Search

To assess the effect of a standardized questionnaire for premenopausal women with abnormal uterine bleeding (AUB) on clinical information collection and duration of consultation.We conducted a before and after study involving 100 premenopausal women undergoing consultation for AUB. During stage 1, 50 consultations were recorded on a consultation sheet with no specific template. During stage 2, 50 women completed a 26-item auto-administered standardized questionnaire before the consultation, which was then reviewed with the consultant and added to the medical record. The duration of consultation was assessed in subgroups of 27 women in each stage. Two independent evaluators assessed the quality and completeness of data collected in the medical records using a score sheet developed by experts. Outcomes from both stages were compared using the t test.The descriptive characteristics were similar in both groups. The mean global scores of the quality and completeness of data collected improved significantly between stages 1 and 2, from 67% ± 12% to 95% ± 5% (P0.0001), as did medical background scores (54% ± 29% vs. 85% ± 13%; P0.0001) and AUB-related symptoms scores (69% ± 13% vs. 97% ± 5%; P0.0001). A mean reduction in duration of consultation of nearly 4 minutes was observed (24.6 ± 4.3 min vs. 20.7 ± 4.8 min; P0.0001).The AUB-specific standardized questionnaire improves quality and completeness of data collected in medical records and reduces duration of consultation.

To evaluate the effect of hormonal suppression on fertility when administered to infertile patients or patient wishing to conceive after surgery for endometriosis.A systematic search of MEDLINE, EMBASE, CENTRAL and ClinicalTrials.gov was performed by two independent reviewers from the databases' inception until December 2020.We included randomized controlled trials comparing any suppressive hormonal therapy to an inactive control (placebo or absence of treatment) after conservative surgery for endometriosis. Studies that did not report fertility outcomes after surgery were excluded.This systematic review and meta-analysis was registered in PROSPERO. Two reviewers extracted data and assessed the risk of bias as well as the strength of evidence using GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines were followed. Relative risks (RRs) were pooled by quantitative random effect meta-analysis. From 3,138 citations, 19 trials (2,028 patients) were included. Overall, no difference was observed between the treatment and the control group for pregnancy (RR 1.15; 95% CI 1.00-1.32) and live births (RR 1.05; 95% CI 0.84-1.32). When pooling all hormonal therapies, the duration of administration of postoperative therapy was identified as a substantial source of heterogeneity between studies (I2 difference=74%) with increased chances of pregnancy compared with control when administered for at least 3 months (RR 1.22; 95% CI 1.04-1.43). Gonadotropin-releasing hormone (GnRH) agonists (14 trials, 1,721 patients) were associated with increased chances of pregnancy compared with placebo or no treatment (RR 1.20; 95% CI 1.03-1.41; I2=25%). Data were limited for other hormonal treatments with no significant difference between groups. Subgroup analyses taking into account the use of fertility treatments (insemination or in vitro fertilization), stages of the disease and risk of bias of included trials did not modify the results.Postoperative hormonal suppression should be considered on a case-by-case basis to enhance fertility while balancing this benefit with the risks of delaying conception. If chosen, GnRH agonists would be the treatment of choice, and a duration of at least 3 months should be favored.PROSPERO, CRD42021224424.

STUDY OBJECTIVE The objective of our study was to provide a contemporary description of hysterectomy practice and temporal trends in Canada. DESIGN A national whole-population retrospective analysis of data from the Canadian Institute for Health Information. SETTING Canada. PATIENTS All women who underwent hysterectomy for benign indication from April 1, 2007, to March 31, 2017, in Canada. INTERVENTIONS Hysterectomy. MEASUREMENTS AND MAIN RESULTS A total of 369 520 hysterectomies were performed in Canada during the 10-year period, during which the hysterectomy rate decreased from 313 to 243 per 100 000 women. The proportion of abdominal hysterectomies decreased (59.5% to 36.9%), laparoscopic hysterectomies increased (10.8% to 38.6%), and vaginal hysterectomies decreased (29.7% to 24.5%), whereas the national technicity index increased from 40.5% to 63.1% (p

BACKGROUND: Uterine fibroids are common in women and their management is heavily influenced by information gathered through imaging. We aimed to evaluate the type and quality of imaging performed for assessment of uterine fibroids in Canada. METHODS: Starting in July 2015, premenopausal women with symptomatic fibroids were enrolled in a prospective, noninterventional, observational registry (Canadian Women With Uterine Fibroids Registry [CAPTURE]) that included 19 Canadian sites. Clinical characteristics were extracted from the baseline visit. We evaluated the association between demographic and clinical variables of interest with regard to imaging type using unadjusted and adjusted logistic regression models. RESULTS: Of 1493 women, 1148 had ultrasonography, 135 had magnetic resonance imaging (MRI), 80 had other types of imaging and 130 did not have imaging reported within 12 months of the baseline visit. After adjusting for demographic and clinical characteristics, patients who underwent MRI had larger fibroids (odds ratio [OR] per 1-cm increase 1.11, 95% confidence interval [CI] 1.05–1.17) and more numerous fibroids (1 v. > 1; OR 1.74, 95% CI 1.14–2.64) compared with those who underwent ultrasonography only. For ultrasonography reporting, quality criteria were met for 268 of 1148 patients (23.3%). There was a difference in the quality of reporting among the 19 sites (p < 0.001). Logistic regression model accounting for within-site variability showed that reporting results from ultrasonography in the province of Quebec were less likely to meet all quality criteria (OR 0.20, 95% CI 0.06–0.66) and those from sites in more populated cities (≥ 400 000 inhabitants) were more likely to do so (OR 6.15, 95% CI 2.20–17.18). INTERPRETATION: We determined that imaging modality for fibroids is associated with patient characteristics. The quality of reporting results for ultrasonography of fibroids in Canada falls short of internationally endorsed guidelines and needs improvement. STUDY REGISTRATION: ClinicalTrials.gov, no. NCT02580578

This study sought to report the feasibility and clinical implications of in-bag morcellation for total laparoscopic hysterectomy (TLH).Women who required uterine morcellation during TLH from January 2017 to December 2018 (at the Centre Hospitalier Universitaire de Québec - CHUL, Québec, QC) were included. Women with a preoperative suspicion of malignancy were excluded (Canadian Task Force classification II-2).During the 2-year study period, uterine morcellation was required in 42% (106 of 252) of women undergoing TLH. Mean uterine weight of morcellated uterus was 541 ± 291 g, with 11 of 106 uteri weighing1000 g. In-bag morcellation was attempted in 84 of 106 (79%) and successfully performed in 79 of 84 (94%) women. Failures resulted from inability to insert the specimen into the bag or apparent perforation. Uncontained morcellation was chosen for 22 of 106 (21%) women, most of whom underwent vaginal morcellation of the uterus. Total operative time was 40 minutes longer for the in-bag morcellation group (170 ± 48 vs. 130 ± 43 min; P 0.001), although this difference can be partly explained by the higher mean uterine size compared with the uncontained morcellation group (580 ± 309 vs. 391 ± 122 g; P = 0.01). In a subgroup analysis of 16 women, the mean times of installation and extraction of the bag were estimated to be 17 ± 9 and 4 ± 3 minutes, respectively. Complications were infrequent (2 of 106) and occurred in the in-bag morcellation group.In-bag morcellation is feasible in a high proportion of women undergoing laparoscopic hysterectomy and is associated with an increase in operative time. Larger studies will be required in order to better assess the risk of complications with in-bag morcellation and the potential benefits of this technique, namely, reducing the spread of tissue.

