregnant women’s serum and because pregnant women may transmit the infection to the fetus, even if the mother is asymptomatic. Congenital Zika virus infection can result in serious sequelae. The United States Centers for Disease Control and Prevention recently revised their algorithm for the diagnosis of Zika virus infection in pregnancy to reflect these principles (algorithm 1) [9]. (See "Zika virus infection: Evaluation and management of pregnant women", section on 'Clinical approach'.)

Pharmacotherapy for smoking cessation during pregnancy (July 2016)

Pregnant women are strongly encouraged to stop smoking, but the efficacy of pharmacotherapy for smoking cessation during pregnancy has been debated. In a prospective questionnaire study of over 1200 pregnant smokers, use of either nicotine replacement therapy (NRT) or bupropion in the first trimester of pregnancy was associated with smoking cessation rates of approximately 80 percent compared with a 0 percent cessation rate for smokers not using either medication [10]. Over 60 percent of NRT and bupropion users who discontinued the medication did not resume smoking during or up to one year after pregnancy. In an adjusted analysis, both medications reduced the risk of prematurity and NRT was also associated with a nearly 40 percent reduced risk for small-for-gestational-age infants compared with continued smoking, although the sample sizes were small. We offer pharmacotherapy to pregnant women as we believe the benefits of quitting with pharmacotherapy outweigh the potential risks. (See "Cigarette smoking: Impact on pregnancy and the neonate", section on 'Nicotine replacement'.)

Safety of intranasal triamcinolone for allergic rhinitis in pregnancy (July 2016)

Intranasal glucocorticoid sprays are highly effective for treatment of allergic rhinitis, but concerns remain about their use in pregnancy. The overall safety of intranasal glucocorticoids in pregnancy was supported by an observational cohort study of over 140,000 pregnant women, of whom 2502 were exposed to these medications during the first trimester [11]. Exposure was not associated with increased rates of miscarriage or overall rates of major congenital malformations compared with non-exposure. Triamcinolone was the only intranasal glucocorticoid of potential concern; first trimester use was associated with abnormalities of the respiratory system and choanal atresia. Although these findings are not conclusive, we prefer to use other intranasal glucocorticoids in the first trimester, such as intranasal mometasone, fluticasone, or budesonide, pending further data [12]. (See "Recognition and management of allergic disease during pregnancy", section on 'Glucocorticoid nasal sprays'.)

WHO recommendations for infant prophylaxis to prevent mother-to-child HIV transmission (July 2016)

The World Health Organization (WHO) has updated its guidelines on the use of antiretroviral agents to manage and prevent HIV infection [13]. One major change from previous WHO statements involves post-exposure prophylaxis of infants born to HIV-infected mothers. The recommended regimen for infant prophylaxis now takes into account the infant's risk of infection, as determined by the timing of maternal infection and maternal antiretroviral treatment, in addition to the type of infant feeding; a two-drug regimen is recommended for high-risk infants (algorithm 2). This recommendation was based, in part, on earlier data that demonstrated a lower HIV transmission rate with dual-agent rather than single-agent prophylaxis among infants born to mothers who had not received antiretroviral agents during pregnancy. (See "Prevention of mother-to-child HIV transmission in resource-limited settings", section on 'Infant antiretroviral use'.)

Induction of labor in women with low Bishop scores (June 2016)

Previously, the HYPITAT randomized trial demonstrated that routine induction of labor in women with mild preeclampsia or gestational hypertension at >360/7 weeks resulted in lower rates of adverse maternal outcome and cesarean delivery compared with expectant management with maternal/fetal monitoring. However, the outcome of women with unfavorable cervixes was not analyzed separately. In a secondary analysis of data from this trial and DIGITAT (pregnancies complicated by fetal growth restriction), induction of labor at term in women with a median Bishop score of 3 (range 1 to 6) was not associated with a higher rate of cesarean delivery than expectant management, and approximately 85 percent of women in both groups achieved a vaginal delivery [14]. Thus, an unfavorable cervix does not alter the decision to induce labor in women with pregnancy-induced hypertension at term. (See "Preeclampsia: Management and prognosis", section on 'Preeclampsia without features of severe disease'.)

