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This review article is attempted to review the cases of 5-mm trocar site hernias (TSHs) after laparoscopic surgery and identify the risks associated with incarceration. We searched the English literature on the PubMed website using the key words “trocar site hernia” and “5 mm”. We evaluated a total of 24 cases of 5-mm TSHs and analyzed and results showed that 17 (71%) and 7 (29%) resulted from gynecologic and gastrointestinal surgeries, respectively. The majority were found at the lateral abdomen (87.5%) and recognized within 2 weeks (87.5%). The most frequently herniated organ (n = 14) was the small bowel. Up to 62.5% of cases (n = 15) were repaired by exploratory laparotomy, and 25% (n = 6) required resection of herniated organs secondary to incarceration. The cases with incarceration were detected at 4.3 ± 2.2 days post-operation and those without incarceration at 47.4 days post-operation. No risk factors could be identified to show a correlation between 5-mm TSHs and incarceration. We concluded that immediate 1--2-week postoperative care is of most importance, since the majority of 5-mm trocar site hernias with or without incarceration occurred within this period.

Peripheral primitive neuroectodermal tumors (pPNETs) of the ovary are rare monophasic teratomas, and fewer than 100 cases have been reported in the literature. pPNETs mainly involve young women during their reproductive age, therefore, accurate diagnosis followed by multimodal treatment should be taken into consideration for fertility preservation. We report a patient with stage IA pPNET of the ovary presenting with acute abdominal pain secondary to torsion that was successfully managed by fertility-sparing surgery and six courses of combination chemotherapy with vincristine, Adriamycin, and cyclophosphamide. She has had a disease-free survival of >3 years. This brief review demonstrates the clinical course of pPNET and summarizes the literature to show that clinical stage at the time of diagnosis is the most important prognostic factor and that the vast majority of recurrences are observed within 10 years.

Objective: To assess the factors associated with future pregnancy and successful delivery in women who were treated for uterine adenomyoma with combination (surgical–medical) therapy using ultramini- or mini-laparotomy conservative surgery and gonadotropin-releasing hormone agonist. Materials and Methods: One hundred and two women were evaluated. Items for analysis included: age, body mass index, and conception history; clinical symptoms of dysmenorrhea and menorrhagia; tumor location and preoperative serum level of cancer antigen 125 (CA125); the intraoperative findings of the weight of the removed tumor, and the uterine cavity opening. Results: After excluding those patients using contraception or searching for an assisted reproductive technique, a total of 56 women were enrolled for analysis. Twenty-three (41.1%) women had 27 clinical pregnancies after 3 years of follow-up; 15 went on to deliver a healthy live-born child; two delivered preterm but healthy babies; seven had elective abortions; four had spontaneous abortions; and one had an ectopic pregnancy. The women who had a successful delivery during the 3-year follow-up after treatment tended to be younger, with a lower body mass index, lower baseline analgesic usage score, and lower preoperative serum level of CA125, be nulliparous, and with an adenoma in an anterior location. The linear regression model showed that age and baseline analgesic usage score were independent predictors of successful delivery and accounted for 56.5% of the total variance related to successful delivery. Conclusion: Age was an important factor associated with future successful delivery, therefore, caution should be taken in considering the maintenance of future fertility in older women treated with surgical–medical therapy.

Objective: Cervicovaginitis is a highly prevalent disease that is a burden on healthcare globally. Immediate and adequate treatment can eradicate the infection and block subsequent complications. The feasibility of achip-based multiplexed immunoassay using liposomal nanovesicles was tested. Materials and Methods: A multiplexed immunoassay chip containing five antibodies for five pathogens (Chlamydia trachomatis, Escherichia coli, Neisseria gonorrhoeae, Streptococcus agalactiae, and Candida albicans) was established and tested. Four patients with spiking of candidiasis were enrolled. The difference between positive and negative readings was evaluated using the paired Student t test. Results: The detection threshold of Candida in this microarray was 100,000 CFU/mL in a vaginal sample, and the time required for the whole procedure was 3 hours. The testing of the four patients showed 100% for both sensitivity and specificity. Conclusion: This microarray chip was a rapid, easy, inexpensive and sensitive tool for detecting female lower genital tract Candida infection in a one-time vaginal sampling process, although the data on the four other pathogens were still unavailable. A larger population study is encouraged to test the validity of this multiplexed immunoassay chip.

Sexual dysfunction refers to difficulties that occur during the sexual response cycle that prevent the individual from experiencing satisfaction from sexual activity. It is relatively difficult to estimate the prevalence of female sexual dysfunction (FSD), because the definition and diagnostic criteria are still controversial and under development. These difficulties reveal our insufficient understanding of the basis of FSD. This review was conducted in an effort to deal with this complicated clinical issue, by examining the most updated clinical criteria of FSD under the context of a redefined female sexual response model.

Menopause is a biological and natural process that occurs as part of aging in women and is secondary to ovarian failure with resultant estrogen deficiency; therefore, menopause should not be considered as a disease. However, there is no doubt that estrogen deficiency induces general psychological and physical changes, and that postmenopausal women will experience many health-related issues and problems, including osteoporotic fractures, coronary heart disease (CHD), and most importantly for the quality of life (QOL) and vasomotor symptoms (VMS) such as hot flashes and night sweats. Hormone therapy (HT) is very effective in the management of postmenopausal women with symptoms. With the large number of patients being treated with HT, especially the combination of estrogen and progestin therapy (EPT) in the Women's Health Initiative (WHI) study, clinicians now recognize the potential adverse effects of EPT. Although this concept is much clearer now, some women might still benefit from short-term HT, especially for young postmenopausal women. In this review, some health issues of postmenopausal women, especially alternative therapies are discussed.

