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Aujourd’hui encore, la prise en charge médicale des personnes transgenres pâtit d’une insuffisance d’offre de soins et de formation des soignants. La mise en œuvre d’une hormonothérapie est souvent souhaitée par les personnes transgenres et il est nécessaire qu’un médecin sache l’instaurer et la suivre tout au long de la transition. Nous abordons dans cette revue le traitement hormonal féminisant (THF) chez les femmes transgenres adultes, et le traitement hormonal masculinisant (THM) chez les hommes transgenres adultes.

Data on preimplantation genetic testing (PGT-M) in patients with genetic susceptibility to cancer are scarce in the literature, while there is, in our experience, a growing familiarity with assisted reproduction techniques (ART) among pathogenic variant heterozygotes. We performed a retrospective multicenter study of PGT-M outcomes among French patients with genetic susceptibility to cancer. Our objectives were to collect data on this complex issue, and to help cancer geneticists counsel their patients of reproductive age. We also wanted to increase awareness regarding PGT-M among cancer genetics professionals. Patients from three university hospital cancer genetics clinics who had requested PGT-M between 2000 and 2019 were included retrospectively. Data were extracted from medical records. Patients were then contacted directly to collect missing and up-to-date information. Out of 41 eligible patients, 28 agreed explicitly to participate when contacted and were therefore included. They carried PV in VHL (n = 9), APC (n = 8), CDH1 (n = 5), STK11 (n = 2), AXIN2, BRCA1, MEN1, and FH (n = 1). Seven patients were denied PGT-M based on multidisciplinary team meetings or subsequently by the ART hospital teams, two changed their minds, and two were yet to start the process. PGT-M was successful in seven patients (25%), with a mean age at PGT-M request of 27. Most had von Hippel-Lindau. PGT-M failed in the remaining ten, with a mean age at PGT-M request of 32. The main reason for failure was non-implantation of the embryo. Of these, four patients were pursuing PGT-M at the time of last contact. PGT-M outcomes in patients with cancer susceptibility syndromes were satisfactory. These patients should be informed about PGT-M more systematically, which would imply greater awareness among cancer genetics professionals regarding ART. Our series was not representative of cancer susceptibility syndromes in general; the predominance of cases with syndromes characterized by early-onset, highly penetrant disease is explained by the restrictive French guidelines.

Supplementary Table 1 from Eighteen Insulin-like Growth Factor Pathway Genes, Circulating Levels of IGF-I and Its Binding Protein, and Risk of Prostate and Breast Cancer

Background: Circulating levels of insulin-like growth factor I (IGF-I) and its main binding protein, IGF binding protein 3 (IGFBP-3), have been associated with risk of several types of cancer. Heritable factors explain up to 60% of the variation in IGF-I and IGFBP-3 in studies of adult twins.Methods: We systematically examined common genetic variation in 18 genes in the IGF signaling pathway for associations with circulating levels of IGF-I and IGFBP-3. A total of 302 single nucleotide polymorphisms (SNP) were genotyped in >5,500 Caucasian men and 5,500 Caucasian women from the Breast and Prostate Cancer Cohort Consortium.Results: After adjusting for multiple testing, SNPs in the IGF1 and SSTR5 genes were significantly associated with circulating IGF-I (P < 2.1 × 10−4); SNPs in the IGFBP3 and IGFALS genes were significantly associated with circulating IGFBP-3. Multi-SNP models explained R2 = 0.62% of the variation in circulating IGF-I and 3.9% of the variation in circulating IGFBP-3. We saw no significant association between these multi-SNP predictors of circulating IGF-I or IGFBP-3 and risk of prostate or breast cancers.Conclusion: Common genetic variation in the IGF1 and SSTR5 genes seems to influence circulating IGF-I levels, and variation in IGFBP3 and IGFALS seems to influence circulating IGFBP-3. However, these variants explain only a small percentage of the variation in circulating IGF-I and IGFBP-3 in Caucasian men and women.Impact: Further studies are needed to explore contributions from other genetic factors such as rare variants in these genes and variation outside of these genes. Cancer Epidemiol Biomarkers Prev; 19(11); 2877–87. ©2010 AACR.

Resume Introduction L’IRM mammaire est l’examen de reference pour le depistage chez les patientes a haut risque genetique de cancer du sein. Sa sensibilite et sa specificite, pouvant etre limitees par le rehaussement physiologique glandulaire, il est actuellement recommande d’effectuer l’IRM de depistage dans la deuxieme semaine du cycle menstruel, ce qui peut compliquer programmation. L’objectif de notre etude etait d’evaluer l’interpretation (ou la performance) de l’IRM realisee hors de la periode souhaitee. Methodes Nous avons analyse les IRM consecutives realisees a l’Hopital Tenon chez les patientes a haut risque genetique, sans antecedent de cancer du sein, entre 2006 et 2016. Nous avons analyse le taux de rehaussement genant l’interpretation (RG) – c’est-a-dire les rehaussements de types III et IV –, le taux d’explorations supplementaires realisees (IRM et biopsie) et la survenue d’evenement d’intervalle dans 2 groupes selon les conditions de realisation de l’examen : programmation adequate (j7–j14) et programmation inadequate (en dehors de la periode recommandee). Resultats Au total, 126 IRM ont ete etudiees, realisees chez 62 patientes porteuses d’une mutation genetique predisposant au cancer du sein (BRCA 1 ou 2 : 91 %, autre : 9 %), d’âge moyen 34,5 ans, en programmation adequate (n = 84), et inadequate (n = 42). Le taux de RG etait comparable dans les 2 groupes (respectivement 31 % et 35,7 %, p = 1), ainsi que la realisation d’explorations complementaires (respectivement 31 % et 45 %, p = 0,11). Conclusion Nos resultats suggerent que la programmation de l’IRM de depistage pourrait etre simplifiee dans la population specifique des patientes indemnes a haut risque genetique de cancer du sein.

Medical care for transgender patients is still characterized by an insufficient availability of healthcare services, as well as by poor provider education and training. Transgender patients often require gender-affirming hormone therapy (GAHT), and physicians, including endocrinologists, general practitioners, and others, should be trained to initiate and monitor these treatments throughout the transition process, and beyond. This article will address the specific issues surrounding GAHT in adult transgender women and men.Hormonothérapies de transition chez les personnes transgenres.Aujourd’hui encore, la prise en charge médicale des personnes transgenres pâtit d’une insuffisance d’offre de soins et de formation des soignants. La mise en œuvre d’une hormonothérapie est souvent souhaitée par les personnes transgenres et il est nécessaire qu’un médecin sache l’instaurer et la suivre tout au long de la transition. Nous abordons dans cette revue le traitement hormonal féminisant (THF) chez les femmes transgenres adultes, et le traitement hormonal masculinisant (THM) chez les hommes transgenres adultes.