Objective To evaluate the benefits and risks of laparoscopic surgery and provide clinical direction on entry techniques, technologies, and their associated complications in gynaecological surgery. Target population All patients, including pregnant women and women with obesity, undergoing laparoscopic surgery for various gynaecological indications. Options The laparoscopic entry techniques and technologies reviewed in formulating this guideline included the closed (Veress needle–pneumoperitoneum–trocar) technique, direct trocar insertion, open (Hasson) technique, visual entry systems, and disposable shielded and radially expanding trocars. Outcomes Implementation of this guideline should optimize decision-making in the selection of entry technique for laparoscopic surgery. Evidence We searched English-language articles from September 2005 to December 2019 in PubMed/MEDLINE, Embase, Science Direct, Scopus, and Cochrane Library using the following MeSH search terms alone or in combination: laparoscopic entry, laparoscopy access, pneumoperitoneum, Veress needle, open (Hasson), direct trocar, visual entry, shielded trocars, radially expanded trocars, and laparoscopic complications. Validation methods The authors rated the quality of evidence and strength of recommendations using the Canadian Task Force on Preventive Health Care approach (Appendix A). Intended audience Surgeons performing laparoscopic gynaecological surgery. SUMMARY STATEMENTS 1Laparoscopic entry using the Veress needle–pneumoperitoneum–trocar (or "closed") technique is practised by the majority of gynaecologists worldwide (I). 2During closed entry, caudal umbilical displacement below the sacrum and great vessels facilitates intraperitoneal placement of the Veress needle and maximizes the success of entry and avoidance of injury (I). 3The Veress needle can be inserted intraperitoneally at umbilical or left upper quadrant sites. Left upper quadrant placement is associated with fewer attempts and fewer conversions to alternative sites (I). 4Initial Veress intraperitoneal pressure of 5Shielded trocars do not result in fewer visceral or vascular injuries during laparoscopic access (II-2). 6The blunt tip of the radially expanding trocars may provide protection from injuries, but the force required for entry is significantly greater than for disposable trocars (I). 7Single-use, push-through, optical trocars are not superior to blind methods of inserting trocars and do not avoid visceral or vascular injury (II-2). 8Reusable visual entry cannulas have no sharp or pointed trocar, minimize port wound size, and reduce insertional force; as a consequence, they may be safer than trocars (II-2). 9Direct trocar insertion is associated with fewer insufflation complications and failed entries. However, there is insufficient evidence to conclude that direct insertion is associated with fewer major complications (I). 10Open entry is neither superior nor inferior to other entry techniques. Open entry has a lower incidence of vascular injuries but a potentially higher incidence of bowel injury (I). 11Laparoscopy can be performed in pregnancy (II-2). RECOMMENDATIONS 1Alternative insertion sites for the Veress needle (e.g., left upper quadrant [Palmer's point], transvaginal, or transuterine) should be considered (1) when an umbilical entry is considered complicated, based on patient history and characteristics (e.g., suspected or known periumbilical adhesions, history or presence of umbilical hernia, low or high body mass index) or (2) after 3 failed attempts at umbilical Veress needle insertion (I-A). 2Elevation of the abdominal wall during insertion of a Veress needle or primary trocar is not routinely recommended because it does not avoid visceral or vessel injury (II-2E). 3Because the position of the umbilicus in relation to the aortic bifurcation varies according to the patient's body mass index, the angle of insertion of the Veress needle at the umbilicus should be adjusted accordingly—from 45° in women of normal body mass to 90° in women with obesity (I-A). 4Previously recommended Veress needle safety checks or tests, such as the saline drop test and aspiration for fluid, have not been found to confirm position and therefore are no longer recommended as best practice (I-A). 5Wiggling the Veress needle from side to side should be avoided; this can increase the risk of complications (II-1E). 6It is appropriate to to leave the source of gas attached to the Veress needle so that the surgeon can use the pressure gauge to measure the intraperitoneal pressure ( 7The volume of CO2 insufflated with the Veress needle before trocar insertion should depend on intra-abdominal pressure. Adequate pneumoperitoneum insufflation should be determined by a pressure of 20–30 mm Hg rather than by CO2 volume (II-1 A). 8During entry using Veress needle insufflation, intraperitoneal pressure may be increased immediately before insertion of the trocars. Transiently high intraperitoneal pressure does not adversely affect cardiopulmonary function in healthy patients (II-1 A). 9The threaded, reusable, visual cannula may be considered a safer instrument for peritoneal entry than conventional trocars (II-2 B). 10Direct trocar insertion may be used in accordance with the surgeon's training, experience, and preference (I B). 11Open (Hasson) entry may be used in accordance with the surgeon's training, experience, and preference (II-2 C). 12Because there is no clear consensus on the optimal method of peritoneal entry, surgeons should use the technique with which they are most comfortable and experienced (II-2 C). 13In women requiring intra-abdominal surgery in pregnancy, Veress needle insufflation at the umbilical site can be employed until 14 weeks gestation (if there are no contraindications), and open (Hasson) entry or left upper quadrant insufflation are preferable after 14 weeks gestation (II-2 B). After 24 weeks gestation, an open (Hasson) entry is recommended (II-2 B).

BACKGROUND Endometrial ablation/resection and the levonorgestrel intra-uterine system (LNG-IUS) are well-established treatment options for heavy menstrual bleeding to avoid more invasive alternatives, such as hysterectomy. OBJECTIVE The aim was to compare the efficacy and safety of endometrial ablation or resection with the LNG-IUS in the treatment of premenopausal women with heavy menstrual bleeding and to investigate sources of heterogeneity between studies. SEARCH METHODS We searched the databases MEDLINE, EMBASE, CENTRAL, Web of Science, Biosis and Google Scholar as well as citations and reference lists published up to August 2019. Two authors independently screened 3701 citations for eligibility. We included randomized controlled trials published in any language, comparing endometrial ablation or resection to the LNG-IUS in the treatment of premenopausal women with heavy menstrual bleeding and a normal uterine cavity. OUTCOMES Thirteen studies (N = 884) were eligible. Two independent authors extracted data and assessed the quality of included studies. Random effect models were used to compare the modalities and evaluate sources of heterogeneity. No significant differences were observed between endometrial ablation/resection and the LNG-IUS in terms of subsequent hysterectomy (primary outcome, risk ratio (RR) = 1.13, 95% CI 0.60 to 2.11, P = 0.71, I2 = 14%, 12 studies, 726 women), satisfaction, quality of life, amenorrhea and treatment failure. However, side effects were less common in women treated with endometrial ablation/resection compared to the LNG-IUS (RR = 0.52, 95% CI 0.37 to 0.71, P 42 years old), although the reduction did not reach statistical significance (RR = 0.51, 95% CI 0.21 to 1.24, P = 0.14, I2 = 0%, 5 studies, 297 women). Finally, sensitivity analysis taking into account the risk of bias of included studies and type of surgical devices (first and second generation) did not modify the results. Most of the included studies reported outcomes at up to 3 years, and the relative performance of endometrial ablation/resection and LNG-IUS remains unknown in the longer term. WIDER IMPLICATIONS Endometrial ablation/resection and the LNG-IUS are two excellent treatment options for heavy menstrual bleeding, although women treated with the LNG-IUS are at higher risk of experiencing side effects compared to endometrial ablation/resection. Otherwise, younger women seem to present a lower risk of eventually requiring hysterectomy when treated with the LNG-IUS compared to endometrial ablation/resection.

We report a case of a pyomyoma in which in-bag morcellation allowed for a total laparoscopic hysterectomy instead of laparotomy, which has been recognized as the standard of care to avoid the spread of infection from morcellation. A 45-year-old multiparous woman presented with sepsis, pelvic pain, and leukocytosis at 1 month after undergoing uterine artery embolization for symptomatic uterine leiomyoma. Pelvic computed tomography scan revealed a 9-cm suspected pyomyoma. A total hysterectomy was performed using a laparoscopic approach with in-bag morcellation. The intervention was successful, and the postoperative course was uneventful. The patient was discharged on postoperative day 1 and was well at 2 months after surgery.

To assess trends and predictors of a high technicity index for hysterectomies performed in the province of Québec.We conducted a retrospective study using the ADAM database to determine the annual number hysterectomies performed for a suspected benign condition and the surgical approach used across 81 hospitals in the province of Québec from 2007 to 2017. We calculated the technicity index for each hospital and analyzed trends in surgical approach using the Cochran-Armitage test. We used logistic regression to assess potential predictors of a high technicity index (70%), including academic centre, urban area, high volume of hysterectomies performed, and greater number of gynaecologists per hospital.Fifty-nine hospitals were eligible for inclusion, representing 96 431 hysterectomies during the study period. Over the decade, the technicity index increased from 43% to 66% (P 0.001, with a 198% increase in laparoscopic hysterectomies (from 685 to 2039 per year; P 0.001), a 50% decrease in abdominal hysterectomies (from 5528 to 2790 per year; P 0.001), and a 8% decrease in vaginal hysterectomies (form 3551 to 3257 per year; P 0.001). Meanwhile, the total number of hysterectomies per year declined by 17% (P 0.001). Being an academic centre was the only significant predictor of a high technicity index70% (68% vs. 38%; OR 7.5; P = 0.047).Technicity is increasing in the province of Québec and the majority of hysterectomies are now performed using a minimally invasive approach. This shift has mainly occurred through an increase in the laparoscopic approach and a decrease in the abdominal approach. Academic centres are more likely to have high technicity indexes.

To evaluate the accuracy of saline infusion sonohysterography in comparison with transvaginal ultrasonography for diagnosing polyps and submucosal leiomyomas in women with abnormal uterine bleeding.We searched the databases MEDLINE, EMBASE, CENTRAL, and ClinicalTrials.gov as well as citations and reference lists to the end of November 2015.Two authors screened 5,347 citations for eligibility. We included randomized controlled trials or prospective cohort studies published in English, assessing the accuracy of saline infusion sonohysterography and transvaginal ultrasonography for diagnosing polyps and submucosal leiomyomas in women with abnormal uterine bleeding. We considered studies using histopathologic specimens obtained at either hysteroscopy or hysterectomy as criterion standard.Twenty-five studies were eligible. Two authors extracted data and assessed the quality of included studies. Bivariate random-effects models were used to compare the different tests and evaluate sources of heterogeneity. Saline infusion sonohysterography was superior to transvaginal ultrasonography with pooled sensitivity and specificity of 0.92 and 0.89 compared with 0.64 and 0.90, respectively (P.001). Transvaginal ultrasound sensitivity for diagnosing polyps was particularly low (0.51). Saline infusion sonohysterography was also compared with hysteroscopy in seven studies and had similar sensitivity but inferior specificity (0.93 and 0.83 compared with 0.95 and 0.90, respectively, P=.007). All three procedures were well-tolerated by women. Saline infusion sonohysterography was successfully completed in 95% of women. Technical variations such as the use of balloon catheters were not found to affect diagnostic accuracy.Transvaginal ultrasonography lacks sensitivity to be used alone to exclude the presence of polyps and leiomyomas in women with abnormal uterine bleeding. Although less specific than hysteroscopy, saline infusion sonohysterography offers a similar detection rate and permits concomitant visualization of the ovaries and myometrium. Cost, convenience, and tolerability of different imaging techniques require further evaluation.PROSPERO International prospective register of systematic reviews, http://www.crd.york.ac.uk/PROSPERO, CRD42016034005.

