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The decades-long global obesity epidemic has resulted in steady increase in the incidence of obesity-related malignancies. The associated diagnostic and therapeutic implications present a clinical challenge for gynecologic oncology treatment strategies. Recent studies have provided solid evidence for an independent, linear, positive correlation between a pathologically increased body mass index and the probability of developing endometrial or postmenopausal breast cancer. The pathogenesis is complex and the subject of current research. Proposed causes include pathologically increased serum levels of sexual steroids and adiponectin, obesity-induced insulin resistance, and systemic inflammatory processes. The scientific evidence for an association between obesity and other gynecological malignancies is, however, less solid. The clinical relevance of obesity as a risk factor for epithelial ovarian cancer, cervical cancer and vulvar cancer appears to be negligible. Nevertheless, obesity appears to have a negative impact on prognosis and oncologic outcomes for all gynecological cancers. Whether or not this effect can be interpreted as correlative or causal is still a subject of ongoing debate.

Purpose On January 1st, 2018, the ÖGZ (Austrian Society of Cytology) revised its cytological nomenclature to make it more similar to the 2015 Bethesda system. Following these changes, the Austrian Society of Gynecology and Obstetrics felt it necessary to revise the approach currently used in Austria to diagnose and treat CIN and to review the procedures to be followed when the quality of cytological specimens is unsatisfactory. It was not possible to adopt the German S3 guideline “Prevention of Cervical Cancer” in its entirety, because the Munich III gynecological cytology nomenclature used in Germany is not used in Austria. This made it necessary to compile a separate scientific opinion for Austria. Methodology The OEGGG worked together with the ÖGZ (Austrian Society for Cytology), AGO Austria (Austrian Working Group for Gynecological Oncology), the AGK (Colposcopy Working Group), and physicians representing gynecologists in private practice. The different scientific associations nominated representatives, who attended the various meetings. After an in-depth analysis of the recent literature, three meetings and numerous votes by telephone, we were able to achieve a consensus about the contents of this guideline. Recommendations The guideline provides recommendations for the diagnosis and treatment of CIN which take account of the gynecological cytology nomenclature used in Austria.

The modern sling procedures for treating female stress urinary incontinence encompass numerous methods, materials and manufacturers. On the basis of the current S2e guidelines, the methods used most frequently in the diagnosis of and therapy for stress urinary incontinence in women are critically illustrated. An individualised procedure is necessary for the choice of the surgical method, especially in the presence of accompanying pathologies. This article is intended to help the treating physician to carry out quality-assured diagnostics and therapy for the patient and to offer the best possible urogynaecological management. In addition to the complications and chances of success of the surgical options, the legal aspects of therapy planning are also taken into consideration.Die modernen Schlingenverfahren zur Behandlung der weiblichen Belastungsinkontinenz variieren heute zwischen zahlreichen Verfahren, Materialien und Herstellern. Basierend auf der aktuellen S2e-Leitlinie werden die am häufigsten angewendeten Verfahren bei der Diagnostik und Therapie der Belastungsinkontinenz der Frau kritisch beleuchtet. Bei der Wahl der Operationsmethode ist ein individualisiertes Vorgehen erforderlich, insbesondere, wenn Begleitpathologien vorliegen. Der Beitrag soll den behandelnden Ärzten helfen, die Diagnostik und Therapie der Patientinnen qualitätsgesichert durchzuführen und die bestmögliche urogynäkologische Versorgung anbieten zu können. Dabei werden neben den Komplikationen und Erfolgsaussichten der operativen Möglichkeiten auch juristische Aspekte bei der Therapieplanung berücksichtigt.

