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Debljina ili pretilost je kronična metabolička bolest karakterizirana prekomjernim nakupljanjem masnog tkiva u organizmu. Iako većinu ljudi zabrinjava uglavnom zbog estetskih razloga, debljina je prvenstveno zdravstveni problem jer je povezana s nizom bolesti i kraćim životnim vijekom. Recentno je debljina stavljena u fokus i zbog pandemije bolesti COVID-19 gdje se utvrdilo kako osobe s debljinom, oboljele od bolesti COVID- 19 imaju povećan rizik od hospitalizacije i smrti. U kliničkoj praksi debljina se procjenjuje indeksom tjelesne mase (ITM), a za dodatnu procjenu nakupljanja visceralnog masnog tkiva, koje je predstavlja veći rizik za oboljenje od metaboličkih i kardiovaskularnih bolesti, koristi se mjera opsega struka (OS). U regulaciju energetske ravnoteže i zaliha masti uključene su složene interakcije između bioloških, bihevioralnih, socijalnih i okolišnih čimbenika. Ciljevi kontrole tjelesne mase naglašavaju važnost realističnog pristupa mršavljenju kako bi se postiglo smanjenje zdravstvenih rizika, a uključuju promicanje gubitka tjelesne mase, održavanje postignute niže tjelesne mase i prevenciju ponovnog debljanja. Kontrola komorbiditeta povezanih s debljinom i poboljšanje kvalitete života osoba koje žive s prekomjernom tjelesnom masom ili debljinom bitan su aspekt liječenja. Liječenje debljine u prvom redu podrazumijeva promjenu načina života i trajno prihvaćanje zdravih navika. Smanjenje prekomjerne tjelesne mase, kao i njeno kasnije održavanje, temelji se na kombinaciji prehrane s energetskom vrijednošću za 500 kcal manjom od dnevnih energetskih potreba i redovitoj tjelesnoj aktivnosti. Bihevioralno-kognitivni pristup temelji se na prevladavanju psiholoških prepreka za usvajanje i primjenu učinkovitih ponašanja u kontroli tjelesne mase. Farmakoterapija za smanjenje tjelesne mase indicirana je kao dodatak dijeti sa smanjenim unosom kalorija i povećanoj tjelesnoj aktivnosti u odraslih osoba s ITM ≥30 kg/m², ali i u osoba s prekomjernom tjelesnom masom s ITM-om ≥27 do 35 kg/m2 s komorbiditetima ili ITM > 40 kg/m2 s ili bez komorbiditeta. Barijatrijska kirurgija najučinkovitija je metoda liječenja osoba s morbidnom debljinom i njom se može postići dugoročni gubitak tjelesne mase. Ove smjernice mogu se jednostavno primijeniti u svakodnevnom radu, a cilj je prepoznavanje i adekvatno liječenje osoba s preuhranjenošću i debljinom od strane svakog liječnika s naglaskom na primjerenu komunikaciju, motivacijski razgovor i edukaciju.