Study Objective To assess the safety and effectiveness of the Minerva endometrial ablation system for treating excessive uterine bleeding in premenopausal women. Design Multicenter, single-arm, objective performance criteria (OPC)-controlled international study (Canadian Task Force classification II-1). Setting Seven academic medical centers. Patients 105 premenopausal women symptomatic for menorrhagia secondary to dysfunctional uterine bleeding. Intervention Patients were treated using the Minerva endometrial ablation system. Measurements and Main Results Study success, based on a pictorial blood loss assessment chart (PBLAC) score ≤75, was observed in 96.2% of the patients at 1 year posttreatment. Some 69.5% of the patients experienced amenorrhea (PBLAC score 0). The mean duration of the procedure was 3.9 minutes. General anesthesia was used in 9% of cases, with the balance being performed under local and/or intravenous or spinal anesthesia regimens. No intraoperative adverse events and/or complications were reported. No patient required hysterectomy or any additional medical and/or surgical interventions to control bleeding during 1 year of follow-up. Efficacy (success) results were compared between the Minerva system and the OPC, which served as a statistical control. The OPC comprised the US Food and Drug Administration's (FDA) reported success rates of all FDA-approved endometrial ablation systems. The Minerva system had a statistically significantly superior success rate compared with the OPC control. Conclusion The Minerva system was found to be safe and effective for treating patients suffering from menorrhagia. The procedure is quick and effective, does not require endometrial pretreatment, and precludes the need for additional surgical interventions to manage menorrhagia.

To provide clinical direction, based on the best evidence available, on laparoscopic entry techniques and technologies and their associated complications.The laparoscopic entry techniques and technologies reviewed in formulating this guideline include the classic pneumoperitoneum (Veress/trocar), the open (Hasson), the direct trocar insertion, the use of disposable shielded trocars, radially expanding trocars, and visual entry systems.Implementation of this guideline should optimize the decision-making process in choosing a particular technique to enter the abdomen during laparoscopy.English-language articles from Medline, PubMed, and the Cochrane Database published before the end of September 2005 were searched, using the key words laparoscopic entry, laparoscopy access, pneumoperitoneum, Veress needle, open (Hasson), direct trocar, visual entry, shielded trocars, radially expanded trocars, and laparoscopic complications.The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on the Periodic Health Examination. RECOMMENDATIONS AND SUMMARY STATEMENT.

Objective To evaluate the diagnostic accuracy of intraoperative laparoscopic imaging tools in reference to that of histopathology for detecting endometriotic lesions and to compare them with conventional white-light inspection by performing a systematic review with meta-analysis. Data Sources We searched the MEDLINE, EMBASE, and CENTRAL databases in addition to citations and reference lists until the end of February 2019. Methods of Study Selection Two authors screened 1038 citations for eligibility. We included randomized controlled trials or prospective cohort studies published in English, assessing the accuracy of intraoperative imaging tools for diagnosing endometriosis during laparoscopy. We considered studies using histopathologic evaluation as a standard criterion. Tabulation, Integration, and Results Seven studies were eligible, including 472 women and 1717 histopathologic specimens, and they involved study of the use of narrow-band imaging (2 studies), 5-aminolevulinic acid–induced fluorescence (2 studies), autofluorescence imaging (1 study), indocyanine green (1 study), and a 3-dimensional robotic laparoscopy (1 study). Two authors extracted data and assessed the validity of the included studies. Bivariate random-effects models and McNemar's test were used to compare the tests and evaluate sources of heterogeneity. Four studies were attributed a high risk of bias, and biopsies of normal-looking peritoneum were not performed to verify the results in 3 studies; both factors were identified as significant sources of heterogeneity, leading to the overestimation of the sensitivity and underestimation of the specificity of imaging tools. In all studies, additional endometriotic lesions were diagnosed with the enhanced imaging tool compared with white-light inspection alone. In the 4 studies that appropriately performed control biopsies (171 women, 448 specimens), enhanced imaging techniques were associated with a higher sensitivity and specificity compared with white-light inspection (0.84 and 0.89 compared with 0.75 and 0.76, respectively, p ≤.001). Adverse events were uncommon (n = 5) and reported only with the use of exogeneous photosensitizers. There were no reports of long-term changes in patient-reported outcomes arising from better detection of endometriosis lesions. Conclusion Studies report that enhanced imaging allows for the detection of additional endometriotic lesions missed by conventional white-light laparoscopy. The benefits of finding these additional lesions using enhanced imaging compared with white-light inspection alone on long-term postoperative outcomes have not been determined, and these tools should be considered only in a research context at this time.

Resume Contexte Les saignements uterins anormaux (SUA) sont directement a l'origine d'un fardeau de sante considerable que doivent porter les femmes, leur famille et la societe en general. Jusqu'a 30 % des femmes chercheront a obtenir l'aide d'un medecin pour contrer ce probleme au cours de leurs annees de fertilite. Objectif Fournir des lignes directrices factuelles a jour quant aux techniques et aux technologies utilisees aux fins de l'ablation de l'endometre (AE), soit une intervention a effraction minimale permettant la prise en charge des SUA d'origine benigne. Methodes Les membres du comite sur la directive clinique ont ete selectionnes en fonction de leurs specialisations respectives en vue de representer une gamme d'experiences pratiques et universitaires : le milieu de pratique au Canada, le type de pratique, la sous-specialite et les antecedents generaux en gynecologie ont donc ete pris en consideration. Le comite a analyse les donnees pertinentes issues de la litterature medicale anglophone (y compris les lignes directrices publiees), en plus d'evaluer les issues chirurgicales et les issues qu'ont connues les patientes a la suite de l'utilisation de diverses techniques d'AE. Les recommandations ont ete formulees par consensus. Donnees La litterature publiee a ete recuperee par l'intermediaire de recherches menees dans MEDLINE et The Cochrane Library en 2013 et en 2014 au moyen d'un vocabulaire controle et de mots cles appropries (p. ex. « endometrial ablation », « hysteroscopy », « menorrhagia », « heavy menstrual bleeding », « AUB », « hysterectomy »). Les resultats ont ete restreints aux analyses systematiques, aux etudes observationnelles et aux essais comparatifs randomises / essais cliniques comparatifs publies en anglais entre janvier 2000 et novembre 2014. Les recherches ont ete mises a jour de facon reguliere et integrees a la directive clinique jusqu'en decembre 2014. La litterature grise (non publiee) a ete identifiee par l'intermediaire de recherches menees dans les sites Web d'organismes s'interessant a l'evaluation des technologies dans le domaine de la sante et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et aupres de societes de specialite medicale nationales et internationales. Valeurs La qualite des resultats a ete evaluee au moyen des criteres decrits dans le rapport du Groupe d'etude canadien sur les soins de sante preventifs (Tableau 1). Resultats Le present document passe en revue les donnees quant aux techniques et aux technologies disponibles en ce qui concerne l'AE, les soins preoperatoires et postoperatoires, le milieu d'intervention, l'anesthesie et les facteurs pratiques a prendre en consideration. Avantages, desavantages et couts La mise en œuvre des recommandations de la presente directive clinique entrainera une amelioration de l'offre de l'AE a titre de traitement efficace contre les SUA. Le respect de ces recommandations permettrait l'execution de l'intervention chirurgicale en cause de facon sure et en maximiserait la reussite pour les patientes. Conclusions L'AE est une option a effraction minimale sure et efficace pour la prise en charge des SUA d'etiologie benigne. Declarations sommaires 1.L'ablation de l'endometre est une intervention chirurgicale a effraction minimale sure et efficace qui en est venue a constituer, dans certains cas, une solution de rechange bien etablie au traitement medical ou a l'hysterectomie pour la prise en charge des saignements uterins anormaux. (I) 2.Une preparation de l'endometre peut etre mise en œuvre pour en faciliter l'ablation resectoscopique et peut egalement etre envisagee dans le cas de certaines techniques non resectoscopiques. Lorsque l'on a recours a l'ablation resectoscopique de l'endometre, l'amincissement preoperatoire de ce dernier donne lieu a une hausse des taux d'amenorrhee a court terme, a une attenuation de l'absorption du liquide de distension et a une reduction de la duree operatoire, par comparaison avec l'absence de traitement. (I) 3.Les techniques non resectoscopiques sont techniquement plus faciles a utiliser que les techniques resectoscopiques, necessitent des temps operatoires plus courts et permettent l'utilisation d'une anesthesie locale (plutot que d'avoir recours a une anesthesie generale). Toutefois, ces deux techniques comptent des taux comparables de satisfaction des patientes et d'attenuation des saignements menstruels abondants. (I) 4.Les techniques resectoscopiques et non resectoscopiques d'ablation de l'endometre comptent toutes de faibles taux de complication. La perforation uterine, la surcharge liquidienne, l'hematometre et les lacerations cervicales sont plus courantes dans le cas de l'AE resectoscopique; les crampes uterines, la douleur et les nausees / vomissements perioperatoires sont plus courants dans le cas de l'AE non resectoscopique. (I) 5.L'efficacite de tous les dispositifs d'ablation non resectoscopique de l'endometre disponibles au Canada a ete demontree en ce qui concerne l'attenuation du flux menstruel; de plus, ils menent tous a des taux eleves de satisfaction des patientes. Le choix du dispositif a utiliser depend principalement de l'opinion du chirurgien et de la disponibilite des ressources. (I) 6.L'utilisation d'anesthesiques et de blocs locaux, d'une analgesie orale et d'une sedation consciente permet la tenue d'une ablation non resectoscopique de l'endometre au sein de milieux necessitant des ressources moindres, y compris dans des milieux non hospitaliers reglementes. (II-2) 7.Les patientes n'etant exposees qu'a de faibles risques et presentant une tolerance satisfaisante a la douleur sont de bonnes candidates pour ce qui est de la tenue d'une ablation endometriale dans un milieu autre qu'en salle d'operation ou dans un centre chirurgical autonome. (II-2) 8.Les techniques d'ablation de l'endometre tant resectoscopiques que non resectoscopiques sont relativement sures et ne comptent que de faibles taux de complication. Parmi les complications les plus graves, on trouve la perforation (s'accompagnant de lesions potentielles aux structures adjacentes), l'hemorragie et l'infection. (II-2) 9.La tenue concomitante d'une sterilisation hysteroscopique et d'une ablation endometriale peut etre sure et efficace tout en favorisant une approche a effraction minimale. (II-2) Recommandations 1.L'evaluation preoperatoire devrait etre exhaustive, de facon a pouvoir ecarter toute contre-indication a l'ablation de l'endometre. (II-2A) 2.Les patientes devraient etre avisees de la necessite d'une contraception permanente a la suite de l'ablation de l'endometre. (II-2B) 3.Les evaluations recommandees en presence de saignements uterins anormaux (dont, entre autres, le prelevement endometrial et l'evaluation de la cavite uterine) sont des composantes necessaires de l'evaluation preoperatoire. (II-2B) 4.Les cliniciens devraient demeurer a l'affut des complications propres a l'ablation resectoscopique de l'endometre, comme celles qui sont associees au produit de distension et aux lesions electrochirurgicales. (III-A) 5.Dans le cas de l'ablation resectoscopique de l'endometre, un protocole strict devrait etre respecte pour ce qui est de la surveillance liquidienne et de la prise en charge, et ce, afin de minimiser le risque de voir se manifester des complications associees a la surcharge de produit de distension. (III-A) 6.Lorsque l'on soupconne qu'une perforation uterine s'est manifestee au cours de la dilatation cervicale ou dans le cadre de l'utilisation du resectoscope (sans electrochirurgie), l'intervention devrait etre abandonnee et la patiente devrait faire l'objet d'une surveillance etroite de facon a ce que l'on puisse demeurer a l'affut des signes d'hemorragie intraperitoneale ou de lesion viscerale. Lorsque la perforation se manifeste dans le cadre d'une electrochirurgie ou lorsque le mecanisme de la perforation demeure incertain, la tenue d'une exploration abdominale est justifiee pour assurer l'hemostase et ecarter la presence de lesions viscerales. (III-B) 7.Dans le cas de l'AE resectoscopique, lorsque la presence d'une perforation uterine a ete ecartee, l'hemorragie aigue pourrait etre prise en charge au moyen d'un tamponnement intra-uterin par sonde de Foley, d'une injection intracervicale de vasopresseurs ou de l'administration de misoprostol par voie rectale. (III-B) 8.Lorsqu'une nouvelle ablation de l'endometre est envisagee a la suite d'une intervention non resectoscopique ou resectoscopique, elle devrait etre menee par un chirurgien hysteroscopique sous visualisation directe de la cavite. Les patientes devraient beneficier de services de counseling au sujet des risques de complications qui sont associes a la tenue d'une nouvelle ablation de l'endometre. (II-2A) 9.En presence d'une pathologie intracavitaire considerable, la tenue concomitante d'une ablation resectoscopique de l'endometre et d'une myomectomie / polypectomie hysteroscopique devrait etre envisagee. (II-3A)