An important role of genetic factors in the development of breast cancer (BC) or ovarian cancer (OC) in Taiwanese (ethnic Chinese) patients has been suggested. However, other than germline BRCA1 or BRCA2 mutations, which are related to hereditary breast-ovarian cancer (HBOC), cancer-predisposition genes have not been well studied in this population. The aim of the present study was to more accurately summarize the prevalence of genetic mutations in HBOC patients using various gene panels ranging in size from BRCA1/2 alone to multi-gene panels. Among 272 HBOC patients analyzed, the prevalence of BRCA1, BRCA2 and non-BRCA1/2 pathogenic mutations was 7.7% (21/272), 6.8% (16/236) and 8.2% (13/159), respectively. The total mutation rate was 18.4% (50/272). Although no founder mutations were identified in this study, two recurrent mutations, BRCA1 (c.3607C>T) and BRCA2 (c.5164_5165 delAG), were found. The main pathogenic/likely pathogenic mutations in non-BRCA1/2 genes included ATM, BRIP1, FANCI, MSH2, MUYTH, RAD50, RAD51C and TP53. The prevalence rate of gene mutations in HBOC patients did not differ with respect to whether BC or OC was the first diagnosis or they presented a family history of the disease or their age at diagnosis. HBOC patients with both BC and OC exhibited a higher prevalence rate of mutations (50.0%) than patients with OC (25.0%) or BC (8.6%) alone. In conclusion, evaluation of hereditary cancer risk in Taiwan HBOC patients, particularly individuals with double cancer, is strongly encouraged. Panel testing can yield additional genomic information, and widespread and well-designed panel testing will help in assessing more accurate mutational prevalence of risk genes.

The relationship between hormones and endometrial cancer is well known because disease states, such as chronic anovulation and endogenous estrogen production from hormone-secreting tumors (for example, granulosa cell tumor of the ovary), are related to excess estrogen, and unopposed estrogen use might lead to endometrial overgrowth, hyperplasia, and subsequent development of endometrial carcinoma. Therefore, the possibility of using antihormone therapy in endometrial carcinoma and/or its precancer lesions, such as simple hyperplasia with and without atypia and complex hyperplasia with and without atypia, is always supposed, as in the management of breast cancer. In addition, if women in whom endometrial cancer is diagnosed are very young, some critical issues should be considered, including the possibility of ovary preservation-partial preservation of fertility and the possibility of both ovary and uterus preservation-complete preservation of fertility. Other factors are also important to consider and include oncologic risk, appropriateness of candidates for treatment, type of hormone use, response rate of hormonal therapy, appropriate surveillance, and additional counseling for issues such as anxiety about relapse and metastasis, distress about side effects, advice of the family, advice of the medical staff, and economic burden. This review will be focused on updated information and recent knowledge of the use of hormones in the management of younger women with endometrial cancer who want fertility preservation.

Objective: The aim of this study was to evaluate the short-term therapeutic outcome of women with symptomatic uterine myomas treated with laparoscopic uterine vessel occlusion (LUVO) or laparoscopic myomectomy (LM). Methods: Ninety-five patients with symptomatic, uncomplicated myomas warranting surgical treatment who expressed a strong desire to retain their uterus were included in this study. Fifty-two patients underwent LUVO and 43 underwent LM. The outcome was measured by comparing blood loss, surgical time, postoperative recovery, postoperative pain (visual analog scale), complications, and success rate in both groups. Results: The general characteristics of the patients were similar in both groups. There were no statistical differences in febrile morbidity, complications, success rate, therapeutic efficacy (symptom relief), and satisfaction rate between the two groups. LUVO had advantages over LM, including less surgical time, minimal blood loss, lower visual analog scale score, and rapid postoperative recovery. Conclusions: Both LUVO and LM might be effective in the management of symptomatic myomas in selected cases, but LUVO seemed to be more acceptable and less invasive in this 1-year short-term follow-up.

Objective: Clinical experience in the management of post-abortion hemorrhage is limited. Case Reports: Two women with severe post-abortion hemorrhage were reported. One case occurred after methotrexate treatment of Cesarean scar pregnancy and the other occurred after abortion surgery. Both patients were successfully treated with a double-balloon cervical ripening catheter inducing intrauterine balloon tamponade. Conclusion: Use of a double-balloon cervical ripening catheter either before or after systemic methotrexate treatment is one of the choices in the management of severe post-abortion hemorrhage and can prevent the use of more invasive and/or destructive procedures.

Objective: Cancer cells reportedly have the ability to escape from the immune system, mainly from natural killer (NK) cells. Although the real mechanisms are complicated, some inhibitors that are secreted from the cancer cells might play an important role. This study’s aim was to investigate the potential mediator released by cancer cells (HeLa) that contributes to the decreased cytotoxicity of NK cells. Methods and Materials: An NK-HeLa coculture system was used to test the hypothesis that the presence of the potential mediator from cancer cells contributes to the decreased cytotoxicity of NK cells. Results: After coculturing with HeLa cancer cells, the cytotoxicity of NK cells was decreased. When the coculture medium and culture medium containing commercialized sialidase were used to culture NK cells, the cytotoxicity of the NK cells was also inhibited. However, cytotoxicity was partially restored by a sialidase inhibitor (DANA). Western blot analysis of the HeLa cells after coculturing with NK cells demonstrated increased Neu2 and Neu3 expression in HeLa cells. Conclusions: The finding that Neu2 and Neu3 expression in cancer cells might be involved in the impaired function of NK cells, which could be restored by a sialidase inhibitor, provides a new concept that could be applied to the management of cancer.