Debljina ili pretilost je kronična metabolička bolest karakterizirana prekomjernim nakupljanjem masnog tkiva u organizmu. Iako većinu ljudi zabrinjava uglavnom zbog estetskih razloga, debljina je ponajprije zdravstveni problem jer je povezana s nizom bolesti i kraćim životnim vijekom. Recentno je debljina stavljena u fokus i zbog pandemije bolesti COVID-19gdje se utvrdilo kako osobe s debljinom, oboljele od bolesti COVID-19, imaju povećan rizik od hospitalizacije i smrti. U kliničkoj praksi debljina se procjenjuje indeksom tjelesne mase (ITM), a za dodatnu procjenu nakupljanja visceralnog masnog tkiva, koje predstavlja veći rizik od metaboličkih i kardiovaskularnih bolesti koristi se mjera opsega struka (OS). U regulaciju energetske ravnoteže i zaliha masti uključene su složene interakcije između bioloških, bihevioralnih, socijalnih i okolišnih čimbenika. Ciljevi kontrole tjelesne mase naglašavaju važnost realističnog pristupa mršavljenju kako bi se postiglo smanjenje zdravstvenih rizika, a uključuju promicanje gubitka tjelesne mase, održavanje postignute niže tjelesne mase i prevenciju ponovnog debljanja. Kontrola komorbiditeta povezanih s debljinom i poboljšanje kvalitete života osoba koje žive s preuhranjenošću ili debljinom bitan su aspekt liječenja. Liječenje debljine u prvom redu podrazumijeva promjenu načina života i trajno prihvaćanje zdravih navika. Smanjenje prekomjerne tjelesne mase, kao i njeno kasnije održavanje, temelji se na kombinaciji prehrane s energetskom vrijednošću za 500 kcal manjom od dnevnih energetskih potreba i redovitoj tjelesnoj aktivnosti. Bihevioralno-kognitivni pristup usmjeren je na prevladavanje psiholoških prepreka za usvajanje i primjenu učinkovitih ponašanja u kontroli tjelesne mase. Farmakoterapija za smanjenje tjelesne mase indicirana je kao dodatak dijeti sa smanjenim unosom kalorija i povećanoj tjelesnoj aktivnosti u odraslih osoba s ITM ≥30 kg/m², ali i u osoba s preuhranjenošću s ITM-om ≥27 do 35 kg/m² s komorbiditetima ili ITM >40 kg/m2 s komorbiditetima ili bez njih. Barijatrijska kirurgija najučinkovitija je metoda liječenja osoba s morbidnom debljinom i njom se može postići dugoročni gubitak tjelesne mase. Ove smjernice mogu se jednostavno primijeniti u svakodnevnom radu, a cilj je prepoznavanje i adekvatno liječenje osoba s preuhranjenošću i debljinom od svakog liječnika s naglaskom na primjerenu komunikaciju, motivacijski razgovor i edukaciju., Obesity is a chronic metabolic disease characterized by abnormal and excessive adipose tissue accumulation in the body. Although most people are concerned mainly for aesthetic reasons, obesity is primarily a health problem because it is associated with a wide range of diseases and shorter life expectancy. Obesity has recently been put in focus due to the COVID-19 pandemic since it has been revealed that patients with obesity are at an increased risk of both hospitalization and death related to COVID-19. In clinical practice, obesity is assessed by body mass index (BMI), whilst for additional assessment of visceral adipose tissue accumulation and distribution, which poses a greater risk of metabolic and cardiovascular disease development, waist circumference is used. A complex interaction among biological, behavioral, social and environmental factors is included in the regulation of energy balance and fat storage. Body weight control goals emphasize the importance of a realistic approach to weight loss in order to reduce health risks. They include promoting weight loss, maintenance of achieved lower/optimal body weight, and prevention of weight regain. Control of obesityrelated comorbidities and improvement of the quality of life of people living with overweight or obesity is an important aspect of treatment. Obesity treatment is primarily based on lifestyle changes and permanent acceptance of healthy habits. A combination of diet with an overall energy value of 500 kcal less than daily energy needs and regular physical activity are of utmost importance for reduction of excess weight, as well as its subsequent maintenance. The cognitive-behavioral approach is aimed at overcoming psychological barriers to the adoption and application of effective behaviors in weight control. Pharmacotherapy for weight loss is indicated as an adjunct to a low-calorie diet and increased physical activity in adults with a BMI ≥30 kg/m2, but also in overweight adults with a BMI ≥27 to 35 kg/m2 with obesity-related comorbidities and in adults with BMI >40 kg/m2 with or without comorbidities. Bariatric surgery is the most effective therapeutic method for treating people with morbid obesity, and thus can ensure long-term weight loss. These guidelines can be easily applied in everyday clinical practice, and their goal is recognition and treatment of persons with overweight and obesity by each physician, with special emphasis on appropriate communication, motivational interviewing/conversation, and education.

Sex hormone binding globulin (SHBG) is an important protein, not only for transporting sex steroids which is its primary role, but with the discovery of a specific receptor that binds SHBG, a novel approach regarding classic ‘free-hormone hypothesis’ should be implemented. Research in SHBG gene and it expression has been done, as well as cellular signaling that controls it. It provides significant knowledge of the impact of certain well –defined cellular level signaling pathways and how they affect the level of SHBG production. Moreover, new insights have proven that SHBG isn’t just a peripherally synthesized protein. Its origin has been proven to exist in the brain, namely in the hypothalamus and the pituitary, where it is spatially closely related to oxytocin-producing neurons. The main peripheral organ that produces SHBG is the liver. Since the liver is the central metabolic organ, certain metabolic diseases will result in changed SHBG serum levels. On the other hand, endocrine disorders that affect tissues involved in sex hormone regulation will also have an impact on SHBG levels. Thusly, SHBG stands as one of the mediators between various endocrine tissues and definitely contributes with its own pathophysiological role in diseases such as: obesity, metabolic syndrome, polycystic ovary syndrome, osteoporosis, breast and prostate cancer. Its value expands to the area of clinical medicine as a marker of certain pathological states. Some studies already established its reliability and the growing trend to implement it as a useful clinical marker is present. It still remains largely understudied, from physiological and clinical aspect, but recent findings give notions that SHBG plays an important role in health and disease and could be a useful assessment marker.

Cervical endometriosis has been reported rarely. A 28-year-old nulliparous woman was referred for surgical management due to persistent dyspareunia. Initial cytological, clinical and laparoscopic finding were unremarkable. Both vaginal ultrasonography and magnetic resonance imaging demonstrated the cystic lesion suggestive of cervical endometriosis. Led by these findings repeated laparoscopy was preformed, left pelvic sidewall opened and endometriotic nodule 3 cm in diameter was found and extirpated just under the left sacrouterine ligament. Histopathological report confirmed the diagnosis of cervical endometriosis. The patient was symptom free at the 6-month follow up. We suggest that cervical endometriosis should be considered in women complaining on persistent dyspareunia while other causes are excluded.