Adipogenesis and lipid storage in human adipose tissue are inhibited by androgens such as DHT. Inactivation of DHT to 3α-diol is stimulated by glucocorticoids in human preadipocytes. We sought to characterize glucocorticoid-induced androgen inactivation in human preadipocytes and to establish its role in the antiadipogenic action of DHT. Subcutaneous and omental primary preadipocyte cultures were established from fat samples obtained in subjects undergoing abdominal surgeries. Inactivation of DHT to 3α/β-diol for 24 h was measured in dexamethasone- or vehicle-treated cells. Specific downregulation of aldo-keto reductase 1C (AKR1C) enzymes in human preadipocytes was achieved using RNA interference. In whole adipose tissue sample, cortisol production was positively correlated with androgen inactivation in both subcutaneous and omental adipose tissue ( P < 0.05). Maximal dexamethasone (1 μM) stimulation of DHT inactivation was higher in omental compared with subcutaneous fat from men as well as subcutaneous and omental fat from women ( P < 0.05). A significant positive correlation was observed between BMI and maximal dexamethasone-induced DHT inactivation rates in subcutaneous and omental adipose tissue of men and women ( r = 0.24, n = 26, P < 0.01). siRNA-induced downregulation of AKR1C2, but not AKR1C1 or AKR1C3, significantly reduced basal and glucocorticoid-induced androgen inactivation rates ( P < 0.05). The inhibitory action of DHT on preadipocyte differentiation was potentiated following AKR1C2 but not AKR1C1 or AKR1C3 downregulation. Specifically, lipid accumulation, G3PDH activity, and FABP4 mRNA expression in differentiated preadipocytes exposed to DHT were reduced further upon AKR1C2 siRNA transfection. We conclude that glucocorticoid-induced androgen inactivation is mediated by AKR1C2 and is particularly effective in omental preadipocytes of obese men. The interplay between glucocorticoids and AKR1C2-dependent androgen inactivation may locally modulate adipogenesis and lipid accumulation in a depot-specific manner.

OBJECTIVE We assessed whether subcutaneous and omental adipocyte hypertrophy are related to metabolic alterations independent of body composition and fat distribution in women. RESEARCH DESIGN AND METHODS Mean adipocyte diameter of paired subcutaneous and omental adipose tissue samples was obtained in lean to obese women. Linear regression models predicting adipocyte size in both adipose tissue depots were computed using body composition and fat distribution measures (n = 150). In a given depot, women with larger adipocytes than predicted by the regression were considered as having adipocyte hypertrophy, whereas women with smaller adipocytes than predicted were considered as having adipocyte hyperplasia. RESULTS Women characterized by omental adipocyte hypertrophy had higher plasma and VLDL triglyceride levels as well as a higher total-to-HDL cholesterol ratio compared with women characterized by omental adipocyte hyperplasia (P < 0.05). Conversely, women characterized by subcutaneous adipocyte hypertrophy or hyperplasia showed a similar lipid profile. In logistic regression analyses, a 10% enlargement of omental adipocytes increased the risk of hypertriglyceridemia (adjusted odds ratio [OR] 4.06, P < 0.001) independent of body composition and fat distribution measures. A 10% increase in visceral adipocyte number also raised the risk of hypertriglyceridemia (adjusted OR 1.55, P < 0.02). Associations between adipocyte size and homeostasis model assessment of insulin resistance were not significant once adjusted for adiposity and body fat distribution. CONCLUSIONS These results suggest that omental, but not subcutaneous, adipocyte hypertrophy is associated with an altered lipid profile independent of body composition and fat distribution in women.

Prostaglandins (PGs) E2 and PGF2α are produced in the endometrium and are important for menstruation and fertility. Dysmenorrhea is associated with increased production of PGF2α relative to PGE2, and the opposite is true for menorrhagia. The pathways leading to PGE2 biosynthesis are well described, but little is known for PGF2α. Aldoketoreductase (AKR)-1C3, the only PGF synthase identified in the human, cannot explain the production of PGF2α by endometrial cells. AKR1B1 appears to be an alternate candidate with promising therapeutic value.The objective of the study was to address whether AKR1B1 (gene ID 231) is a functional PGF2α synthase in the human endometrium and a valid therapeutic target for menstrual pain.The design of the study was basic laboratory analyses to identify gene expression and protein levels associated with PGF2α production in endometrial tissues and endometrial cells from cycling women aged between 23 and 52 yr undergoing biopsies or hysterectomy for diverse gynecological disorders.AKR1B1 is expressed at a high level during the menstrual cycle during the secretory phase and in both epithelial and stromal cells, whereas AKR1C3 was found only in epithelial cells. Purified recombinant AKR1B1 protein, gene silencing, and transient transfection experiments all concur to demonstrate that this enzyme is a functional PGF synthase. Ponalrestat, a specific inhibitor developed to block AKR1B1 activity, reduced PGF2α production in response to IL-1β in both cultured endometrial cells and endometrial explants.The human aldose reductase AKR1B1 currently associated with diabetes complications is also a highly functional PGF synthase responsible for PGF2α production in the human endometrium and a potential target for treatment of menstrual disorders.

Estradiol (E2) is produced locally in adipose tissue and could play an important role in fat distribution and accumulation, especially in women. It is well recognized that aromatase is expressed in adipose tissue; however the identity of its estrogenic 17beta-hydroxysteroid dehydrogenase (17beta-HSD) partner is not identified. To gain a better knowledge about the enzyme responsible for the conversion of estrone into estradiol, we determined the activity and expression levels of known estrogenic 17beta-HSDs, namely types 1, 7 and 12 17beta-HSD in preadipocytes before and after differentiation into mature adipocytes using an adipogenic media. Estrogenic 17beta-HSD activity was assessed using [(14)C]-labelled estrone, while mRNA expression levels of types 1, 7 and 12 17beta-HSD were quantified using real-time PCR and protein expression levels of type 12 17beta-HSD was determined using immunoblot analysis. The data indicate that there is a low conversion of E1 into E2 in preadipocytes; however this activity is increased approximately 5-fold (p0.0001) in differentiated adipocytes. The increased estrogenic 17beta-HSD activity is consistent with the increase in protein expression levels of 17beta-HSD12.