Polyhydramnios due to X-linked Bartter syndrome (May 2016)

The most common type of Bartter syndrome presenting in utero is an autosomal recessive disorder that results in fetal polyuria and subsequent polyhydramnios between 24 and 30 weeks of gestation. Persistent postnatal renal salt wasting requires life-long treatment. Recently, a severe but transient type of antenatal Bartter's syndrome was attributed to mutations in the MAGED2 gene, which maps to the X-chromosome and appears to be essential for fetal renal salt reabsorption and maintenance of normal amniotic fluid homeostasis [15]. This X-linked disorder has very early onset of severe polyhydramnios (median 19 to 20 weeks of gestation), often resulting in preterm birth (median gestational age 22 to 34 weeks), but symptoms disappear spontaneously in infants who survive. Prenatal or early postnatal genetic diagnosis can avoid potentially harmful therapeutic interventions. (See "Polyhydramnios", section on 'Etiology'.)

OFFICE GYNECOLOGY

Vaginal prasterone for dyspareunia in postmenopausal women (November 2016)

In November 2016, the US Food and Drug Administration approved the use of prasterone (also known as dehydroepiandrosterone [DHEA]) for treatment of dyspareunia in women with vulvovaginal atrophy (VVA) due to menopause [16]. In an earlier randomized trial of women with VVA and moderate to severe dyspareunia, 12 weeks of daily intravaginal DHEA resulted in improved scores for pain during sexual activity and other key domains of female sexual function (desire, arousal, lubrication, orgasm, satisfaction) compared with placebo [17]. However, patients may find daily dosing more cumbersome than twice weekly dosing with vaginal estrogen preparations. (See "Treatment of genitourinary syndrome of menopause (vulvovaginal atrophy)", section on 'Dehydroepiandrosterone (prasterone)'.)

Combination antiretroviral treatment in pregnancy (November 2016)

Combination antiretroviral treatment (ART) has become the worldwide standard of care for HIV-infected pregnant women, both for their own health and for prevention of HIV transmission to their infants. In a large randomized trial of HIV-infected pregnant women in Africa and India, antepartum ART (with one of two different protease inhibitor-based regimens) resulted in lower transmission rates compared with zidovudine plus single-dose nevirapine (0.5 versus 1.8 percent) [18]. Rates of preterm birth at <37 weeks were higher with the ART regimens than with zidovudine, but more significant prematurity (<34 weeks) and neonatal deaths were not increased. Clinicians should discuss with patients the potential risk for adverse pregnancy outcome with certain ART regimens. (See "Safety and dosing of antiretroviral medications in pregnancy", section on 'Preterm birth'.)

Long-acting reversible contraception and teenage pregnancy rates (November 2016)

In a systematic review of nine studies including nearly 27,000 adolescent and young adult women (≤25 years), the 12-month continuation rate was nearly twice as high with the intrauterine device or contraceptive implant as with other contraceptive methods (approximately 85 percent versus 40 to 50 percent) [19]. Increased contraceptive use, particularly increased use of these highly effective long-acting reversible contraceptive (LARC) methods, contributed to the historically low teenage pregnancy rate in 2015 [20]. These observations support our recommendations to highlight LARC methods when discussing contraception with adolescents and young adults. (See "Pregnancy in adolescents", section on 'Epidemiology' and "Contraception: Overview of issues specific to adolescents", section on 'Long-acting reversible methods'.)

Updated US guidelines on HIV infection and pregnancy (November 2016)

The Department of Health and Human Services in the United States recently published updated guidelines on the evaluation and management of HIV-infected pregnant women to reduce the risk of perinatal transmission [21]. Preferred antiretroviral agents for initiation in pregnant women are now tenofovir-disoproxil-fumarate plus emtricitabine or lamivudine, abacavir-lamivudine, ritonavir-boosted atazanavir, ritonavir-boosted darunavir, and raltegravir. Other agents are not recommended for routine initiation in pregnant women because of limited data during pregnancy, but women who become pregnant while taking other commonly used agents can continue their regimen if they have achieved viral suppression. (See "Antiretroviral and intrapartum management of pregnant HIV-infected women and their infants in resource-rich settings", section on 'Antiretroviral selection and management'.)

