Dydrogesterone is proposed as a new treatment for endometriosis. It effectively tackles chronic inflammation associated with endometriosis by reducing proinflammatory cytokines and increasing progesterone receptor expression. Clinical evidence shows that dydrogesterone provides symptomatic relief for endometriosis-related pain and improves quality of life. It also reduces the development of new endometriotic lesions and induces atrophy of ectopic endometrial tissue. Unlike other medications, dydrogesterone does not inhibit ovulation or require estrogen add-back therapy, and it may improve pregnancy outcomes for women with endometriosis.
Dydrogesterone का नया अवतार (Part 1) Dr Sharda Jain Lifecare Centre
This document provides an overview of endometriosis, including:
1. Definitions, symptoms, prevalence, risk factors, and theories of pathogenesis. Chronic inflammation plays a key role in the development and progression of endometriosis.
2. Diagnosis is based on clinical history and laparoscopic inspection with biopsy. Staging uses the ASRM or ENZIAN classification systems. Early diagnosis is important to mitigate symptoms and disease progression.
3. Endometriosis is associated with infertility due to factors like lesions, cysts, inflammation, and hormonal imbalances that create an adverse pelvic environment.
4. Medical therapy is essential as endometriosis cannot be cured,
Role of Dydrogesterone in Recurrent Pregnancy Loss Dr Sharda Jain Lifecare Centre
Dydrogesterone is commonly used by Indian gynecologists to treat recurrent pregnancy loss. It has higher bioavailability than natural micronized progesterone when taken orally. Dydrogesterone has an immunomodulatory effect that may help prevent miscarriage by inhibiting pro-inflammatory cytokines and increasing anti-inflammatory cytokines and progesterone-induced blocking factor production. It also increases uterine and endometrial blood flow by stimulating nitric oxide production. Several studies and meta-analyses indicate dydrogesterone may be more effective than natural micronized progesterone for treating recurrent pregnancy loss when taken orally, due to its higher bioavailability and specific affinity for progesterone receptors.
This document discusses progesterone and its role in female reproduction. It begins by explaining that fertility and menstruation are controlled by hormones, including estrogen and progesterone. Progesterone prepares the uterine lining for pregnancy and supports gestation. Dydrogesterone is then introduced as a synthetic progestogen used to treat gynecological disorders caused by low progesterone levels, such as premenstrual syndrome and recurrent miscarriage. Its mechanism of action, pharmacokinetics, indications, and dosage are described. Finally, a randomized controlled trial is summarized that found dydrogesterone to be as effective as micronized progesterone for luteal support during in vitro fertilization, with the benefit of oral versus vaginal administration.
Luteal phase support in ART Cases Dr Sharda Jain Lifecare Centre
The document discusses luteal phase support in assisted reproductive technology (ART) cycles. It provides 3 key points:
1. Luteal phase deficiency is common in ART cycles due to multiple factors like multifollicular development and aspiration of granulosa cells, leading to premature luteolysis and defective progesterone secretion.
2. Progesterone supplementation is important for luteal phase support as progesterone prepares the endometrium, decreases uterine contractility, and regulates immunity - all of which are important for embryo implantation and maintenance of early pregnancy.
3. Oral dydrogesterone is recommended for luteal phase support in ART cycles due to its greater bioavailability allowing the use of lower doses, minimal side effects
Role of Dydrogesterone in repeated pregnancy lossNiranjan Chavan
Dydrogesterone has been shown to effectively treat recurrent pregnancy loss by modulating the immune system. It shifts the balance from a pro-inflammatory Th1 response towards an anti-inflammatory Th2 response by [1] inhibiting the production of Th1 cytokines IFN-γ and TNF-α and [2] inducing production of the Th2 cytokines IL-4 and IL-6. This results in improved pregnancy outcomes by supporting embryonic development. Clinical studies demonstrate dydrogesterone significantly reduces miscarriage rates in women with recurrent pregnancy loss.
Recurrent pregnancy losses managing the unexplainedravikantraj55
This document discusses recurrent pregnancy losses and managing unexplained causes. It begins with an introduction to Dr. Manju Gita Mishra who has extensive experience in obstetrics and gynecology. The document then covers definitions of recurrent pregnancy loss, common causes, diagnostic evaluation, and treatment options including progesterone supplementation which some studies have found reduces subsequent miscarriage rates in women with unexplained recurrent miscarriages. It discusses challenges in identifying the cause in about 50% of recurrent pregnancy loss cases and stratifying women into those whose losses are likely due to chance versus an underlying abnormality.
Role of Dydrogesterone in Threatened Abortion Dr Sharda Jain Lifecare Centre
*EXPERINCE SHARING By EXPERTS*
Dr Uma Rai(DGF *E*)
Dr Sangeetaa Gupta(DGF *E*)
Dr Neerja Varshney(DGF *E*)
Dr Surjeet Kapoor(DGF *E*)
Dr Rupam arora(DGF *E*)
Dr Meenakshi Ahuja(DGF *S* )
Dr.Harsha khullar(DGF *C* )
Dr Mamta mittal(DGF *N*)
Dr Leena Sreedhar(DGF *D*)
Dr.Dipti Nabh(DGF *E*)
Dr. Shama Batra(DGF *E*)
Dr Poonam Paul(DGF *SW*)
PAN DGF ( DELHI GYNAECOLOGIST FORUM) CME ON DYDROGESTERONE ON 3/2 /22
Dydrogesterone का नया अवतार (Part 1) Dr Sharda Jain Lifecare Centre
This document provides an overview of endometriosis, including:
1. Definitions, symptoms, prevalence, risk factors, and theories of pathogenesis. Chronic inflammation plays a key role in the development and progression of endometriosis.
2. Diagnosis is based on clinical history and laparoscopic inspection with biopsy. Staging uses the ASRM or ENZIAN classification systems. Early diagnosis is important to mitigate symptoms and disease progression.
3. Endometriosis is associated with infertility due to factors like lesions, cysts, inflammation, and hormonal imbalances that create an adverse pelvic environment.
4. Medical therapy is essential as endometriosis cannot be cured,
Role of Dydrogesterone in Recurrent Pregnancy Loss Dr Sharda Jain Lifecare Centre
Dydrogesterone is commonly used by Indian gynecologists to treat recurrent pregnancy loss. It has higher bioavailability than natural micronized progesterone when taken orally. Dydrogesterone has an immunomodulatory effect that may help prevent miscarriage by inhibiting pro-inflammatory cytokines and increasing anti-inflammatory cytokines and progesterone-induced blocking factor production. It also increases uterine and endometrial blood flow by stimulating nitric oxide production. Several studies and meta-analyses indicate dydrogesterone may be more effective than natural micronized progesterone for treating recurrent pregnancy loss when taken orally, due to its higher bioavailability and specific affinity for progesterone receptors.
This document discusses progesterone and its role in female reproduction. It begins by explaining that fertility and menstruation are controlled by hormones, including estrogen and progesterone. Progesterone prepares the uterine lining for pregnancy and supports gestation. Dydrogesterone is then introduced as a synthetic progestogen used to treat gynecological disorders caused by low progesterone levels, such as premenstrual syndrome and recurrent miscarriage. Its mechanism of action, pharmacokinetics, indications, and dosage are described. Finally, a randomized controlled trial is summarized that found dydrogesterone to be as effective as micronized progesterone for luteal support during in vitro fertilization, with the benefit of oral versus vaginal administration.
Luteal phase support in ART Cases Dr Sharda Jain Lifecare Centre
The document discusses luteal phase support in assisted reproductive technology (ART) cycles. It provides 3 key points:
1. Luteal phase deficiency is common in ART cycles due to multiple factors like multifollicular development and aspiration of granulosa cells, leading to premature luteolysis and defective progesterone secretion.
2. Progesterone supplementation is important for luteal phase support as progesterone prepares the endometrium, decreases uterine contractility, and regulates immunity - all of which are important for embryo implantation and maintenance of early pregnancy.
3. Oral dydrogesterone is recommended for luteal phase support in ART cycles due to its greater bioavailability allowing the use of lower doses, minimal side effects
Role of Dydrogesterone in repeated pregnancy lossNiranjan Chavan
Dydrogesterone has been shown to effectively treat recurrent pregnancy loss by modulating the immune system. It shifts the balance from a pro-inflammatory Th1 response towards an anti-inflammatory Th2 response by [1] inhibiting the production of Th1 cytokines IFN-γ and TNF-α and [2] inducing production of the Th2 cytokines IL-4 and IL-6. This results in improved pregnancy outcomes by supporting embryonic development. Clinical studies demonstrate dydrogesterone significantly reduces miscarriage rates in women with recurrent pregnancy loss.
Recurrent pregnancy losses managing the unexplainedravikantraj55
This document discusses recurrent pregnancy losses and managing unexplained causes. It begins with an introduction to Dr. Manju Gita Mishra who has extensive experience in obstetrics and gynecology. The document then covers definitions of recurrent pregnancy loss, common causes, diagnostic evaluation, and treatment options including progesterone supplementation which some studies have found reduces subsequent miscarriage rates in women with unexplained recurrent miscarriages. It discusses challenges in identifying the cause in about 50% of recurrent pregnancy loss cases and stratifying women into those whose losses are likely due to chance versus an underlying abnormality.
Role of Dydrogesterone in Threatened Abortion Dr Sharda Jain Lifecare Centre
*EXPERINCE SHARING By EXPERTS*
Dr Uma Rai(DGF *E*)
Dr Sangeetaa Gupta(DGF *E*)
Dr Neerja Varshney(DGF *E*)
Dr Surjeet Kapoor(DGF *E*)
Dr Rupam arora(DGF *E*)
Dr Meenakshi Ahuja(DGF *S* )
Dr.Harsha khullar(DGF *C* )
Dr Mamta mittal(DGF *N*)
Dr Leena Sreedhar(DGF *D*)
Dr.Dipti Nabh(DGF *E*)
Dr. Shama Batra(DGF *E*)
Dr Poonam Paul(DGF *SW*)
PAN DGF ( DELHI GYNAECOLOGIST FORUM) CME ON DYDROGESTERONE ON 3/2 /22
Dydrogesterone has higher bioavailability (up to 28%) compared to micronized progesterone (less than 10%), allowing it to be effective at a much lower dose of 10-30 mg/day versus 200-300 mg/day for micronized progesterone. Dydrogesterone also causes fewer adverse effects due to its minimal activation of non-progesterone receptors. While dydrogesterone has extensive clinical trial evidence and approvals for threatened miscarriage and progesterone deficiencies, micronized progesterone only has trials and approval for secondary amenorrhea.
Role of progestogens in obstetrics and gynecologyAhmad Saber
The
different progestogens with their overlapping effects on estrogen, androgen, glucocorticoid,
and mineralocorticoid receptors are described in order to allow the clinician to make the most appropriate choice of progestogen.