Due to variability in size, number, and location of uterine fibroids (UFs), symptoms can range widely among women. We sought to characterize burden of illness and quality of life (QoL) among women with symptomatic UFs.An online survey queried the gynecologic health and menstrual cycle of Canadian women aged 20 to 49. Respondents reporting current UFs were assigned an Overall Severity Score based on a validated health-related QoL questionnaire (the UFS-QOL) and were dichotomized as having mild or moderate/severe UF. Subjects with moderate/severe UFs were matched 1:3 to non-UF subjects on age, race, and parity.Of 9413 women with complete data, 384 (4.1%) reported physician-diagnosed UFs; of these, 50.6% met criteria for moderate/severe symptoms. Compared with matched non-UF respondents, moderate/severe UF respondents reported significantly greater mean menstrual duration (6.2 vs 5.0 days), more healthcare visits (emergency department, walk-in, family doctor, and specialist; total 10.5 vs 4.9 visits/6 months), and greater use of prescription analgesics (47.7% vs 26.7%) and iron supplements (29.7% vs 12.2%) (P 0.05 for all). They spent more on feminine hygiene products ($32.0 vs $21.6/month) and reported losing nearly a full day of work/month (mean 7.6 hours) due to UFs. Women with moderate/severe UFs also scored lower on all QoL domains, compared to those with mild UF symptoms. Survey responses consistent with moderate/severe UFs were also identified in women who made no report of physician-diagnosed UFs, some of whom may be experiencing substantial burden due to undiagnosed UFs or other gynecologic conditions with related symptoms.All outcomes recorded in this online survey were based on self-report. Therefore, respondents' claims of medical diagnoses, including medical history, UF status and the presence or absence of potentially confounding comorbidities, could not be confirmed clinically.Women experienced significant healthcare utilization, medication use, and financial and QoL burdens as a result of moderate/severe UF symptoms. Prevalence of moderate/severe UFs may be conservatively estimated at 2%, based on this cohort of reproductive-age Canadian women. The extent of UF underdiagnosis in the general population remains to be elucidated.

BACKGROUND: Decidualization of endometrial stromal cells is essential for successful implantation and pregnancy. Prostaglandins (PG) have been shown to be required for the initiation and maintenance of decidualization in animal models. The transport of PG across the plasma membrane is mediated by carriers such as prostaglandin transporter (PGT). Our recent data have shown the expression of human PGT (hPGT) in the endometrium during the menstrual cycle. The objective of the present study was to characterize hPGT in decidualized stromal cells. METHODS AND RESULTS: Human endometrial stromal cells were treated with a combination of cAMP and medroxyprogesterone acetate to induce decidualization. Decidualization was confirmed by morphological differentiation and increased secretion of prolactin. A large increase in hPGT mRNA level, as measured by real-time PCR analysis, was observed in decidual cells compared with control. Similarly, a 2-fold up-regulation of hPGT and 3-12-fold increase in PG biosynthetic enzymes were obtained at the protein level. Decidual cells exhibited a higher isotopic PGE 2 uptake and greater intracellular PG levels than control. CONCLUSIONS: The higher uptake of PG by decidual cells is highly likely to be mediated via hPGT. PGT is a newly identified regulator of PG action at the cellular level and likely contributes to the regulation of PG action in female reproductive processes.

Prostaglandins (PGs) are important regulators of reproductive function. The mechanism by which PGs are transported across the biological membrane is a new emerging field of investigation. Prostaglandin transporter (PGT) has been identified as a functional PG carrier. The aim of our study was to outline the expression of PGT in the human endometrium across the menstrual cycle. Quantitative RT-PCR showed human PGT (hPGT) expression to be strong in the proliferative and early secretory phases and low in the middle to late secretory phase. Northern blot analysis revealed hPGT mRNA transcript of 4 kb in the human endometrium. A peptide-directed polyclonal antibody was generated in rabbits against the 22 amino acids forming the C terminus of hPGT. Antibody specificity was demonstrated by Western blot. Immunoblots of endogenous hPGT in the human endometrium revealed a 70-kDa protein in endometrial cells. Endometrial biopsies collected across the menstrual cycle were used to assess hPGT protein expression by immunohistochemistry. hPGT was immunolocalized to luminal, glandular epithelial, and stromal cells. Because it was observed at the mRNA level, semiquantitative analysis showed a higher protein expression in proliferative and early secretory phases than in the mid-late secretory phase. In conclusion, our study revealed that hPGT expression is modulated in epithelial and stromal cells of the human endometrium at both mRNA and protein levels during the menstrual cycle. These findings support a role for hPGT as an important new player in the regulation of PG action in the human endometrium.

BACKGROUND: Inflammatory mediators such as prostaglandins (PG), chemokines, cytokines and their interactions regulate reproductive functions. The relationship between PG and monocyte chemoattractant protein-1 (MCP-1) has not been elucidated in human endometrium. The presence of hCG receptors in the human endometrium suggests that this embryonic signal may exert a local function in this tissue. Our objectives were to investigate the possible association between PG and MCP-1 and to examine the role of hCG in interleukin-1b (IL-1b)-regulated PG and MCP-1 production in human endometrium. METHODS: Primary cell cultures isolated from endometrial biopsies were used as an in vitro model. PG and MCP-1 levels were measured in the culture medium. RESULTS: IL-1b stimulates the production of both PG and MCP-1. Neither COX inhibitors nor direct addition of PG affects MCP-1 production. By contrast, MCP-1 is able to induce PGE2 and PGF2a in a concentration-dependent manner but it does not appear to contribute to the increase in PG accumulation following IL-1b stimulation. hCG inhibits IL-1b-induced PG level. However, hCG has no effect on either basal or IL-1b-mediated MCP-1 level. CONCLUSIONS: PG are not involved in the regulation of MCP-1 production in endometrial cells. hCG appears to play a local function in the endometrium.

We examined abdominal sc and visceral adipose tissue metabolism in a sample of 19 regularly cycling premenopausal women (age 46.3 +/- 3.7 yr) and 10 women with natural menopause or pharmacological ovarian suppression (age 51.1 +/- 9.2 yr). Subcutaneous and visceral (omental, epiploic) adipose tissue biopsies were obtained during abdominal hysterectomies. Body composition and adipose tissue distribution were measured before the surgery by dual x-ray absorptiometry and computed tomography, respectively. Ovarian hormone-deficient women tended to be older (P = 0.08) and were characterized by increased visceral adipose tissue area (P < 0.05). Subcutaneous adipocyte size, lipoprotein lipase (LPL) activity, and basal lipolysis were not significantly different between groups. On the other hand, omental fat cell size was significantly higher in ovarian hormone-deficient women, compared with premenopausal women (P < 0.05). The omental/sc LPL activity ratio and omental adipocyte basal lipolysis were also significantly higher in ovarian hormone-deficient women (P < 0.05 for both comparisons). Significant positive correlations were found between visceral adipose tissue area and omental LPL activity (r = 0.54, P < 0.003), omental adipocyte basal lipolysis (r = 0.66, P < 0.0001), and omental fat cell size (r = 0.81, P < 0.0001). In multivariate analyses, ovarian status was no longer a significant predictor of adipose cell metabolism variables after visceral adipose tissue area was entered into the model, with the exception of the omental/sc LPL activity ratio, which remained independently associated with ovarian status. In conclusion, although the size of the visceral adipose tissue compartment was an important determinant of adipocyte metabolism in this depot, the increased omental/sc LPL activity ratio in ovarian hormone-deficient women supports the notion of a predominant visceral fat storage in these women.

Study Objective To assess and compare intraoperative and postoperative pain associated with NovaSure impedance-controlled endometrial ablation system and ThermaChoice system. Design Prospective, international, multicenter, double-arm study (Canadian Task Force classification II-1). Setting Academic medical centers and private offices. Patients Sixty-seven premenopausal women with menorrhagia. Intervention Endometrial ablation with either the NovaSure (37 women) or ThermaChoice (30) system. NovaSure-treated patients received no endometrial pretreatment; those treated with ThermaChoice received the recommended 3-minute suction dilatation and curettage. Measurements and Main Results Standard pain measurement instruments (visual analog scale, numeric rating scale) were used to assess intraoperative and postoperative pain. Serum levels of prostaglandin-F 2α were measured before and 5, 30, and 60 minutes after the procedure. Patients treated with the NovaSure system reported statistically significantly lower intraoperative and postoperative pain than those treated with the ThermaChoice system (p 2α values did not differ statistically between groups. Conclusion The NovaSure system is associated with statistically significantly lower intraoperative and postoperative pain than ThermaChoice system, and endometrial ablation with NovaSure could become an office-based procedure.