La contraception d’urgence (CU) évolue depuis les années 1960, devenant de mieux en mieux tolérée par les femmes qui la prennent. Les contraceptions d’urgence hormonales ont ainsi utilisé des doses d’hormones de plus en plus faibles, avec des schémas d’utilisation simplifiés. Les œstrogènes ont finalement été abandonnés, conduisant à la mise en vente de ces contraceptions sans besoin d’une prescription. Le dispositif intra-utérin au cuivre, qui nécessite, quant à lui, le recours à un professionnel de santé, est moins accessible. Pourtant, il permet l’instauration d’une contraception au long cours. Malgré des progrès indéniables, la contraception d’urgence reste encore trop peu utilisée, faute d’une information efficace mais aussi de différents freins.

The evolution of medical care for transgender people currently makes it possible to propose fertility preservation. Fertility preservation should be initiated before the start of hormonal treatments and/or surgical procedures. The “reproductive” aspect and the desire for parenthood among transgender people have long been ignored. However, these aspects are important to consider and fertility preservation should be discussed before the start of the physical transition. The aim of this review is to assess the literature on fertility preservation for transgender women (“male to female”). Many uncertainties remain regarding the impact of hormonal treatments on the reproductive functions of transgender women and their reversibility. However, the significant increase in the number of recently published articles is evidence of the improvement in the conditions of access to these procedures for women starting a transition process. Nevertheless, there are still a number of barriers that can prevent or delay this process., L’évolution de l’accompagnement médical des personnes transgenres permet actuellement de proposer la mise en place de stratégies de préservation de la fertilité, idéalement avant l’instauration des traitements hormonaux et/ou actes chirurgicaux. La dimension « reproductive » et le désir de parentalité chez les personnes transgenres ont longtemps été ignorés. Ces aspects sont pourtant importants à considérer et des mesures de préservation de la fertilité doivent donc être discutées avant le démarrage du parcours médical de transition physique. Cette revue a pour objectif de réaliser un état des lieux de la littérature concernant la préservation de la fertilité des femmes transgenres (« male to female »). De nombreuses incertitudes persistent quant à l’impact des traitements hormonaux sur les fonctions de reproduction des femmes transgenres et leur réversibilité. Cependant, l’augmentation importante du nombre des articles récemment publiés témoigne de l’amélioration des conditions d’accès à ces procédures pour les femmes qui démarrent un parcours de transition. Il reste néanmoins un certain nombre de barrières qui peuvent empêcher ou retarder ce processus.

Resume Les patients presentant un diabete de type 1 (DT1), hommes et femmes, ont une diminution significative de la fertilite, et notamment en cas de diabete apparu precocement, meme si cette tendance tend globalement a s’amenuiser. Les causes de cette baisse de fertilite ont evolue avec le temps et les progres de la prise en charge du DT1, mais aussi avec la progression de l’« epidemie » de surpoids et d’obesite. Les aspects psychosociaux sont egalement un determinant important. Les patients doivent etre informes de la possibilite de cryopreservation de gametes en cas de menace sur la fertilite ulterieure.

FERTILITY PRESERVATION BEFORE OVARIAN MALIGNANCY TREATMENT While most ovarian epithelial malignancies affect postmenopausal women, 12% occur in reproductive age patients. In addition, borderline ovarian tumors and rare non epithelial ovarian tumors are diagnosed in young patients as well. The prognosis of early-stage epithelial tumors, non-epithelial and frontier tumors is good. Increased knowledge in this specific field now allows the development of fertility preservation strategies. They include conservative surgery when applicable, associated with oocyte and / or ovarian tissue cryopreservation. Indications remain limited, and any decision must be validated by a multidisciplinary expert committee. The different strategies depend on specific tumoral or genetic context.PRÉSERVATION DE LA FERTILITÉ AVANT TRAITEMENT D’UN CANCER DE L’OVAIRE Le cancer épithélial de l’ovaire atteint en majorité les patientes ménopausées. Cependant, 12 % des patientes ont moins de 44 ans. Les tumeurs frontières de l’ovaire et les tumeurs rares non épithéliales sont diagnostiquées plus fréquemment chez les femmes en âge de procréer. Le pronostic des stades précoces et des tumeurs non épithéliales est favorable. Les avancées scientifiques permettent de développer des stratégies de préservation de la fertilité, qui reposent d’abord sur la possibilité d’une chirurgie conservatrice et sur la préservation de gamètes ou de tissus germinaux. Les indications restent néanmoins limitées, et toute décision doit être discutée en réunion de concertation pluridisciplinaire (RCP) de recours. Les différentes stratégies dépendent du contexte tumoral ou génétique.

Despite considerable advances in recently developed combined oral contraceptives (COCs), resulting in lower rates of adverse events while maintaining contraceptive efficacy, there is interest in further innovation.Estetrol (E4), a native oestrogen, and progestin drospirenone (DRSP) were combined in a new COC. A European expert panel reviewed the pharmacology, efficacy, and safety and tolerability of this combination. Their findings are presented as a narrative review.E4 15 mg/DRSP 3 mg in a 24/4 regimen provided effective contraception with good cycle control, characterised by a predictable regular bleeding pattern and minimal unscheduled bleeding, together with a good safety profile. The combination was associated with high user satisfaction, well-being, and minimal changes in body weight. The effects on endocrine and metabolic parameters were limited, and the combination was found to have a limited impact on liver function and lipid and carbohydrate metabolism. Moreover, its effect on several haemostatic parameters was lower than that of comparators containing ethinyl oestradiol (EE) 20 µg/DRSP 3 mg and EE 30 µg/levonorgestrel 150 µg.E4 15 mg/DRSP 3 mg provides safe and effective contraception, with high user satisfaction and predictable bleeding. Further research will evaluate the long-term safety of the COC.

