Purpose Sex hormones play a role in bone density, cardiovascular health and wellbeing throughout reproductive lifespan. Women with primary ovarian insufficiency (POI) have lower estrogen levels requiring hormone therapy (HT) to manage symptoms and to protect against adverse long-term health outcomes. Yet, the effectiveness of HT in preventing adverse outcomes has not been systematically assessed. We summarize the evidence regarding effects of HT on bone and cardiovascular health in women with POI. Methods A comprehensive search of the electronic databases MEDLINE, EMBASE and Scopus was conducted by a medical reference librarian from database inception to January 2016. Randomized trials and observational cohort studies with an estrogen-based HT intervention in women with POI under the age of 40 were included. Reviewers worked independently and in duplicate to assess eligibility and risk of bias, and extract data of interest from each study. Results The search identified 1670 articles; 12 met inclusion criteria. Four randomized clinical trials and 8 cohort studies at high risk of bias enrolled 806 women with POI. The most common HT formulations were transdermal estradiol and oral conjugated equine estrogen combined with medroxyprogesterone acetate. Bone mineral density was the most frequent outcome, with 3 out of 8 studies showing HT associated increase benefits. Only 1 study reported effects on fractures or vasomotor symptoms and none on cardiovascular mortality. Results regarding lipid profiles were inconsistent. Conclusions Evidence supporting bone and cardiovascular benefits of HT in women with POI is limited by high risk of bias, reliance on surrogate outcomes and heterogeneity of trials regarding the formulation, dose, route of administration and regimen of HT. Further research addressing patient important outcomes such as fractures, stroke and cardiovascular mortality are crucial to optimize benefits of this therapy. Registration PROSPERO CRD 4201603616

Patients with Turner syndrome have adverse bone and cardiovascular outcomes from chronic estrogen deficiency. Hence, long-term estrogen replacement therapy is the cornerstone treatment. The estimates of its effect and optimal use, however, remain uncertain. We aimed to summarize the benefits and harms of estrogen replacement therapy on bone, cardiovascular, vasomotor and quality of life outcomes in patients with Turner syndrome. A comprehensive search of four databases was performed from inception through January 2016. Randomized clinical trials and observational cohort studies studying the effect of estrogen replacement therapy in patients with Turner syndrome under the age of 40 were included. Independently and in duplicate reviewers selected studies, extracted data and assessed risk of bias. Subgroup analyses were based on route of administration and type of estrogen formulation. Twenty-five studies at moderate to high risk of bias (12 randomized trials, 13 cohort studies) with 771 patients were included. Using random-effects models, estrogen replacement therapy showed an increase in bone mineral density [weighted mean change from baseline 0.09 g/cm2 (0.04-0.14)] that differed by type of estrogen but not route of administration. Oral estrogen replacement therapy showed a higher increase in high density lipoprotein cholesterol levels when compared to transdermal [weighted mean difference 9.33 mg/dl (4.82-13.85)] with no significant effect on other lipid fractions. The current evidence suggests possible benefit of estrogen replacement therapy on bone mineral density and high density lipoprotein cholesterol. Whether this improvement translates into changes in patient important outcomes (cardiovascular events or fractures) remains uncertain. Larger randomized clinical trials with direct comparisons on patient important outcomes are necessary.

OBJECTIVE: To investigate published cases of cervical ectopic pregnancy between 2000 and 2018 and compare management strategies and treatment success rates based on initial patient characteristics. METHODS: PubMed, EMBASE, and Web of Science were searched to capture peer-reviewed citations published between 2000 and 2018. Cases reporting either β-hCG level, crown–rump length, or gestational sac diameter for each individual patient were included. Data regarding the article information, patient characteristics, treatment used, and outcomes were collected. Initial success was defined as resolution of the cervical ectopic pregnancy with the predefined treatment plan. Initial failure was defined as the requirement of additional unplanned interventions due to the predefined treatment plan not being successful. End success was defined as resolution of the cervical ectopic pregnancy without hysterectomy. RESULTS: A total of 204 articles from 44 countries comprising 454 cases were reviewed. The initial β-hCG level ranged from 9 to 286,500, with a median of 14,773, and gestational age ranged from 4 to 18 weeks, with an average of 7 4/7 weeks (±2 0/7 weeks). In looking at initial success, compared with methotrexate alone, dilation, and curettage (odds ratio [OR] 2.26; 95% CI 2.64–10.45), dilation and curettage combined with uterine artery embolization (OR 4.85; 95% CI 2.06–11.44) and uterine artery embolization (OR 5.17; 95% CI 1.14–23.53) were more effective options. More than half of patients (50.2%) required multiple interventions, and 41 (9%) resulted in hysterectomy. CONCLUSIONS: Management of cervical ectopic pregnancies should be guided by patient stability, β-hCG level, size of pregnancy, and fetal cardiac activity but may benefit from a planned multimodal approach.