Objectives The aim of this guideline is to provide clinicians with an understanding of the pathophysiology, prevalence, and clinical significance of myomata and the best evidence available on treatment modalities. Options The areas of clinical practice considered in formulating this guideline were assessment, medical treatments, conservative treatments of myolysis, selective uterine artery occlusion, and surgical alternatives including myomectomy and hysterectomy. The risk-to-benefit ratio must be examined individually by the woman and her health care provider. Outcomes Implementation of this guideline should optimize the decision-making process of women and their health care providers in proceeding with further investigation or therapy for uterine leiomyomas, having considered the disease process and available treatment options, and reviewed the risks and anticipated benefits. Evidence Published literature was retrieved through searches of PubMed, CINAHL, and Cochrane Systematic Reviews in February 2013, using appropriate controlled vocabulary (uterine fibroids, myoma, leiomyoma, myomectomy, myolysis, heavy menstrual bleeding, and menorrhagia) and key words (myoma, leiomyoma, fibroid, myomectomy, uterine artery embolization, hysterectomy, heavy menstrual bleeding, menorrhagia). The reference lists of articles identified were also searched for other relevant publications. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date limits but results were limited to English or French language materials. Searches were updated on a regular basis and incorporated in the guideline to January 2014. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, and national and international medical specialty societies. Benefits, Harms, and Costs The majority of fibroids are asymptomatic and require no intervention or further investigations. For symptomatic fibroids such as those causing menstrual abnormalities (e.g. heavy, irregular, and prolonged uterine bleeding), iron defficiency anemia, or bulk symptoms (e.g., pelvic pressure/pain, obstructive symptoms), hysterectomy is a definitive solution. However, it is not the preferred solution for women who wish to preserve fertility and/or their uterus. The selected treatment should be directed towards an improvement in symptomatology and quality of life. The cost of the therapy to the health care system and to women with fibroids must be interpreted in the context of the cost of untreated disease conditions and the cost of ongoing or repeat investigative or treatment modalities. Values The quality of evidence in this document was rated using the criteria described in the Report of the Caadian Task Force on Preventive Health Care (Table 1). Summary Statements 1.Uterine fibroids are common, appearing in 70% of women by age 50; the 20% to 50% that are symptomatic have considerable social and economic impact in Canada. (II-3) 2.The presence of uterine fibroids can lead to a variety of clinical challenges. (III) 3.Concern about possible complications related to fibroids in pregnancy is not an indication for myomectomy except in women who have had a previous pregnancy with complications related to these fibroids. (III) 4.Women who have fibroids detected in pregnancy may require additional maternal and fetal surveillance. (II-2) 5.Effective medical treatments for women with abnormal uterine bleeding associated with uterine fibroids include the levonorgestrel intrauterine system, (I) gonadotropin-releasing hormone analogues, (I) selective progesterone receptor modulators, (I) oral contraceptives, (II-2) progestins, (II-2) and danazol. (II-2) 6.Effective medical treatments for women with bulk symptoms associated with fibroids include selective progesterone receptor modulators and gonadotropin-releasing hormone analogues. (I) 7.Hysterectomy is the most effective treatment for symptomatic uterine fibroids. (III) 8.Myomectomy is an option for women who wish to preserve their uterus or enhance fertility, but carries the potential for further intervention. (II-2) 9.Of the conservative interventional treatments currently available, uterine artery embolization has the longest track record and has been shown to be effective in properly selected patients. (II-3) 10.Newer focused energy delivery methods are promising but lack long-term data. (III) Recommendations 1.Women with asymptomatic fibroids should be reassured that there is no evidence to substantiate major concern about malignancy and that hysterectomy is not indicated. (III-D) 2.Treatment of women with uterine leiomyomas must be individualized based on symptomatology, size and location of fibroids, age, need and desire of the patient to preserve fertility or the uterus, the availability of therapy, and the experience of the therapist. (III-B) 3.In women who do not wish to preserve fertility and/or their uterus and who have been counselled regarding the alternatives and risks, hysterectomy by the least invasive approach possible may be offered as the definitive treatment for symptomatic uterine fibroids and is associated with a high level of satisfaction. (II-2A) 4.Hysteroscopic myomectomy should be considered first-line conservative surgical therapy for the management of symptomatic intracavitary fibroids. (II-3A) 5.Surgical planning for myomectomy should be based on mapping the location, size, and number of fibroids with the help of appropriate imaging. (III-A) 6.When morcellation is necessary to remove the specimen, the patient should be informed about possible risks and complications, including the fact that in rare cases fibroid(s) may contain unexpected malignancy and that laparoscopic power morcellation may spread the cancer, potentially worsening their prognosis. (III-B) 7.Anemia should be corrected prior to proceeding with elective surgery. (II-2A) Selective progesterone receptor modulators and gonadotropin-releasing hormone analogues are effective at correcting anemia and should be considered preoperatively in anemic patients. (I-A) 8.Use of vasopressin, bupivacaine and epinephrine, misoprostol, peri-cervical tourniquet, or gelatin-thrombin matrix reduce blood loss at myomectomy and should be considered. (I-A) 9.Uterine artery occlusion by embolization or surgical methods may be offered to selected women with symptomatic uterine fibroids who wish to preserve their uterus. Women choosing uterine artery occlusion for the treatment of fibroids should be counselled regarding possible risks, including the likelihood that fecundity and pregnancy may be impacted. (II-3A) 10.In women who present with acute uterine bleeding associated with uterine fibroids, conservative management with estrogens, selective progesterone receptor modulators, antifibrinolytics, Foley catheter tamponade, and/or operative hysteroscopic intervention may be considered, but hysterectomy may become necessary in some cases. In centres where available, intervention by uterine artery embolization may be considered. (III-B)

Study Objective To compare the safety and effectiveness of the NovaSure impedance-controlled endometrial ablation system with hysteroscopic wire loop resection plus rollerball ablation for treatment of excessive uterine bleeding in premenopausal women. Design Randomized, multicenter, double-arm study (Canadian Task Force classification I). Setting Nine academic medical centers and private offices. Patients Two hundred sixty-five premenopausal women with symptomatic menorrhagia. Intervention Ablation performed with the NovaSure system or wire loop resection and rollerball. Measurements and Main Results Success [pictorial blood loss-assessment chart (PBLAC) score ≤75] was achieved in 88.3% of NovaSure-treated and 81.7% of rollerball-treated patients. One year after treatment 90.9% and 87.8%, respectively, reported normal bleeding or less (PBLAC ≤100) and 41% and 35%, respectively, experienced amenorrhea (PBLAC = 0). Mean procedure time was 4.2 minutes (average 84 sec) in the NovaSure group and 24.2 minutes in the rollerball group. Local and/or intravenous sedation was administered in 73% of NovaSure patients and 18% of rollerball patients. Intraoperative adverse events occurred less frequently with NovaSure (0.6%) than with rollerball (6.7%). Postoperative adverse events occurred in 13% and 25.3% of patients, respectively. Conclusion The NovaSure system was safe and effective in treatment of women with menorrhagia. The procedure is both quick and effective, and eliminates the expense and side effects of endometrial pretreatment.

Is hysterosalpingosonography (sono-HSG) an accurate test for diagnosing tubal occlusion in subfertile women and how does it perform compared with hysterosalpingography (HSG)?sono-HSG is an accurate test for diagnosing tubal occlusion and performs similarly to HSG.sono-HSG and HSG are both short, well-tolerated outpatient procedures. However, sono-HSG has the advantage over HSG of obviating ionizing radiation and the risk of iodine allergy, being associated with a greater sensitivity and specificity in detecting anomalies of the uterine cavity and permitting concomitant visualization of the ovaries and myometrium.A systematic review and meta-analysis of studies published in any language before 14 November 2012 were performed. All studies assessing the accuracy of sono-HSG for diagnosing tubal occlusion in a subfertile female population were considered.We searched Medline, Embase, Cochrane Library, Web of Science and Biosis as well as related articles, citations and reference lists. Diagnostic studies were eligible if they compared sono-HSG (±HSG) to laparoscopy with chromotubation in women suffering from subfertility. Two authors independently screened for eligibility, extracted data and assessed the quality of included studies. Risk of bias and applicability concerns were investigated according to the Quality Assessment of Diagnostic Accuracy Study (QUADAS-2). Bivariate random-effects models were used to estimate pooled sensitivity and specificity with their 95% confidence intervals (95% CIs), to generate summary receiver operating characteristic curves and to evaluate sources of heterogeneity.Of the 4221 citations identified, 30 studies were eligible. Of the latter, 28 reported results per individual tube and were included in the meta-analysis, representing a total of 1551 women and 2740 tubes. In nine studies, all participants underwent HSG in addition to sono-HSG and laparoscopy, allowing direct comparison of the accuracy of sono-HSG and HSG. Pooled estimates of sensitivity and specificity of sono-HSG were 0.92 (95% CI: 0.82-0.96) and 0.95 (95% CI: 0.90-0.97), respectively. In nine studies (582 women, 1055 tubes), sono-HSG and HSG were both compared with laparoscopy, giving pooled estimates of sensitivity and specificity of 0.95 (95% CI: 0.78-0.99) and 0.93 (95% CI: 0.89-0.96) for sono-HSG, and 0.94 (95% CI: 0.74-0.99) and 0.92 (95% CI: 0.87-0.95) for HSG, respectively. Doppler sonography was associated with significantly greater sensitivity and specificity of sono-HSG compared with its non-use (0.93 and 0.95 versus 0.86 and 0.89, respectively, P = 0.0497). Sensitivity analysis regarding methodological quality of studies was consistent with these findings. We also found no benefit of the commercially available contrast media over saline solution in regard to the diagnostic accuracy of sono-HSG.Methodological quality varied greatly between studies. However, sensitivity analysis, taking methodological quality of studies into account, did not modify the results. This systematic review did not allow the distinction between distal and proximal occlusion. This could be interesting to take into account in further studies, as the performance of the test may differ for each localization.Given our findings and the known benefits of sono-HSG over HSG in the context of subfertility, sono-HSG should replace HSG in the initial workup of subfertile couples.This study was funded by personal funds. There are no conflicts of interest to declare.This review has been registered at PROSPERO: Registration number #CRD42013003829.