Points essentiels Transition hormonale et chirurgicale Depuis la loi de 2016, les personnes transgenres ne doivent plus apporter la preuve « irreversible et medicale d’une transformation physique » pour pouvoir effectuer un changement de sexe a l’Etat Civil, ce qui met fin a la sterilisation systematique et ouvre la possibilite d’une transition seulement hormonale. Or, les traitements hormonaux peuvent avoir un impact sur la fertilite des personnes transgenres, compromettant un projet ulterieur de parentalite. Preservation de fertilite Certains centres d’etude et de conservation des œufs et du sperme (CECOS), s’appuyant sur la loi bioethique de 2011, proposent desormais des autoconservations de gametes feminines et masculines avant la mise en place des traitements hormonaux de substitution, ou a l’occasion d’une fenetre therapeutique. Techniques de preservation de la fertilite La preservation de la fertilite chez les femmes transgenres repose essentiellement sur l’autoconservation de spermatozoides. Pour les hommes transgenres, la preservation de la fertilite repose sur la cryoconservation d’ovocytes matures apres stimulation ovarienne. Parentalite Outre l’evaluation de l’impact psychique de la prise en soins afin de prevenir de potentiels effets deleteres, la consultation psychosexologique offre une possibilite d’expression du desir d’enfant, desir souvent longtemps inhibe, ainsi que d’une information sur les possibilites de reutilisation.

BRCA1 and BRCA2 (BReast CAncer susceptibility genes) are two tumor-suppressor genes associated with the hereditary breast and ovarian cancer susceptibility syndrome. Recent studies also suggest an increased lung adenocarcinoma risk in carriers.We conducted a multi-center retrospective study in 18 different French pulmonology and/or oncology departments on medico-administrative and clinical data prospectively collected in the Clinical Data Warehouse (CDW) of Greater Paris University Hospitals (Assistance Publique-Hôpitaux de Paris, AP-HP). Clinical characteristics and outcomes of patients with LC and a previously known BRCA1/2gl variant were retrospectively evaluated.17 patients with LC and known BRCA1/2gl variant were included. Patients were most women, former smokers with localized disease and BRCA2 variants. All LC were adenocarcinoma. For patients with medical history of cancer, median time from the first cancer in the BRCA spectrum and the LC occurrence was 20 years. Median disease-free survival (DFS) and overall survival (OS) in localized tumor (Stage I and II) was not reached and 78.6 months, respectively. In advanced cancer (Stade III and IV) median progression free survival was 9.7 months and median OS was 17.8 months. Univariate OS and DFS/PFS analyses by BRCA status did not find significant differences.Results seem to show particular LC features in carriers of BRCA2 variants: adenocarcinoma subtype, woman, former or non-smoker.

Introduction : Up to 30% of couples may face secondary infertility. The impact of ectopic pregnancy, spontaneous abortion, pregnancy termination or live birth with caesarean section may impair further fertility in different ways. However, secondary infertility after physiological vaginal life childbirth has been little studied. The aim of this study was to describe the population and the fertility issues and analyze the predictive factors of success in in vitro fertilization in women presenting secondary infertility after a physiological vaginal childbirth. Material and methods : This single-centre retrospective study included women aged 18-43 years consulting between 2013 and 2020 for secondary infertility in a couple having already had previous vaginal life childbirth. Couples’ characteristics, management decision after the first consultation and IVF outcomes were analyzed. Results : Secondary infertility was found in 286 couples, out of whom 138 had a history of vaginal life childbirth. Population was characterized by an advanced female age and overweight. After the first consultation, IVF was performed in only 40% of couples. No predictive factor of live birth was found. Conclusion : Our study shows that in couples with secondary infertility after prior physiological delivery cigarette smoking is frequent in male partners, and ovarian reserve markers are altered. However, no statistically significant predictive factor of live birth after IVF treatment has been identified. Further large prospective studies are necessary.

INTRODUCTION: Organized and individual breast screening have been accompanied by an increase in the detection of "atypical breast lesions "(ABL). Recently, the NOMAT multicenter study proposed a predictive model of the risk of developing breast cancer after detection of an ABL in order to avoid surgical removal of "low-risk" lesions. It also aimed to provide information on psychological experience, in particularly anxiety, to assist in the shared medical decision process. METHODS: Three hundred women undergoing surgery for ABL were included between 2015 and 2018 at 18 French centers. Women completed questionnaires before and after surgery assessing their level of anxiety (STAI-State, STAI-Trait), their level of tolerance to uncertainty, their perceived risk of developing a breast cancer, and their satisfaction with the management care. RESULTS: One hundred nighty nine patients completed the STAI-Status before and after surgery. Overall, a decrease in anxiety level (35.4 vs 42.7, p

Emergency contraception (EC) has evolved since the 1960's to enable a better tolerance. Lower hormone doses, simplified schemes, withdrawal of estrogens have led to a user friendly, over-the-counter available EC. The copper intra-uterine device, requiring health care professionals' intervention, is less accessible. However, it allows simultaneous initiation of a reliable long-term contraception. Unfortunately, EC is still underused and information reinforcement is needed to overcome reluctance to its use.La contraception d’urgence - Une longue histoire.La contraception d’urgence (CU) évolue depuis les années 1960, devenant de mieux en mieux tolérée par les femmes qui la prennent. Les contraceptions d’urgence hormonales ont ainsi utilisé des doses d’hormones de plus en plus faibles, avec des schémas d’utilisation simplifiés. Les œstrogènes ont finalement été abandonnés, conduisant à la mise en vente de ces contraceptions sans besoin d’une prescription. Le dispositif intra-utérin au cuivre, qui nécessite, quant à lui, le recours à un professionnel de santé, est moins accessible. Pourtant, il permet l’instauration d’une contraception au long cours. Malgré des progrès indéniables, la contraception d’urgence reste encore trop peu utilisée, faute d’une information efficace mais aussi de différents freins.

International audience; (1) Background: although most patients with epithelial ovarian cancer (EOC) undergo radical surgery, patients with early-stage disease, borderline ovarian tumor (BOT) or a non-epithelial tumor could be offered fertility-sparing surgery (FSS) depending on histologic subtypes and prognostic factors. (2) Methods: we conducted a systematic review to assess the safety and fertility outcomes of FSS in the treatment of ovarian cancer. We queried the MEDLINE, PubMed, Cochrane Library, and Cochrane (“Cochrane Reviews”) databases for articles published in English or French between 1985 and 15 January 2021. (3) Results: for patients with BOT, FSS should be offered to young women with a desire to conceive, even if peritoneal implants are discovered at the time of initial surgery. Women with mucinous BOT should undergo initial unilateral salpingo-oophorectomy, whereas cystectomy is an acceptable option for women with serous BOT. Assisted reproductive technology (ART) can be initiated in patients with stage I BOT if infertility persists after surgery. For patients with EOC, FSS should only be considered after staging for women with stage IA grade 1 (and probably 2, or low-grade in the current classification) serous, mucinous or endometrioid tumors. FSS could also be offered to patients with stage IC grade 1 (or low-grade) disease. For women with serous, mucinous or endometrioid high-grade stage IA or low-grade stage IC1 or IC2 EOC, bilateral salpingo-oophorectomy and uterine conservation could be offered to allow pregnancy by egg donation. Finally, FSS has a large role to play in patients with non- epithelial ovarian cancer, and particularly women with malignant ovarian germ cell tumors.