The therapy of choice for breast cancer patients requiring adjuvant chemo- or radiotherapy is increasingly guided by the principle of weighing the individual effectiveness of the therapy against the associated side effects. This has only been made possible by the discovery and validation of modern biomarkers. In the last decades and in the last few years some biomarkers have been integrated in clinical practice and a number have been included in modern study concepts. The importance of biomarkers lies not merely in their prognostic value indicating the future course of disease but also in their use to predict patient response to therapy. Due to the many subgroups, mathematical models and computer-assisted analysis are increasingly being used to assess the prognostic information obtained from established clinical and histopathological factors. In addition to describing some recent computer programmes this overview will focus on established molecular markers which have already been extensively validated in clinical practice and on new molecular markers identified by genome-wide studies.Die Therapiewahl für die Mammakarzinompatientin in der adjuvanten Situation folgt immer mehr dem Prinzip, die individuelle Therapieeffektivität und die Nebenwirkungen gegeneinander abzuwägen. Die Entdeckung und Validierung moderner Biomarker ermöglicht erst dieses Vorgehen. In den letzten Jahrzehnten und insbesondere in den letzten Jahren konnten einige Biomarker in die klinische Praxis und in moderne Studienkonzepte integriert werden. Nicht nur der Vorhersage der Prognose kommt hierbei eine besondere Bedeutung zu, sondern auch der Vorhersage des Therapieansprechens durch Prädiktivfaktoren. Die Nutzung der prognostischen Information aus etablierten, klinischen und histopathologischen Faktoren erfolgt aufgrund der Vielzahl von Untergruppen mehr und mehr in Form von mathematischen Modellen und computergestützter Auswertung. Neben der Darstellung aktueller Programme soll in dieser Übersichtsarbeit des Weiteren der Fokus auf etablierten, molekularen Markern, die bereits eine umfassende klinische Validierung vorweisen können, und neuen molekularen Markern liegen, die durch genomweite Ansätze identifiziert wurden.

Background: We present a series of skin-sparing mastectomies (SSMs) with skin reduction and immediate breast reconstruction to treat large and ptotic breasts. The technique combines oncological mastectomy with immediate subpectoral implant placement as a single-step procedure. Methods: Data was collected from a prospective database from February 2009 to April 2011. A total of 24 patients with macromastia or pronounced ptosis fulfilled the criteria for skin-saving mastectomy. All operations were carried out as a single-step procedure with adaptation of the contralateral breast by reduction mastopexy. Results: A total of 27 SSMs were performed in 24 patients. The mean implant volume was 265 cm3. Immediate reconstruction of the nipple-areola complex was done in 22 patients. The cosmetic and functional results were assessed in all patients 6 months postoperatively; mean follow-up time was 13 months. Mean patient age was 49 years. The cosmetic result was assessed as “very good” or “good” by 22 patients; 2 patients graded the result as “unsatisfactory”. There was one local recurrence. Conclusion: Our results support the use of this technique as a safe oncoplastic procedure which is well tolerated by patients.

Hypoactive Sexual Desire Disorder (HSDD) is the most common form of FSD (Female Sexual Dysfunction) and the most common sexual disorder in women in clinical practice. HSDD is defined as a deficiency or absence of sexual fantasies and of the desire for sexual activity with a great impact on interpersonal relationships which cannot be attributed to other causes such as psychiatric or medical illnesses or the effect of particular drugs. Both pre- and postmenopausal women may be affected by HSDD. The pathophysiology of HSDD is not known in any detail; the current scientific opinion is that it may be due to a neurobiological imbalance in the inhibitory and excitatory factors which control sexual desire in the brain. HSDD leads to reduced sexual and interpersonal satisfaction and is associated with high emotional psychological strain. Gynecologists should be first persons to whom women affected with HSDD should be able to turn, but due to the lack of specialist training, time, and effective therapy many doctors shy away from broaching the topic. The Decreased Sexual Desire Screener (DSDS®) is a short and simple diagnostic tool for the detection of HSDD by non-specialist colleagues. As the range of therapies currently available to women with HSDD is limited, multidimensional treatments should be offered to women with HSDD.

Since suburethral vaginal slings introduced a new era for the treatment of genuine stress urinary incontinence, new surgical techniques with alloplastic meshes have begun to be used in pelvic reconstructive surgery for vaginal prolapse. Thus established procedures without artificial materials are competing directly against new techniques using modern meshes. Controlled clinical trials will be necessary to allow a direct comparison in terms of evidence-based medicine. There are a variety of different vaginal and abdominal approaches available to treat prolapse. We describe the classic procedures and the new techniques using alloplastic material. The currently available data are presented and discussed. Standard operations such as colporrhaphy, abdominal sacral colpopexy and vaginal sacrospinous fixation still offer high success rates with only few complications. Although the abdominal route may offer some advantages with respect to the recurrence of prolapse, especially in the anterior compartment, and sexual function, vaginal sacrospinous colpopexy is characterized by a lower postoperative morbidity and comparable cure rates. The problem of the simultaneous correction of accompanying stress urinary incontinence versus correction following reconstructive surgery alone is discussed. Following the widespread use of new techniques and meshes, a new spectrum of postoperative complications ranging from erosions to infections has emerged, requiring an adequate management. As the current data only covers relatively small numbers and long-term follow-up is lacking, a final statement on the use of mesh material in reconstructive pelvic surgery cannot be made so far. While classic procedures without a mesh should be preferred for primary operations, mesh enforcement offers a promising alternative for relapse cases and in high-risk situations.