Assess the evolution of the technicity index for hysterectomies in Québec.We used the ADAM ( Analyse en direct des actes médicaux) database to determine the number of hysterectomies done each year within 79 hospitals in Québec from 2002 to 2009. Excluding oncologically indicated surgeries, we calculated the number of hysteretomies and the proportion performed by the vaginal route (laparoscopically assisted or not), by laparoscopu, and by laparotomy for each study year.We obtained complete data fo 67 (85%) of 79 hospitals, for a total of 74 210 (94%) of 79 305 hysterectomies done. We observed a decline in the total number of hysterestomies from 12 860 in 2002-2003 to 8010 in 2008-2009 (P0.001) Furthermore, the proportion of hysterectomies done by laparoscopy increased, the proportion of vaginal hysterectomies remained stable, and the proportion of hysterectomies done by laparoscopy increased. For all of Québec, the technicity index increased from 39.9% in 2002-2003 to 44.3% in 2008-2009 (P0.001).The number of hysterectomies is declining and the technicity index is increasing in Quebec. We believe that this can be attributed to an increased use of medical alternatives and the presence of gynaecologists better trained in advanced laparoscopic surgery.

A 46-year-old woman had an unusual complication from uterine myoma embolization by development of extensive necrosis with subsequent uterine perforation at the location of a previous myomectomy. We suggest that a scarred uterus may be a risk factor for uterine fibroid embolization complications, such as uterine necrosis.

Despite national guidelines recommending that most hysterectomies should be performed vaginally or with laparoscopic assistance, the majority are still performed by laparotomy. Advocating for minimally invasive hysterectomy requires a strategy outlining the benefits and risks of the various approaches. We propose the use of "technicity," an index that has been used in France to compare the performance of hospitals across the country. Technicity is defined by the number of hysterectomies performed vaginally and laparoscopically divided by the total number of hysterectomies performed annually in a single department. We have developed a scoring system to demonstrate the advantages of less invasive surgical approaches, thereby supporting the concept of technicity and its relevance to practice. Using technicity, gynaecologists throughout Canada can monitor their shift towards minimally invasive procedures for hysterectomy, for the benefit of patients and society.

Adipose tissue glucocorticoid action relies on local enzymatic interconversion and glucocorticoid receptor (GR) availability. 11β-Hydroxysteroid dehydrogenase type 1 (11β-HSD1), 2 (11β-HSD2) and hexose-6-phosphate dehydrogenase (H6PDH) are likely involved in glucocorticoid activation/inactivation within adipose tissue. We examined adipose tissue mRNA expression of genes related to glucocorticoid action and their association with total and visceral adiposity. Messenger RNA was measured in paired subcutaneous and omental fat samples obtained from 56 women (age: 47.3 ± 4.8 years, BMI: 27.1 ± 5.2 kg/m(2)) undergoing gynaecological surgery. Expression levels of 11β-HSD2, H6PDH and GRα were higher in omental adipose tissue while 11β-HSD1 expression was similar between fat compartments. Subcutaneous and omental 11β-HSD1 mRNA abundances were positively associated with total and visceral adiposity whereas omental H6PDH mRNA abundance was negatively associated with these measures. Only omental 11β-HSD1 mRNA expression remained significantly associated with visceral adipose tissue area following statistical adjustment for fat mass, age and menopausal status. Omental 11β-HSD1 mRNA expression explained 19.1% of the variance in visceral adipose tissue area. Omental fat tissue 11β-HSD-1 protein and cortisol levels were higher in visceral obese women, supporting findings obtained with 11β-HSD-1 mRNA. These results suggest that among the transcripts examined only omental 11β-HSD1 is independently associated with visceral obesity in women.

Objective This study aimed to evaluate the impact of anesthesia on the absorption of glycine in operative hysteroscopy. Study Design A retrospective cohort study was performed over 2 years. The absorption of glycine was compared among general anesthesia, local anesthesia with intravenous sedation, and spinal anesthesia. Multiple logistic regression analyses were performed. Results In all, 282 operative hysteroscopies were reviewed. The median absorption was 145 mL (10th-90th centile: 0-963 mL) for general anesthesia, 35 mL (10th-90th centile: 0-389 mL) for local anesthesia, and 100 mL (10th-90th centile: 0-500 mL) for spinal anesthesia ( P = .002). In comparison with general anesthesia, local anesthesia was associated with lower rate of absorption of 500-1000 mL (4.2% vs 13.4%) and of 1000-1500 mL (3.6% vs 9.8; P = .002). Laparoscopic tubal ligation performed during the procedure was also associated with higher glycine absorption (odds ratio, 3.63; 95% confidence interval, 1.12-11.84). Conclusions Local anesthesia with sedation is associated with significantly decreased glycine absorption and lower rate of absorption > 500 mL when compared with general anesthesia.

Background The optimal intraperitoneal pressure during laparoscopy is not known. Recent literature found benefits of using lower pressures, but the safety of doing abdominal surgery with low peritoneal pressures needs to be assessed. This systematic review compares low with standard pneumoperitoneum during gynecologic laparoscopy. Database We searched Medline, Embase, and the Cochrane Library for randomized controlled trials comparing intraperitoneal pressures during gynecologic laparoscopy. Two authors reviewed references and extracted data from included trials. Risk ratios, mean differences, and standard mean differences were calculated and pooled using RevMan5. Of 2251 studies identified, three were included in the systematic review, for a total of 238 patients. We found a statistically significant but modest diminution in postoperative pain of 0.38 standardized unit based on an original 10-point scale (95% confidence interval [CI], -0.67 to -0.08) during the immediate postoperative period when using low intraperitoneal pressure of 8 mm Hg compared with ≥ 12 mm Hg and of 0.50 (95% CI, -0.80 to -0.21) 24 hours after the surgery. Lower pressures were associated with worse visualization of the surgical field (risk ratio, 10.31; 95% CI, 1.29-82.38). We found no difference between groups over blood loss, duration of surgery, hospital length of stay, or the need for increased pressure. Conclusion Low intraperitoneal pressures during gynecologic laparoscopy cannot be recommended on the behalf of this review because improvement in pain scores is minimal and visualization of the surgical field is affected. The safety of this intervention as well as cost-effectiveness considerations need to be further studied.

Objective To provide clinical direction, based on the best evidence available, on laparoscopic entry techniques and technologies and their associated complications. Options The laparoscopic entry techniques and technologies reviewed in formulating this guideline include the classic pneumoperitoneum (Veress/trocar), the open (Hasson), the direct trocar insertion, the use of disposable shielded trocars, radially expanding trocars, and visual entry systems. Outcomes Implementation of this guideline should optimize the decision-making process in choosing a particular technique to enter the abdomen during laparoscopy. Evidence English-language articles from Medline, PubMed, and the Cochrane Database published before the end of September 2005 were searched, using the key words laparoscopic entry, laparoscopy access, pneumoperitoneum, Veress needle, open (Hasson), direct trocar, visual entry, shielded trocars, radially expanded trocars, and laparoscopic complications. Values The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on the Periodic Health Examination. Recommendations and Summary Statement 1.Left upper quadrant (LUQ, Palmer's) laparoscopic entry should be considered in patients with suspected or known periumbilical adhesions or history or presence of umbilical hernia, or after three failed insufflation attempts at the umbilicus (II-2 A). Other sites of insertion, such as transuterine Veress CO 2 insufflation, may be considered if the umbilical and LUQ insertions have failed or have been considered and are not an option (I-A). 2.The various Veress needle safety tests or checks provide very little useful information on the placement of the Veress needle. It is therefore not necessary to perform various safety checks on inserting the Veress needle; however, waggling of the Veress needle from side to side must be avoided, as this can enlarge a 1.6 mm puncture injury to an injury of up to 1 cm in viscera or blood vessels (II-1 A). 3.The Veress intraperitoneal (VIP-pressure ->10 mm Hg) is a reliable indicator of correct intraperitoneal placement of the Veress needle; therefore, it is appropriate to attach the CO 2 source to the Veress needle on entry (II-1 A). 4.Elevation of the anterior abdominal wall at the time of Veress or primary trocar insertion is not routinely recommended, as it does not avoid visceral or vessel injury (II-2 B). 5.The angle of the Veress needle insertion should vary according to the BMI of the patient, from 45° in non-obese women to 90° in obese women (II-2 B). 6.The volume of CO 2 inserted with the Veress needle should depend on the intra-abdominal pressure. Adequate pneumoperitoneum should be determined by a pressure of 20 to 30 mm Hg and not by predetermined CO 2 volume (II-1 A). 7.In the Veress needle method of entry, the abdominal pressure may be increased immediately prior to insertion of the first trocar. The high intraperitoneal (HIP-pressure) laparoscopic entry technique does not adversely affect cardiopulmonary function in healthy women (II-1 A). 8.The open entry technique may be utilized as an alternative to the Veress needle technique, although the majority of gynaecologists prefer the Veress entry. There is no evidence that the open entry technique is superior to or inferior to the other entry techniques currently available (II-2 C). 9.Direct insertion of the trocar without prior pneumoperitoneum may be considered as a safe alternative to Veress needle technique (II-2). 10.Direct insertion of the trocar is associated with less insufflation-related complications such as gas embolism, and it is a faster technique than the Veress needle technique (I). 11.Shielded trocars may be used in an effort to decrease entry injuries. There is no evidence that they result in fewer visceral and vascular injuries during laparoscopic access (II-B). 12.Radially expanding trocars are not recommended as being superior to the traditional trocars. They do have blunt tips that may provide some protection from injuries, but the force required for entry is significantly greater than with disposable trocars (I-A). 13.The visual entry cannula system may represent an advantage over traditional trocars, as it allows a clear optical entry, but this advantage has not been fully explored. The visual entry cannula trocars have the advantage of minimizing the size of the entry wound and reducing the force necessary for insertion. Visual entry trocars are non-superior to other trocars since they do not avoid visceral and vascular injury (2 B).