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in women of reproductive age. It shares many features with the metabolic syndrome (insulin resistance, an increase in body mass index, changes in lipidogram, increases in C-reactive protein due to chronic inflammation). As a long-term consequence, development of cardiovascular disease (CVD) is likely. The purpose of this retrospective observational study was to explore if cardiometabolic risk factors (BMI, HOMA-IR, total cholesterol, TG, LDL-C, HDL-C, CRP) worsen over time in PCOS patients. The data of 36 PCOS patients aged 26.5  6.4, in whom the diagnosis was made according to the Rotterdam criteria, was included in the study. The metabolic parameters were taken from hospital records of University Hospital Petrova Gynecological Clinic in Zagreb, Croatia. We included laboratory values measured at the starting point of the study, in 2007, and after nine years, in 2016. No significant worsening of cardiometabolic risk factors was found after the nine years. Only the percentage of PCOS patients with a BMI > 25 increased from 25.0% to 33.3% (P = 0.002). Further studies should be conducted with a larger sample size and longer duration of observation.

Polycystic ovary syndrome (PCOS) is the most frequent endocrine disorder in women of reproductive age. The aim of this study was to evaluate the influence of TAAAA repeat allele length on serum SHBG levels and on cardiovascular risk factors in PCOS patients. Ninety-one Croatian women with PCOS and 99 healthy control women of reproductive age were enrolled. Phenotypic hyperandrogenism, BMI and waist–to-hip ratio were recorded. Hormonal profiles, fasting insulin and glucose levels, lipid profile and C–reactive protein were measured. Genotyping of the TAAAA repeat polymorphism in the SHBG gene was performed. No significant difference was found in the frequency and distribution of TAAAA repeat alleles between PCOS patients and controls (P=0.739). Serum SHBG levels were inversely correlated with serum CRP levels (R=0.489, P

The fundamental reason for using oral hormonal contraception is protection from unwanted pregnancies and their most unwanted consequences, artificial abortions. Countries reporting a low rate of effective contraceptive methods usage, like hormonal contraception, notice a high rate of deliberately induced abortions. The main reasons for low rate of hormonal contraceptives use have been recognized and they include wrong perception and misinformation’s amongst women, incorrect information’s given by health care providers and insufficient choice of contraceptive that allows individualization of the therapy. Current expectations from contraception are not just high contraceptive efficacy, but also the improvement of the symptoms associated with menstrual cycle, and all this, with minimal health risks. It is well known that different hormonal contraceptives, in spite of the same therapeutic indications have different individual tolerance and different non-contraceptive benefits. Therefore, the variety of hormonal contraceptives of different dose and composition is necessary to allow individual selection of therapy. The oral hormonal contraceptive with 0, 03 mg of ethinyl estradiol (EE)/2 mg chlormadinone acetate (CMA) is a low- dose oral hormonal contraceptive with antiandrogenic effect. It is proved to be safe and effective oral hormonal contraceptive with a corrected Pearl Index of 0, 04 and positive effects on indicators of cardiovascular risk, as well as with very low risk of occurrence of venous thromboembolism of 2, 07/10 000 women per year. Because of its proven antiandrogenic action it demonstrates a beneficial effect on the skin and hair in reducing acne, seborrhea and hirsutism. The ability of this contraceptive to significantly reduce monthly bleeding and pain indicates its potential use in the treatment of anemia and dysmenorrhea. The combination of these benefits and the absence of weight gain, as well as positive psychotropic action with the absence of negative effects on libido contribute to high compliance and a low discontinuation rate of the treatment.

Venous thromboembolism (VTE) is the most important side effect of using hormone replacement therapy (HRT). Biological and epidemiological studies have shown that oral administration of estrogen is associated with an increased risk of VTE compared to transdermal route of administration. Addition of progestogen to estrogen further increases the risk of VTE. Different pharmacological classes of progestogens differently contribute to the risk of VTE. Observational studies observed that the application of micronized progesterone and didrogesteron are safer regarding the risk of VTE compared to other progestins. These results should be further confirmed in the randomized studies. A personal or family history of VTE, existence of hereditary thrombophilia or/and multiple risk factors for VTE represent a strong contraindication to oral HRT use. In such persons the application of transdermal estrogen can be considered after careful individual evaluation of the benefits and risks. Transdermal estrogen should be also the first choice in overweight/obese women requiring HRT.

Venska tromboembolija (VTE) najvažniji je neželjeni učinak hormonskoga nadomjesnog liječenja (HNL). Biološke i epidemiološke studije pokazale su da oralna primjena estrogena nosi povišen rizik od nastanka VTE-a u odnosu na transdermalnu primjenu. Dodatak progestagena još povisuje rizik od nastanka VTE-a. Različite farmakološke klase progestagena drugačije pridonose riziku od nastanka VTE-a. Opservacijske su studije pokazale da je primjena mikroniziranog progesterona i didrogesterona sigurnija glede rizika od VTE-a u odnosu na druge progestine. Ove je rezultate nužno provjeriti randomiziranim studijama. Osobna ili obiteljska anamneza opterećena VTE-om, postojanje nasljedne trombofilije i/ili multiplih rizičnih čimbenika za nastanak VTE-a kontraindikacije su za uporabu HNL-a. U takvih se osoba može razmatrati primjena transdermalnog estrogena nakon pomne individualne procjene koristi i rizika. Transdermalno primijenjeni estrogeni također bi trebali biti prvi izbor u žena s prekomjernom tjelesnom masom, odnosno pretilosti koje trebaju primjenu HNL-a.