Fragestellung: Goserelin unterdruckt uber den Umweg der Blockierung der hypophysaren Gonadotropin-Synthese die ovarielle Steroidproduktion, ist aber nicht in der Lage, die periphere Steroidproduktion zu inhibieren. Der Aromatase-Inaktivator Exemestan fuhrt dagegen sowohl peripher als auch in den gonadalen Synthesestatten zu einem optimalen Abfall der Estrogen-Spiegel. Somit musste die Kombination von Goserelin und Exemestan in der adjuvanten Therapie des primaren Mammakarzinoms bei pramenopausalen Patientinnen zur Optimierung des Therapieergebnisses fuhren. Die zu erwartende klimakterische Symptomatik unter diesem Therapieregime kann moglicherweise durch Zusatz von Tibolon als Additivum gemildert werden. Ziel der vorliegenden Arbeit ist es, das Risiko und die Tolerabilitat einer solchen Medikamentenkombination aus Goserelin und Exemestan mit und ohne Tibolon zu uberprufen. Material und Methoden: Es handelt sich um eine offene, randomisierte, multizentrische ADAGIO (Adjuvante Aromasin-Goserelin Studie)-Pilotstudie, Dauer 24 Wochen. 48 pramenopausale Patientinnen (Alter 35 - 55 Jahre) mit histologisch gesichertem, rezeptorpositivem Mammakarzinom mit niedrigem Risiko (pT1, N0, M0 [Grading 1 - 2]) wurden in die Studie aufgenommen. Die Patientinnen wurden in vier Therapiearme randomisiert: Goserelin, 3,6 mg Depot, s.c. alle 28 Tage; Goserelin plus Exemestan oral, 25 mg taglich; Goserelin plus Tibolon 2,5 mg oral, taglich; Goserelin plus Exemestan plus Tibolon. Ergebnisse: In allen vier Therapiearmen kam es zu einem rapiden Abfall der Serumspiegel fur Estradiol, Estron und Estronsulfat auf postmenopausale Werte; LH und FSH wurden ebenfalls supprimiert. Die Differenzen zwischen den Therapiegruppen waren nicht signifikant. Die klimakterischen Symptome nahmen an Intensitat uber den Behandlungszeitraum zu. Die Patientinnen, die Tibolon als Zusatztherapie erhielten, wiesen signifikant weniger Hitzewallungen (p < 0,01), Schlafstorungen (p < 0,05), Libidoverlust (p < 0,01) und vaginale Trockenheit (p < 0,05) auf. Die Kombination Goserelin/Exemestan reduzierte die Knochendichte nicht mehr als Goserelin allein. Es wurde aber ein Trend hin zu einem protektiven Effekt auf die Knochendichte bei Zusatz von Tibolon beobachtet. Signifikante Differenzen hinsichtlich unerwunschter Nebenwirkungen im Vergleich aller vier Therapiearme waren nicht zu verifizieren. Schlussfolgerung: Die kombinierte Therapie von Goserelin und Exemestan ist so sicher und gut tolerabel wie die Standardtherapie mit Goserelin allein. Das Additivum Tibolon reduziert signifikant eine Reihe durch die Therapie induzierter klimakterischer Symptome und scheint positiven Einfluss auf die Knochendichte zu nehmen. Purpose: Goserelin suppresses ovarian function, but does not inhibit oestrogen production in peripheral tissues. Therefore addition of the aromatase inactivator exemestane may optimally decrease oestrogen levels. The combination of goserelin and exemestane may therefore be useful in the adjuvant treatment of primary breast cancer. The climacteric symptoms expected with this regimen may be relieved by tibolone. Material and Methods: The 24-week, open, randomised, multicentre ADAGIO (Adjuvant Aromasin combined with Goserelin) pilot study was conducted in 48 premenopausal women (aged 35 - 55 years) with histologically confirmed oestrogen and/or progesterone receptor-positive, node negative primary breast cancer (pT1, M0 [grade 1 - 2]) of low or intermediate risk. Patients were randomised to one of four groups: goserelin 3.6 mg depot implanted s.c. every 28 days; goserelin plus oral exemestane 25 mg/day; goserelin plus oral tibolone 2.5 mg/day; or goserelin plus exemestane and tibolone. Results: There was a rapid fall in serum oestradiol, oestrone and oestrone sulphate to postmenopausal levels in all four treatment groups; there were no significant differences between the groups. LH and FSH were also suppressed. Climacteric symptoms increased in intensity in all groups, although patients receiving tibolone had significantly fewer hot flushes (p < 0.01), sleep disorders (p < 0.05), loss of libido (p < 0.01) and vaginal dryness (p < 0.05). The combination of goserelin and exemestane did not reduce bone mineral density (BMD) more than goserelin alone. There was a trend towards a protective effect of tibolone on BMD. There were no significant differences in adverse events between the four groups and no serious adverse events were observed. Conclusions: Combination treatment with goserelin and exemestane is as safe and well tolerated as standard treatment with goserelin alone. The addition of tibolone reduces the severity of some climacteric symptoms and may also reduce bone loss.

