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Background: In recent years, the available evidence revealed that mechanical hysteroscopic tissue removal (mHTR) systems represent a safe and effective alternative to conventional operative resectoscopic hysteroscopy to treat a diverse spectrum of intrauterine pathology including endometrial polyps, uterine myomas, removal of placental remnants and to perform targeted endometrial biopsy under direct visualisation. This innovative technology simultaneously cuts and removes the tissue, allowing one to perform the procedure in a safer, faster and more effective way compared to conventional resectoscopic surgery., Objective: To review currently available scientific evidence concerning the use of mechanical hysteroscopic morcellators and highlight relevant aspects of the technology., Material and Methods: A narrative review was conducted analysing the available literature regarding hysteroscopic tissue removal systems., Main Outcome Measures: Characteristics of available mHTR systems, procedures they are used for, their performance including safety aspects and their comparison., Results: A total of 7 hysteroscopic morcellators were identified. The diameter of the external sheet ranged from 5.25 to 9.0 mm, optics ranged from 0.8 to 6.3 mm with 0o angle. The cutter device diameter ranged from 2.9 to 4.5 mm most of them with rotation and reciprocation., Conclusion: We conclude that the adoption of mHTR has shown to reduce operating time, simultaneously cutting and suctioning tissue fragments avoiding the need for multiple removal and reinsertions of the device into the uterine cavity as well as reducing the volume of distension media required to complete the procedure compared to using the hysteroscopic resectoscope.

Aim: To compare the recurrence of benign endometrial polyps after office hysteroscopic polypectomy performed with a bipolar electrode (BE) or a small diameter hysteroscopic tissue removal system (HTRs)., Methods: From July 2018 to December 2019 we evaluated the charts of 114 asymptomatic fertile women who underwent office hysteroscopic polypectomy, 1 year before, for a single large benign endometrial polyp (size between 10 and 20 mm) using a 4 mm continuous flow hysteroscope with a BE or a 5 mm HTRs. Patients, divided into two groups according to surgical procedure, each performed exclusively by one expert gynecologist, were scheduled for a 12-month postoperative transvaginal sonography to evaluate the recurrence of endometrial polyps., Results: Forty-eight women of the BE group and 42 of the HTRs group were considered for the 1-year transvaginal sonography follow-up. Five polyps were identified in the BE group and three in the HTRs group (5/48 vs 3/42, P = n.s.). All polyps were removed hysteroscopically (in three out of five and in two out of three cases, respectively, in the same places of the previous polypectomy) and evaluated as 'benign' by the pathologist., Conclusion: Office hysteroscopic endometrial polypectomy with small HTRs compared to BE revealed at a 1-year follow-up no difference in terms of complete removal and recurrence of polyps. HTRs polypectomy resulted in less pain and significantly quicker time of procedure compared to BE. This data should be kept in mind for patient comfort any time hysteroscopic polypectomy is planned in an office setting., (© 2020 Japan Society of Obstetrics and Gynecology.)

Surgery is the most frequent treatment in women with symptomatic uterine fibroids. A new medical approach with ulipristal acetate (UPA) has been suggested. The aim of this study was to provide data on effectiveness and safety of UPA in premenopausal women with symptomatic uterine fibroids. This was a multicenter retrospective cohort study. Data on all consecutive premenopausal women with symptomatic uterine fibroids referred to three Italian centers were included in a dedicated merged database. Women aged 18-55 years, who received pharmacologic therapy with UPA 5 mg orally once a day, were included in the study. The primary outcome was the percentage of women who underwent surgery after UPA treatment. One hundred and forty-two premenopausal women with uterine fibroids were included in this study. The mean age was 43.2 years. Eighty-one (57.0%) of 142 women treated with UPA had only medical treatment and did not undergo surgery. Surgical treatment occurred in 70, 23, 32, and 8% of the women who received one course, two courses, three courses, or four courses, of UPA treatment, respectively. The incidence of side effects was 10.6%. The effectiveness and safety of repeated UPA treatment courses in reducing number of women requiring surgery is confirmed by real-world data.

Aim: This retrospective multicenter study was carried out to evaluate feasibility, effectiveness and patient acceptability of a small diameter hysteroscopic tissue removal system in the treatment of large endometrial polyps (≥20 mm), usually not removed in an office setting., Methods: Hundred and forty-six women with a single greater than 10-mm diameter polyp considered for polypectomy between April 2016 and August 2017. Sixty-five of these patients had a polyp size greater than 20 mm. All hysteroscopic polypectomy, using Hysteroscopic Tissue Removal system (TruClear 5C System Medtronic), were performed in an office setting with vaginoscopic approach., Results: Procedural success, time to complete the polypectomy and patient pain scores were evaluated. Polyps less than 20 mm were completely removed in 79/81 cases (97.53%). The completeness of greater than or equal to 20-mm polyp removal was achieved in 63/65 cases (96.92%). The median time for polypectomy was 4.19 ± 1.03 min for polyps less than 20 mm and 4.97 ± 1.30 min for polyps greater than or equal to 20 mm, respectively. Pain was minimal and brief, and the mean pain score measured on a 10-point visual analog scale at the end of polypectomy showed no significant difference between the two groups. In 4/79 (5.06%) cases with polyps less than 20 mm and in 4/63 (6.35%) cases with polyps greater than or equal to 20 mm women reported moderate pain. All specimens were adequate for pathologic measurements., Conclusion: Hysteroscopic treatment of polyps greater than or equal to 20 mm in size with TruClear 5C is feasible and well tolerated in an office setting with no significant difference regarding completeness compared to polyps less than 20 mm, but with a minimal increase in procedure times., (© 2018 Japan Society of Obstetrics and Gynecology.)