Dydrogesterone is a progestin hormone used to regulate the healthy growth and shedding of the womb lining. It was first introduced in 1961 and is now approved in over 100 countries. It works by selectively binding to progesterone receptors and has an active metabolite called 20α-dihydrodydrogesterone that is non-sedative. Dydrogesterone is used orally at doses of 5-40 mg daily or via intramuscular injection of 100 mg daily to treat menstrual disorders, prevent miscarriage, treat endometriosis, support fertility, and prevent thickening of the uterine lining during hormone replacement therapy. Common side effects include headaches, breast pain or tenderness, spotting, and changes to menstrual periods
Since the first formal description of LPD in 1949 as a possible cause of infertility and recurrent miscarriage by Jones. Innumerable investigations have been undertaken in an effort to verify its existence or to characterize its pathophysiology, diagnosis, and treatment. The consensus of the literature is that LPD does exist and that its cause is multifactorial like abnormal folliculogenesis, inadequate LH surge,inadequate secretion of progesterone by the corpus luteum, aberrant end-organ response by the endometrium.
It describes the Progesterone physiology. It describes the latest evidence as regards progesterone formulations, use of progesterone as Luteal phase support. It scrutinizes the value of serum progesterone in monitoring luteal phase
Threatened Miscarriage Verdict is out on Hormonal Treatment Dr Jyoti AgarwalLifecare Centre
- Threatened miscarriage occurs in around 15% of clinically recognized pregnancies and can cause significant emotional and psychological stress for couples.
- Multiple meta-analyses and randomized controlled trials have found that oral administration of dydrogesterone is more effective at reducing the risk of miscarriage in cases of threatened miscarriage compared to vaginal progesterone or no treatment.
- Dydrogesterone has higher bioavailability when taken orally compared to micronized progesterone, requires a lower dose, and may have immunomodulatory properties that further reduce the risk of miscarriage.
Evidence for a significant effect in favor of progesterone for luteal phase support. Best result with synthe7c progesterone.
• Evidence that the addi7on of othe substances such as estrogen or hCG doe not improve outcomes.
• Evidence for equivalence of IM and vaginal routes of administra7on. Vaginal route is best tolerated by pa7ents.
• hCG, or hCG plus progesterone, was associated with a higher risk of OHSS. The use of hCG should therefore be avoided.
• Evidence showing a benefit from the addi7on of GnRH agonist to progesterone in luteal phase support
Management : Endometriosis & Pain Dr Sharda Jain Lifecare Centre
1. The document discusses endometriosis and pain management options. It provides an overview of endometriosis and the mechanisms behind the pain associated with the condition.
2. It then summarizes various medical and surgical treatment options for managing endometriosis pain. Medical options discussed include NSAIDs, combined hormonal contraceptives, progestins, GnRH agonists, and aromatase inhibitors. The mechanisms, effectiveness, and side effects of each are outlined.
3. Surgical treatment approaches like conservative and definitive surgery are also summarized. Conservative surgery aims to relieve pain while preserving fertility, while definitive surgery involves oophorectomy or hysterectomy to induce menopause in women who do not desire future
This document provides information on progestins and their use in treating endometriosis. It focuses on dienogest, a new hybrid progestin. It discusses dienogest's pharmacological properties, advantages over other treatments like GnRH agonists, and clinical trial results showing its efficacy and safety. Long-term use of up to 52 weeks is shown to control symptoms with minimal side effects. Dienogest also allows for prompt return of fertility and ovulation after treatment.
Progesterone plays an important role in pregnancy. While progesterone supplementation may reduce miscarriage rates in women with threatened miscarriage or recurrent miscarriage, evidence is still preliminary. The PROMISE trial found no significant difference in live birth rates between progesterone and placebo in women with unexplained recurrent miscarriage. Guidelines provide consensus recommendations but state evidence is still limited. Progesterone appears safe with no significant adverse maternal or fetal effects reported. Further research is still needed to define optimal formulations, doses and durations of progesterone supplementation.
This document summarizes evidence on the use of progesterone to prevent preterm birth. It finds that progesterone reduces the risk of preterm birth before 37 weeks in women with a prior preterm delivery or short cervix. Progesterone may also reduce complications for infants born preterm to mothers receiving it. However, progesterone does not prevent early preterm birth in twin or triplet pregnancies. No long-term harms were seen in children exposed to progesterone prenatally.
Oxidative Stress is a major contributor of unexplained female infertility and male factor infertility.Recent Cochrane database metanalysis suggests there is a low but significant improvement in fertility with use of various micronutrients and antioxidant supplements.
Update on LETROZOLE Current Guidelines for Ovulation Induction Dr. Sharda Jain Lifecare Centre
Update on LETROZOLE Current Guidelines for Ovulation Induction
LET NOT FORGET
WHY
??
LETROZOLE was withdrawn from
Indian market (2012)
“SAFETY ISSUES”
“Could Be Teratogenic In Human”?
This document discusses the use of letrozole for ovulation induction. It begins by explaining how letrozole works at a molecular level to stimulate follicular growth, noting key differences from clomiphene citrate such as not blocking estrogen receptors and maintaining feedback inhibition. Clinical studies are then summarized finding letrozole to have higher ovulation and live birth rates than clomiphene citrate, especially in women with PCOS or who are clomiphene citrate resistant. The document concludes by stating letrozole has been used successfully for ovulation induction in PCOS, intrauterine insemination, and ovarian stimulation for IVF/ICSI.
This document discusses gonadotropin ovarian stimulation. It begins by describing the different types of anovulation and ovarian stimulation protocols. It then discusses the different types of gonadotropin (Gnt) preparations including urinary and recombinant gonadotropins. Patient selection criteria and indications for ovarian stimulation are outlined. A low-dose step-up protocol is recommended to reduce risks of ovarian hyperstimulation syndrome and multiple pregnancies. Monitoring involves ultrasounds and bloodwork. Ovulation rates are over 90% while pregnancy rates range from 5-90% depending on factors. Complications include ovarian hyperstimulation syndrome and multiple pregnancies.
DHEA supplementation can improve ovarian reserve and fertility outcomes in women with diminished ovarian reserve. It acts early in follicle development to stimulate growth and maturation. Studies show DHEA increases levels of AMH, the number of eggs and embryos retrieved in IVF, and pregnancy rates while decreasing cancellation rates. The optimal dosage is 25mg three times daily until pregnancy is achieved. DHEA is not recommended for PCOS patients unless they have low testosterone levels and are poor responders.
This document summarizes the role of progesterone in different contexts. It discusses how progesterone prepares the endometrium for implantation and supports early pregnancy. It reviews evidence from meta-analyses and clinical trials on the use of progesterone to prevent miscarriage in women with recurrent miscarriage, finding a beneficial effect. The document also examines evidence related to progesterone supplementation for luteal phase support in IVF cycles and for treating threatened abortion, finding current evidence is limited and more research is still needed.
Optimizing The outcome of Threatened Abortion Dr Sharda Jain Lifecare Centre
- Around 70% of conceptions are lost prior to live birth, with 30% lost before implantation and 30% after implantation but before a missed period. Threatened abortion refers to vaginal bleeding or pain, or both, in early pregnancy when the cervical os remains closed.
- Studies have shown that counseling reduces adverse psychological effects from miscarriage. Treatment with dydrogesterone has been shown to reduce pregnancy loss in threatened abortion during the first trimester compared to placebo or no treatment. However, treatment with vaginal progesterone compared to placebo appears to have little effect on reducing miscarriage rates.
- Meta-analyses of multiple randomized controlled trials found that treatment with dydrogesterone for threatened miscarriage significantly reduced miscarriage
Cabgolin in Endometriosis - Recent advances.pptxVidushRatan1
This document discusses endometriosis, a condition where endometrial-type mucosa grows outside the uterine cavity. It predominantly affects women during their reproductive years and is associated with pelvic pain and infertility. The exact prevalence is unknown due to reliance on surgical visualization for diagnosis. Current medical therapies include analgesics, hormonal therapies, and GnRH analogues which have side effects. Surgical treatments also carry risks. The document discusses the role of angiogenesis in the pathogenesis and survival of endometriotic lesions. Emerging evidence suggests estrogens can both promote and inhibit endometrial vessel growth. Anti-angiogenic treatments have shown success in experimental models by inhibiting new vessel formation. Dopamine agonists like cabergoline are
Dydrogesterone has higher bioavailability (up to 28%) compared to micronized progesterone (less than 10%), allowing it to be effective at a much lower dose of 10-30 mg/day versus 200-300 mg/day for micronized progesterone. Dydrogesterone also causes fewer adverse effects due to its minimal activation of non-progesterone receptors. While dydrogesterone has extensive clinical trial evidence and approvals for threatened miscarriage and progesterone deficiencies, micronized progesterone only has trials and approval for secondary amenorrhea.
Role of progestogens in obstetrics and gynecologyAhmad Saber
The
different progestogens with their overlapping effects on estrogen, androgen, glucocorticoid,
and mineralocorticoid receptors are described in order to allow the clinician to make the most appropriate choice of progestogen.
Dydrogesterone is a progestin hormone used to regulate the healthy growth and shedding of the womb lining. It was first introduced in 1961 and is now approved in over 100 countries. It works by selectively binding to progesterone receptors and has an active metabolite called 20α-dihydrodydrogesterone that is non-sedative. Dydrogesterone is used orally at doses of 5-40 mg daily or via intramuscular injection of 100 mg daily to treat menstrual disorders, prevent miscarriage, treat endometriosis, support fertility, and prevent thickening of the uterine lining during hormone replacement therapy. Common side effects include headaches, breast pain or tenderness, spotting, and changes to menstrual periods
Since the first formal description of LPD in 1949 as a possible cause of infertility and recurrent miscarriage by Jones. Innumerable investigations have been undertaken in an effort to verify its existence or to characterize its pathophysiology, diagnosis, and treatment. The consensus of the literature is that LPD does exist and that its cause is multifactorial like abnormal folliculogenesis, inadequate LH surge,inadequate secretion of progesterone by the corpus luteum, aberrant end-organ response by the endometrium.
It describes the Progesterone physiology. It describes the latest evidence as regards progesterone formulations, use of progesterone as Luteal phase support. It scrutinizes the value of serum progesterone in monitoring luteal phase
Threatened Miscarriage Verdict is out on Hormonal Treatment Dr Jyoti AgarwalLifecare Centre
- Threatened miscarriage occurs in around 15% of clinically recognized pregnancies and can cause significant emotional and psychological stress for couples.
- Multiple meta-analyses and randomized controlled trials have found that oral administration of dydrogesterone is more effective at reducing the risk of miscarriage in cases of threatened miscarriage compared to vaginal progesterone or no treatment.
- Dydrogesterone has higher bioavailability when taken orally compared to micronized progesterone, requires a lower dose, and may have immunomodulatory properties that further reduce the risk of miscarriage.
Evidence for a significant effect in favor of progesterone for luteal phase support. Best result with synthe7c progesterone.
• Evidence that the addi7on of othe substances such as estrogen or hCG doe not improve outcomes.