We examined the expression and activity of two enzymes from the aldoketoreductase (AKR) family 1C, namely type 5 17β-hydroxysteroid dehydrogenase (17β-HSD-5, AKR1C3) and type 3 3α-hydroxysteroid dehydrogenase (3α-HSD-3, AKR1C2) in female sc and omental adipose tissue and in preadipocyte primary cultures. 17β-HSD-5 preferentially synthesizes testosterone from the inactive adrenal precursor androstenedione, whereas 3α-HSD-3 inactivates dihydrotestosterone. mRNAs of both enzymes were detected in adipose tissue from the omental and sc compartments. Real-time PCR quantification indicated a 3-fold higher 3α-HSD-3 expression compared with 17β-HSD-5, and the expression of both enzymes tended to be higher in the sc vs. the omental depot. Accordingly, dose-response and time-course experiments performed in preadipocyte primary cultures indicated that 3α-HSD activity was higher than 17β-HSD activity (13-fold maximum velocity difference). We measured 3α-HSD activity in omental and sc adipose tissue samples of 32 women for whom body composition and body fat distribution were evaluated by dual-energy x-ray absorptiometry and CT, respectively. We found that androgen inactivation in omental adipose tissue through 3α-HSD activity was significantly higher in women with elevated vs. low visceral adipose tissue accumulation (1.7-fold difference; P < 0.05). Moreover, omental adipose tissue 3α-HSD activity was positively and significantly associated with CT-measured visceral adipose tissue (r = 0.43; P < 0.02) and omental adipocyte diameter (r = 0.42; P < 0.02). These results indicate that local androgen inactivation is a predominant reaction in female abdominal adipose tissue, with the greatest conversion rates observed in the presence of abdominal visceral obesity. Increased androgen inactivation in omental adipose tissue of abdominally obese women may impact locally on the regulation of adipocyte metabolism.

Operative hysteroscopy requires the use of a distension medium and its absorption can lead to serious consequences from intravascular volume overload and water intoxication. We compared the impact of 2 types of anesthesia (general anesthesia and local anesthesia with sedation) on the absorption of glycine solution in operative hysteroscopy.A randomized controlled trial was conducted over a 17-month period. Eligible patients undergoing operative hysteroscopy for abnormal uterine bleeding were randomized in 2 groups: a general anesthesia group and a local anesthesia with sedation group. The primary outcome was the median absorption of the glycine solution (10th-90th percentile) measured with an automated tandem canister system. Secondary outcomes included incidence of absorption1000 mL, discontinued surgery because of excessive absorption, median change in serum sodium, postoperative hyponatremia, and patients' postoperative quality of life at 24 hours (8-item Short Form Health Survey questionnaire). Nonparametric analyses (Mann-Whitney U test, χ(2) test, and Fisher exact test) were used.Of 142 eligible patients, 95 agreed to participate and were randomized. Women who underwent general anesthesia had a higher median absorption of the glycine solution (10th-90th percentile) compared with women who underwent local anesthesia with sedation (480 mL [76-1300 mL] vs 253 mL [70-728 mL]; P = 0.005). General anesthesia was also associated with a higher rate of glycine solution absorption (1000 mL [20% vs 4%; P = 0.009]) and a more rapid rate of decrease in serum sodium (≥10 mEq/L [8% vs 0%; P = 0.005]) than local anesthesia with sedation. Postoperative quality of life measures as rated by the patients were comparable between the 2 groups.Compared with general anesthesia, local anesthesia with sedation is associated with less glycine absorption and should be considered the preferred method of anesthesia for operative hysteroscopy.

Background and Objective: Ambulatory total laparoscopic hysterectomy (TLH) could lead to significant cost savings, but some fear the effects of what could be premature postsurgical discharge. We sought to estimate the feasibility and safety of TLH as an outpatient procedure for benign gynecologic conditions. Methods: We report a prospective, consecutive case series of 128 outpatient TLHs performed for benign gynecologic conditions in a tertiary care center. Results: Of the 295 women scheduled for a TLH, 151 (51%) were attempted as an outpatient procedure. A total of 128 women (85%) were actually discharged home the day of their surgery. The most common reasons for admission the same day were urinary retention (19%) and nausea (15%). Indications for hysterectomy were mainly leiomyomas (62%), menorrhagia (24%), and pelvic pain (9%). Endometriosis and adhesions were found in 23% and 25% of the cases, respectively. Mean estimated blood loss was 56 mL and mean uterus weight was 215 g, with the heaviest uterus weighing 841 g. Unplanned consultation and readmission were infrequent, occurring in 3.1% and 0.8% of cases, respectively, in the first 72 hours. At 3 months, unplanned consultation, complication, and readmission had occurred in a similar proportion of inpatient and outpatient TLHs (17.2%, 12.5%, and 4.7% versus 18.1%, 12.7%, and 5.4%, respectively). In a logistic regression model, uterus weight, presence of adhesions or endometriosis, and duration of the operation were not associated with adverse outcomes. Conclusion: Same-day discharge is a feasible and safe option for carefully selected patients who undergo an uncomplicated TLH, even in the presence of leiomyomas, severe adhesions, or endometriosis.

Background During human pregnancy, the placental villi produces high amounts of estradiol. This steroid is secreted by the syncytium, which is directly in contact with maternal blood. Estradiol has to cross placental foetal vessels to reach foetal circulation. The enzyme 17beta-hydroxysteroid dehydrogenase type 2 (17beta-HSD2) was detected in placental endothelial cells of foetal vessels inside the villi. This enzyme catalyzes the conversion of estradiol to estrone, and of testosterone to androstenedione. It was proposed that estradiol level into foetal circulation could be regulated by 17beta-HSD2. Methods We obtained placentas from 10 to 26 6/7 weeks of pregnancy from women undergoing voluntary termination of pregnancy, term placentas were collected after normal spontaneous vaginal deliveries. We quantified 17beta-HSD2 mRNA levels in mid-gestation and term human placenta by RT-QPCR. We produced a new anti-17beta-HSD2 antibody to study its spatio-temporal expression by immunohistochemistry. We also compared steroid levels (testosterone, estrone and estradiol) and 17beta-HSD2 mRNA and protein levels between term placenta and endometrium. Results High 17beta-HSD2 mRNA and protein levels were found in both mid-gestation and term placentas. However, we showed that 17beta-HSD2 mRNA levels increase by 2.27 fold between mid-gestation and term. This period coincides with a transitional phase in the development of the villous vasculature. In mid-gestation placenta, high levels of 17beta-HSD2 were found in mesenchymal villi and immature intermediate villi, more precisely in endothelial cells of the stromal channel. At term, high levels of 17beta-HSD2 were found in the numerous sinusoidal capillaries of terminal villi. 17beta-HSD2 mRNA and protein levels in term placentas were respectively 25.4 fold and 30 to 60 fold higher than in the endometrium. Steroid levels were also significantly higher in term placenta than in the endometrium. Conclusion The spatial and temporal expression of 17beta-HSD2 in the placenta during pregnancy and the comparison of 17beta-HSD2 expression and steroid levels between placental villi and endometrium are compatible with a role in the modulation of active and inactive forms of estrogens. Our observations strongly support the hypothesis that 17beta-HSD2 acts as a barrier decreasing estradiol secretion rates in the foetal circulation.

Background: Hysterosalpingosonography has been suggested as a less invasive alternative to hysterosalpingography for detecting tubal occlusion among subfertile women. We aim to determine the diagnostic accuracy of hysterosalpingosonography and to compare it to hysterosalpingography. Methods/design: We will conduct a systematic review of diagnostic test accuracy. We will search Medline, Embase, Cochrane Library, Web of Science and Biosis, as well as reference lists of included studies and previous related review articles. Diagnostic studies that compared hysterosalpingosonography ± hysterosalpingography to laparoscopy with chromotubation in women suffering from subfertility will be eligible. Two authors will independently screen for inclusion, data extraction, and quality assessment. Methodological quality will be assessed using the Quality Assessment of Diagnostic Accuracy Study 2 tool (QUADAS-2). We will use SAS 9.3 (SAS Institute Inc., Cary, NC, USA, 2011) to program bivariate random-effects models, estimate pooled sensitivity and specificity with 95% confidence intervals and to generate summary receiver operating characteristics curves. We will perform sensitivity analyses to examine the effect of differences in techniques used for hysterosalpingosonography and in methodological quality of studies. Discussion: This systematic review will help to determine if hysterosalpingosonography is an adequate alternative screening test for diagnosing tubal occlusion. Accuracy of specific sono-HSG techniques may also be identified. Trial registration: This review has been registered at PROSPERO. The registration number is CRD42013003829.