Systemic administration of cytotoxic drugs is the primary treatment strategy for patients with advanced cancer. The effect of cytotoxic drugs is to disrupt the DNA of the cells, rendering them unable to replicate and finally killing them; therefore, the fundamental role of a wide range of treatment regimens is typically to induce lethal toxicity in the largest possible number of cancer cells. However, these cytotoxic drugs also damage the normal cells of the host, which limits the dose of the cytotoxic drug. Thus, cancer patients are usually treated at or near the maximum tolerated dose with the implicit intent of eradicating (curing) the tumor after balancing between efficacy in tumor killing and toxicity to the host. With significantly improving patient care, most efforts are focused on the corollary, “The higher the dose, the better.” However, the concept that cancer could be considered as a chronic disease and might be treated like other chronic diseases to achieve a status called tumor dormancy is gaining popularity. In addition, there has been increasing interest in putting more effort into administering cytotoxic drugs on a more continuous basis, with a much shorter break period, or none at all, and generally lower doses of various cytotoxic drugs or combinations with other newer, targeted therapies, like anti-angiogenesis agents. This practice has come to be known as metronomic chemotherapy. There is still much to be learned in this field, especially with regard to optimization of the proper drugs, dose, schedule, and tumor type applications. This review will explore recent studies that have addressed the mechanism of metronomic chemotherapy in the management of various tumors, especially gynecologic cancers.

Objective: To present a prenatal diagnosis of microdeletion 16p13.11 with partial monosomy of 2q37.1-qter and partial trisomy of 7p15.3-pter in a fetus with bilateral ventriculomegaly, agenesis of corpus callosum, and polydactyly. Case Report: A 41-year-old well-being Taiwanese, nulligravida woman received amniocentesis at a gestational age of 18 weeks for advanced maternal age. The fetus' karyotype showed 46,XY,der(2)t(2;7)(q36.2;p15.1). Both parents also received cytogenetic examinations and the mother's karyotype revealed 46,XX,t(2;7)(2q36.2;p15.1). High-resolution ultrasound showed the fetus had bilateral ventriculomegaly, agenesis of corpus callosum, and polydactyly of the right hand. After the termination of this pregnancy, the whole genome oligonucleotide-base array comparative genomic hybridization (CGH) by using fetal skin cells demonstrated a 8.44-Mb deletion at 2q37.1 (234602276-243041305), a 22.8-Mb duplication (65558-22869338) at 7p15.3, and an additional 1.32-Mb deletion (14968855-16292235) at 16p13.11. Conclusion: Array CGH is a useful tool not only to discover the genomic imbalance at the breakpoints as well as to detect unexpectedly complex rearrangements in other chromosomes. Our case also provided evidence that genomic aberration at chromosome 16p13.11 involves in the formation of polydactyly.

Osteoporotic patients with existing fractures are at substantially higher risk of subsequent fractures than those free of fractures. Given the lack of head-to-head comparison trials, indirect comparison of various antiosteoporosis treatments may be an alternative way to develop a preliminary idea. The objective of this study is to conduct a systematic review of antiosteoporosis treatment clinical trials that have investigated on patients with existing fractures. All the results of randomized placebo-controlled trials of the available antiosteoporosis treatments, including bisphosphonates, selective estrogen receptor modulators, calcitonin, strontium ranelate, and agents derived from parathyroid hormone, on patients with existing fractures were summarized. All the antiosteoporotic agents had significant efficacy in increasing lumbar spine bone mineral density and reduction in the occurrence of any new vertebral fractures. All interventions provided gains in quality-adjusted life-years compared with patients without treatment. The results from an indirect comparison must be interpreted with caution due to heterogeneous study design, discrepancies of disease severity at baseline, and differences in analytical methodologies. The devastating complications subsequent to osteoporotic fractures create medical and financial burdens; therefore, treatment of patients with osteoporotic fractures should be positioned in the top priority in the utilization of medical resources.

Objective: Amniocentesis is a popular and effective prenatal diagnostic tool for chromosomal disorders. It is well-established that the risk of chromosomal abnormalities increases with maternal age; however, other related indications are seldom reported. Herein, we report our 30-year experience with amniocentesis from a single medical center, focusing on the indications and rates of abnormality. Material and Methods: A retrospective review of 16,749 pregnant women in the mid-trimester between January 1981 and December 2010 was conducted. The medical records were analyzed. Results: The indications for amniocentesis were advanced maternal age (≥ 34 years old) (n=10,970, 65.5%), increasing-risk maternal triple-marker Down's screening test (≥ 1/270) (n=2090, 12.5%), history of abnormal offspring birth (n=792, 4.7%), abnormal ultrasound findings (n=484, 2.9%), parent with abnormal karyotype (n=252, 1.5%), family history of chromosomal abnormality (n=183, 1.1%), drug and radiation exposure (n=165), abnormal chorionic villus sampling (CVS) results (n=25), intrauterine fetal death (n=50), and other non-specific causes (n=1662, 9.9%). The rate of abnormality for each indication was 16% in the abnormal CVS group, 12% in the intrauterine fetal death group, 11.5% for parental chromosomal abnormality, 8.7% in the abnormal ultrasound finding group, 3.0% in the increasing-risk maternal triple-marker Down's screening test group, 2.5% in the advanced maternal age group, 1.5% for other non-specific causes, 1.4% for history of abnormal offspring birth, and 1.1% for family history of chromosomal abnormality. Conclusions: Both parents with abnormal karyotype and abnormal ultrasound findings are indications for which consideration of further amniocentesis is highly recommended.