Study Objective: To compare the costs of hysteroscopic polypectomy using mechanical and electrosurgical systems in the hospital operating room and an office-based setting., Design: Retrospective cohort study (Canadian Task Force classification II-2)., Setting: Tertiary referral hospital and center for gynecologic care., Patients: Seven hundred and fifty-four women who underwent endometrial polypectomy between January 20, 2015, and April 27, 2016., Interventions: Hysteroscopic endometrial polypectomy performed in the same-day hospital setting or office setting using one of the following: bipolar electrode, loop electrode, mechanical device, or hysteroscopic tissue removal system., Measurements and Main Results: The various costs associated with the 2 clinical settings at Palagi Hospital, Florence, Italy were compiled, and a direct cost comparison was made using an activity-based cost-management system. The costs for using reusable loop electrode resection-16 or loop electrode resection-26 were significantly less expensive than using disposable loop electrode resection-27, the tissue removal system, or bipolar electrode resection (p = .0002). Total hospital costs for polypectomy with all systems were significantly less expensive in an office setting compared with same-day surgery in the hospital setting (p = .0001). Office-based hysteroscopic tissue removal was associated with shorter operative time compared with the other procedures (p = .0002) CONCLUSION: The total cost of hysteroscopic polypectomy is markedly higher when using disposable equipment compared with reusable equipment, both in the hospital operating room and the office setting. Same-day hospital or office-based surgery with reusable loop electrode resection is the most cost-effective approach in each settings, but requires experienced surgeons. Finally, the shorter surgical time should be taken into consideration for patients undergoing vaginal polypectomy in the office setting, owing more to patient comfort than to cost savings., (Copyright © 2017 American Association of Gynecologic Laparoscopists. Published by Elsevier Inc. All rights reserved.)

Study Objective: To describe safety, tolerability, and effectiveness results through a minimum 2-year follow-up of patients who underwent permanent sterilization with the Essure insert., Design: A retrospective multicenter study (Canadian Task Force classification II2)., Setting: Seven general hospitals and 4 clinical teaching centers in Italy., Patients: A total of 1968 women, mean age 39.5 years (range, 23-48 years) who underwent office hysteroscopic sterilization using the Essure insert between April 1, 2003, and December 30, 2014., Intervention: The women underwent office hysteroscopic bilateral Essure insert placement, with satisfactory device location and tube occlusion based on hysterosalpingography or hysterosalpingo-contrast sonography (HyCoSy)., Measurements and Main Results: Placement rate, successful bilateral tubal occlusion, perioperative adverse events, early postoperative (during the first 3 months of follow-up), and late complications were evaluated. Satisfactory insertion was accomplished in 97.2% of women and, in 4, perforation and 1 expulsion were detected during hysterosalpingography. Three unintended pregnancies occurred before the 3-month confirmation test. Two pregnancies were reported among women relying on the Essure inserts. Postprocedure pain was minimal and brief; in 9 women, pelvic pain became intractable, necessitating removal of the devices via laparoscopy. On telephone interviews, overall satisfaction was rated as "very satisfied" by the majority of women (97.6%), and no long-term adverse events were reported., Conclusion: The findings from this extended Italian survey further support the effectiveness, tolerability, and satisfaction of Essure hysteroscopic sterilization when motivated women are selected and well informed of the potential risks of the device. Moreover, the results do not demonstrate an increased incidence of complications and pregnancies associated with long-term Essure use. Patients with a known hypersensitivity to nickel may be less suitable candidates for the Essure insert., (Copyright © 2017 AAGL. Published by Elsevier Inc. All rights reserved.)

Objective: Polypectomy under hysteroscopic guidance is the treatment of choice for most endometrial polyps, but mechanical or electrical effects at the time of surgery may result in artifactual displacement of tissue with obvious resultant diagnostic problems. The purpose of this study was to record qualitative and quantitative histopathological artifacts and to assess differences between artifacts found in specimens obtained by different surgical polypectomy techniques., Study Design: During the period from November 2012 to March 2013, 90 retrospective consecutive polyp histopathological slides and their reports were identified for this study. Initially reported slides were reviewed blind by two histopathologists, who were not provided with any surgical details. The issued reports and those of the reviewing pathologists were then compared., Results: Of the 90 reviewed polyp slides, there was complete agreement on the initial issued report in all cases., Conclusions: Removal of endometrial polyps in an office setting using mechanical instruments, bipolar electrode or a hysteroscopic morcellator provides adequate tissue for histological diagnosis, and there is no difference between these three techniques for adequacy of histological examination, despite the effects of thermal injury or tissue fragmentation., (Copyright © 2015. Published by Elsevier Ireland Ltd.)