• Evidence for equivalence of IM and vaginal routes of administra7on. Vaginal route is best tolerated by pa7ents.
• hCG, or hCG plus progesterone, was associated with a higher risk of OHSS. The use of hCG should therefore be avoided.
• Evidence showing a benefit from the addi7on of GnRH agonist to progesterone in luteal phase support
Management : Endometriosis & Pain Dr Sharda Jain Lifecare Centre
1. The document discusses endometriosis and pain management options. It provides an overview of endometriosis and the mechanisms behind the pain associated with the condition.
2. It then summarizes various medical and surgical treatment options for managing endometriosis pain. Medical options discussed include NSAIDs, combined hormonal contraceptives, progestins, GnRH agonists, and aromatase inhibitors. The mechanisms, effectiveness, and side effects of each are outlined.
3. Surgical treatment approaches like conservative and definitive surgery are also summarized. Conservative surgery aims to relieve pain while preserving fertility, while definitive surgery involves oophorectomy or hysterectomy to induce menopause in women who do not desire future
This document provides information on progestins and their use in treating endometriosis. It focuses on dienogest, a new hybrid progestin. It discusses dienogest's pharmacological properties, advantages over other treatments like GnRH agonists, and clinical trial results showing its efficacy and safety. Long-term use of up to 52 weeks is shown to control symptoms with minimal side effects. Dienogest also allows for prompt return of fertility and ovulation after treatment.
Progesterone plays an important role in pregnancy. While progesterone supplementation may reduce miscarriage rates in women with threatened miscarriage or recurrent miscarriage, evidence is still preliminary. The PROMISE trial found no significant difference in live birth rates between progesterone and placebo in women with unexplained recurrent miscarriage. Guidelines provide consensus recommendations but state evidence is still limited. Progesterone appears safe with no significant adverse maternal or fetal effects reported. Further research is still needed to define optimal formulations, doses and durations of progesterone supplementation.
This document summarizes evidence on the use of progesterone to prevent preterm birth. It finds that progesterone reduces the risk of preterm birth before 37 weeks in women with a prior preterm delivery or short cervix. Progesterone may also reduce complications for infants born preterm to mothers receiving it. However, progesterone does not prevent early preterm birth in twin or triplet pregnancies. No long-term harms were seen in children exposed to progesterone prenatally.
Oxidative Stress is a major contributor of unexplained female infertility and male factor infertility.Recent Cochrane database metanalysis suggests there is a low but significant improvement in fertility with use of various micronutrients and antioxidant supplements.
Update on LETROZOLE Current Guidelines for Ovulation Induction Dr. Sharda Jain Lifecare Centre
Update on LETROZOLE Current Guidelines for Ovulation Induction
LET NOT FORGET
WHY
??
LETROZOLE was withdrawn from
Indian market (2012)
“SAFETY ISSUES”
“Could Be Teratogenic In Human”?
This document discusses the use of letrozole for ovulation induction. It begins by explaining how letrozole works at a molecular level to stimulate follicular growth, noting key differences from clomiphene citrate such as not blocking estrogen receptors and maintaining feedback inhibition. Clinical studies are then summarized finding letrozole to have higher ovulation and live birth rates than clomiphene citrate, especially in women with PCOS or who are clomiphene citrate resistant. The document concludes by stating letrozole has been used successfully for ovulation induction in PCOS, intrauterine insemination, and ovarian stimulation for IVF/ICSI.
This document discusses gonadotropin ovarian stimulation. It begins by describing the different types of anovulation and ovarian stimulation protocols. It then discusses the different types of gonadotropin (Gnt) preparations including urinary and recombinant gonadotropins. Patient selection criteria and indications for ovarian stimulation are outlined. A low-dose step-up protocol is recommended to reduce risks of ovarian hyperstimulation syndrome and multiple pregnancies. Monitoring involves ultrasounds and bloodwork. Ovulation rates are over 90% while pregnancy rates range from 5-90% depending on factors. Complications include ovarian hyperstimulation syndrome and multiple pregnancies.
DHEA supplementation can improve ovarian reserve and fertility outcomes in women with diminished ovarian reserve. It acts early in follicle development to stimulate growth and maturation. Studies show DHEA increases levels of AMH, the number of eggs and embryos retrieved in IVF, and pregnancy rates while decreasing cancellation rates. The optimal dosage is 25mg three times daily until pregnancy is achieved. DHEA is not recommended for PCOS patients unless they have low testosterone levels and are poor responders.
This document summarizes the role of progesterone in different contexts. It discusses how progesterone prepares the endometrium for implantation and supports early pregnancy. It reviews evidence from meta-analyses and clinical trials on the use of progesterone to prevent miscarriage in women with recurrent miscarriage, finding a beneficial effect. The document also examines evidence related to progesterone supplementation for luteal phase support in IVF cycles and for treating threatened abortion, finding current evidence is limited and more research is still needed.
Optimizing The outcome of Threatened Abortion Dr Sharda Jain Lifecare Centre
- Around 70% of conceptions are lost prior to live birth, with 30% lost before implantation and 30% after implantation but before a missed period. Threatened abortion refers to vaginal bleeding or pain, or both, in early pregnancy when the cervical os remains closed.
- Studies have shown that counseling reduces adverse psychological effects from miscarriage. Treatment with dydrogesterone has been shown to reduce pregnancy loss in threatened abortion during the first trimester compared to placebo or no treatment. However, treatment with vaginal progesterone compared to placebo appears to have little effect on reducing miscarriage rates.
- Meta-analyses of multiple randomized controlled trials found that treatment with dydrogesterone for threatened miscarriage significantly reduced miscarriage
Cabgolin in Endometriosis - Recent advances.pptxVidushRatan1
This document discusses endometriosis, a condition where endometrial-type mucosa grows outside the uterine cavity. It predominantly affects women during their reproductive years and is associated with pelvic pain and infertility. The exact prevalence is unknown due to reliance on surgical visualization for diagnosis. Current medical therapies include analgesics, hormonal therapies, and GnRH analogues which have side effects. Surgical treatments also carry risks. The document discusses the role of angiogenesis in the pathogenesis and survival of endometriotic lesions. Emerging evidence suggests estrogens can both promote and inhibit endometrial vessel growth. Anti-angiogenic treatments have shown success in experimental models by inhibiting new vessel formation. Dopamine agonists like cabergoline are
This document provides an overview of endometriosis from Dr. S.N. Sethi. Some key points:
- Endometriosis is often misdiagnosed, taking an average of 8 years to diagnose correctly.
- It is estrogen-dependent and invasive, with lesions found in various locations besides the uterus.
- Symptoms include pelvic pain and infertility. Dienogest is highlighted as an effective long-term medical treatment that provides pain relief and few side effects.
- Studies show Dienogest significantly reduces endometriosis lesions and symptoms compared to placebo and has similar efficacy to leuprolide with fewer side effects.
Dienogest+ Ethinyl Estradiol Role in oral contraception & Acne Dr Sharda Jain...Lifecare Centre
Dienogest + Ethinyl Estradiol is a combination oral contraceptive pill that provides contraception and treats mild to moderate acne. It contains the 4th generation progestin Dienogest and the estrogen Ethinyl Estradiol. Dienogest has anti-androgenic properties and does not have the side effects seen with other progestins like weight gain, acne, or changes in lipids. It works primarily by suppressing gonadotropins to inhibit ovulation and by changing cervical mucus to block sperm entry. Clinical trials demonstrate it is effective contraception with fewer side effects than other pills.
1. Ulipristal acetate is a selective progesterone receptor modulator approved for treatment of uterine fibroids. It binds to progesterone receptors and blocks their action, reducing fibroid size and symptoms without affecting estrogen levels.
2. Studies showed ulipristal acetate effectively controlled bleeding and reduced fibroid volumes more rapidly than leuprolide acetate. It maintained fertility without significant safety issues.
3. Long term treatment with ulipristal acetate provided sustained control of bleeding and pain, with shrinkage of fibroid volumes maintained during off treatment periods. Quality of life was improved.
The document summarizes gonadal hormones and their inhibitors. It discusses synthetic estrogens and their clinical uses, including for primary hypogonadism, postmenopausal hormonal therapy, and contraception. It also covers progestins, their classification and clinical uses. Adverse effects and contraindications of estrogens are mentioned. Selective estrogen receptor modulators, aromatase inhibitors, and other hormones and their inhibitors are also summarized.
Endometriomas (chocolate cysts) are associated with infertility in 17-44% of endometriosis cases. Sampson's theory of retrograde menstruation leading to implantation and growth of endometrial tissue is still widely accepted, but does not fully explain all cases of endometriosis. Factors like genetic predisposition, immunological and hormonal changes, oxidative stress, and environmental toxins likely all contribute to the initiation and maintenance of endometriosis. The disease and associated endometriomas can cause infertility through effects on the endometrium like dysregulation of genes important for embryo implantation, and increased inflammatory cytokines that are cytotoxic and disrupt the uterine environment.
The document discusses various topics related to contraception including:
1. Temporary contraceptive methods like pills, patches, rings, and injections act by stopping ovulation and thickening cervical mucus. They come in various hormone formulations and dosages.
2. Long-acting reversible contraceptives like IUDs and implants can provide contraception for years. IUDs with progestins can suppress ovulation while implants release progestins to thicken cervical mucus.
3. Other methods discussed include vaginal microbicides, tubal occlusion procedures, and emerging male contraceptives that aim to suppress sperm production.
The document provides a high-level overview of many common reversible contraceptive options,
Uterine Fibroids: Symptoms, Causes, Risk Factors & Treatment uterine fibroids aren't associated with an increased risk of uterine cancer and almost never develop into cancer
Recent advances in endometriosis were discussed. Endometriosis is a chronic disease where endometrial tissue grows outside the uterus, affecting around 10% of women. Dienogest, a progestin, was shown to be effective in reducing endometriosis-associated pelvic pain in randomized controlled trials. Dienogest 2mg daily for 24 weeks provided pain relief similar to leuprolide acetate but with fewer side effects. Long-term use of dienogest for 65 weeks maintained pain relief with a favorable safety profile. Dienogest was as effective as goserelin in reducing postoperative recurrence of endometriosis at 24 months.
ENDOMETRIOSIS UPDATEFocus on Dienogest Dr Sharda jain dr Jyoti Agarwal Lifecare Centre
ENDOMETRIOSIS UPDATEFocus on Dienogest
AGENDA
Background
What’s New in Endometriosis
Clinical Discussions in Managing Endometriosis
Newer Evidences on Dienogest
Uterine fibroids are noncancerous growths of the uterus that often appear during childbearing years. Also called leiomyomas (lie-o-my-O-muhs) or myomas, uterine fibroids aren't associated with an increased risk of uterine cancer and almost never develop into cancer.
Fibroids range in size from seedlings, undetectable by the human eye, to bulky masses that can distort and enlarge the uterus. You can have a single fibroid or multiple ones. In extreme cases, multiple fibroids can expand the uterus so much that it reaches the rib cage and can add weight.