Objective: This paper reports the long-term follow-up (62–83 months) of women with unexplained subfertility secondary to severe adenomyosis treated with the combination of conservative surgery and gonadotropin releasing hormone agonist (GnRH agonist) therapy. Materials and Methods: A retrospective study included nine patients with a history of > 3 years of unexplained infertility who had extensive uterine adenomyosis. These nine couples were diagnosed with unexplained infertility after excluding other possible causes, such as the male factor, ovulation disorders, structural abnormality, and infections. All were essentially normal except for presumed uterine adenomyosis and elevated serum levels of CA125. All underwent a careful excision of the adenomyosis tissue using a microsurgical technique, and then a six-month course of GnRH agonist therapy. The outcome evaluations included serum level of CA125, degree of dysmenorrhea, and rate of spontaneous pregnancy. Results: Postoperative follow-up showed that the severity of dysmenorrhea was significantly improved. The improvement scale was positively correlated with a decline in the serum level of CA125. A postoperative serum CA125 decreased to less than 10.00 IU/mL predicted well the spontaneous pregnancy rate, especially during the therapy. In the end, only two women became pregnant and finally delivered viable babies in this study. Conclusions: Although the combination of careful conservative surgery and GnRH agonist therapy might provide some benefits in patients with unexplained infertility and presumed severe adenomyosis, two-thirds of the patients still failed to become pregnant. The postoperative serum level of CA125 could predict the future pregnancy rate.

Objective: Previously, we found that altered sialidases in HeLa cells in a natural killer-HeLa (NK-HeLa) coculture system contributed to the decreased cytotoxic ability of NK cells. However, changes that occur in the glycosylation of the HeLa cells in the NK-HeLa coculture system remain unknown. Materials and Methods: An NK-HeLa coculture system was used to examine the changes that occur in the gangliosides of HeLa cells. Results: GD3 expression in HeLa cells was significantly increased in the NK-HeLa coculture system. Exogenous ganglioside GD3 decreased the cytotoxic ability of the NK cells, which could be restored by the addition of the anti-GD3 antibody. Coadministration of GD3 and sialidase further decreased the cytotoxic ability of the NK cells, which could be partially restored by the addition of a sialidase inhibitor (DANA). GD3 expression in HeLa cells also decreased following DANA treatment. Conclusions: This study suggests that interactions between ganglioside GD3 and sialidases in HeLa cells influence the cytotoxic ability of NK cells.

Uterine fibroids (also called leiomyomas or myomas) are the most common disorder among women of reproductive age, with an incidence of between 20% and 80%; they are often detected incidentally in routine healthy examinations, through bimanual pelvic and/or ultrasound examination, because uterine fibroids are rarely associated with symptoms. Sometimes, uterine fibroids may be complicated by a variety of symptoms, including menstrual disturbance (e.g., menorrhagia, dysmenorrhea, intermenstrual bleeding), pressure symptoms, bloated sensation, increased urinary frequency, bowel disturbance, or pelvic pain; therefore definite treatment is requested. Hysterectomy may be the first choice for women who have completed their child-birth; however, many women may prefer to keep the uterus if the uterine fibroids-related symptoms can be appropriately controlled. Among these conservative therapies, myomectomy may be one of the most popular methods for the woman who would like to preserve her future fertility, as the majority of symptoms can be relieved by myomectomy; this contributes to the value of this review. This review addresses the use of myomectomy in the management of symptomatic uterine fibroids.

Abstract According to the literature review, CO2 insufflation on parasitic myoma implantation is not well studied, and we concur that our study is related to “Morcellation-induced parasitic myomas.” We did not compare CO2 insufflation to non-insufflation in our study. The reason is the efficacy of gasless laparoscopic myomectomy and morcellation is not well established and this modality is seldom performed. Moreover, the effects of pneumoperitoneum on mesothelial cells and the role of the entire peritoneal cavity as a cofactor in adhesion formation have become well established, the role of CO2 insufflation in the establishment of parasitic myomas has not yet been studied. As such, more in-depth and well-designed studies for the role of CO2 insufflation are needed.

Objective: To study the possible non-genomic effect of selective estrogen receptor modulators on human dermal fibroblasts (HDF). Materials and Methods: WS1 cells were used to test the effect of raloxifene. The mRNA expressions of estrogen receptor (ER) α and β and G protein-coupled ER 1(GRP30) were examined by reverse transcription polymerase chain reaction. Apoptosis was identified by TUNEL assay and FACS analysis. MAPK and PI3 K/Akt pathways were determined by immunoblotting analysis. Results: Neither ERα nor ERβ, but GPR30 was detected in WS1 cells. Raloxifene increased apoptosis, which was blocked by pertussis toxin, an inhibitor of G protein, or by LY294002. Phosphorylated p38 MAPK and Akt were also increased after raloxifene treatment. Conclusion: SERMs could induce apoptosis of HDF through G protein and PI3 K/Akt signaling, which may help understand the role of SERMs on the skin.