(1) Background: Ulipristal acetate (UPA) is a selective progesterone receptor modulator (SPRM) widely used for emergency contraception and mid- to long-term leiomyoma treatment. The aim of this study was to identify modifications of miRNA expression in superficial and basal layers of the human endometrium at the end of the UPA treatment for at least 3 months. (2) Methods: Microarray miRNA analysis of formalin-fixed, paraffin-embedded hysterectomy tissue samples was conducted, followed by an Ingenuity Pathway Analysis. Samples were divided into three groups: women having had 3 months of UPA treatment (n = 7), and two control groups of UPA-naïve women in the proliferative (n = 8) or secretory (n = 6) phase. (3) Results: The UPA modified the expression of 59 miRNAs involved in the processes of cell cycle, carcinogenesis, and inflammation. Their expression profiles were different in the basal and superficial layers. Most of the processes influenced by the UPA in the basal layer were connected to the cell cycle and immune regulation. (4) Conclusion: Specific changes were observed in both layers of the endometrium in the UPA group. However, the miRNA expression in the basal layer was not consistent with that in the superficial layer. Other large studies analysing the long-term impact of SPRM on endometrial miRNA expression are necessary.

Research question The reproductive potential of transgender people may be impaired by gender-affirming hormone treatment (GAHT) and is obviously suppressed by gender-affirming surgery involving bilateral orchiectomy. The evolution of medical support for transgender people has made fertility preservation strategies possible. Fertility preservation in transgender women mainly relies on sperm cryopreservation. There are few studies on this subject, and the sample sizes are small, and so it difficult to know whether fertility preservation procedures are feasible and effective in trans women. Design This retrospective study reports the management of fertility preservation in transgender women referred to the study centre for sperm cryopreservation, and the semen parameters of trans women were compared with those of sperm donors. Results Ninety-six per cent of transgender women who had not started treatment benefitted from sperm cryopreservation, compared with 80% of those who attempted a therapeutic window and 50% of those receiving hormonal treatment at the time of sperm collection. No major impairment of semen parameters was observed in transgender women who had not started GAHT compared with sperm donors. However, even though the frequency of oligozoospermia was no different, two transgender women presented azoospermia. Some transgender women who had started GAHT could benefit from sperm freezing. None of them were treated with gonadotrophin-releasing hormone (GnRH) analogues. Conclusions Parenthood strategies for transgender people have long been ignored, but this is an important issue to consider, especially because medical treatments and surgeries may be undertaken in adolescents or very young adults. Fertility preservation should ideally be offered prior to initiation of GAHT.

Objective Fertility-sparing treatment is based on progestin therapy and is known to be safe and effective. International recommendations advise the use of megestrol acetate or medroxyprogesterone acetate. However, chlormadinone acetate has fewer undesirable effects and can be used in patients with a history of thromboembolism who are at high vascular risk. In the present prospective study, we aimed to confirm that the efficiency of the use of chlormadinone acetate for 6 months to obtain remission of atypical hyperplasia or endometrial carcinoma is comparable to that of the use of other fertility-sparing treatments. Method The present study is based on the PREFERE prospective registry. All the patients received three or six months of chlormadinone acetate and were evaluated by hysteroscopic resection and pipelle sampling every three months. Results Ninety-four patients were included. Seventy-nine patients achieved complete remission at 6 months (84%). No patients stopped treatment due to a lack of tolerance. Twenty-four percent of the patients achieved a live birth. Conclusion Chlormadinone acetate is an effective and well-tolerated fertility-sparing treatment. Its benefits over other progestins are its tolerability, and its absence of contraindications which makes chlormadinone acetate a good choice for patients with thromboembolism and high vascular risk.

Research question Does mild COVID-19 infection affect the ovarian reserve of women undergoing an assisted reproductive technology (ART) protocol? Design A prospective observational study was conducted between June and December 2020 at the ART unit of Tenon Hospital, Paris. Women managed at the unit for fertility issues by in-vitro fecundation, intracytoplasmic sperm injection (IVF/ICSI), fertility preservation, frozen embryo transfer or artificial insemination, and with an anti-Mullerian hormone (AMH) test carried out within 12 months preceding ART treatment, were included. All the women underwent a COVID rapid detection test (RDT) and AMH concentrations between those who tested positive (RDT positive) and those who tested negative (RDT negative). Results The study population consisted of 118 women, 11.9% (14/118) of whom were COVID RDT positive. None of the tested women presented with a history of severe COVID-19 infection. The difference between the initial AMH concentration and AMH concentration tested during ART treatment was not significantly different between the COVID RDT positive group and COVID RDT negative group (–1.33 ng/ml [–0.35 to –1.61) versus –0.59 ng/ml [–0.15 to –1.11], P = 0.22). Conclusion A history of mild COVID-19 infection does not seem to alter the ovarian reserve as evaluated by AMH concentrations. Although these results are reassuring, further studies are necessary to assess the effect of COVID-19 on pregnancy outcomes in women undergoing ART.

International audience; The molecular responses to hormonal stimuli in the endometrium are modulated at the transcriptional and post-transcriptional stages. Any imbalance in cellular and molecular endometrial homeostasis may lead to gynecological disorders. MicroRNAs (miRNAs) are involved in a wide variety of physiological mechanisms and their expression patterns in the endometrium are currently attracting a lot of interest. miRNA regulation could be hormone dependent. Conversely, miRNAs could regulate the action of sexual hormones. Modifications to miRNA expression in pathological situations could either be a cause or a result of the existing pathology. The complexity of miRNA actions and the diversity of signaling pathways controlled by numerous miRNAs require rigorous analysis and findings need to be interpreted with caution. Alteration of miRNA expression in women with endometriosis has been reported. Thus, a potential diagnostic test supported by a specific miRNA signature could contribute to early diagnosis and a change in the therapeutic paradigm. Similarly, specific miRNA profile signatures are expected for RIF and endometrial cancer, with direct implications for associated therapies for RIF and adjuvant therapies for endometrial cancer. Advances in targeted therapies based on the regulation of miRNA expression are under evaluation.