Symptoms:
Many women who have fibroids don't have any symptoms. In those that do, symptoms can be influenced by the location, size and number of fibroids.
In women who have symptoms, the most common signs and symptoms of uterine fibroids include:
Heavy menstrual bleeding
Menstrual periods lasting more than a week
Pelvic pressure or pain
Frequent urination
Difficulty emptying the bladder
Constipation
Backache or leg pains
Endometriosis is a painful and debilitating disease where endometrial tissue grows outside the uterus, most commonly on the ovaries, fallopian tubes, and surrounding tissues. It is a benign condition that can spread in a manner similar to cancer. While its exact causes are unknown, theories include retrograde menstruation through the fallopian tubes and dissemination through other means. Diagnosis involves clinical examination, ultrasound, MRI, and laparoscopy. Treatment aims to relieve pain and treat infertility, and involves medical therapies like hormonal drugs or surgery to remove endometrial growths. Recurrence rates after treatment remain high, and the condition poses challenges to fertility. Further research seeks new biomarkers and better understanding of
LUTEAL PHASE SUPPORT CHOOSING THE RIGHT PROGESTERONEDr. Girija Wagh
Increasing maternal age, need for assited reproduction also has increased the need for appropriate luteal phase support During the luteal phase of the menstrual cycle, progesterone plays a crucial role in preparing the uterine lining for potential embryo implantation. In assisted reproductive technologies (ART) and fertility treatments, optimizing luteal phase support is essential for successful outcomesAdministering exogenous (external) progesterone during the luteal phase is associated with significantly higher pregnancy rates compared to placebo or no treatmentWomen undergoing ART are appropriate candidates for luteal phase supportchoosing the right progesterone for luteal phase support is critical for optimizing fertility treatments. Collaboration among specialists ensures better outcomes for patients
This document provides guidelines for the management of menorrhagia (abnormal uterine bleeding). It discusses medical management including hormonal therapies like combined oral contraceptives and progestogens. It also discusses minimally invasive surgical procedures for endometrial ablation like hysteroscopic ablation and newer techniques like microwave and radiofrequency ablation. Other procedures mentioned include uterine artery embolization and hysterectomy if other options fail. It provides details on treatment approaches, expected outcomes, advantages and disadvantages of different treatment modalities.
PANEL DISCUSSION ON ENDOMETRIOSIS IN ADOLESCENTS (2018 )Lifecare Centre
PANEL DISCUSSION ON ENDOMETRIOSIS IN ADOLESCENTS (2018 ) MODERATOR
DR SHARDA JAIN
DR ILA GUPTA
DR DIPTI NABH
panelist
UMA RAI
RAJ BOKARIA
JYOTI AGARWAL
JYOTI BHASKER
RENU CHAWLA
DIPTI NABH
VANDANA GUPTA
The thin endometrium refers to the lining of the uterus, known as the endometrium, being insufficiently thick. This condition is typically characterized by a reduced thickness of the endometrial layer, which plays a crucial role in supporting the implantation and development of a fertilized egg during the menstrual cycle.
A thin endometrium is commonly associated with hormonal imbalances, such as low estrogen levels, which are vital for the growth and maintenance of the endometrial tissue. Inadequate blood flow to the uterus, chronic inflammation, or certain medical conditions can also contribute to this condition. Women with a thin endometrium may experience difficulties in achieving and maintaining pregnancy, as the thin lining may not provide an optimal environment for the embryo to implant and thrive.
Addressing the underlying causes of a thin endometrium often involves hormonal therapies to regulate estrogen levels, lifestyle modifications, and sometimes surgical interventions. Fertility treatments, such as in vitro fertilization (IVF), may be considered to overcome the challenges associated with a thin endometrium.
In conclusion, a thin endometrium can pose challenges to fertility and reproductive health, requiring a comprehensive approach to address the underlying factors and improve the chances of successful conception.
This document discusses various methods of contraception, including natural methods, barrier methods, intrauterine devices, implants, injections, oral contraceptives, and emergency contraception. It provides details on the mechanisms of action, effectiveness, and side effects of different hormonal contraceptives containing progestins and/or estrogens, such as combined oral contraceptives, progestin-only pills, contraceptive patches, vaginal rings, and injectables. The document also discusses criteria for use and cautions for different contraceptive methods.
Similar to Deck on current treatment approaches in endometriosis (PART II) Dr Jyoti AgARWAL Dr Sharda Jain (20)
The Newer Concepts In Endometriosis Management : Dr Sharda JainLifecare Centre
The Newer Concepts In
Endometriosis Management
ENDOMETRIOSIS IS ENIGMA
DIAGNOSTIC DELEMMA
DEBILITATING DISEASE QOL
PROGRESSIVE DISEASE
RECURRENCE IS BIG PROBLEM
NO FINAL VERDICT ON CAUSE
NO PERMANENT CURE
The exact prevalence of endometriosis is unknown, but estimates 10% in the general female population in India but up to 50% in infertile women
The Newer Concepts forReduced Surgery to preserve fertility in Endometrios...Lifecare Centre
The Newer Concepts forReduced Surgery to preserve fertility in Endometriosis
ENDOMETRIOSIS IS ENIGMA
DIAGNOSTIC DILEMMA
DEBILITATING DISEASE QOL
PROGRESSIVE DISEASE
RECURRENCE IS BIG PROBLEM
NO FINAL VERDICT ON CAUSE
NO PERMANENT CURE
The exact prevalence of endometriosis is unknown, but estimates 10% in the general female population in India but up to 50% in infertile women
Anemia Free India Gynaecologist to focuss on *12gm Haemoglobin at Delivery I...Lifecare Centre
Important Highlights
Prophylactic Iron and Folic Acid Supplementation in all six target age groups.
Intensified year-round Behaviour Change Communication (BCC) Campaign for:(a) improving compliance to IFA and deworming, (b) enhancing appropriate infant and young child feeding practices, (c) encouraging increase in intake of iron-rich food through diet and/or fortified foods (d) ensuring delayed cord clamping .
Testing and treatment of anaemia, using digital methods and point of care treatment, with special focus on pregnant women and school-going adolescents.
Addressing non-nutritional causes of anaemia
in endemic pockets with special focus on malaria, hemoglobinopathies and fluorosis
Liver Dialogue for Gynaecologists : Dr Sharda JainLifecare Centre
This document discusses the functions of the liver and various liver function tests. It notes that the liver has important metabolic, excretory, protective, hematological, synthetic and storage functions. It then describes several common liver function tests including SGPT, SGOT, GGT, ALP, bilirubin, total protein, albumin, PT, bleeding time and clotting time. It provides details on the clinical significance, normal ranges and potential causes of interference for each of these tests. The document emphasizes that liver function tests can help screen for and diagnose liver dysfunction, assess prognosis, and monitor response to therapy.
National Tuberculosis elimination programme (NIKSHAY)Big Challenge to GOI : ...Lifecare Centre
India has a high tuberculosis (TB) burden, accounting for approximately 50% of global cases. The Government of India's National Tuberculosis Elimination Program (NTEP) aims to eliminate TB in India by 2025 through programs like NIKSHAY and NIKSHAY MITRA SCHEME. However, India faces significant challenges to eliminating TB, including delays in diagnosis, drug-resistant strains, poor treatment adherence, stigma, comorbidity with HIV/AIDS, weaknesses in healthcare infrastructure, and social determinants like poverty and overcrowding. Overcoming these challenges will require sustained political will, funding, and strengthened surveillance and monitoring systems.
This document discusses innovations and breakthroughs in in vitro fertilization (IVF). It covers the following topics in 3 sentences or less:
Genetic screening techniques like preimplantation genetic diagnosis (PGD) and preimplantation genetic screening (PGS) are discussed to select embryos without genetic disorders or the highest chance of implantation. Time-lapse monitoring is presented as a way to continuously monitor embryo development in real-time without disruptions. Stem cell therapy and its potential role in inducing ovarian regeneration and sustained ovarian function is briefly covered.
Strategies for Improving Success Rates in ART PARTLifecare Centre
Strategies for Improving Success Rates in ART
Part - 2
Strategies for Improving Success Rates in ART
Tailoring Controlled Ovarian Stimulation
Strategies for Luteal Phase in ART cycles
Endometrial Receptivity Array
20 Simple ways for the Indian public to save water on World Water Day : Dr Sh...Lifecare Centre
Simple ways for the Indian public to save water on World Water Day include fixing leaks, installing faucet aerators to reduce water flow, and taking shorter showers. Other tips are to turn off taps when not in use, collect rainwater, and reuse greywater from washing for gardening. People should also use buckets instead of hoses for tasks like washing vehicles and water plants wisely to minimize evaporation.
Vaccination during Pregnancy & its Importance : Dr Sharda JainLifecare Centre
This document discusses the importance of vaccination during pregnancy. Some key points:
- Global and national health authorities recommend vaccines for influenza, tetanus, diphtheria, and pertussis during pregnancy to protect both mother and baby. Maternal immunization provides passive immunity to newborns.
- Pregnant women and young infants are especially vulnerable to certain infections. Vaccination of mothers during pregnancy is the most effective strategy to protect newborns who are too young for certain vaccines.
- Clinical trials have shown vaccines such as the Tdap and influenza vaccines to be generally safe and effective for pregnant women and their infants. Maternal immunization has significantly reduced disease in newborns for illnesses like
How to optimize success rates in ART? : Dr Sharda JainLifecare Centre
How to optimize success rates in ART? : Dr Sharda Jain
How to improve success rates in ART?
The big debate कार्य में आनंद
Evolution of In-vitro Fertilization (IVF)
Factors Influencing IVF Success Ist Part
Strategies for Improving Success Rates in ART Second Part
Innovations & Breakthroughs in IVF Part Three
OPEN DEBATE
SOCIALEGG FREEZING : Dr Poorva Bhargav and Dr Sharda JainLifecare Centre
SOCIALEGG FREEZING : Dr Poorva Bhargav and Dr Sharda Jain
Introduction
Social egg freezing (oocyte cryopreservation for non-medical reasons) has evolved as a proactive option for women looking to extend their reproductive possibilities past their peak childbearing years
It is the process of saving or protecting eggs, or reproductive tissues so that a person can use them to have biological children in future
White Coat Hypertension During Pregnancy : Dr Sharda JainLifecare Centre
During pregnancy, white coat hypertension has an average prevalence of 15% to 30%. While 60-70% of detected cases of white coat hypertension actually have true gestational hypertension or pre-existing essential hypertension that require monitoring and treatment. Choices of anti-hypertension medication during pregnancy need to be considered carefully.
White Coat hypertension Why it is Important? : Dr Sharda JainLifecare Centre
This document outlines an epidemiology and definitions presentation on hypertension. It discusses types of hypertension like white coat hypertension, where anxiety in a medical environment causes abnormally high readings. Isolated systolic hypertension is also covered, noting that systolic blood pressure is a more important risk factor after age 50. Statistics are provided on hypertension being a major cause of premature death worldwide and its prevalence in India. The summary concludes that white coat hypertension has a prevalence of 20-35% and is associated with minimal increased risk, though 60-70% of cases ultimately have true hypertension requiring treatment and monitoring.