Despite the widespread availability of highly effective methods of contraception, unintended pregnancy is common. Unplanned pregnancies have been linked to a range of health, social and economic consequences. Emergency contraception reduces risk of pregnancy after unprotected intercourse, and represents an opportunity to decrease number of unplanned pregnancies and abortions. Emergency contraception pills (ECP) prevent pregnancy by delaying or inhibiting ovulation, without interfering with post fertilization events. If pregnancy has already occurred, ECPs will not be effective, therefore ECPs are not abortificants. Ulipristal acetate (17alpha-acetoxy-11beta-(4N-N,N-dymethilaminophenyl)-19-norpregna--4,9-diene-3,20-dione) is the first drug that was specifically developed and licensed for use as an emergency contraceptive. It is an orally active, synthetic, selective progesterone modulator that acts by binding with high affinity to the human progesterone receptor where it has both antagonist and partial agonist effects. It is a new molecular entity and the first compound in a new pharmacological class defined by the pristal stem. Up on the superior clinical efficacy evidence, UPA has been quickly recognized as the most effective emergency contraceptive pill, and recently recommended as the first prescription choice for all women regardless of the age and timing after intercourse. This article provides literature review of UPA and its role in emergency contraception.

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Uterine perforation related to the insertion of levonorgestrel-releasing intrauterine system (LNG – IUS) is a rare but potentially serious complication. There are no specific diagnostic guidelines for diagnosis and management of uterine perforation with LNG-IUS. We present a case of 38-year-old patient admitted to the Clinic for Women’s Diseases complaining of lower abdominal pain eight days following the insertion of LNG-IUS that reported to be painless and uneventful. The pelvic examination performed on arrival confirmed non-visualization of the LNG-IUS strings. Transvaginal ultrasound that was performed failed to identify the LNG- IUS device inside the uterine cavity, whereas transabdominal ultrasound (TAUS) was suggestive of LNG-IUS located inside the abdominal cavity. Laboratory findings were unremarkable. Abdominal X-ray study was obtained, and it confirmed the diagnosis of intra-abdominal location of LNG-IUS. Laparoscopy was performed ; the LNG-IUS was found and easily removed from the right part of the posterior cul-de-sac.

Authors explaned possible complications and therapeutic approach

Study question: Altered adipose tissue secretion plays a central role in the meta- bolic abnormalities observed in PCOS. This study was conducted to determine the concentrations of adipokines in different phenotypes of PCOS women, hy- pothesizing that normal-weight, normoinsulinemic PCOS women, with mildest phenotype also present with changes in adipokine secretion compared to controls. Summary answer: There was no difference in adipokines serum levels be- tween different PCOS phenotypes. Lower levels of adiponectin and ghrelin, and higher levels of leptin and resistin were observed in all lean PCOS phenotypes without hyperinsulinemia compared to controls suggesting that other intrinsic PCOS factor is in the culprit of these abnormalities. What is known already: Women with PCOS have significantly elevated leptin and resistin, and lower adiponectin and ghrelin serum levels compared to healthy women. Whether these abnormalities are secondary to obesity/ab- dominal fat distribution/hyperandrogenism/hyperinsulinemia or represents the intrinsic PCOS abnormality is yet to be determined. There is a limited data on the adipokine serum levels in four main PCOS phe- notypes defined by the Rotterdam Criteria. The majority of them observed posi- tive association of serum adipokine concentrations and PCOS phenotype severity. Study design, size, duration: Observational, prospective study of 186 women with PCOS fulfilling Rotterdam criteria and 162 weight and age-matched women was conducted from 2009 to 2013. Five groups were created: A) O (Oligoovulation) + H (Hyperandrogenism) + P (Polycystic ovaries) (n = 102) ; B) O + H (n = 15), C) H + P (n = 27) ; D) O + P (n = 42) and E) (control group). Participants/materials, setting, methods: Body mass index (BMI), waist/ hip ratio (WHR) and hirsutism were evaluated. Serum concentrations of a leptin, adiponectin, resistin, ghrelin, androgens, sex hormone binding globulin (SHBG), glucose and insulin were measured. Free testosterone and homeostatic model assessment of insulin resistance (HOMA-IR) were calculated. Results were analyzed using SPSS 17 for Windows. Main results and the role of chance: No association was found between the leptin, resistin, adiponectin and ghrelin serum levels with severity of PCOS pheno- type (all p > 0.05). We observed higher levels of leptin and resistin and lower levels of adiponectin and ghrelin in all PCOS phenotypes compared to control group (all p < 0.001). The most prominent finding was the lower adiponectin (p < 0.001) and ghrelin (p < 0.001) serum levels and higher levels of leptin (p < 0.001) and resistin (p < 0.001) in lean PCOS patients without hyperandrogenemia and insulin resis- tency (phenotype D) compared to healthy controls (group E).Limitations, reason for caution: Small sample size in group B. HOMA-IR was used instead of more reliable but technically difficult hyperinsulinemic- euglycemic clamp technique. With significant variations in PCOS presentation seen in different ethnic populations, generalizing data obtained from any single ethnic group to other population groups should be approached with caution. Wider implications of the findings: Although the O + P phenotype itself is under dispute, our data show that the normal-weight, normoinsulinemic PCOS women, who share this phenotype present with alterations in adipokines metabolism, the finding that was previously observed in PCOS women in general. This may suggest that some other intrinsic PCOS factor other than obesity, hyperandrogenism or hyperinsulinemia modulates the adipose tissue dysfunction which merit further research.