Purpose: HER-2 blocking strategies, for instance with trastuzumab (Herceptin®), have been successfully used in therapy of breast cancer. To study molecular mechanisms and the efficiency of HER-2 blocking therapies we established a mouse tumor model that allows switching-off of HER-2 expression in tumor tissue. Material and Methods: NIH3T3 cells conditionally expressing HER-2 by the TET-OFF system (NIH3T3-HER-2 cells) were subcutaneously injected into the dorsal skin of nude mice. These cells allowed switching-off of HER-2 expression by exposure to anhydrotetracycline. We examined the influence of HER-2 down-regulation on tumor volume of subcutaneously growing tumors in nude mice. Tumor development was studied by magnetic resonance imaging. HER-2 expression was quantified by Western Blot analysis. Results: Eight to ten days after injection of 7 × 10 6 NIH3T3-HER-2 cells small subcutaneously growing tumors became visible. A surprisingly efficient tumor remission was observed already 7 days after switching-off of HER-2 expression: mice with initial tumor volumes of 0.8, 1.2, 3.9 and 14.9 cm 3 showed a decrease in tumor volumes to 1.9, 11.8, 11.3 and 25.8%, respectively, compared to the respective volumes before anhydrotetracycline administration. In contrast, a steady increase in tumor volume was observed for mice not exposed to anhydrotetracyclin. Conclusion: Switching-off of HER-2 expression causes a strong remission already after 7 days. Interestingly, the extent of tumor remission depends on initial tumor size, whereby a stronger remission can be achieved for smaller tumors. Our data support clinical studies testing HER-2 blocking strategies as adjuvant therapy for early breast cancer.

OBJECTIVE: The aim of the study was to compare the perinatal outcome of spontaneously conceived twins with those conceived after in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI). MATERIAL AND METHODS: A retrospective study was performed. Clinical data of 188 twin pregnancies was collected from the Department of Obstetrics and Gynecology, University Hospital of Mainz for the years 1996-2006. The twins were divided into 2 groups according to the manner of conception: spontaneously conceived twins (n = 142) and twins (n = 46) conceived after IVF and ICSI. In order to investigate the perinatal outcome of spontaneous twins and twins conceived by assisted reproductive technology (ART), we evaluated the following parameters: maternal age, fertility, nulliparity rate, gestational age, mode of delivery, fetal weight and Apgar score. RESULTS: No significant difference was found in maternal age, fertility and gestational age between spontaneous twins and IVF/ICSI twins. Maternal gestational age was 255 days in the spontaneous group and 254 days in IVF/ICSI group. Fetal weight and Apgar score were similar between the two groups. The nulliparity rate was higher in IVF/ICSI group. Obviously there were more cesarean sections in the IVF/ICSI group than in the spontaneous group (76.2 % and 42.5 %, respectively). CONCLUSIONS: Duration of gestation, neonatal birth weight and Apgar score were similar between IVF/ICSI twins and spontaneous twins. IVF/ICSI twins had a higher cesarean section rate.