Objective: To evaluate the x-ray appearance of Essure microinserts 5 years after their insertion., Design: Prospective controlled study., Setting: Tertiary referral centers for gynecologic care., Patient(s): Forty-five consecutive women with successful hysteroscopic bilateral placement of the Essure devices and postprocedure satisfactory hysterosalpingography confirmation test., Intervention(s): Pelvic anteroposterior x-ray., Main Outcome Measure(s): Stability and and symmetric appearance of Essure microinsert positions; measurement of the intrauterine distance between the two devices., Result(s): After 5 years from their placement, no detachment nor fracture of devices was observed. x-Ray recognition of the device after 5 years showed findings similar to those recorded at 3 months' follow-through hysterosalpingography., Conclusion(s): x-Ray evaluation of findings related to stability of position, symmetric appearance, and distance between the two Essure microinserts corroborates the irreversibility and the reliability of the fibrotic reaction that ensured tubal occlusion after devices placement., (Copyright © 2011 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To obtain data on correlates of climacteric symptoms in women around menopause attending menopause clinics in Italy., Methods: Since 1997 a large cross sectional study has been conducted on the characteristics of women around menopause attending a network of first level menopause outpatient's clinics in Italy. A total of 66,501 (mean age 54.4 years) women are considered in the present paper., Results: The odds ratios of moderate and severe hot flashes/night sweats were lower in more educated women and (for severe symptoms only) in women reporting regular physical activity. Depression, difficulty to sleep, forgetfulness and irritability tended to be less frequent in more educated women and (depression only) in women reporting regular physical activity. Parous women reported more frequently these symptoms., Conclusions: This large study confirms in Southern European population that low education, body mass index and low physical activity are associated with climacteric symptoms. Parous women are at greater risk of psychological symptoms.

Objective: To analyze risk factors for type 2 diabetes among women attending menopause clinics in Italy for counselling about the menopause., Subjects: Women attending a network of first-level outpatient menopause clinics in Italy for general counselling about menopause or treatment of menopausal symptoms., Methods: Cross-sectional study with no exclusion criteria. Type 2 diabetes was defined according to National Diabetes Data Groups Indications and the fasting blood glucose at an oral glucose tolerance test within the previous year., Results: Out of the 44 694 considered in this analysis, 808 had a diagnosis of diabetes type 2 (1.8%). In comparison with women aged < 50 years, the multivariate odds ratios (OR) of type 2 diabetes were 1.31 (95% confidence interval (CI), 0.99-1.74) for women aged 50-52 years, 1.66 (95% CI, 1.27-2.17) at 53-56 years and 2.84 (95% CI, 2.20-3.67) in women aged > or = 57 years. Type 2 diabetes was less frequently reported in more educated women (OR high school/university vs. primary school = 0.44 (95% CI, 0.36-0.55)). Being overweight was associated with an increased risk of type 2 diabetes. In comparison with women reporting a low level of physical activity, the multivariate OR of type 2 diabetes was 0.67 (95% CI, 0.54-0.84) for women reporting regular physical activity. In comparison with premenopausal women, the multivariate OR of type 2 diabetes was 1.38 (95% CI, 1.03-1.84) in women with natural menopause. This finding was present also after allowing for the potential confounding effect of age. The multivariate OR of diabetes for users of hormonal replacement therapy was 0.58 (95% CI, 0.46-0.73)., Conclusions: This large cross-sectional study suggests that postmenopausal women are at higher risk of type 2 diabetes after allowance for the effect of age. Other main determinants of risk of type 2 diabetes in women around menopause were low socioeconomic status and being overweight. Diabetes was found less frequently in those taking hormone replacement therapy.

Immunoreactive (Ir) beta-endorphin concentrations were determined in plasma, anterior pituitary (AP), neurointermediate pituitary lobe (NIL) and mediobasal hypothalamus (MBH) of pregnant (12-14 and 18-20 days) and fertile control rats, during labour and lactation. Immunoreactive Met-enkephalin concentrations were also evaluated in the MBH. Concentrations of Ir beta-endorphin in plasma, AP and NIL of rats during early and late pregnancy were significantly higher than in controls, the plasma and AP contents showing an increasing pattern in the second half of gestation. During labour, Ir beta-endorphin concentrations in plasma and AP reached the highest values, whereas those in NIl remained unchanged. Lactating rats showed Ir beta-endorphin concentrations in NIL and plasma in a range similar to that found in pregnant rats, resulting in concentrations in the AP not significantly different from those of nonpregnant controls. Immunoreactive beta-endorphin and Ir Met-enkephalin concentrations in MBH of pregnant rats were almost twice as high as in controls, rising markedly during labour; during lactation levels were in the same range as in non-pregnant controls. These results indicate that pregnancy and labour are characterized by high plasma, pituitary and hypothalamic concentrations of Ir-beta-endorphin as well as by high hypothalamic Ir Met-enkephalin levels, and that Ir beta-endorphin concentrations vary differently during pregnancy, lactation and labour in the two pituitary lobes, supporting the existence of different control mechanisms in the AP and NIL.