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Obesity has a deteriorating impact on women with PCOS, although prevalence and the impact of specific traits of PCOS remain inconstant in different populations. Therefore, the aim of this study was to explore the differences in clinical, hormonal and metabolic features between obese and nonobese Croatian women diagnosed as having PCOS according to Rotterdam consensus criteria. The study included 74 obese and 208 nonobese women with PCOS. Clinical, biochemical and metabolic variables were compared among those PCOS subgroups. Obese subjects with PCOS had a higher risk of developing oligo-amenorrhea (OR 3.7; 95% CI, 1.1-12.5) and lower risk for developing hirsutism and acne (OR 0.2; 95% CI, 0.1-0.3 and OR 0.8; 95% CI 0.5-1.4, respectively). Obese PCOS subjects also had a higher risk of developing hyperandrogenemia (OR 2.5; CI 95% 0.9-6.7), insulin resistance (OR 4.5; CI 95%, 2.6-7.9), hypercholesterolemia (OR 5.0, CI 95% 2.5-10.2), hypertriglyceridemia (OR 5.2; 95% CI, 2.9-9.2) as well as elevated serum CRP levels (OR 4.1; 95% CI 1.4-12.2) compared to nonobese PCOS women. In conclusion, nonobese Croatian women with PCOS are more inclined to cosmetic problems associated with PCOS then metabolic ones. This is the first study to report the impact of obesity on acne and irregular menses as a study outcome. Obesity deteriorates menstrual regularity, insulin sensitivity and lipid profile in Croatian women with PCOS; therefore one of the fundamental treatment strategies of PCOS should be obesity prevention.

The aim of this study was to calculate the relative prevalence of all phenotypes of polycystic ovary syndrome (PCOS) and to compare them for anthropometrical, hormonal and metabolic differences according to the Rotterdam Criteria. A total of 300 women with PCOS aged 26.7 +/- 5.6 years (mean +/- SD) and 100 women aged 28.3 +/- 4.1 years (mean +/- SD) were included in a control group. Anthropometrical, hormonal and metabolic parameters were compared between the groups. The most prevalent phenotype in our population was the most severe, phenotype A (56.7%), followed by phenotype D (26.7%) and phenotype C (14.3%). Phenotype B was present in only 2.3% of patients. The four main phenotypes did not differ in age, BMI and WHR. Women with phenotypes A and C had increased levels of LH and an increased LH/FSH ratio along with elevated androgen levels compared to the other groups. Serum glucose levels did not differ between the groups studied, however, higher levels of insulin, GIR and HOMA-IR were found between phenotype A and the control group. Phenotype C PCOS or ovulatory PCOS have the same characteristics as classic PCOS, however in a more mild form, which represents a transition between the classic form and the control group. Compared to the control group, phenotype D had higher mean levels of serum testosterone (still within normal range) along with elevated LH levels and LH/FSH ratio, similar to classic PCOS. However, compared with women diagnosed with PCOS based on hyperandrogenism, oligo-ovulation and polycystic ovaries, these patients demonstrated milder endocrine and metabolic abnormalities. Therefore, from an endocrine point of view, our study supports the inclusion of a normoandrogenic anovulatory phenotype in PCOS diagnostic criteria.

Obesity and insulin resistance is a common finding in patients with polycystic ovary syndrome (PCOS). Significant number of PCOS women experience insulin resistance that is irrespective of the degree of obesity suggesting possible genetic basis. Therefore, several polymorphisms of the genes encoding for the insulin (INS), insulin receptor (INSR) or insulin receptor substrates (IRS) involved in postreceptor signaling have been explored for their association with abnormal sensitivity to insulin in PCOS. The aim of the present study was to determine whether selected polymorphisms of INS, INSR and IRS-1 are associated with the development of PCOS as well as with increased insulin resistance in Croatian women with PCOS. The study enrolled 150 women with PCOS and 175 control women. The diagnosis of PCOS was based on Rotterdam consensus criteria. Each subject underwent an evaluation of body mass index (BMI), hirsutism, acne and menstrual cycle abnormalities as well as follicular stimulating hormone (FSH), luteinizing hormone (LH), total and free testosterone, androstendione, dehydroepiandrosterone sulphate (DHEAS), sex hormone binding globulin (SHBG), fasting glucose and fasting insulin. Insulin resistance (IR) was quantified using the homeostatic model assessment of IR (HOMA-IR). Molecular analyses for the genetic polymorphisms were preformed. There was a significant difference in clinical and biochemical characteristics of the studied groups except for BMI and fasting glucose levels. No significant differences were observed in the genotype and allele distribution of the VNTR INS, C/T INSR, Gly792Arg IRS-1 polymorphisms between cases and controls. Moreover, no association was found between VNTR INS, C/T INSR and Gly792Arg IRS-1 polymorphism and parameters of insulin resistance in PCOS patients. In conclusion, our data does not support an association between VNTR INS, C/T INSR and Gly792Arg IRS-1 polymorphism and susceptibility to PCOS or insulin resistance in Croatian women with PCOS.