International audience

Introduction Recurrent miscarriages are defined as three or more early miscarriages before 12 weeks of gestation. The aim of this study was to describe a cohort of women with unexplained recurrent miscarriages, evaluate several potential biomarkers of immune origin and describe the outcome of pregnancies under immunomodulatory therapies METHODS: Women having a history of at least 3 early miscarriages without any etiology were recruited from 3 university hospitals. Results Among 101 women with recurrent miscarriages, overall, 652 pregnancies have been included in the analysis. Women which experienced miscarriages were older (33.3 ± 5.4 versus 31.9 ± 6.7; p = 0.03), with history of more pregnancies (4 (2-6) versus 3.5 (1-5.75); p 0.0008), and less frequently the same partner (406 (74%) versus 79 (86%); p=0.01). There was no difference in the level and frequencies of biomarkers of immune origin (NK, lymphocyte, gammaglobulins and blood cytokine levels and endometrial uNK activation status), except the higher rates of positive antinuclear antibodies in women with live birth (12 (13%) versus 36 (7%); p=0.03). Among the 652 pregnancies, 215 (33%) have been treated and received either aspirin/low weighted molecular heparin (LMWH) and/or combined to different lines of immunomodulatory treatment. Patients with pregnancy under treatment had a significantly higher rate of cumulative live birth rate that those with untreated ones (43.0% vs 34.8%; p = 0.04). When compared to patients with untreated pregnancies, patients with steroids during the pregnancy had twice more chances to obtain live birth (OR 2.0, CI95% 1.1 - 3.7, p = 0.02). Conclusions Unexplained recurrent miscarriages could have improved obstetrical outcome under immunomodulatory therapies and in particular steroids.

Objective Pregnancy associated breast cancer (PABC) are defined as breast cancer diagnosed during pregnancy and during the year following delivery. The prediction of poor prognosis events (PPE) such as recurrence is a major medical challenge of management for women with PABC. The aim of this study was to build a nomogram based on selected clinical and histological variables to predict recurrence. Study Design This retrospective study included 96 patients with PABC from January 2002 to January 2018. A multivariate Cox analysis of selected risk factors was performed and a nomogram to predict recurrence was built. The nomogram was internally validated. Results The overall recurrence rate was 22% (21/95) and the 3-years recurrence rate was 13% (12/95). Age at diagnosis, histological type, immuno-histological class, tumor stage (TNM), node stage (TNM) were associated with PPE in univariate analysis, and were included in the final Cox model to develop the nomogram. The predictive model had a concordance index of 0.83 (95% Confidence Interval (CI), 0.81-0.85) and 0.78 (95% CI, 0.76-0.80) before and after the 200 repetitions of bootstrap sample corrections, respectively, and showed a good calibration. Conclusion Our results support the use of the present nomogram based on 5 clinical and pathological characteristics to predict PPE in PABC with a high concordance. External validation is required to recommend this nomogram in routine practice.

Introduction The prevalence of pregnancy-associated breast cancer is increasing. HER2-positive breast cancers typically have a poor prognosis. The objective of our study was to compare the prognosis of patients with HER2-positive breast cancer diagnosed during pregnancy (HER2-positive BCP) to young women diagnosed with HER2-positive breast cancer outside of pregnancy (HER2 non-BCP). Methods Data of patients managed for invasive breast carcinoma between January 2005 and 2020 were retrospectively collected from the database of Tenon University Hospital (Paris, France), part of the “Cancer lié à la Grossesse” network. Results Fifty-one patients with HER2-positive BCP were matched on age at diagnosis with 51 HER2-positive non-BCP patients. Locally advanced disease with axillary lymph node involvement were frequent. Tumors were frequently aggressive with high grade (p = 0.57) and high Ki67 (p = 0.15). Among the HER2-positive BCP patients, the mean term at diagnosis was 19.3 week of gestation (WG). Eighty-four percent of the patients continued their pregnancy with a mean term at delivery of 34.2WG. Chemotherapy modalities differed between the two groups: neoadjuvant chemotherapy was more frequent in the HER2-positive BCP group (p = 0.03) and adjuvant chemotherapy more frequent in the HER2 non-BCP group (p = 0.009). The recurrence rate was 10% (n = 5) and 18% (n = 9) in the HER2-positive BCP and HER2 non-BCP groups, respectively, p = 0.25. Breast cancer-free survival was poorer in the HER2-positive BCP group with earlier recurrence, p = 0.008. No difference in type of recurrence was found between the groups (p = 0.58). Conclusion This matched case-control study implies that patients with HER2-positive BCP still have a poorer prognosis than non-pregnant HER-positive patients., Highlights • Trastuzumab improved survival in HER2-positive patients with early, locally advanced and metastatic breast cancer. • Administration of trastuzumab is contraindicated during pregnancy. • Patients with HER2-positive breast cancer during pregnancy have a poorer prognosis than non-pregnant HER-positive patients. • The prognosis of patients with HER2-positive breast cancer is not related to the term of diagnosis.

Resume Les mouvements de lutte et de liberation sociale depuis les annees 1960 ont permis tres progressivement aux communautes LGBTQI+ d’acceder a une prise en charge medicale adaptee a leurs besoins specifiques. Aujourd’hui encore, la prise en charge medicale des personnes transgenre pâtit d’une insuffisance d’offre de soins et de formation des soignants. La mise en œuvre d’une hormonotherapie est souvent souhaitee par les personnes transgenres et il est necessaire qu’un medecin (endocrinologue, gynecologue, medecin generaliste, etc.) sache l’instaurer et la suivre tout au long du parcours de transition, puis au-dela. Les therapeutiques sont complexes, avant puis apres une eventuelle reassignation chirurgicale. Nous aborderons ici le traitement hormonal feminisant (THF) chez les femmes transgenres adultes.