Know Your Blood Pressure Understanding Blood Pressure Reading : Dr Sharda JainLifecare Centre
Hypertension, or high blood pressure, affects over a quarter of the global adult population. A blood pressure reading contains two numbers that indicate systolic and diastolic pressure. There are different types of hypertension including primary or essential hypertension and secondary hypertension caused by an underlying medical condition.
This document provides an overview of stillbirths including definitions, epidemiology, etiology, approaches to management of stillbirth cases and subsequent pregnancies. It notes that the stillbirth rate in India in 2021 was 12.4 per 1000 births. Investigating the causes of stillbirth involves examining the mother, fetus, placenta and membranes through history, examinations, tests and potentially an autopsy. Managing subsequent pregnancies after a stillbirth includes increased surveillance and optimizing any medical conditions to reduce recurrence risks. The aim is to reduce India's stillbirth rate to 10 per 1000 births by 2030.
IRON DEFICIENCY ANEMIA OVERVIEW WITH FOCUS ON PARENTRAL IRON THERAPY : Dr ...Lifecare Centre
This document provides an overview of iron deficiency anemia with a focus on parental iron therapy. Some key points:
- Iron deficiency anemia affects around 2 billion people globally and has a prevalence of 50.1% among pregnant women in India.
- Parenteral iron therapies like ferric carboxymaltose are recommended for pregnant women who are anemic late in pregnancy or those with low compliance to oral iron due to the ability to deliver a complete replacement dose in a single infusion.
- Ferric carboxymaltose has advantages over earlier parenteral iron formulations as it is a robust carbohydrate-iron complex that allows for higher dosing, has a shorter infusion time, and has a
CHECK LIST FOR ART SPECIALIST BEFORE IVF-ICSI FOR PATIENTS SEEKING IVF -ICSI ...Lifecare Centre
The document provides a checklist for an ART specialist to follow before performing IVF-ICSI treatment for patients. It outlines several areas to evaluate including conducting medical evaluations of both partners, assessing fertility through testing, providing psychological evaluation and counseling, reviewing lifestyle factors and making modifications, ensuring vaccinations are up to date, screening for infections, considering genetic testing, providing preconception care, discussing financial aspects and consent forms, explaining the ovarian stimulation and embryo transfer processes, and scheduling follow up appointments. The specialist should tailor the checklist to each patient's specific needs and circumstances and provide clear communication and support throughout the IVF-ICSI process.
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
TEST BANK For Community and Public Health Nursing: Evidence for Practice, 3rd...Donc Test
TEST BANK For Community and Public Health Nursing: Evidence for Practice, 3rd Edition by DeMarco, Walsh, Verified Chapters 1 - 25, Complete Newest Version TEST BANK For Community and Public Health Nursing: Evidence for Practice, 3rd Edition by DeMarco, Walsh, Verified Chapters 1 - 25, Complete Newest Version TEST BANK For Community and Public Health Nursing: Evidence for Practice, 3rd Edition by DeMarco, Walsh, Verified Chapters 1 - 25, Complete Newest Version Test Bank For Community and Public Health Nursing: Evidence for Practice 3rd Edition Pdf Chapters Download Test Bank For Community and Public Health Nursing: Evidence for Practice 3rd Edition Pdf Download Stuvia Test Bank For Community and Public Health Nursing: Evidence for Practice 3rd Edition Study Guide Test Bank For Community and Public Health Nursing: Evidence for Practice 3rd Edition Ebook Download Stuvia Test Bank For Community and Public Health Nursing: Evidence for Practice 3rd Edition Questions and Answers Quizlet Test Bank For Community and Public Health Nursing: Evidence for Practice 3rd Edition Studocu Test Bank For Community and Public Health Nursing: Evidence for Practice 3rd Edition Quizlet Test Bank For Community and Public Health Nursing: Evidence for Practice 3rd Edition Stuvia Community and Public Health Nursing: Evidence for Practice 3rd Edition Pdf Chapters Download Community and Public Health Nursing: Evidence for Practice 3rd Edition Pdf Download Course Hero Community and Public Health Nursing: Evidence for Practice 3rd Edition Answers Quizlet Community and Public Health Nursing: Evidence for Practice 3rd Edition Ebook Download Course hero Community and Public Health Nursing: Evidence for Practice 3rd Edition Questions and Answers Community and Public Health Nursing: Evidence for Practice 3rd Edition Studocu Community and Public Health Nursing: Evidence for Practice 3rd Edition Quizlet Community and Public Health Nursing: Evidence for Practice 3rd Edition Stuvia Community and Public Health Nursing: Evidence for Practice 3rd Edition Test Bank Pdf Chapters Download Community and Public Health Nursing: Evidence for Practice 3rd Edition Test Bank Pdf Download Stuvia Community and Public Health Nursing: Evidence for Practice 3rd Edition Test Bank Study Guide Questions and Answers Community and Public Health Nursing: Evidence for Practice 3rd Edition Test Bank Ebook Download Stuvia Community and Public Health Nursing: Evidence for Practice 3rd Edition Test Bank Questions Quizlet Community and Public Health Nursing: Evidence for Practice 3rd Edition Test Bank Studocu Community and Public Health Nursing: Evidence for Practice 3rd Edition Test Bank Quizlet Community and Public Health Nursing: Evidence for Practice 3rd Edition Test Bank Stuvia
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Our backs are like superheroes, holding us up and helping us move around. But sometimes, even superheroes can get hurt. That’s where slip discs come in.
Osteoporosis - Definition , Evaluation and Management .pdfJim Jacob Roy
Osteoporosis is an increasing cause of morbidity among the elderly.
In this document , a brief outline of osteoporosis is given , including the risk factors of osteoporosis fractures , the indications for testing bone mineral density and the management of osteoporosis
2. Causes
progesterone
resistance in the
endometrium
Repetitive retrograde endometrial
shedding exacerbates
progesterone resistance
Endometriotic lesions and surrounding
peritoneal fluid are rich in reactive oxygen
species
Chronic inflammation
Oxidative stress
Dydrogesterone effectively
tackles chronic inflammation
Increasing progesterone
receptor expression
Decreasing proinflammatory
cytokines
Dydrogesterone exerts
endothelial anti-
inflammatory actions via a
decrease in expression of
leukocyte adhesion
molecules.
Progesterone Action is Crucial to Decrease
Inflammation In The Endometrium
3. Dydrogesterone Effectively Tackles Chronic Inflammation
Associated With Endometriosis
Reduces TNF-α-induced
NF-κ-activation and
suppresses proliferation of
endometriotic stroma
cells.
Suppresses IL-8 production
in lymphocytes.
Increases NO production
that plays an anti-
inflammatory role.
IL-8
TNF-α
Lymphocyte
Stromal cell in
endometriotic implant
TNF-α-induced
NF-Кβ activation
induces proliferation
Growth factors
Neoangiogenesis
DYD
Acts on
Proliferation
DYD
TNF-α-induced
upregulation
DYD reduces
Influence of dydrogesterone on TNF-α and IL-8–induced inflammatory
reactions in lymphocytes and proliferation of endometriotic stromal cells
4. Dydrogesterone Enhances Quality of Life and Reproductive
Health as it leads to
Endometriosis therapy should enhance quality of life and
reproductive health
No inhibition of
ovulation
Reduction in
pain symptoms/
size of
endometriosis
lesions
Improvement in
quality of life
parameters
Improved
pregnancy
outcomes
7. Cyclic application
(days 5–25 of cycle)
10–20 mg for 4
months provides
symptomatic relief to
women with
dysmenorrhea
Fewer days of bleeding
60% decrease in abdominal
cramping and pain
Reduction in severity of headache
and nausea/vomiting
Dydrogesterone
Was first reported to be effective in endometriosis in the 1960s
The overall success rate is around 90%
reduction in the number/severity of symptoms
Laparoscopic examination in several of the studies supports its usage
8. Baseline After therapy
Mean laparoscopic scoring of severity 14.5±8.6 2.1±3.4
15%
improvement
75%
elimination
Laparoscopic examination
of endometriosis
Kaiser E, Wagner ThA. TW Gynäkologie.1989;2:386–388.
Dydrogesterone: 10 mg per day from
5th to 15th day; 20 mg per day from
16th to 25th day of each cycle.
20 patients
Duration of treatment:
6–9 months
4 cases
15 out of 20
Laparoscopic examination confirmed elimination of endometriosis in 15 out of
20 (75%) cases and improvement of endometriosis in another 4 cases (15%)
9. Dydrogesterone inhibit development of
new endometriotic lesions
Dydrogesterone
Reduced
CYR61 and VEGFA
gene expression1
Reductions in:1
• neoangiogenesis
• blood vessel density
Reduced proliferation
of endometriotic
stromal cells1,2
Dydrogesterone can reduce the expression of transcription factors and growth factors
involved with the establishment and maintenance of endometriotic lesions
Reduced
development of
endometriotic
lesions
Reduced MMP
gene expression1
Reduced extracellular degradation
of the peritoneal mesothelium1
Reduced growth and
implantation of
endometriotic tissue1
Reduced
TNF-α-induced
activation of NF-κβ2
Reduced expression
of growth-promoting
cytokines (including IL-8)
10. Dydrogesterone Induces Atrophy In
Ectopic Endometrial Tissue
Study involved 15 sites in Japan.
• Dydrogesterone 10 mg twice daily orally was
administered for 21 days (day 5-25 of each cycle) for 4
cycles.
• The study group comprised women with an
endometrioma aged 20 to 49 (47.4% cases aged ≥40
years).
• Endometrioma volume was reduced in 50% (26/52),
unchanged in 25% (13/52) of women from baseline to
the end of cycle 5
• Dydrogesterone significantly reduced total
dysmenorrhea scores and severity of dysmenorrhea
pain
Kitawaki J, Koga K, Kanzo T, Momoeda M. An assessment of the efficacy and safety of dydrogesterone in women with ovarian
endometrioma: An open-label multicenter clinical study. Reprod Med Biol. 2021 Jun 4;20(3):345-351
Mean (+SD) volume of ovarian endometriomas from
before treatment initiation to end of Cycle 5
Dydrogesterone inhibits the formation
of de novo endometriotic tissue while
leaving the endometrium unaffected
11. Post-Laparoscopic Treatment of Endometriosis With
Dydrogesterone : very effective
98 pts
10 mg/day or 20 mg/day ( severe
cases) days 5 to 25 of each cycle
• Trivedi et al. designed an open, prospective, multicenter study to assess the efficacy and safety of
dydrogesterone in the post-laparoscopic treatment of endometriosis in Indian patients
• Ninety-eight patients with minimal, mild, moderate, or severe endometriosis, with or without infertility, who had
undergone laparoscopy, were treated with dydrogesterone
• Pelvic pain, dysmenorrhea, and dyspareunia improved significantly (by 29%, 32%, and 38%, respectively, p<0.05)
after the first cycle of treatment
• By the end of the sixth cycle, the reduction in pelvic pain, dysmenorrhea, and dyspareunia was 95%, 87%, and 85%,
respectively
Trivedi P, Selvaraj K, Mahapatra PD, et al
Gynecol Endocrinol 2007;23(Suppl 1):73–76.