The aim of this study was to calculate the relative prevalence of all phenotypes of polycystic ovary syndrome (PCOS) and to compare them for anthropometrical, hormonal and metabolic differences according to the Rotterdam Criteria. A total of 300 women with PCOS aged 26.7±5.6 years (median±SD) and 100 women aged 28.3±4.1 years (median±SD) were included in a control group. Anthropometrical, hormonal and metabolic parameters were compared between the groups. The most prevalent phenotype in our population was the most severe, phenotype A (56.7%), followed by phenotype D (26.7%) and phenotype C (14.3%). Phenotype B was present in only 2.3% of patients. The four main phenotypes did not differ in age, BMI and WHR. Women with phenotypes A and C had increased levels of LH and an increased LH/FSH ratio along with elevated androgen levels compared to the other groups. Serum glucose levels did not differ between the groups studied, however, higher levels of insulin, GIR and HOMA-IR were found between phenotype A and the control group. Phenotype C PCOS or ovulatory PCOS have the same characteristics as classic PCOS, however in a more mild form, which represents a transition between the classic form and the control group. Compared to the control group, phenotype D had higher mean levels of serum testosterone (still within normal range) along with elevated LH levels and LH/FSH ratio, similar to classic PCOS. However, compared with women diagnosed with PCOS based on hyperandrogenism, oligo-ovulation and polycystic ovaries, these patients demonstrated milder endocrine and metabolic abnormalities. Therefore, from an endocrine point of view, our study supports the inclusion of a normoandrogenic anovulatory phenotype in PCOS diagnostic criteria.

Hormonsko nadomjesno liječenje (HNL) ima važnu ulogu kod žena s nedostatkom estrogena. Simptomi i znaci nedostatka estrogena koji dovode do smanjenja kvalitete života primarno se očituju kod žena reprodukcijske dobi s hipoestrogenim amenorejama, onih s prijevremenom menopauzom, te kod žena u klimakteriju i postmenopauzi. Korištenje HNL-a (estrogena samih ili u kombinaciji s progestagenima) zbog dokazane učinkovitosti u smanjenju simptoma koji se povezuju s nedostatkom estrogena je opravdana. No njihova je primjena zbog povećanja nekih zdravstvenih rizika, primarno venske tromboembolije i karcinoma dojke, vremenski ograničena. HNL je predmet brojnih rasprava i spekulacija još od 1960. godine. Prema posliednjim istraživanjima HNL se preporučuje u liječenju vazomotornih tegoba, urogenitalne atrofije te u prevenciji osteoporotičnih prijeloma. Liječenje treba provoditi najnižom učinkovitom dozom kroz najkraće moguće vrijeme i uz odgovarajuće praćenje. Liječenje treba individualizirati sukladno potrebama i rizicima svake pacijentice. Iako ne postoje jasni znanstveni dokazi, prema današnjim smjernicama, HNL ne treba primjenjivati dulje od pet godina. HNL blago povećava rizik karcinoma dojke. Rizik je ovisan o trajanju korištenja, kao i putu primjene HNL-a, a nije ovisan o dozi primjenjenih hormona. Rizik je veći ako se uz estrogene koristi i progestagen. HNL povećava gustoću dojki u 25% žena što smanjuje osjetljivost mamografije. HNL ne pridonosi primarnoj i sekundarnoj prevenciji ishemične bolesti srca ili cerebrovaskularnih incidenta. Povećava rizik tromboemboličkih incidenata te se ne provodi u žena s tromboemboličkim incidentom u anamnezi. Progestageni primijenjeni bez estrogena, u žena koje ne smiju uzimati estrogene mogu povoljno utjecati na postmenopauzalne simptome, ali njihova primjena uvećava rizik nastanka karcinoma dojke. Primjenjeni u visokim dozama, progestageni uvećavaju rizik tromboemboličkih incidenata. Deset godina nakon WHI (Women's Health Initiative) studije bilježi se pad uporabe HNL-a za oko 70%. U isto vrijeme, postoji sve veći interes za primjenu alternativnih metoda liječenja, uključujući i fitoestrogene. Dokazi o učinkovitosti, kliničkoj primjeni i troškovima alternativnih oblika liječenja su ograničeni. Pad korištenja HNL-a rezultirao je porastom učestalosti fraktura te povećanjem korištenja antidepresiva. Cilj ovog rada je prikazati najnovije spoznaje o dobrobitima i rizicima korištenja hormonskog nadomjesnog liječenja.