Purpose To evaluate the agreement between automatic assessment software of breast density based on artificial intelligence (AI) and visual assessment by a senior and a junior radiologist, as well as the impact on the assessment of breast cancer risk (BCR) at 5 years. Materials and methods We retrospectively included 311 consecutive women (mean age, 55.6 ± 8.5 [SD]; range: 40–74 years) without a personal history of breast cancer who underwent routine mammography between January 1, 2019 and February 28, 2019. Mammographic breast density (MBD) was independently evaluated by a junior and a senior reader on digital mammography (DM) and synthetic mammography (SM) using BI-RADS (5th edition) and by an AI software. For each MBD, BCR at 5 years was estimated per woman by the AI software. Interobserver agreement for MBD between the two readers and the AI software were evaluated by quadratic κ coefficients. Reproducibility of BCR was assessed by intraclass correlation coefficient (ICC). Results Agreement for MBD assessment on DM and SM was almost perfect between senior and junior radiologists (κ = 0.88 [95% CI: 0.84–0.92] and κ = 0.86 [95% CI: 0.82–0.90], respectively) and substantial between the senior radiologist and AI (κ = 0.79; 95% CI: 0.73–0.84). There was substantial agreement between DM and SM for the senior radiologist (κ = 0.79; 95% CI: 0.74–0.84). BCR evaluation at 5 years was highly reproducible between the two radiologists on DM and SM (ICC = 0.98 [95% CI: 0.97–0.98] for both), between BCR evaluation based on DM and SM evaluated by the senior (ICC = 0.96; 95% CI: 0.95–0.97) or junior radiologist (ICC = 0.97; 95% CI: 0.96–0.98) and between the senior radiologist and AI (ICC = 0.96; 95% CI: 0.95–0.97). Conclusion This preliminary study demonstrates a very good agreement for BCR evaluation based on the evaluation of MBD by a senior radiologist, junior radiologist and AI software.

BACKGROUND: Although therapeutic lateral neck dissection (LND) may be indicated in thyroid carcinoma, the cervical lymph node groups IIA and IIB, according to Robbins classification, are often not removed. The aim of our study was to determine the relevance of complete comprehensive LND in thyroid carcinoma. METHODS: We conducted a retrospective study between January 2011 and August 2018 in a university teaching hospital. Histopathological analysis of LND performed during total thyroidectomy in thyroid carcinoma was reviewed according to lymph node level. To demonstrate that neck dissection of upper groups, IIA/IIB, is necessary when therapeutic LND is indicated in thyroid carcinoma, we compared histopathological involvement in complete comprehensive LND of the upper groups IIA/IIB to the lower groups III/IV/V. RESULTS: A total of 30 LND (24 patients) were suitable for analysis. Analysis by neck side revealed that comprehensive LND dissection samples were negative in 3 cases, and positive in 27. In those 27 positive LND, 15 demonstrated involvement of the groups IIA/IIB, and 12 were positive for involvement of the III/IV/V groups only. The combined presence of positive IIA/IIB and positive III/IV/V was observed in 15 of the 27 neck sides. There was no positive IIA/IIB without positive involvement of III/IV/V groups. CONCLUSIONS: The high rate of positive cervical lymph nodes in the upper groups IIA/IIB supports complete comprehensive LND rather than selective III/IV/V LND in thyroid carcinoma surgery. However, impact on survival and whether postoperative radioactive iodine treatment may be modulated remain to be studied.

Objective To describe strategy and results of fertility preservation (FP) in patients with malignant and borderline ovarian tumors. Methods Consecutive cohort study of 43 women with malignant or borderline ovarian tumors who underwent FP between February 2013 and July 2019. The study was conducted in national expert center in Tenon University Hospital, Sorbonne University: French ESGO-certified ovarian cancer center and pregnancy-associated cancer network (CALG). Main outcome measure was FP technique proposed by multidisciplinary committee, FP technique used, time after surgery, number of fragments, histology and follicle density (if ovarian tissue freezing), number of expected, retrieved and frozen oocytes (if ovarian stimulation). Results Pathological diagnosis was malignant epithelial ovarian tumor in five women (11.6%), rare malignant ovarian tumor in 14 (32.6%), borderline in 24 (55.8%), and mostly unilateral (79.1%) and stage I (76.7%). Mean age at diagnosis was 26.8 ± 6.9 years and mean tumor size 109.7 ± 61 mm. Before FP, mean AFC was 11.0 ± 6.1 and AMH levels were 2.7 ± 4.6 ng/mL. Six ovarian tissue-freezing procedures were performed (offered to 13). Twenty-four procedures of ovarian stimulation and oocyte freezing were performed after surgical treatment for 19 women (offered to 28) with a median interval of 188 days. The mean number of mature oocytes retrieved per stimulation was 12.4 ± 12.8. At least 10 mature oocytes were frozen for 52.6% of the women. No FP was offered to five women. Conclusion Oocyte and ovarian tissue cryopreservation should be offered to patients with malignant and borderline ovarian tumors. More data are needed to confirm ovarian stimulation and ovarian tissue grafting safety.

Background The management of endometriosis-related infertility is still under debate. The Endometriosis Fertility Index (EFI) score is performant to predict the occurrence of a spontaneous pregnancy following surgery, but was not evaluated in a cost-effectiveness perspective. Our objective was to quantify fertility outcomes, and costs of different care pathways for endometriosis-associated infertility after primary surgery, with a stratification on the EFI score. Study design We conducted a cost-effectiveness analysis based on a decision-tree model in a Tertiary-care university hospital. Extracted form a prospectively maintained database, 608 patients with endometriosis-associated infertility, who underwent laparoscopic treatment with an evaluation of the EFI score, were discriminated between different strategies: natural conception, immediate IVF-ICSI, delayed IVF-ICSI. The pregnancy rate and the live birth rate were the effectiveness outcomes. We considered direct and indirect costs in each strategies. The analysis was stratified according to the EFI score. Results After surgery, 163 women with immediate IVF-ICSI (strategy I) were compared with 445 women who had natural conception attempts during a year (strategy II). After a year failure of natural conception attempts, 133 women continuing natural conception attempts (strategy III) were compared with 168 women who had delayed IVF-ICSI (strategy IV). The respective PR and LBR were 62.6 % and 52.1 % for strategy I, and 32.4 % and 23.8 % for strategy II. Compared to strategy II, strategy I was more costly and more effective (Incremental Cost Effectiveness Ratio (ICER): 31,469 €/pregnancy and 33,568 €/live birth)). No added benefit was observed for patients in strategy I with an EFI score [0−3] after two IVF-ICSI cycles. Strategy III was strongly dominant versus strategy IV for patients with an EFI score [9–10]. Compared to strategy III, strategy VI was more costly and more effective (ICER: 79,674 €/pregnancy, 53,188 €/pregnancy and 27,748 €/pregnancy respectively for patients with an EFI score [7–8], [4–6] and [0−3]). Conclusion Immediate IVF-ICSI after surgery is effective but associated with substantial costs for the healthcare system. Taking into account healthcare costs, the EFI is a useful score for helping a couple decide between different care pathways –natural conception, immediate or delayed IVF-ICSI– after surgery for endometriosis-associated infertility.