Incidence of sexually transmitted infections in the United States (November 2016)

The total number of cases of chlamydia (over 1.5 million), gonorrhea (nearly 400,000), and syphilis (nearly 24,000) reported to the Centers for Disease Control and Prevention in the United States in 2015 was the highest ever recorded in a given year [22]. Chlamydia and gonorrhea continued to occur most commonly among 15 to 24 year olds, and men who have sex with men accounted for the majority of gonorrhea and primary/secondary syphilis cases. These surveillance data highlight the importance of sexually transmitted infection prevention efforts, screening, and treatment among at-risk individuals. (See "Epidemiology of Chlamydia trachomatis infections", section on 'Incidence' and "Epidemiology and pathogenesis of Neisseria gonorrhoeae infection", section on 'Incidence' and "Syphilis: Epidemiology, pathophysiology, and clinical manifestations in HIV-uninfected patients", section on 'Epidemiology' and "Screening for sexually transmitted infections".)

Postmenopausal estrogen and cognitive function (August 2016)

While limited observational and clinical trial data have suggested that early, but not late, postmenopausal exposure to estrogen provides protection against later cognitive impairment, a new randomized trial found no benefit of estrogen regardless of when it was started. In the Early versus Late Intervention Trial with Estradiol (ELITE), 643 postmenopausal women, stratified according to time since menopause (<6 years [early] versus >10 years [late]), received oral estradiol (with progesterone for women with a uterus) or placebo for a median of five years [23]. When compared with placebo, estradiol, whether it was started early or late, had no effect on verbal memory, executive function, or global cognition. (See "Estrogen and cognitive function", section on 'Younger menopausal women'.)

Sleep disorders in the menopausal transition: Telephone-based cognitive behavioral therapy (August 2016)

New-onset sleep disturbances are common in perimenopausal and menopausal women, occurring most often in women with hot flashes, but also in women without hot flashes. Midlife women with insomnia are usually treated with pharmacologic therapies (estrogen or hypnotic agents), but effective behavioral therapies are also available, including in-person cognitive behavioral training (CBT) for insomnia. In-person CBT, while effective, has practical limitations (availability, cost, and scheduling challenges), so alternative CBT strategies have been explored. In one trial, 106 peri- and postmenopausal women with insomnia and hot flashes were randomly assigned to an eight-week intervention with telephone-based cognitive behavioral therapy for insomnia (CBT-I) versus standard menopause education control (MEC) (also telephone-based) [24]. After eight weeks, CBT-I, but not MEC, resulted in a clinically meaningful insomnia score reduction. The percentage of women who achieved Insomnia Index Severity scores in the “no insomnia” range was 70 and 24 percent for CBT-I and MEC, respectively. CBT-I reduced hot flash “bother” but not frequency. (See "Menopausal hot flashes", section on 'Promising therapies: Need further study'.)

Treatment failure of pharyngeal gonorrhea following combination antimicrobial therapy (July 2016)

Because of concerns about the decreasing susceptibility of Neisseria gonorrhoeae to several classes of antibiotics, combination antimicrobial therapy with ceftriaxone plus a second agent, preferably azithromycin, is the recommended treatment for uncomplicated gonorrhea. However, treatment failure following combination therapy has now been reported, in a heterosexual man from the United Kingdom who presented with both urogenital and pharyngeal infection [25]. Although the urogenital infection was successfully treated with ceftriaxone plus azithromycin, the pharyngeal infection persisted, and decreased susceptibility to both agents was detected in the post-treatment isolate. This report, in addition to surveillance reports suggesting increasing rates of decreased susceptibility to azithromycin in N. gonorrhoeae isolates in the United States [26], highlights the need for novel treatment strategies for gonorrhea in the face of rising antimicrobial resistance. (See "Treatment of uncomplicated gonococcal infections", section on 'Monitoring for and managing treatment failure' and "Treatment of uncomplicated gonococcal infections", section on 'Rationale for dual therapy'.)