U predavanju su prikazani naši rezultati o osobinama i rizicima PCOS u Hrvatskoj

Prikazan je utjecaj steroidnih hormona na rizik nastanka venskih tromboza

Predstavljena je nova FIGO klasifikacija abnormalnih krvarenja iz maternice, te dan postupnik obrade i liječenja COEIN uzroka nenormalnih krvarenja iz maternice

Introduction: The incidence of iatrogenic parasitic myomas associated with the laparoscopic use of electric tissue morcellation is increasing. Morcellation remnants may implant and grow around the peritoneal cavity captivating blood supply from adjacent structure. We report a case of an unusual manifestation of a large parasitic myoma interspersed with endometrial cysts arising six years after laparoscopic myomectomy. Matherials and methods: A 40-year-old nulliparous women underwent laparoscopic myomectomy with electric tissue morcellation for subserous myoma with no intraoperative or postoperative complications. Six years later she presented with large pelvic mass and abdominal discomfort. On physical exam a firm mobile mass about 8 cm in diameter was found in the left pelvis and just above the uterus. Pelvic ultrasound demonstrated a cystic mass (5x2x2.5cm) with ultrasound appearance similar to observed in the case of endometriomas. Results: Laparoscopy was preformed and a large clustered vascularised mass firmly attached to uterine fundus and rectum was found and excised. Cross-section of the tumor revealed multiple cystic cavities filled with altered blood. Hystologically tumor was composed of smooth muscle cells and multiple cavities covered with endometrial stroma and endometrial epithelium. Discussion. All tissue pieces that are morcellated should be diligently removed and irrigated. Implantation and regrowth of morcellated remnants may result with formation of bizarre appearing tumors. Therefore, a parasitic myoma must be included in the differential diagnosis if a solid tumor is found succeeding the use of electric tissue morcellation.

XO

Obesity and insulin resistance is a common finding in patients with polycystic ovary syndrome (PCOS). Significant number of PCOS women experience insulin resistance that is irrespective of the degree of obesity suggesting possible ge- netic basis. Therefore, several polymorphisms of the genes encoding for the insulin (INS), insulin receptor (INSR) or in- sulin receptor substrates (IRS) involved in postreceptor signaling have been explored for their association with abnormal sensitivity to insulin in PCOS. The aim of the present study was to determine whether selected polymorphisms of INS, INSR and IRS-1 are associated with the development of PCOS as well as with increased insulin resistance in Croatian women with PCOS. The study enrolled 150 women with PCOS and 175 control women. The diagnosis of PCOS was based on Rotterdam consensus criteria. Each subject underwent an evaluation of body mass index (BMI), hirsutism, acne and menstrual cycle abnormalities as well as follicular stimulating hormone (FSH), luteinizing hormone (LH), to- tal and free testosterone, androstendione, dehydroepiandrosterone sulphate (DHEAS), sex hormone binding globulin (SHBG), fasting glucose and fasting insulin. Insulin resistance (IR) was quantified using the homeostatic model assess- ment of IR (HOMA-IR). Molecular analyses for the genetic polymorphisms were preformed. There was a significant dif- ference in clinical and biochemical characteristics of the studied groups except for BMI and fasting glucose levels. No significant differences were observed in the genotype and allele distribution of the VNTR INS, C/T INSR, Gly792Arg IRS-1 polymorphisms between cases and controls. Moreover, no association was found between VNTR INS, C/T INSR and Gly792Arg IRS-1 polymorphism and parameters of insulin resistance in PCOS patients. In conclusion, our data does not support an association between VNTR INS, C/T INSR and Gly792Arg IRS-1 polymorphism and susceptibility to PCOS or insulin resistance in Croatian women with PCOS.

XO

XO

Obesity has a deteriorating impact on women with PCOS, although prevalence and the impact of specific traits of PCOS remain inconstant in different populations. Therefore, the aim of this study was to explore the differences in clinical, hormonal and metabolic features between obese and nonobese Croatian women diagnosed as having PCOS according to Rotterdam consensus criteria. The study included 74 obese and 208 nonobese women with PCOS. Clinical, biochemical and metabolic variables were compared among those PCOS subgroups. Obese subjects with PCOS had a higher risk of developing oligo- amenorrhea (OR 3.7 ; 95% CI, 1.1-12.5) and lower risk for developing hirsutism and acne (OR 0.2 ; 95% CI, 0.1-0.3 and OR 0.8 ; 95% CI 0.5-1.4, respectively). Obese PCOS subjects also had a higher risk of developing hyperandrogenemia (OR 2.5 ; CI 95% 0.9-6.7), insulin resistance (OR 4.5 ; CI 95%, 2.6-7.9), hypercholesterolemia (OR 5.0, CI 95% 2.5-10.2), hypertriglyceridemia (OR 5.2 ; 95% CI, 2.9-9.2) as well as elevated serum CRP levels (OR 4.1 ; 95% CI 1.4-12.2) compared to nonobese PCOS women. In conclusion, nonobese Croatian women with PCOS are more inclined to cosmetic problems associated with PCOS then metabolic ones. This is the first study to report the impact of obesity on acne and irregular menses as a study outcome. Obesity deteriorates menstrual regularity, insulin sensitivity and lipid profile in Croatian women with PCOS ; therefore one of the fundamental treatment strategies of PCOS should be obesity prevention.