Recurrence rate of
endometriosis is high after
surgery
12. Effective Post-Laparoscopic Treatment of
Endometriosis With Dydrogesterone
Trivedi P, et al. Gynecol Endocrinol 2007;23(Suppl 1):73–76.
0
0.5
1
1.5
2
0 1 2 3 4 5 6
Assessment of endometriosis symptoms for 6 months
Pelvic pain score
Dysmenorrhoea score
Dyspareunia score
Month of treatment
Pain
score
*
*
*
**
98 patients
10 mg/day dydrogesterone or 20 mg/day (in
severe cases) on days 5 to 25 of each cycle
3–6 months
Overall, 21.1% of patients were considered cured and 66.7% showed improvement.
13. High Satisfaction With Dydrogesterone Therapy for
Endometriosis
22.2
52.2
20
5.6
13.3
56.7
25.6
4.4
0
10
20
30
40
50
60
Excellent Good Satisfactory Bad
Proportion
of
patients
(%)
Global assessment of treatment
Patient Doctor
74.4%
rated
good/excellent
Patient
5.6%
rated poor
70.0%
rated
good/excellent
Doctor
4.4%
rated poor
Dydrogesterone is an effective and safe post-laparoscopic treatment for endometriosis.
Trivedi P, et al. Gynecol Endocrinol 2007;23(Suppl 1):73–76.
No adverse events were reported by any of the patients
14. Clinical Evidence:
Avoids Inhibition of Ovulation
& Improves Pregnancy Outcomes
Management of infertility in women
with endometriosis is a complex issue
15. Current medical therapies both hormonal and non-hormonal have been fairy
successful to provide symptomatic relief but Inhibit Ovulation and Delay
Conception
01
02
03
04
No evidence that
medical therapy alone
or in combination with
surgery improves
fertility.1
Suppress
ovulation;
cannot be used
in women
desiring
fertility.1
Delay in
conception
Do not
provide fertile
benefit after
treatment
There is a requirement of a therapy that can avoid unwanted side effects
and specifically target the lesions without affecting the ovarian function
1. Rafique S, et al. Clin Obstet Gynaecol. 2017;60(3):485. 2. Elnashar A. Middle East Fertil Soc J. 2015;20(2):61–9.
16. Does not cause anovulation
unlike other gestagens
Does not affect serum
estradiol levels
Induces decidual transformation
and necrosis & resorption of
endometrial implant
Continuous application of dydrogesterone
Dydrogesterone Does Not Inhibit Ovulation
Since dydrogesterone therapy does
not cause a hypoestrogenic state,
estrogen add-back therapy not
needed
17. Progesterone receptor activation
Upregulation of progesterone-induced blocking
factor (PIBF)
PIBF increases production of regulatory cytokines and
blocks pro-inflammatory cytokines.
Prerequisite to successful treatment of endometriosis-
associated infertility
Dydrogesterone
induces PIBF
production
Dydrogesterone Improves Pregnancy Outcomes By
Reducing Levels of Inflammatory Markers
18. Metabolite of Dydrogesterone Improves Endometrial
Receptivity and Pregnancy Outcomes
Metabolite Dihydrodydrogesterone retains immunomodulatory effects of
dydrogesterone
Induces
nitric oxide
synthesis
Improves uterine and
subendometrial blood
flow
Increases utero–
placental
circulation
Improves
endometrial
receptivity
and
pregnancy
outcomes
19. Dydrogesterone Has a Favorable Safety Profile for Women
Wanting to Conceive
No estrogen-
associated side
effects
No intrauterine
deaths, congenital
abnormalities, or
pregnancy-related
complications
Improved quality
of life
High selectivity for
progesterone
receptors; minimizes
activation of other
receptors and
unwanted effects
20. Makhmudova GM, et al. Akush Ginekol (Sofiia). 2003;42(4):42–46.
Efficacy of Dydrogesterone Treatment in Women With Endometriosis After
Reconstructive Surgery
Total, 300 infertile patients with endometriosis undergoing laparoscopy were divided in five groups & advised
follow-up 12 months after end of treatment
50% pregnancy rate with dydrogesterone
63.3% pregnancy rate with danazol
• Depo-medroxyprogesterone acetate (MPA), 50 mg each week for 3 months
• Dydrogesterone 10 mg OD on days 5 to 25 of each cycle for 6 months
• Norethisterone 10 mg OD for 6 months
• Danazol 400 mg BID for 6 months
• Coagulation of lesions, no medical treatment
0% 25% 50% 75%
No medical treatment
Danazol
Norethisterone
Dydrogesterone
Depot-MPA
Pregnancy rate after 6 months of therapy
20% during therapy, 30%
immediately after
7.6±1.2 months after the product was
stopped
BID: Twice daily; MPA: Medroxyprogesterone acetate; OD: Once daily.
21. 1. Orazov MR, et al. Int J Pharm Res. 2019;11(3):1001–1006. 2. Prescribing information of Duphaston®. Available at: https://data.health.gov.il/drugs/alonim/Duphaston_dr_1410193172635.pdf.
3. Seibel MM, et al. Fertil Steril. 1982;38(5):534–7. 4. Dmowski WP. Prog Clin Biol Res. 1982;112:167. 5. Makhmudova GM, et al. Akush Ginekol (Sofiia). 2003;42(4):42–46.
Dydrogesterone does not inhibit
ovulation and can be used before
and during pregnancy Danazol induces a state of
pseudomenopause and delays
conception by at least 6 months
Recommendation
Dydrogesterone
Most effective therapy and
most preferable drug
Hormonomodulative therapy after
surgical treatment of endometriosis
22. Latest Updates on Use of
Dydrogesterone in Treatment
of Endometriosis
23. 3 months (cycles)
of treatment
6 months (cycles)
of treatment
Follow-up period
Study aim
To study the efficacy of
dydrogesterone in laparoscopy-
confirmed cases of endometriosis
Patient population
Women 18–45 years of age with
endometriosis and chronic pelvic
pain with or without
dysmenorrhea (N=350)
N=350
Prolonged cyclical
treatment group
(n=273)
Continuous treatment
regimen group (n=77)
aIn the overall study population; bbetween days 5 and 25 of the menstrual cycle
HR-QoL, health-related quality of life; ITT, intent-to-treat
Sukhikh GT, et al. 2021. Submitted manuscript
Visit 1 Visit 2 Visit 3
Baseline
ITT population
Primary
endpoint
To compare the change in intensity of chronic pelvic
pain from baseline to Month 6 between patients
receiving prolonged cyclical or continuous treatment
regimens of dydrogesterone
Secondary
endpoints
To determine changes from baseline to Month 6 in:a
• Intensity of chronic pelvic pain
• The number of days per menstrual cycle when
analgesics were taken
• Severity of dysmenorrhea
• Duration of menstrual cycles
• Patient-reported sexual well-being
• HR-QoL
ORCHIDEA is a large, multicenter clinical trial
(10 mg, 2–3 times /day)
24. 5.7
***
2.5
5.8
***
2.8
0
1
2
3
4
5
6
7
Baseline Month 6
Mean
intensity
of
chronic
pelvic
pain,
NRS
Prolonged cyclical regimen (n=198) Continuous regimen (n=66)
–3.3
(56% reduction)
–3.0
(52%
reduction)
***p<0.0001 vs baseline; aAnalysis population comprised patients who were selected by propensity score matching
NRS, numerical rating scale
Sukhikh GT, et al. 2021. Submitted manuscript
The difference
between the two
treatment regimens
was not statistically
significant
Pelvic pain intensity at baseline and Month 6 (n=264a)
ORCHIDEA primary efficacy endpoint demonstrated
Significant reduction (52%) in chronic pelvic pain
Both prolonged cyclical and continuous treatment regimens with dydrogesterone led to
similar, significant improvements in chronic pelvic pain during the ORCHIDEA study
(assessed using the 11-point numerical rating scale)
25. There was a reduction in the number of days with
analgesics during the study
1.1
*
0.7
*
0.5
*
0.3
*
0.2
*
0.2
0.0
0.2
0.4
0.6
0.8
1.0
1.2
Cycle 1 Cycle 2 Cycle 3 Cycle 4 Cycle 5 Cycle 6
Mean
number
of
days
with
analgesics
(per
cycle)
Cycles of treatment with dydrogesterone
–0.9
(82% reduction)
*p<0.05 vs Cycle 1
1. Sukhikh GT, et al. 2020. Submitted manuscript; 2. Abbott data on file. ORCHIDEA clinical study report. 2020
Patients experienced significant decreases in the
number of days on which analgesics were required
Analgesic use during treatment (N=350)1
The overall
reduction in use
of analgesics
(80%)
was statistically
significant
26. 5.4
***
3.4
***
2.4
6.0
***
3.7
***
2.6
0
1
2
3
4
5
6
7
Baseline Month 3 Month 6
Mean
intensity
of
chronic
pelvic
pain
and
dysmenorrhea,
NRS
Chronic pelvic pain Dysmenorrhea
ORCHIDEA secondary endpoints demonstrated
improved symptoms of endometriosis
3
***
3.5
***
3.8
0
1
2
3
4
5
6
7
Baseline Month 3 Month 6
Mean
sexual
well-being,
Likert
scale
0.8
(27% increase)
–3.0
(56% reduction)
–3.4
(57% reduction)
***p<0.0001 vs baseline; aData from both treatment regimens
NRS, numerical rating scale
Sukhikh GT, et al. 2021. Submitted manuscript
Treatment with dydrogesterone during the ORCHIDEA study led to significant
improvements in chronic pelvic pain, dysmenorrhea, and sexual well-being
Chronic pelvic pain and dysmenorrhea intensity
during treatmenta (N=350)
Sexual well-being
during treatmenta (N=350)
27. Multiple measures of HR-QoL improved
during the study
41.7
53.1
55.8
73.1
56.2
66.4
54.4
66.4
41.2
85.5 83.5
80.2
***
61.7
***
71.9
***
27.3
***
93.0
***
94.2 ***
86.6
0
20
40
60
80
100
Perceived health
status
Mental health Pain Physical functioning Role functioning Social functioning
Mean
SF-20
score
Baseline Month 3 Month 6
19.9b
(48% increase)
18.8b
(35% increase)
–28.4b
(51% decrease)
20.1b
(27% increase)
38.5b
(68% increase) 20.0b
(30% increase)
Treatment with dydrogesterone led to significant
improvements in multiple measures of HR-QoL during the
ORCHIDEA study
HR-QoL scores during treatmenta (N=350)
28. Dydrogesterone Improves Quality of Life at All Stages
of Endometriosis
● Visit 1 (Baseline) ● Visit 3 (after 6 months of dydrogesterone therapy) *p<.0001
I
Stages of endometriosis (R-AFS) II III IV
Health perception*
Pain*
Psychic health*
Physical functioning*
Role functioning*
Social functioning*
43
55
55
72
66
68
64
71
29
94
98
91
0 50 100
+50%
+34%
+30%
-47%
+29%
+49%
42
54
55
75
58
67
61
72
29
91
94
85
0 50 100
+62%
+27%
+21%
-47%
+34%
+45%
43
54
54
74
60
69
65
74
24
94
96
89
0 50 100
+61%
+29%
+28%
-57%
+36%
+53%
35
46
62
69
29
56
50
68
32
92
84
79
0 50 100
+189%
+41%
+34%
-48%
+49%
+42%
SF-20 score
Dydrogesterone improves the quality of life during all the
four stages of endometriosis
29. Dydrogesterone in Endometriosis: Recommended
Regimen
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28
Prolonged cyclical regimen
Continuous regimen
Dydrogesterone is the only gestagen of choice
Dydrogesterone
20–30 mg per day
for 6 months or
longer
30. Endometriosis
affects 10% of
women during
their reproductive
age, of which up to
50% women suffer
from infertility.