Shortage of benzathine penicillin G (Bicillin L-A) (May 2016)

In May 2016, the United States Centers for Disease Control and Prevention reported a manufacturing delay of benzathine penicillin G (Bicillin L-A), which is the treatment of choice for all stages of syphilis [27]. In light of potential shortages of this agent, it is important for clinicians to note that only a single dose of benzathine penicillin G is warranted for early syphilis (table 1). Pregnant women with syphilis should be prioritized for benzathine penicillin G, and so alternative regimens, such as doxycycline, may need to be used for nonpregnant adults if supplies are limited. Bicillin C-R (equal concentrations of procaine and benzathine penicillin G) should not be used to treat syphilis. (See "Syphilis: Treatment and monitoring", section on 'Penicillin as the treatment of choice'.)

GYNECOLOGIC SURGERY

Guidance on hysteroscopic sterilization from the US FDA (November 2016)

Hysteroscopic placement of micro-inserts into the fallopian tubes is a minimally invasive approach to female sterilization; however, long-term complications are a concern. In October 2016 the US Food and Drug Administration (FDA) issued final guidance related to this procedure, recommending a boxed warning regarding potential adverse effects and the potential need for surgical removal to manage these effects [28]. The FDA also recommended a checklist highlighting key risk and benefit information to be reviewed and signed by the patient and physician and provided an example of a procedural consent form. (See "Hysteroscopic sterilization", section on 'Statements from regulatory organizations'.)

In-bag morcellation (August 2016)

Use of contained tissue extraction during power morcellation of uterine tissue has been hypothesized to reduce the risk of disseminating cells from an unsuspected malignancy. A new tissue containment system (PneumoLiner) for use with certain laparoscopic power morcellators was approved by the US Food and Drug Administration (FDA) in April 2016 [29]. However, this device has not been proven to reduce the risk of spreading cancer.

A recent multicenter prospective study of women who underwent hysterectomy or myomectomy using a contained power morcellation technique (not the PneumoLiner) reported spillage of tissue or dye in 9.2 percent of cases, even though containment bags were intact [30]. The only randomized trial of in-bag manual versus uncontained power morcellation in women undergoing laparoscopic myomectomy found no differences in total procedure time, morcellation time, simplicity of morcellation, or operative complications [31]. Further study is needed to evaluate the safety of in-bag morcellation and the efficacy in containing cells. (See "Uterine tissue extraction by morcellation: Techniques and clinical issues", section on 'Containment systems'.)

GYNECOLOGIC ONCOLOGY

Risk of preterm delivery following loop electrosurgical excision procedure (LEEP) (November 2016)

Studies have consistently found an increased risk for preterm delivery in pregnancies conceived after cold knife conization, but data are mixed regarding the risk with laser conization and loop electrosurgical excision procedure (LEEP). In the largest study of pregnancy outcomes after treatment for cervical intraepithelial neoplasia (CIN), a Norwegian registry study of almost 10,000 births confirmed that prior treatment for CIN was associated with an increased risk of preterm birth compared with no prior treatment [32]. The strongest associations were for cold knife and laser conization, but a small increase in risk was also observed for LEEP. Women with CIN 2,3 who plan future childbearing should be counseled about the risks and benefits of both treatment and observation. (See "Cervical intraepithelial neoplasia: Reproductive effects of treatment", section on 'Risks of individual treatment methods'.)

Niraparib maintenance therapy in platinum-sensitive, recurrent ovarian cancer (October 2016)

In a phase III trial, niraparib was compared with placebo in approximately 550 patients with platinum-sensitive, recurrent ovarian cancer, stratified by germline mutation status [33]. Niraparib improved progression-free survival in all patient groups, although over a third experienced severe hematologic toxicity. In the absence of overall survival data, and given significant toxicity, the appropriate timeframe and strategy for further treatment (with niraparib as maintenance therapy, or with chemotherapy upon disease progression) is unclear. Niraparib remains investigational and should not be used outside of a clinical trial. (See "Medical treatment for relapsed epithelial ovarian, fallopian tubal, or peritoneal cancer: Platinum-sensitive disease", section on 'Niraparib'.)