Cervical ectopic pregnancies represent fewer than 0.1% of all ectopic pregnancies but carry increased risk of significant hemorrhage and long-term reproductive consequences if not managed properly. In part due to the rarity of their occurrence, a standard-of-care protocol for management of cervical ectopic pregnancy (EP) other than hysterectomy does not exist. A trend toward more conservative management has broadened the literature; however, it is unclear what clinical characteristics can be used to guide choice of treatment.This retrospective study aimed to investigate published cases of cervical EP to determine how initial patient characteristics may be used to guide management strategies based on treatment success rate. PubMed, EMBASE, and Web of Science were searched for peer-reviewed citations published between 2000 and 2018. Included cases reported one of the following: initial β-human chorionic gonadotropin (β-hCG), crown-rump length (CRL), or gestational sac diameter. Cases were excluded that reported heterotopic pregnancy, were a result of in vitro fertilization, or included cervicoisthmic pregnancy. Patient characteristics abstracted from studies included age, gravidity, parity, initial β-hCG, CRL, gestational sac diameter, presence of fetal cardiac activity, and hemodynamic stability at initial presentation. Also abstracted were outcomes including initial treatment success and failure defined as resolution of cervical EP with the predefined treatment plan and requirement of additional and unplanned interventions due to predefined treatment plan failure, respectively. The primary exposure variable was the treatment, which was divided into systemic methotrexate (MTX), uterine artery embolization (UAE), dilatation and curettage (D&C), potassium chloride, MTX + UAE, D&C + UAE, and other. The primary study outcome was the initial success of planned treatments provided to the patient.A total of 204 articles from 44 countries including 454 cases were reviewed. Median β-hCG was 14,733 mIU/mL and median gestational age 7 weeks 4 days. Compared with MTX alone, other treatment methods had an increased likelihood of initial treatment success including UAE (

INTRODUCTION: Cervical pregnancies are 0.01% of ectopic pregnancies and pose a considerable risk of hemorrhage. There is currently no consensus on management. This is a systematic review of published cases in the last decade. METHODS: PubMed and other databases were searched on July 2, 2017 using variations of the terms “cervical ectopic pregnancy” and “cervical pregnancy” for peer-reviewed citations published in English, Spanish, or French between 2007 and 2017. RESULTS: One-hundred-and-eleven articles representing 209 patients were included. Initial interventions included expectant management (3); vaginal removal of lesion (2); uterine artery embolization (UAE) (1); UAE and curettage (34); curettage (42); UAE and methotrexate (22); methotrexate alone (79); hysteroscopic resection (12), UAE and laparoscopy (5), and hysterectomy (6). Sixty patients failed initial intervention, including 38 who received methotrexate alone (58%), 5 who underwent methotrexate with UAE (26%), and 10 who underwent curettage (23%). Thirty-seven patients experienced hemorrhage, including 21% who initially received methotrexate; 40% who initially underwent curettage; and 12% of those initially managed with curettage and UAE. These patients were managed with hysterectomy (6); cerclage (4); curettage (7); UAE (7), and UAE and curettage (3). Overall patients did well with conservative management. CONCLUSION: For stable cervical ectopic patients, conservative management with methotrexate (including intraamniotic feticide if fetal cardiac activity is present) may be considered. Importantly, uterine artery embolization is worth considering prior to either surgical or medical management, and is recommended in any unstable patient.

INTRODUCTION: The purpose of our study was to explore the relationship between reproductive autonomy and shared decision making in women exposed to Zika virus during pregnancy. METHODS: We used a participatory action approach to conduct an exploratory qualitative study of English and Spanish- speaking women who were offered serum or ultrasound screening due to Zika exposure during pregnancy or immediately postpartum. We performed qualitative interviews in the patient's native language based on the Reproductive Autonomy scale and the Three Talk Model for shared decision making. Two coders used modified grounded theory to analyze transcribed interviews by hand. RESULTS: We interviewed 18 patients, at an inner city safety net hospital from May to December 2017. Most participants were Spanish speaking (72%), Hispanic (77%), and reported unplanned pregnancies (61%). Participant narratives demonstrated reproductive autonomy in pregnancy decision-making with community-based decision support, fatalism around pregnancy continuation, and very limited engagement around decisions regarding Zika virus testing. Hierarchy in provider dynamics, perceived stigma around emigration and travel, and language barriers impacted participant engagement in shared decision making-including choice, options, and decision talk. Narratives demonstrated limited participant perception of personal and fetal risk, and limited knowledge around Zika virus screening and treatment, which was inadequately addressed during counseling discussions. CONCLUSION: Participants demonstrated autonomy in reproductive decision-making that did not extend to decisions related to perinatal Zika testing. Shared decision making tools that address provider-patient relationship and stigma, in addition to clinical content may improve shared decision making and patient engagement in the management of complex pregnancies in vulnerable populations.

In the original publication, the given and family name of the author Mohammad Hassan Murad was incorrect. This has been corrected with this erratum.

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