01
Delayed
diagnosis is a
major problem
leading to
increased distress
among patients.
02
Infertile women are
6 to 8 times more
likely to have
endometriosis than
fertile women.
03
Medical treatment
should regress
endometrioid
lesions, pain, and
menstrual disorders
while preserving
ovarian reserve and
fertility during long-
term use.
04
Key Messages
31. 01 02
Blocks proliferation
and facilitates
apoptosis of
endometriotic
lesions
03
Does not suppress
ovarian function
when given at
therapeutic doses
and preserves
fecundity
04
01 02
Demonstrates anti-
angiogenic and anti-
inflammatory effects
Effectively relieves
endometriosis-
associated pain
with minimal
adverse events
Compensates luteal
phase insufficiency
05
Dydrogesterone is an effective choice for management of endometriosis-
associated infertility
Now let us discuss why dydrogesterone is the right choice for the treatment of endometriosis.
Progesterone action is crucial to decreasing inflammation in the endometrium, and deviant progesterone signaling results in a proinflammatory phenotype. Conversely, chronic inflammation can induce a progesterone-resistant state. Repetitive retrograde endometrial shedding begets chronic peritoneal inflammation, which further exacerbates progesterone resistance.1 Dydrogesterone may overcome this phenomenon by increasing progesterone receptor expression and decreasing proinflammatory cytokines.1
Oxidative stress is another mechanism involved in progesterone resistance in endometriosis.2,3 The endometriotic lesions and the surrounding peritoneal fluid are rich in reactive oxygen species.2 Dydrogesterone exerts endothelial anti-inflammatory actions (i.e. via a decrease in expression of leukocyte adhesion molecules), thereby attenuating oxidative stress.3
References
Patel BG, Rudnicki M, Yu J, et al. Progesterone resistance in endometriosis: Origins, consequences and interventions. Acta Obstet Gynecol Scand. 2017;96(6):623–32.
Reis FM, Coutinho LM, Vannuccini S, et al. Progesterone receptor ligands for the treatment of endometriosis: The mechanisms behind therapeutic success and failure. Hum Reprod Update. 2020;26(4):565–585.
Chen JT, Kotani K. Different effects of oral contraceptive and dydrogesterone treatment on oxidative stress levels in premenopausal women. J Clin Med Res. 2018;10(2):146–53.
Dydrogesterone controls the growth of endometriosis by an anti-inflammatory mechanism. Tumor necrosis factor (TNF)-α and estradiol induce the proliferation of endometriotic stroma cells via nuclear factor (NF)-kappa-β, whereas dydrogesterone reduces TNF-α-induced NF-kappa-β activation. Interleukin (IL)-8 is one of the most potent angiogenic factors. Dydrogesterone also modulates immune responses via suppression of IL-8 production in lymphocytes. The increase in nitric oxide production seen with dydrogesterone also plays an important anti-inflammatory role.
Reference
Schweppe KW. The place of dydrogesterone in the treatment of endometriosis and adenomyosis. Maturitas. 2009;65:S23–7.
Dydrogesterone enhances the quality of life and reproductive health as it leads to improvement of various endometriosis-related problems. It helps in:
Reduction in pain symptoms/ size of endometriosis lesions1
Improvement in quality of life parameters1
No inhibition of ovulation2
Improved pregnancy outcomes3
References
Patient Information Leaflet of Duphaston®, 06.07.2020. In Russian only.
Schweppe KW. The place of dydrogesterone in the treatment of endometriosis and adenomyosis. Maturitas. 2009;65:S23–7.
Griesinger G, Tournaye H, Macklon N, et al. Dydrogesterone: Pharmacological profile and mechanism of action as luteal phase support in assisted reproduction. Reprod Biomed Online. 2019;38(2):249–59.
Here we will discuss the clinical evidence for dydrogesterone in the management of endometriosis.
Now let us discuss the role of dydrogesterone in reduction of endometriosis-related pain and improvement of quality of life.
Dydrogesterone was first reported to be effective in endometriosis in the 1960s. The overall success rate with dydrogesterone is around 90%, as reported in small studies and clinical case reports.1 The majority of women became symptom-free or experienced a significant
reduction in the number/severity of symptoms. Laparoscopic examination in several of the studies supported these findings.1
Cyclic application of 10–20 mg dydrogesterone, from days 5–25 of the menstrual cycle, for at least four cycles has also been shown to induce regular menstruation with reduced blood loss, and fewer days of bleeding, combined with excellent symptomatic relief (60% decrease in abdominal cramping and pain), and reduction in the severity of headache and nausea/vomiting in women with dysmenorrhea.1–3
References
Schweppe KW. The place of dydrogesterone in the treatment of endometriosis and adenomyosis. Maturitas. 2009;65:S23–7.
Carp HJ, Soriano D, Zolti M. Progestogens and Endometriosis. In Progestogens in Obstetrics and Gynecology. 2015:129–147. Springer, Cham.
Taniguchi F, Ota I, Iba Y, et al. The efficacy and safety of dydrogesterone for treatment of dysmenorrhea: An open‐label multicenter clinical study. J Obstet Gynaecol Res. 2019;45(1):168–75.
In the same study, the mean laparoscopic scoring of severity was 14.5±8.6 at the baseline and 2.1±3.4 after dydrogesterone therapy. Laparoscopic examination confirmed elimination of endometriosis in 15 out of 20 (75%) cases and improvement of endometriosis in another 4 cases (15%).
Reference
Kaiser E, Wagner ThA. Die Behandlung der Endometriose mit Dydrogesteron. TW Gynaekologie 1989;2:386–8.
Like all progestogens, dydrogesterone is believed to suppress endometrial proliferation by attenuating the expression of interleukin-8 (IL-8) via a reduction in tumor necrosis factor alpha (TNF-α)-induced activation of nuclear factor kappa beta (NF-kB) in endometrial stromal cells2
For shed endometrial tissues to implant and become established endometriotic lesions, it is believed that matrix metalloproteinases (MMPs) are required for extracellular matrix degradation during penetration of the peritoneal mesothelium and invasion of the host tissue, and angiogenesis is necessary to provide oxygen and nutrients1
In a mouse model of endometriosis, dydrogesterone was shown to decrease proliferation of endometrial stromal cells and to reduce the expression of MMP-2 and -3, and the angiogenic factors vascular endothelial growth factor A (VEGFA) and cysteine-rich angiogenic inducer 61 (CYR61)1
This suggests that dydrogesterone may have an inhibitory effect on implantation and growth of endometrial tissue by inhibiting expression of MMPs and angiogenesis1
References
Mönckedieck V, Sannecke C, Husen B, et al. Progestins inhibit expression of MMPs and of angiogenic factors in human ectopic endometrial lesions in a mouse model. Mol Hum Reprod 2009;15(10):633–643
Horie S, Harada T, Mitsunari M, et al. Progesterone and progestational compounds attenuate tumor necrosis factor alpha-induced interleukin-8 production via nuclear factor-kappa B inactivation in endometriotic stromal cells. Fertil Steril. 2005;83:1530–1535
Trivedi et al. designed an open, prospective, multicenter study to assess the efficacy and safety of dydrogesterone in the post-laparoscopic treatment of endometriosis in Indian patients. Ninety-eight patients with minimal, mild, moderate, or severe endometriosis, with or without infertility, who had undergone laparoscopy, were treated with dydrogesterone 10 mg/day (or 20 mg/day in severe cases) orally from day 5 to day 25 of each cycle for 3–6 months. Pelvic pain, dysmenorrhea, and dyspareunia improved significantly (by 29%, 32%, and 38%, respectively, p<0.05) after the first cycle of treatment. By the end of the sixth cycle, the reduction in pelvic pain, dysmenorrhea, and dyspareunia was 95%, 87%, and 85%, respectively.
Reference
Trivedi P, Selvaraj K, Mahapatra PD, et al. Effective post-laparoscopic treatment of endometriosis with dydrogesterone. Gynecol Endocrinol 2007;23(Suppl 1):73–76.
Trivedi et al. designed an open, prospective, multicenter study to assess the efficacy and safety of dydrogesterone in the post-laparoscopic treatment of endometriosis in Indian patients. Ninety-eight patients with minimal, mild, moderate, or severe endometriosis, with or without infertility, who had undergone laparoscopy, were treated with dydrogesterone 10 mg/day (or 20 mg/day in severe cases) orally from day 5 to day 25 of each cycle for 3–6 months. Pelvic pain, dysmenorrhea, and dyspareunia improved significantly (by 29%, 32%, and 38%, respectively, p<0.05) after the first cycle of treatment. By the end of the sixth cycle, the reduction in pelvic pain, dysmenorrhea, and dyspareunia was 95%, 87%, and 85%, respectively.
Reference
Trivedi P, Selvaraj K, Mahapatra PD, et al. Effective post-laparoscopic treatment of endometriosis with dydrogesterone. Gynecol Endocrinol 2007;23(Suppl 1):73–76.
A total of 21.1% of patients were considered cured and 66.7% showed improvement. According to the patients, 74.4% considered
the treatment to be good or excellent, with only 5.6% rating it as poor. Similarly, the physicians rated 70.0% of the cases as good or excellent, and only 4.4% as poor. No adverse events were reported by any of the patients. In conclusion, dydrogesterone is an effective and safe post-laparoscopic treatment for endometriosis.
Reference
Trivedi P, Selvaraj K, Mahapatra PD, et al. Effective post-laparoscopic treatment of endometriosis with dydrogesterone. Gynecol Endocrinol 2007;23(Suppl 1):73–76.
Now let us discuss the role of dydrogesterone in improvement of pregnancy outcomes.