Objects: Chlamydia (Chlamydia trachomatis) is a common sexually transmitted infection that places a heavy burden on women and neonatal health. To avoid severe sequelae such as female infertility, ectopic pregnancy, neonatal infection, such as ophthalmitis, and chronic pelvic pain prompt and appropriate antibiotic treatment seems the best policy in treating this group of patients. However, adequate treatment is not easy because many factors can interfere with an early and rapid identification of Chlamydia infection, including complicated mixed microflora of the vagina and cervix, a nonuser-friendly detection system, and the time required for identification, even with the combination of specific complaints and a high level of clinical alertness. When dealing with a female patient in a point-of-care (POC) clinic, we need to find the best strategy to provide the most efficient way to detect this infection. Materials and Methods: Totally five traditional methods and advanced technologies used for the diagnosis of Chlamydia infection in women were reviewed. A criterion proposed by World Health Organization with an acronym of ASSURED, representing affordable price, high sensitivity, high specificity, user-friendly design, rapid process, minimal equipment, and delivered-or-not, was used to reexamine these tools if they are the best tools. A multiplexed microchip-based immunoassay was evaluated as a potential tool. The ASSURED score was compared and a Chi-square test with a p value less than 0.05 was considered significant. Results: Traditional methods, such as symptoms approach, microscopic examination, and microorganism culture that have been broadly used once, are affordable, simple, and equipment-free but their relatively low sensitivity and specificity limit their use as a test of POC setting for these infected women. On the other hand, advanced technologies, such as antigen detection by immunoassay and nucleic acid amplification tests, have contributed to major progress in the diagnosis of Chlamydia because of its accuracy, convenience, and time saving. However, nucleic acid amplification tests are too expensive, so they cannot be accepted as a screening tool in a developing country. The only significant finding with p value less than 0.01 was achieved when a more sensitive immunoassay system developed successfully as a test of POC setting. Conclusions: Eventually, advances in laboratory techniques will satisfy our needs to detect Chlamydia infection economically and instantly. Microarray chips might be a relatively rapid, easy, inexpensive, and sensitive tool to detect many pathogens, including Chlamydia, using a one-time vaginal sampling process, which might make a POC policy possible.

Vesicovaginal fistula (VVF) is relatively common after radiotherapy, but the formation of a bladder stone after VVF is still rare. The diagnosis is often delayed, and mortality sometimes occurs with delayed diagnosis and treatment, especially in elderly and disabled women. To increase knowledge of this unusual condition—vesical stone associated with VVF—we present a case report, and summarize the published cases to review this topic, focusing on the etiology, symptoms and signs, and recent management strategy. Finally, based on this case report, we emphasize that careful physical examination and the use of less invasive and economic tools, such as plain X-ray are important to investigate this very sick and old lady, because these strategies could help us to make an accurate diagnosis earlier without the need for more aggressive, invasive, and expensive tools.

Extensive adenomyosis (adenomyosis) or its variance, localized adenomyosis (adenomyoma) of the uterus, is often described as scattered, widely-distributed endometrial glands or stromal tissue found throughout the myometrium layer of the uterus. By definition, adenomyosis consists of epithelial as well as stromal elements, and is situated at least 2.5 mm below the endometrial–myometrial junction. However, the diagnosis and clinical significance of uterine adenomyosis and/or adenomyoma remain somewhat enigmatic. The relationship between infertility and uterine adenomyosis and/or adenomyoma is still uncertain, but severe endometriosis impairs the chances of successful pregnancy when using artificial reproductive techniques. To date, there is no uniform agreement on the most appropriate therapeutic methods for managing women with uterine adenomyosis and/or adenomyoma who want to preserve their fertility. Fertility has been restored after successful treatment of adenomyosis using multiple modalities, including hormonal therapy and conservative surgical therapy via laparoscopy or exploratory laparotomy, uterine artery embolization, and other methods, including a potential but under- investigated procedure, magnetic resonance-guided focused ultrasound. This review will explore recent publications that have addressed the use of different approaches in the management of subfertile women with uterine adenomyosis and adenomyoma.

Objective: To determine the acceptability and effectiveness of a gonadotropin-releasing hormone (GnRH) agonist for the treatment of perimenopausal women with symptomatic uterine myomas. Materials and Methods: The participants included 43 women with symptomatic myomas who wished to retain their uteri. All the women were older than 45 years old, agreed to use the GnRH agonist for menopause induction, and were without any underlying malignancy. They were treated with six courses of GnRH agonist between 2004 and 2005. The definition of re-intervention included: (1) surgical intervention, such as hysterectomy, myomectomy or laparoscopic uterine vessel occlusion, or (2) modification of GnRH agonist use. Modification of GnRH agonist use included either failure to complete a 6-month GnRH agonist treatment course, or re-use of GnRH agonist with/without interruption of continuity. Failure was defined as women who underwent surgical intervention or failed to complete the 6-month GnRH agonist treatment. Evaluations were performed every 6 months, for up to 2 years. Results: Re-intervention rates were 14.0% (n = 6), 23.3% (n = 10) and 32.6% (n = 14), and failure rates were 7.0% (n = 3), 11.6% (n = 5) and 16.3% (n = 7), at the end of the 6-, 12- and 24-month follow-up periods, respectively. Three patients failed to complete the 6-month GnRH agonist treatment, and four received surgical interventions. Conclusion: More than 80% of women in this study benefited from the use of GnRH agonist to produce menopause, suggesting that this can be an alternative choice for managing perimenopausal women with symptomatic uterine myomas.

Ascites is a pathologic accumulation of fluid within the peritoneal cavity, and usually develops as a result of liver disease, congestive heart failure or nephrotic syndrome. Ascites is also a common manifestation of some gynecologic diseases. It is important that health care workers consider gynecologic problems among the potential differential diagnoses in patients presenting with ascites. Various kinds of ovarian diseases, such as epithelial ovarian cancer, benign ovarian fibroma, stromal hyperplasia, ovarian hyperstimulation syndrome, primary peritoneal serous carcinoma, endometriosis and peritoneal tuberculosis, should be kept in mind when women are found to have ascites.