The new development of single-incision slings (SIS) for the treatment of female stress urinary incontinence offers comparable results with only minimal side effects and will find wide acceptance in modern incontinence surgery. This mini-sling is inserted over a single vaginal incision and fixed on both sides to the pelvic wall tissue with special anchors, without passing through the groin and avoiding a blind tape passage. Compared with the established sub-urethral tapes, there are comparable success rates with fewer complications. Randomised prospective studies are needed to evaluate whether, in the long run, the benefits of the single incision technique can be correlated with satisfying continence results.Die Neuentwicklung von Single-Incision-Schlingen (SIS) bei der operativen Therapie der Belastungsinkontinenz der Frau ist mit vergleichbaren Kontinenzraten und nur geringsten Nebenwirkungen verbunden und kann in Zukunft breite Anwendung in der Inkontinenztherapie finden. Diese minimalinvasiven Schlingen werden über eine singuläre vaginale Inzision eingebracht und bds. an der Beckenwand über verschiedene Haltesysteme verankert. Bei gleicher Wirkung durch suburethralen Bandsupport wird hier jedoch eine Blindpassage wie bei den bekannten retropubischen oder transobturatorischen Systemen vermieden. Im Vergleich zu den etablierten suburethralen Schlingen zeigen sich in den ersten Untersuchungen äquivalente Erfolgsraten und deutlich geringere Nebenwirkungen. Hierzu müssen prospektive Studien die Wertigkeit im Vergleich zu den etablierten Verfahren noch belegen.

Illicit drug abuse, as well as smoking, are known risk factors in the development of intrauterine growth retardation. In an attempt to clarify the influence of these two aetiological factors, a retrospective analysis was carried out. 35 drug- and nicotine-addicted pregnant women were compared to 104 smokers and 101 non-smoking controls with regard to foetal outcome. Relative risk estimates for intrauterine growth retardation of the drug and nicotine group were 3.14 (95% confidence limits 1.88-5.25; p = 0.0001) whereas the smoking group had 1.39 (95% confidence limits 0.96-2.02; p = 0.0482) compared to non-smoking controls. The foetal outcome was best in the latter group: children of drug-addicted mothers had a considerably higher morbidity and mortality rate. This study shows an almost threefold risk for intrauterine growth retardation in drug-addicts who smoke, compared to nicotine abuse alone.

In a retrospective study, we analysed 26 CO2-laser vulvectomies within the observation period between 1982 and 1990. Indications for vulvectomies were invasive malignancies of the vulva, FIGO stage I to III. 91.7% were squamous cell carcinomas. The mean age of patients was 69.3% (43 to 87) years. Five radical local excisions, one modified radical vulvectomy and in all other cases radical vulvectomy was performed. Laser surgery of the vulva was combined with bilateral lymphadenectomy or radiotherapy of inguinal lymph nodes. If necessary, a gluteal rotation flap was built to achieve closure of the wound without tension. No serious intra- or postoperative complications were observed, wound breakdown with per secundam healing as the most common complication occurred in 29.1%. Functional and cosmetic results were examined in a detailed follow-up at least 12 months postoperatively, showing promising results (56.3% good, 37.5% satisfactory, 6.3% unsatisfactory). The surgical procedure, perioperative management, recurrence rate (3 patients, 12.5%), as well as functional and cosmetic results, are presented and discussed in detail. The use of CO2-laser in surgical treatment of vulvar malignancies improves cosmetic and functional results. This is important, particularly with regard to the increasing number of young women with vulvar neoplasia.

For creation of a neovagina in patients with congenital vaginal agenesis, a variety of operative procedures are recommended. Basically, two different procedures are described: (1) Application of pressure or traction to the perineum and (2) plastic-surgical operations. Since 1981, the 2nd Department of Obstetrics and Gynecology, Vienna, utilises the method described by Vecchietti. 9 Patients with congenital absence of the vagina and one with vaginal occlusion after radiotherapy underwent Vecchietti's procedure. Patients were seen after a follow-up period of at least 5 years. We evaluated morphological and functional long-term results using a detailed questionnaire as well as clinical investigations including cytological smears, screening for vaginal infections and determination of sexual hormone levels in peripheral blood. To evaluate distensibility and greatest cross-sectional diameter of the neovagina, a vaginal cast (vinyl-polysiloxan) was obtained. All patients treated for congenital malformations showed good to excellent functional results.