Currently, several therapeutic options, both hormonal and non-hormonal, are available to provide symptomatic relief and control the progression of the disease. They have been fairy successful in controlling pelvic pain in women with endometriosis. In carefully selected women these medications can be used either alone or in combination with surgery. However, they are limited by their side effects and negative impact on fertility.1
Currently there is no evidence that the medical therapy alone or a combination of medical therapy with surgery improves fertility. Management of infertility in women with endometriosis is a complex issue and needs to take into account the age, duration of infertility, severity of symptoms and stage of the disease.1 Another limitation is that prolonged use of these therapies suppresses ovulation, and therefore, cannot be used in women desiring fertility.1 A prolonged delay in the resumption of ovulation leads to delayed conception. These therapies have also not been shown to provide any fertile benefit subsequent to treatment.2
Therefore, there is a requirement of a therapy that can avoid unwanted side effects and specifically target the lesions without affecting the ovarian function.1
References
Rafique S, Decherney AH. Medical management of endometriosis. Clin Obstet Gynaecol. 2017;60(3):485.
Elnashar A. Emerging treatment of endometriosis. Middle East Fertil Soc J. 2015;20(2):61–9.
Unlike other progestins, continuous application of dydrogesterone does not cause anovulation when used in therapeutic doses, and does not affect the serum estradiol levels. Dydrogesterone therapy induces decidual transformation along with resultant necrosis and resorption of the endometrial implant.1
Since dydrogesterone therapy does not cause a hypoestrogenic state, estrogen add-back therapy becomes irrelevant.1,2
References
Schweppe KW. The place of dydrogesterone in the treatment of endometriosis and adenomyosis. Maturitas. 2009;65:S23–7.
Rafique S, Decherney AH. Medical management of endometriosis. Clin Obstet Gynaecol. 2017;60(3):485.
Dydrogesterone acts via the progesterone receptor and produces a mediator protein known as progesterone-induced locking factor (PIBF). The PIBF favors the development of human T helper (Th) cells producing Th2-type cytokines as well as regulatory cytokines and blocks the production of pro-inflammatory (Th1-type) cytokines, which is a prerequisite to the successful treatment of endometriosis-associated infertility.1,2
References
Patki A, Pawar VC. Modulating fertility outcome in assisted reproductive technologies by the use of dydrogesterone. Gynecol Endocrinol. 2007;23 (Suppl 1):68–72.
Orazov MR, Radzinsky VY, Khamoshina MB, et al. The efficacy of combined management of endometriosis-associated infertility. Int J Pharm Res. 2019;11(3):1001–1006.
The metabolite dihydrodydrogesterone retains the immunomodulatory effects of its parent molecule dydrogesterone by bringing about a shift in cytokine production profiles by suppressing the production of the pro-inflammatory cytokines and upregulating the production of the anti-inflammatory cytokine.1
Dihydrodydrogesterone induces nitric oxide (NO) synthesis, and consequently improves the uterine and subendometrial blood flow, increases utero-placental circulation and improves endometrial receptivity and pregnancy outcomes.2
References
Raghupathy R, Al-Azemi M. Modulation of cytokine Production by the Dydrogesterone Metabolite Dihydro Dydrogesterone. Am J Reprod Immunol. 2015;74(5):419-26.
Abdel-Razik M, El-Berry S, Mostafa A. The effects of nitric oxide donors on uterine artery and sub-endometrial blood flow in patients with unexplained recurrent abortion. J Reprod Infertil. 2014;15(3):142-146.
Dydrogesterone has a favorable safety profile for women wanting to conceive. The benefits include:
High selectivity for progesterone receptors; minimizes activation of other receptors and unwanted effects1
No estrogen-associated side effects2
No intrauterine deaths, congenital abnormalities, or pregnancy-related complications3
Improved quality of life2
References
Griesinger G, Tournaye H, Macklon N, et al. Dydrogesterone: Pharmacological profile and mechanism of action as luteal phase support in assisted reproduction. Reprod Biomed Online. 2019;38(2):249–59.
Schweppe KW. The place of dydrogesterone in the treatment of endometriosis and adenomyosis. Maturitas. 2009;65:S23–7.
Arab H, Alharbi AJ, Oraif A, et al. The role of progestogens in threatened and idiopathic recurrent miscarriage. Int J Womens Health. 2019;11:589.
Makhmudova et al. present outcomes of inspection of 300 women suffering from genital endometriosis. Localization and thermocoagulation of endometriosis was performed by diagnostic and operative laparoscopy. After operation women were treated with hormonomodulative therapy. Patients were divided in five groups, depending on prescribed treatment and advised follow-up 12 months after end of treatment. For comparison there are presented groups of patients without hormonal treatment after operation.
Significant pregnancy rates were observed with dydrogesterone and danazol treatment. The pregnancy rate as 50% after dydrogesterone therapy (20% during therapy and 30% immediately after therapy). However, the pregnancy rate was 63.3% with danazol, 7.6±1.2 months after the treatment was stopped.
Reference
Makhmudova GM, Nazhmutdinova DK, Gafarova DKh, et al. Efficacy of duphaston treatment in women with endometriosis after reconstructive surgery. [in Bulgarian] Akush Ginekol (Sofiia). 2003;42(4):42–46.
Dydrogesterone does not inhibit ovulation and can be used before and during pregnancy,1,2 whereas danazol induces a state of pseudomenopause and delays chances of conception by at least 6 months after therapy.3,4
Therefore , the authors concluded that the most effective is therapy with progestine dydrogesterone. Dydrogesterone was indicated as the most preferable drug. The authors recommend hormonomodulative therapy after surgical treatment of endometriosis.5
References
Orazov MR, Radzinsky VY, Khamoshina MB, et al. The efficacy of combined management of endometriosis-associated infertility. Int J Pharm Res. 2019;11(3):1001–1006.
Prescribing information of Duphaston®. Available at: https://data.health.gov.il/drugs/alonim/Duphaston_dr_1410193172635.pdf.
Seibel MM, Berger MJ, Weinstein FG, et al. The effectiveness of danazol on subsequent fertility in minimal endometriosis. Fertil Steril. 1982;38(5):534–7.
Dmowski WP. Danazol in the treatment of endometriosis and infertility. Prog Clin Biol Res. 1982;112:167.
Makhmudova GM, Nazhmutdinova DK, Gafarova DKh, et al. Efficacy of duphaston treatment in women with endometriosis after reconstructive surgery. [in Bulgarian] Akush Ginekol (Sofiia). 2003;42(4):42–46.
Now let us discuss the latest updates on use of dydrogesterone in treatment of endometriosis.
ORCHIDEA (NCT03690765) is an observational, open-label, multicenter study of real clinical practice evaluating the effects of oral dydrogesterone for the management of endometriosis with chronic pelvic pain.
Patients received dydrogesterone (10 mg, 2–3 times per day) either cyclically (on days 5–25 of each menstrual cycle) or continuously. Multiple aspects of pain and health-related quality of life were assessed over a 6-month treatment period.
Reference
Sukhikh GT, et al. 2021. Prolonged cyclical and continuous regimens of dydrogesterone are effective for reducing chronic pelvic pain in women with endometriosis: results of the ORCHIDEA study. Submitted manuscript
The intensity of chronic pelvic pain assessed by patients using the 11-point numerical rating scale was more than halved after 6 months of treatment with dydrogesterone, with no difference observed between the two dydrogesterone treatment regimens (both p<0.0001 vs baseline)
Reference
Sukhikh GT, et al. 2021. Prolonged cyclical and continuous regimens of dydrogesterone are effective for reducing chronic pelvic pain in women with endometriosis: results of the ORCHIDEA study. Submitted manuscript
Reference
Sukhikh GT, et al. 2020. Prolonged cyclical and continuous regimens of dydrogesterone are effective for reducing chronic pelvic pain in women with endometriosis: results of the ORCHIDEA study. Submitted manuscript
Within 3 months of initiating treatment with dydrogesterone, the intensity of both chronic pelvic pain and dysmenorrhea (assessed using the 11-point numerical rating scale) was significantly reduced (p<0.0001 vs baseline); further reductions were observed at Month 6
Sexual well-being, assessed on a 5-point Likert scale, was significantly improved at Months 3 and 6 of treatment (p<0.0001 vs baseline at both timepoints)
Reference
Sukhikh GT, et al. 2021. Prolonged cyclical and continuous regimens of dydrogesterone are effective for reducing chronic pelvic pain in women with endometriosis: results of the ORCHIDEA study. Submitted manuscript
The Short Form-20 questionnaire examines six aspects of health-related quality of life: perceived health status; mental health; bodily pain; and physical, role, and social functioning
Significant improvements in all six domains were observed after 6 months of dydrogesterone treatment (magnitude 27–68% compared with baseline; all p<0.0001)
Numerical improvements from baseline were observed in all domains after 3 months of treatment
Bodily pain was reduced by 51% at Month 6
Reference
Sukhikh GT, et al. 2021. Prolonged cyclical and continuous regimens of dydrogesterone are effective for reducing chronic pelvic pain in women with endometriosis: results of the ORCHIDEA study. Submitted manuscript
The study further showed that six months of dydrogesterone therapy improved the quality of life of patients in all the four stages of endometriosis. Various parameters, including perception of health, psychic health, pain, physical functioning, role functioning, and social functioning, improved significantly upon six months of treatment with dydrogesterone.
References
1. Report of the results of ORCHIDEA, a multicenter open-label observational study of dydrogesterone in the treatment of endometriosis in Russia. Data from Abbott. In Russian only.
2. Prof. A.V. Kozachenko, presentation at the 14th International Congress of Reproductive Medicine, Moscow, January 21, 2020. In Russian only.
The study showed that dydrogesterone 20-30 mg per day, either cyclical or continuous regimen for 6 months and longer is the only gestagen for a doctor to have a choice between two efficacious regimens for endometriosis.
References
1. Report of the results of ORCHIDEA, a multicenter open-label observational study of dydrogesterone in the treatment of endometriosis in Russia. Data from Abbott. In Russian only.
2. Prof. A.V. Kozachenko, presentation at the 14th International Congress of Reproductive Medicine, Moscow, January 21, 2020. In Russian only.
The key takeaways from this presentation are:
Endometriosis affects about 10% of women during their reproductive age, of which up to 50% women suffer from infertility.
Delayed diagnosis is a major problem leading to increased distress among patients.
Infertile women are 6 to 8 times more likely to have endometriosis than fertile women.
Medical treatment should regress endometrioid lesions, pain, and menstrual disorders while preserving ovarian reserve and fertility during long-term use.
The key takeaways from this presentation are:
Dydrogesterone is the best choice for endometriosis-associated infertility.
Does not suppress ovarian function when given at therapeutic doses.
Does not require estrogen add-back therapy.
Compensates luteal phase insufficiency.
Avoids estrogen-associated side effects and improves quality of life.
Preserves fecundity with minimal side effects and recurrence.