Safety of opportunistic salpingectomy (August 2016)

Opportunistic salpingectomy is a novel strategy for primary prevention of epithelial fallopian tube, ovarian, and peritoneal cancer in women at average risk for this cancer undergoing pelvic surgery for a benign indication. In the first randomized trial of opportunistic salpingectomy versus no opportunistic salpingectomy in such women, operative complications and anti-müllerian hormone levels (a measure of ovarian reserve) were similar in both groups at three months [34]. This trial provides evidence of the short-term safety of this strategy, but large long-term trials are needed to evaluate efficacy and hormonal sequelae over time. (See "Opportunistic salpingectomy for ovarian, fallopian tubal, and peritoneal carcinoma risk reduction", section on 'Ovarian function'.)

Outcome of myomectomy with morcellation in unsuspected uterine sarcoma (August 2016)

Uterine morcellation and myomectomy in women with unsuspected uterine cancer can potentially spread malignant cells, but few data are available about the frequency of tumor dissemination and prognosis. A retrospective cohort study of 59 women with a postoperative diagnosis of previously unsuspected uterine sarcoma compared outcomes of those who underwent myomectomy with morcellation (n = 30) with those who underwent total hysterectomy (n = 29) [35]. At five years, myomectomy with morcellation was associated with significantly lower overall survival rate (38 versus 43 percent) and a trend toward lower recurrence-free survival (24 versus 46 percent). These data illustrate the potential effects of myomectomy with morcellation in women with uterine sarcoma. (See "Differentiating uterine leiomyomas (fibroids) from uterine sarcomas", section on 'Myomectomy'.)

Role of endometrial sampling in preoperative diagnosis of uterine sarcoma (August 2016)

Uterine sarcoma is a rare and aggressive malignancy, with few reliable methods for preoperative diagnosis. In a recent study including 68 women with leiomyosarcoma who underwent endometrial sampling before surgery, the sensitivity of the test for diagnosis of features of a smooth muscle malignancy was 52 percent (leiomyosarcoma: 35 percent, spindle cell or other features suspicious for malignancy: 16 percent) [36]. There was no significant difference in test performance between office endometrial biopsy and dilation and curettage. We suggest endometrial sampling for women with a uterine mass and signs, symptoms, risk factors, or other findings that raise suspicion of uterine sarcoma or endometrial carcinoma or for women in whom planned surgical treatment includes intraperitoneal morcellation. (See "Differentiating uterine leiomyomas (fibroids) from uterine sarcomas", section on 'Endometrial sampling'.)

Guidelines for vulvar cancer treatment from the NCCN (June 2016)

The National Comprehensive Cancer Network (NCCN) has released guidelines for the first time on the treatment of squamous cell vulvar carcinoma [37]. The guidelines address surgery, chemotherapy, and radiation. Key sections regarding surgical resection include use of a ≥1 cm margin for surgical resection and, for women with positive margins, consideration of nodal status in deciding whether to perform a repeat resection. These guidelines are consistent with established practice in gynecologic oncology. Their publication adds an important tumor site to existing NCCN guidelines on cervical, uterine, and ovarian cancers. (See "Squamous cell carcinoma of the vulva: Staging and surgical treatment", section on 'Treatment of positive or narrow margins'.)

Management of vaginal cytology results (May 2016)

Vaginal cancer is a rare disease, and screening with vaginal cytology is advised only for selected women at high risk (eg, prior hysterectomy and history of high-grade cervical intraepithelial neoplasia). The American Society for Colposcopy and Cervical Pathology (ASCCP) has published new guidance regarding the management of vaginal cytology results (algorithm 3) [38]. Indications for vaginal colposcopy were provided and included: high-grade squamous intraepithelial lesion (HSIL), atypical squamous cells cannot exclude high-grade lesion (ASC-H), or atypical glandular cells (AGC); atypical squamous cells of undetermined significance (ASC-US) with human papillomavirus (HPV) 16/18-positive; and follow-up testing for ≥ASC-US or HPV-positive. This is the first guideline to address management of vaginal cytology results. (See "Cervical and vaginal cytology: Interpretation of results (Pap test report)", section on 'Management of results'.)