Summary: Uterine myomas are the most common benign tumors in the female reproductive tract. Most women with myomas are asymptomatic. Therefore, expectant observation and follow-up are often recommended for these myoma patients. However, myomas may cause menstrual symptoms, pelvic pain, pressure complaints, subfer-tility or pregnancy-related complications, with resultant requests for a definitive treatment. The management of myomas has become multidisciplinary in the past 20 years. Basically, the choice of treatment depends on the patient's age, the reason for treatment, the issue of fertility preservation, and the patient's preference. The treatment spectrum includes an expectant management, medical therapy, surgical intervention, uterine artery embolization or ablative techniques. Medical therapy is an option for women with symptomatic myomas who prefer non-surgical treatment, consider fertility preservation, or expect a less aggressive operation after shrinkage of the uterine volume. This review will summarize the recent well-documented drugs for the management of uterine myomas. Key Words: medical therapy, uterine myomas

Summary: The link between hormones and breast cancer growth and development has been recognized for more than a century. Estrogen stimulates the proliferation of breast epithelial cells, and both endogenous and exogenous estrogens have been implicated in the pathogenesis of breast cancer. Classically, estrogen action at target sites around the body is mediated through related but distinct estrogen receptors (ERs), designated ERα and ERβ, to alter gene expression. This accumulating understanding of the mechanism of action of estrogen led ultimately to the design of antiestrogenic agents that work by virtue of their interaction with the ER; these drugs have come to be known as selective estrogen receptor modulators (SERMs). Tamoxifen, a SERM, emerged as the first antiestrogenic agent that is clinically applicable to breast cancer. Tamoxifen became the “gold standard” and established the principles of tumor targeting and identified the appropriate treatment strategy to aid survivorship in breast cancer patients, with enhancement of disease-free survival and a 50% decrease in recurrences observed in ER-positive patients 15 years after diagnosis. However, because of the many adverse events in the use of tamoxifen, some of which have contributed to significant morbidity and mortality, drug modification which has resulted in fewer incidences of adverse events without compromising the therapeutic effect for breast cancer prevention may face an easier road to acceptance. Raloxifene may be a better alternative, since evidence from large clinical trials showed that raloxifene not only decreases the incidence of osteoporosis and related fractures, but also offers benefits for breast cancer prevention. The results from the Study of Tamoxifen and Raloxifene (STAR) trial showed the superiority of raloxifene over tamoxifen, not only for the equal efficacy in the prevention of invasive breast cancer but also for the fewer serious adverse events. Taken together, without other competition so far, raloxifene is recommended for postmenopausal women with osteoporosis who also need breast cancer prevention. Key Words: breast cancer, estrogen, estrogen receptor, raloxifene, selective estrogen receptor modulator, tamoxifen

Objective: Cervical pregnancy is a rare life-threatening form of ectopic pregnancy. In the past, hysterectomy was often the only choice available because of profuse hemorrhage that accompanied the attempts of removal of the cervical pregnancy. Case Report: We present a case of a successful surgical resection of a cervical pregnancy. Diagnosis of a viable cervical pregnancy was made at 9 weeks by ultrasound. Acute abdominal pain, massive vaginal bleeding, and impending shock occurred suddenly in this patient. In order to preserve her future fertility, we used a series of modified procedures, step-by-step, to minimize and control acute hemorrhaging, including transient ligation of the cervicovaginal branches of the uterine vessels with an 18-Fr Foley catheter, vasopressin use, resection of the ectopic pregnancy mass, compression using a 24-Fr Foley catheter, and finally, wound closure. Intraoperative blood loss was less than 400 mL. This treatment was successful, with resumption of normal menstrual cycles and a normal transvaginal ultrasonographic appearance of the cervical canal documented 3 months after the initial diagnosis. Conclusion: The use of modified surgical procedures, step-by-step, is a good alternative to total hysterectomy for managing cervical pregnancies that require urgent attention.

For decades, hormone therapy (HT) has been the mainstay for managing menopausal symptoms. However, the prolonged use of either single estrogen therapy (ET) or a combination therapy of estrogen and progestogen (EPT) might be associated with a slightly increased risk of breast cancer. Alternative therapies that are effective in the prevention and/or treatment of menopause, having associated morbidities but no unwanted effects, are of primary interest in clinical practice. Tibolone (Livial; NV Organon, Oss, The Netherlands) is structurally related to 19-nortestosterone derivatives and is a new postmenopausal regimen with a unique pharmacological profile, licensed for the relief of climacteric symptoms and the prevention of osteoporosis in postmenopausal women. Tibolone exhibits weak estrogenic, progestogenic, and androgenic activities, which in theory might influence the breast. The effect of tibolone on breast tissue, however, is obscure. The purpose of this study was to assess the effects of tibolone on breast safety, and the collected data include preclinical models, clinical observation, and epidemiologic study. Although in vitro studies showed conflicting results (with the majority being favorable effects) regarding the effects of tibolone on breast cells, in vivo studies showed favorable effects of tibolone on the breast in animal models. Similarly, an epidemiologic study indicated an increased risk of breast cancer when tibolone was used to manage climacteric symptoms of postmenopausal women, but accumulated data obtained from radiologic studies (mammography) showed a possible protective effect of tibolone on the breast. Taken together, we conclude that tibolone, if not superior to conventional HT, may be more acceptable to clinicians as a therapeutic drug option for use with symptomatic menopausal women. Only time will tell whether tibolone will be the preferred option.