Recurrent implantation failure is defined as the absence of pregnancy after at least three transfers of good-quality embryos after in vitro fecundation/intracytoplasic sperm injection.The aim of this study was to describe a multicentre cohort of women with unexplained RIF, to analyse the factors associated with clinical pregnancy and to evaluate the immunomodulatory therapies efficacy.Women were consecutively recruited from university departments with unexplained RIF.Sixty-four women were enrolled with mean age 36 ± 3 years. The rates of clinical pregnancy in 64 women were compared in untreated and treated cycles and according to therapies used during the last prospectively followed embryo transfer. A clinical pregnancy after the transfer was noted in 56 % pregnancies on intralipids and in 50 % on prednisone, versus 5 % in untreated ones (p0.001). The 340 embryo transfers of these 64 women resulted in 68 clinical pregnancies and 18 live births. Clinical pregnancies were significantly more frequent in treated versus untreated embryo transfers (44 % vs 9 %; p0.001) with odds ratio at 8.13 (95 % CI 4.49-14.72, p0.0001). Cumulative pregnancy rates were higher for steroid-treated transfers than for untreated transfers when considering overall transfers before and after using steroids and also only those under steroids. Cumulative pregnancy rates were not different from steroid- and intralipid-treated embryo transfers CONCLUSIONS: In this multicentre study of women with unexplained RIF, use of immunomodulatory treatments before embryo transfer resulted in higher clinical pregnancy. Randomised, well-designed studies in well-defined population of RIF women are necessary to confirm our preliminary data.

Introduction In retrospective cohort study of women with unexplained recurrent implantation failure (RIF) and miscarriage (RM), we analyzed the efficacy and safety of intralipid therapy to obtain a live birth. Patients and methods Women with unexplained RM and/or RIF were included from 2015 to 2018 from three French university hospitals. Results Among 187 women treated for unexplained recurrent miscarriages and implantation failures, 26 women with median age of 36 years (29−43) received intralipid therapy. Among these 26 women, 10 women with a median age of 33 years (31−40) had a history of spontaneous recurrent miscarriages, with a median of 5 (4–8) previous miscarriages. Live births occurred in 7 (70 %) pregnancies under intralipids and were significantly more frequent than in women with recurrent miscarriages who did not receive intralipid therapy (n = 20, p = 0.02). Age, number of previous miscarriages, and additional therapies did not significantly differ between the two groups. Among the 26 included women, 16 had a history of recurrent implantation failures, with median age of 37 years (29−43) and median 9.5 (3–19) embryo transfers. Clinical pregnancy occurred in 9 (56 %) women receiving intralipids after embryo transfers under intralipids among which 5 (55 %) resulted in a live birth. Comparing successful pregnancies under intralipids with those with fetal loss, no significant differences have been noted. Conclusion Intralipids could be an effective and safe therapy in women with unexplained recurrent miscarriages and infertility.

Resume Ces Recommandations pour la pratique clinique en contraception sont les premieres promues par le College national des gynecologues et obstetriciens francais (CNGOF), afin d'aider le praticien a prendre une decision medicale en lui fournissant une synthese des donnees scientifiques existantes sur le sujet. La methodologie de la Haute Autorite de sante (HAS) a ete adoptee. Douze questions pratiques ont ete selectionnees par le comite d'organisation et le groupe de travail. La litterature a ete analysee jusqu'en decembre 2017, des recommandations basees sur le niveau de preuve ont ete proposees affectees d'un grade. Les textes longs, dont cette synthese est issue, ont ete relus par des experts en contraception et des praticiens du secteur prive ou public, ayant une activite en contraception. Des recommandations pratiques sont ainsi proposees pour la conduite de la consultation de contraception, l'information sur les methodes contraceptives, leurs risques et benefices non contraceptifs, la gestion de la contraception hormonale en pratique, la contraception intra-uterine, la contraception d'urgence, les methodes locales et naturelles, la contraception chez les adolescentes, apres 40 ans, en situation a risque vasculaire ou carcinologique. La contraception definitive et l'emploi pour la contraception de molecules ne disposant pas d'une autorisation de mise sur le marche ont ete exclus du champ de ces recommandations. L'avenir de la contraception a court et moyen terme tel qu'il peut etre anticipe aujourd'hui, passe avant tout par le bon usage des moyens dont nous disposons aujourd'hui, l'information des femmes et l'amelioration de l'acces aux contraceptions pour toutes les femmes. C'est l'objectif poursuivi par ces recommandations de pratique clinique du CNGOF.

Results from studies reporting the optimal stimulation duration of IVF-ICSI cycles are inconsistent. The aim of this study was to determine whether, in the presence of early ovulation-triggering criteria, prolonged ovarian stimulation modified the chances of a live birth. This cross-sectional study included 312 women presenting triggering criteria beginning from D8 of ovarian stimulation. Among the 312 women included in the study, 135 were triggered for ovulation before D9 (D ≤ nine group) and 177 after D9 (D > nine group). The issues of fresh +/− frozen embryo transfers were taken into consideration. Cumulative clinical pregnancy and live-birth rates after fresh +/− frozen embryo transfers were similar in both groups (37% versus 46.9%, p = 0.10 and 19.3% versus 28.2%, p = 0.09, respectively). No patient characteristics were found to be predictive of a live birth depending on the day of ovulation trigger. Postponing of ovulation trigger did not impact pregnancy or live-birth rates in early responders. A patient’s clinical characteristics should not influence the decision process of ovulation trigger day in early responders. Further prospective studies should be conducted to support these findings.