Polycystic ovary syndrome (PCOS) is a common endocrine condition affecting women of reproductive age. There are many typical signs and symptoms that allow for the diagnosis of PCOS depending on the criteria used. Interestingly, ethnicity influences the extent of these signs and symptoms; therefore, the frequency of symptoms varies between different countries and ethnic groups. The prevalence of this syndrome in Croatia is unknown, and it's clinical and biochemical characteristics have not yet been reported. During this study, we used the Rotterdam criteria to evaluate 365 Croatian women with PCOS, and compared them to 304 age matched controls to assess the clinical and biochemical abnormalities that occur in PCOS patients. The mean age of PCOS patients at presentation was 26.1 +/- 5.9 years and of controls were 28.0 +/- 4.2 years. Women with PCOS has significantly higher body mass index (BMI) than the control group, although in both groups most patients had normal weight (76.2% vs. 87.8%). Abdominal distribution of fat tissue was similar in both groups. Menstrual cycle abnormalities were observed in 90.7% of PCOS patients, and ultrasonographic appearance of polycystic ovaries was reported in 97.3% of PCOS cases. Nearly 75% of patients with PCOS had hirsutism and 49.6% had acne. We recorded significantly higher serum levels of luteinizing hormone (LH), total testosterone (TT), free testosterone (fT) and insulin, while the serum levels of sex hormone binding globuline (SHBG) and follicular stimulating hormone (FSH) were significantly lower than in the control group. Serum glucose values were not significantly different between the groups. In conclusion, chronic anovulation, hirsutism and ultrasound appearance of polycystic ovaries are the dominant features of PCOS in Croatian population. The majority of patients with PCOS had normal body weight. The incidence of insulin resistance in this group of patients is less than the previously described frequency in other populations of patients with PCOS and normal weight.

The aim of the paper was to evaluate current emergency contraception (EC) methods and policies in order to implement lessons learned and maximize potential population impact while introducing dedicated EC pills in Croatia. Literature search for potential reasons for EC failing to show positive population impact and detecting actionable points to be implemented in national guidelines. Six potential reasons for ECs failure to show population impact were evaluated and four actionable points were detected: low use of EC compared to the numbers of risk events, low awareness on EC in general population, differences in efficacy of EC methods and EC vailability. In order to ensure EC's population impact in Croatia it is of a critical relevance to establish continuous education programs for population of women at risk. When recommending an EC method, superior efficacy must be a key decision-making criteria therefore cooper IUD and ulipristal acetate should be our primary options. Counseling is a critical step to ensure maximal efficacy of the EC method, but also to encourage future use of regular contraceptives. Finally, national ECP dispension protocol is needed to close the loop from effective women screening, prompt yet appropriate ECP administration/dispensing towards structured follow up after EC pills intake.

The aim of the paper was to evaluate current emergency contraception (EC) methods and policies in order to implement lessons learned and maximize potential population impact while introducing dedicated EC pills in Croatia. Literature search for potential reasons for EC failing to show positive population impact and detecting actionable points to be implemented in national guidelines. Six potential reasons for ECs failure to show population impact were evaluated and four actionable points were detected: low use of EC compared to the numbers of risk events, low awareness on EC in general population, differences in efficacy of EC methods and EC vailability. In order to ensure EC's population impact in Croatia it is of a critical relevance to establish continuous education programs for population of women at risk. When recommending an EC method, superior efficacy must be a key decision-making criteria therefore cooper IUD and ulipristal acetate should be our primary options. Counseling is a critical step to ensure maximal efficacy of the EC method, but also to encourage future use of regular contraceptives. Finally, national ECP dispension protocol is needed to close the loop from effective women screening, prompt yet appropriate ECP administration/dispensing towards structured follow up after EC pills intake.

Hormone Replacement Therapy and Urogenital aging

istraživana je uloga gena kandidata u nastanku sindroma policističnih jajnika

Belara, hormonska kontracepcija

Indukcija ovulacije danas – indikacije, lijekovi, protokoli.

probiotici, vaginalno zdravlje

individualizacija, hormonska kontracepcija

Unatoč brojnim, danas dostupnim metodama kontracepcije stopa neplaniranih trudnoća u Republici Hrvatskoj neprihvatljivo je visoka. Novi oblici hormonske kontracepcije ženama nude veći izbor, manje rizika i bolje podnošenje, što će, nadamo se, u konačnici rezultirati manjom stopom neželjenih trudnoća. Liječnici se moraju upoznati s novim dostignućima na polju hormonske kontracepcije kako bi mogli individualizirati izbor. U ovom se članku navode novi načini, režimi i oblici primjene hormonske kontracepcije.

vitrification, oocytes

Antiandrogens and androgen ihibitors

hitna kontracepcija

Dvadesetminutno izlaganje o najnovijim spoznajama vezano uz genetiku PCOS te uloge adipokina u patofiziologiji PCOS.

mormo upisati

progestagen, kontracepcija

Hormonska kontracepcija: Individualizacija, dobrobiti i rizici.

U radu je dan pregled najnovijih saznanja o hitnoj kontracepciji

Izneseni su stavovi i preporuke o hormonskom nadomjesnom liječenju 9 godina nakon objave WHI studije