Menopause occurs naturally when the ovary ceases folliculogenesis, or artificially by surgical and/or medical ablation of the ovarian function. Menopause is a hypoestrogenic state, which may adversely affect estrogen target tissues, such as the brain, skeleton and skin, as well as the cardiovascular and genitourinary systems, with resultant frequency and severity of climacteric symptoms. The climacteric symptoms, however, vary significantly among women. For decades, hormone therapy (HT) has been the mainstay and is considered the most effective for managing menopausal symptoms. The prolonged use of either single estrogen therapy or a combination therapy of estrogen and progestogen (EPT) might be associated with a slightly increased risk of breast cancer and many resultant adverse events, such as coronary heart disease, stroke and venous thromboembolism. Perhaps because the clear benefits are limited to these end points of HT in treating menopausal women, the relatively significant adverse event profiles of these women may not be enough to trigger primary care physicians to be more aggressive than they have been to date in treating climacteric symptoms of postmenopausal women. However, severe climacteric symptoms really disturb the woman's life. Some epidemiologic studies have shown that the increased risk for breast cancer after 5 years of combined EPT is similar in magnitude to other lifestyle variables, such as 10-year delayed menopause, fewer pregnancies and reduced breastfeeding, postmenopausal obesity, excessive alcohol or cigarette use, and lack of regular exercise. Furthermore, elevated serum concentrations of either endogenous or exogenous (replaced by HT) sex hormone in either pre- or postmenopausal women are associated with an increased risk of breast cancer. Finally, the increased breast cancer risk diminishes soon after discontinuing hormones, and largely disappears by 5 years after cessation. Taken together, low-dose conventional HT can be used with symptomatic menopausal women, but is worthy of further evaluation because we found the following potential benefits, including (i) low-dose oral EPT appears to be effective for the alleviation of climacteric symptoms; (ii) it has a good tolerability profile with a low incidence of the most common and problematic side effects, such as breast tenderness and an increased mammographic density. Altogether, when compared with the standard dose HT, physicians may prefer to use low-dose HT initially in managing the climacteric symptoms of postmenopausal women. Time will prove.

Objective: Ovarian malignancy is highly suspected when patients present with an ovarian cystic mass lesion accompanied with ascites. However, aside from the primary origin, a metastatic lesion should be considered, since the ovary is frequently metastasized from cancers of other organs, such as the genital tract, gastrointestinal tract, and breast. Herein, we report the case of a patient with a left adnexal mass and ascites to emphasize consideration of metastatic ovarian tumors from non-gynecologic organs. Case Report: A 47-year-old woman with a history of right breast infiltrating lobular carcinoma, T3N0M0, grade 3, was treated with modified radical mastectomy and axillary lymph-node dissection in July 2001. Tumor recurrence was noted in December 2003. Therefore, she underwent palliative radiotherapy and various kinds of chemotherapy. In March 2006, she experienced poor appetite and abdominal fullness, and was found to have a 12-cm adnexal mass accompanied with ascites. Ovarian cancer was suspected, and exploratory laparotomy was performed. However, metastatic carcinoma of the ovary of breast origin was finally diagnosed. Conclusion: In cases of pelvic tumors in patients who have a history of other primary cancers, metastasis should be suspected initially. Although the prognoses of these patients seem to be worse, intensive cytoreductive surgery would improve quality of life and offer a chance of better survival in highly selected patients.

Objective: To present the phenomenon of the postoperative rapid progression of mature cystic teratoma (MCT) with malignant transformation (MT) when intraoperative spillage occurs during operation. Case Report: Two patients with MCT were treated, one with total hysterectomy plus bilateral salpingooophorectomy in an exploratory laparotomy, and the other with cystectomy with laparoscopy, respectively. Tumor spillage occurred during both operations. The postoperative pathology showed MCT with MT (squamous cell carcinoma type). Both patients were referred to our hospital and underwent treatment (3 months and 8 days, respectively, after the initial operation). At the secondary laparotomy for staging surgery, tumor dissemination was observed in both patients. Conclusion: Whether or not tumor dissemination is correlated with tumor rupture during operation, we emphasize that any patient with a preoperative diagnosis of MCT should have it removed intact to avoid the possibly catastrophic event of tumor dissemination.

Objective: The compliance of women living in Taiwan with the selective tissue estrogenic activity regulator (STEAR) tibolone has seldom been reported. The purpose of this study was to evaluate the short-term compliance of perimenopausal women living in Taiwan in taking tibolone, and the efficacy of the drug. Materials and Methods: A total of 289 perimenopausal women who had experienced mild to severe climacteric symptoms were enrolled in this study. Every woman was evaluated before (baseline), during (end of the third month), and after therapy (end of the sixth month) with 2.5 mg tibolone daily. Efficacy was assessed from improvement in climacteric symptoms and compliance was also assessed. Results: A total of 275 women were still on tibolone treatment by the end of the study, revealing a high rate (95.2%) of retention. Breast tenderness was significantly reduced, from 26.5% to 2.8%. The reported rate of insomnia was 50.5% at baseline, and had been reduced to 20.4% by the end of the study. Bleeding episodes dropped from 87.4% at baseline to 39.4% at the end of the study. The rate of mood instability was significantly reduced, from 84.1% at baseline to 44.3% at the end of the study. Libido improved from 15.9% at baseline to 61.6% at the end of the study, a unique benefit of tibolone due to the androgenic effect of its d-isomer. Most women (84.1%) had an increase in body weight ranging from 0.5 to 3 kg. Fourteen subjects dropped out for the following reasons: three women had acne and/or allergic reaction, four had a significant increase in body weight and/or water retention, one had headache, and the other six dropped out for personal reasons. Conclusion: Tibolone can improve the climacteric symptoms of perimenopausal women living in Taiwan. With the exception of increased body weight, no major side-effect was noted during this short-term study.