Introduction The effect of coronavirus disease (COVID-19) on pregnancy outcome in women with sickle cell disease (SCD) is unknown. Objectives To analyze the severity of the SARS-CoV-2 infection in pregnant women with SCD and its impact on pregnancy. Methods This retrospective cohort study included SCD pregnant women tested positive for COVID-19 between March 2020 – February 2021. The primary endpoint was the severity of the COVID-19 infection. Secondary endpoints were pregnancy complications and fetal outcomes. Results During the study period among 82 pregnant women with SCD, 8 have presented symptoms suggestive of COVID-19 and were tested positive. A common mild clinical presentation was observed in 6 women (75%), one woman was asymptomatic and one required oxygen. The latter was admitted to the Intensive Care Unit and a cesarean section was performed in the context of an ongoing vaso-occlusive crisis and acute chest syndrome together with incidental preeclampsia. Labor was induced in another patient who developed a vaso-occlusive crisis after COVID-19 remission. Fetal outcomes were good with an average Apgar score of 10 and normal umbilical blood pH at birth. Two newborns were small-for-gestational-age as expected on the ultrasound follow-up before occurrence of COVID-19. Conclusion COVID-19 infection in our population of pregnant women with SCD had typical presentation and rarely triggered a sickle cell crisis or other complications. Fetal outcomes were good and did not seem to be directly influenced by the SARS-CoV-2 virus. Further studies are required to confirm these observations as compared to the population of women with SCD without COVID-19 infection.

First-line diagnostic investigations for endometriosis are physical examination and pelvic ultrasound. The second-line investigations are: targeted pelvic examination performed by an expert clinician, transvaginal ultrasound performed by an expert physician sonographer (radiologist or gynaecologist), and pelvic MRI. Management of endometriosis is recommended when the disease has a functional impact. Recommended first-line hormonal therapies for the management of endometriosis-related pain are combined hormonal contraceptives (CHCs) or the 52mg levonorgestrel-releasing intrauterine system (IUS). There is no evidence base on which to recommend systematic preoperative hormonal therapy solely to prevent surgical complications or facilitate surgery. After surgery for endometriosis, a CHC or 52mg levonorgestrel-releasing IUS is recommended as first-line treatment when pregnancy is not desired. In the event of failure of the initial treatment, recurrence, or multiorgan involvement, a multidisciplinary team meeting is recommended, involving physicians, surgeons and other professionals. A laparoscopic approach is recommended for surgical treatment of endometriosis. HRT can be offered to postmenopausal women who have undergone surgical treatment for endometriosis. Antigonadotrophic hormonal therapy is not recommended for patients with endometriosis and infertility to increase the chances of spontaneous pregnancy, including postoperatively. Fertility preservation options must be discussed with patients undergoing surgery for ovarian endometriomas.

The available literature, from 2006 to 2017, on hormonal treatment has been analysed as a contribution to the HAS-CNGOF task force for the treatment of endometriosis. Available data are heterogeneous and the general level of evidence is moderate. Hormonal treatment is usually offered as the primary option to women suffering from endometriosis. It cannot be used in women willing to conceive. In women who have not been operated, the first line of hormonal treatment includes combined oral contraceptives (COC) and the levonorgestrel-releasing intra uterine system (52mg LNG-IUS). As a second line, desogestrel progestin only pills, etonogestrel implants, GnRH analogs (GnRHa) with add back therapy and dienogest can be offered. Add back therapy should include estrogens to prevent bone loss and improve quality of life, it can be introduced before the third month of treatment to prevent side effects. The literature does not support preoperative hormonal treatment for the sole purpose of reducing complications or recurrence, or facilitating surgical procedures. After surgical treatment, hormonal treatment is recommended to prevent pain recurrence and improve quality of life. COCs or LNG IUS are recommended as a first line. To prevent recurrence of endometriomas COC is advised and maintained as long as tolerance is good in the absence of pregnancy plans. In case of dysmenorrhea, postoperative COC should be used in a continuous scheme. GnRHa are not recommended in the sole purpose of reducing endometrioma recurrence risk.

Resume Historiquement, le depistage du cancer du sein s’est base quasi exclusivement sur le facteur de risque âge pour determiner la strategie d’exploration par mammographie. En France, le critere densite mammaire a egalement ete pris en consideration pour decider d’ajouter une echographie mammaire en cas de seins de type denses ou tres denses. L’emergence de la tomosynthese mammaire associee a la mammographie reconstruite devrait permettre d’optimiser le nombre de cancers du sein detectes tout en reduisant un grand nombre de faux positifs et en limitant la dose d’irradiation, facteurs a l’origine d’une importante controverse actuelle sur la valeur du depistage mammographique par tomosynthese. Hormis, la categorie des patientes a tres haut risque (risque genetique identifie) ou une strategie specifique par IRM mammaire est validee, il est actuellement difficile d’affiner de facon objective la strategie d’exploration en se basant sur la combinaison de facteurs de risque de plus faible impact (antecedents familiaux, nulliparite, impregnation alcoolique, etc.). Aussi, de nouvelles strategies basees sur une evaluation du risque plus personnalise (s’integrant dans une medecine dite de precision) sont a l’etude en Europe (etude « My PEBS ») et aux Etats-Unis (etude « WISDOM ») afin de mieux adapter les examens de depistages a chaque patiente pour maximiser le nombre de cancers detectes en diminuant le nombre de faux positifs.

Resume Objectif L’objectif de ce travail est d’evaluer la place des nouveaux traitements dans la prise en charge de l’endometriose en dehors du contexte d’infertilite. Methodes Une revue de la litterature a ete effectuee en consultant les donnees Medline jusqu’en juillet 2017. Resultats Le dienogest est efficace par rapport au placebo a court terme (NP2) et long terme (NP4) pour le traitement de l’endometriose douloureuse. En comparaison aux agonistes de la GnRH, le dienogest est aussi efficace en termes de diminution de douleur et d’amelioration de la qualite de vie chez les patientes non operees (NP2), de meme que pour la recidive des lesions d’endometriose et la symptomatologie en postoperatoire (NP2). Les donnees concernant les antagonistes de la GnRH, les modulateurs selectifs des recepteurs a la progesterone de meme que les inhibiteurs selectifs (anti-TNF-α, inhibiteurs des metalloproteases matricielles, inhibiteurs des facteurs de croissance de l’angiogenese) sont insuffisantes pour apporter une preuve de l’interet en pratique clinique pour la prise en charge de l’endometriose douloureuse (NP3). Conclusion Le dienogest est recommande en seconde intention pour la prise en charge de l’endometriose douloureuse (Grade B). En l’absence de donnees suffisantes, les anti-aromatases, l’elagolix, les SERM, les SPRM et les anti-TNF-α ne sont pas recommandes pour la prise en charge de l’endometriose douloureuse (Grade C).