REPRODUCTIVE ENDOCRINOLOGY

Frozen versus fresh embryo transfer for women with polycystic ovary syndrome (August 2016)

Traditionally, fresh embryos are transferred at the initial in-vitro fertilization (IVF) cycle and excess embryos are frozen for future use. However, women with polycystic ovary syndrome (PCOS) may have improved outcomes with transfer of frozen embryos. In a recent trial of 1500 subfertile women with PCOS in China randomly assigned to fresh or frozen embryo transfer, frozen embryo transfer resulted in a higher frequency of live birth and lower frequencies of pregnancy loss and ovarian hyperstimulation syndrome (OHSS), but the frequency of preeclampsia was increased [39]. Of note, the study protocol differed from standard IVF protocols in the United States (US) and the mean body mass index (BMI) of the subjects was much lower than the BMI of women with PCOS in the US. Given these concerns and the higher risk for preeclampsia, we do not recommend routine transfer of frozen rather than fresh embryos in women with PCOS undergoing IVF in the US. (See "In vitro fertilization", section on 'Women with polycystic ovary syndrome (PCOS)'.)

IVF and risk of breast cancer (July 2016)

The body of evidence suggests that breast cancer risk is not increased after in vitro fertilization (IVF), but is limited by lack of long-term follow-up data. In a recent Dutch cohort study of over 19,000 women treated with IVF between 1983 and 1995 and followed for a median of 21 years, the risk of breast cancer was similar to that in subfertile women not treated with IVF and in the general population, adjusted for parity and age at first birth [40]. These data are reassuring, but difficult to generalize to women undergoing contemporary IVF treatment since IVF drug regimens have changed over time and improved success rates have reduced the number of cycles women are exposed to these regimens. Additionally, only 14 percent of the cohort was age >60 years, so the risk of postmenopausal breast cancer was not well defined. (See "In vitro fertilization", section on 'Breast cancer risk'.)

Polycystic ovary syndrome: Weight loss before ovulation induction improves live birth rates (July 2016)

For anovulatory women with polycystic ovary syndrome (PCOS) who are overweight or obese, we suggest weight loss prior to initiating ovulation induction therapy. Modest weight loss of 5 to 10 percent has been associated with an improvement in metabolic status, a reduction in serum androgen concentrations, and resumption of ovulation in some studies, but data on pregnancy rates have been limited. In a post hoc comparison of two multicenter, concurrent trials in overweight/obese women with PCOS undergoing ovulation induction with four cycles of clomiphene citrate, a 16-week pretreatment lifestyle intervention (diet, exercise, medication) before starting clomiphene resulted in an approximate 6.5 percent weight loss from baseline and cumulative per-cycle ovulatory and live birth rates of 62 and 25 percent, respectively [41]. In contrast, in women who underwent immediate clomiphene therapy, ovulatory and live birth rates were lower (45 and 10.2 percent, respectively). (See "Treatment of polycystic ovary syndrome in adults", section on 'Weight loss'.)

UROGYNECOLOGY

Cranberry products and urinary tract infection in women (October 2016)

Numerous clinical studies on the effects of cranberry products on recurrent urinary tract infection (UTI) in women have failed to clearly demonstrate a preventive benefit. In a year-long randomized trial among female nursing home residents, cranberry capsules similarly did not reduce adjusted rates of bacteriuria plus pyuria or symptomatic UTI compared with placebo [42]. While we do not suggest cranberry products to reduce the risk of recurrent UTI, there is likely little harmful effect. (See "Recurrent urinary tract infection in women", section on 'Cranberry products'.)

Treatment for refractory urgency urinary incontinence in women (October 2016)

Whether onabotulinumtoxinA (BoNT-A) or sacral neuromodulation (SNM) is the better treatment for women with refractory urgency urinary incontinence (UUI) is unclear. In a randomized trial directly comparing the two approaches, the BoNT-A group had greater reductions in daily UUI episodes and bothersome symptoms [43]. However, the small statistical differences may not be clinically significant, particularly since the risk of urinary tract infection increased. Thus, we believe that both treatments are reasonable treatment options for refractory UUI. (See "Use of botulinum toxin for treatment of non-neurogenic lower urinary tract conditions".)

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