Objective: To share our experience of prenatal classical phenylketonuria (PKU) diagnosis using the polymerase chain reaction (PCR), automatic sequencing, and linkage analysis with short tandem repeats (STRs). Materials and Methods: Eight pregnant women who had delivered one baby with confirmed classical PKU were enrolled. They underwent amniocentesis and blood sampling. Genomic DNA was extracted from peripheral blood leukocytes and amniotic cells. Oligonucleotide primers for each specific exon, intron, enhancer, and STR of intron 3 were used for PCR amplification. The sequence was analyzed and the mutant pattern was determined. Results: Of the eight fetuses, one was normal, one had disease, five were disease-free carriers, and one test was indeterminate. Identified mutations included R408Q (n = 4), R241C (n = 3), R413P (n = 1), A434D (n = 1), and G257V (n = 1). Conclusion: The combination of amniocentesis and PCR can successfully detect fetuses with classical PKU early in pregnancy. Based on our experience, common mutations were R408Q and R241C.

Sex hormones including progestins, androgens, and estrogens produced de novo from cholesterol within the ovary play important roles in the growth and differentiation of reproductive tissues and in the maintenance of fertility. Sex hormone effects are often mediated through the sex hormone receptors (SRs). SRs, members of the steroid receptor superfamily, function as sex hormone-dependent transcriptional regulators. After binding the ligand, the activated SR is able to recognize palindromic DNA sequences, called sex hormone response elements, and form a complex with SR-associated proteins to induce the expression of SR target genes. The precise role of sex hormones in follicular development and ovulation remains to be elucidated. The data presented here arise from studies designed to resolve this issue. The use of gene-targeting technology and transgenic techniques to disrupt the genes encoding several members of the SR family, including progesterone receptor A, progesterone receptor B, estrogen receptor !, estrogen receptor”, and androgen receptor, has had a great impact, evident in the generation of several “knockout” mice for SRs. This review discusses the advances originating from the gene-targeting boom and the SR knockout mice. The broad content of this review is a reflection of the current state of research in female ovulation from these knockout female mice models.

A 31-year-old pregnant woman complained of occasional abdominal pain with a gradually enlarging ovarian cyst at 14 weeks of gestation. Follow-up sonography confirmed the right ovarian cyst, 8.5 cm in size, with regional diffuse bright echoes and hyperechoic lines and dots. Mature cystic teratoma was diagnosed. Single-port laparoscopic surgery was scheduled to prevent cyst enlargement or torsion during pregnancy. Enucleation of the cyst was conducted smoothly without intra-abdominal spilling and removed through the transumbilical port. The overall blood loss was 50 mL. The operative time was 2 hours, and there were no intraoperative complications. Histology of the cyst confirmed a mature cystic teratoma. There was no preterm labor during follow-up. We successfully performed single-port laparoscopic ovarian cystectomy during pregnancy, which was followed by an unremarkable antenatal course. The benefit and safety of single-port laparoscopic cystectomy make it a good alternative choice for surgical intervention during pregnancy.

Sialic acids and their derivatives are ubiquitous at the terminal positions of the oligosaccharides of glycoproteins that play roles in a variety of biologic processes, such as cell-cell communication, cell-matrix interaction, adhesion, and protein targeting. Altered sialyltransferase (ST) expression plays an important role in oncogenesis, tumor progression, and lymph node metastases. For example, in squamous cell carcinoma of the cervix, α2,6-ST I shows positive correlation not only with oncogenesis, but also with tumor metastases to the pelvic lymph node. The over-expression of α2,6-ST I is due to reactivation of the hepatic form of the promoter. With advanced metastases, α2,3-linkage also dramatically changes, and this change more accurately predicts pelvic lymph node metastases in squamous cell carcinoma of the cervix. This laboratory successfully cloned α2,3-, α2,6-, and α2,8-ST genes to screen a powerful anti-ST reagent, soyasaponin I (SsaI). SsaI is not cytocidal but, in contrast, has a cytostatic effect on cancer cells, mainly slowing cell growth and division. It also modifies the invasive behavior of cancer cells such as migration and adhesion. Thus, altered glycosylation is important in gynecologic cancers, especially squamous cell carcinoma of the cervix. In future, the functional roles of ST in cancer pathogenesis may be elucidated. For example, specific anti-ST inhibitors could clarify the role of changing sialylation in cancer behavior, monoclonal antibodies to certain glycosylated epitopes will help diagnosis of such tumors and, most importantly, both these techniques will offer therapeutic avenues designed to attack tumor cells via their glycans in the near future.

Objective: Although cervical cancer is a very common gynecologic malignancy, skin metastasis presenting as an initial sign of recurrent or persistent disease is extremely rare. Case Report: A 72-year-old woman was diagnosed with squamous cell carcinoma of the cervix (FIGO stage, IIB), which was treated with concurrent chemoradiation. After treatment, she was followed up regularly, without evidence of disease. One year later, many erythematous lesions were noted on the extremities, trunk, and scalp. Some of skin lesions grew rapidly. Excision biopsy was performed and showed metastatic carcinoma, favoring a squamous cell type. The patient then underwent a series of imaging examinations, including magnetic resonance imaging of the pelvis and computed tomography of the chest, and a whole body bone scan showed disseminated diseases involving the lung and bone. Palliative chemotherapy was prescribed, and the skin lesions responded relatively well, but disease involving the vital organs still progressed during treatment. The patient died of the disease 6 months after the appearance of the skin lesion. Conclusion: This report supports the concept that skin metastasis is a late manifestation and an ominous sign for cervical cancer patients, and also indicates the uncontrolled or widespread metastasis of the disease.