In the ambulatory assessment of women with abnormal uterine bleeding, the main aim is to reach a diagnosis and thereby allow appropriate treatment. Excluding endometrial pathology, particularly carcinoma and hyperplasia, is of paramount importance. However there is no consensus as to which set of investigations should be used (hysteroscopy, ultrasonography and endometrial sampling). There is a lack of good quality research evidence on the accuracy of the various diagnostic tests in predicting endometrial lesions. This dearth of relevant evidence prompted the research presented in this thesis to address and answer the following research questions: • What is the accuracy of outpatient miniature hysteroscopy / ultrasonography in the identification of premalignant and malignant endometrial lesions? • What is the relative significance of hysteroscopic and ultrasonographic evidence of endometrial atrophy in relation to an insufficient sample on outpatient endometrial biopsy? • What is the risk of premalignant and malignant pathology among endometrial polyps? What is the significance of various risk factors associated with endometrial polyps? • What is the feasibility of multivariable analysis to evaluate combinations of diagnostic tests in the diagnosis of endometrial disease? Findings and Conclusions Positive hhysteroscopy is accurate in ruling in endometrial cancer and hyperplasia (the LR was 51.1 (95% CI 7.9-326.9). Using endometrial thickness >4mm at ultrasound scan, ultrasound is accurate in ruling out endometrial cancer and hyperplasia (the LR was 0.14 (95%CI 0.02-0.64). Insufficient sample on endometrial biopsy was more common among cases with hysteroscopic finding of endometrial atrophy (adjusted OR= 4.79, 95% CI 1.05-21.91, p=0.04) and less common among cases with sonographic endometrial thickness above 5mm (adjusted OR=0.19, 95% CI 0.07-0.53, p=0.001). Therefore insufficient sample may be considered a substitute to absence of pathology provided the hysteroscopic and sonographic endometrial assessment is consistent with endometrial atrophy. Hyperplasia was more frequent in endometrial specimens with polyps than in those without (9.7% vs 4.8%, OR=2.1, 95% CI 0.85-5.2), but the rate of carcinoma in the two groups was not statistically different (4.8% vs 3.2%, OR=1.5, 95% CI 0.46-5.0). Tamoxifen treatment was associated with endometrial polyps (adjusted OR= 8.16, 95% CI 2.01-33.2, p=0.003) but hormone replacement therapy was not (adjusted OR=1.35, 95% CI 0.65 – 2.81, p=0.42). The true clinical value of a test lies in the added information over and above what was already known from the history and examination. It is feasible to develop a stepwise multivariable analytic approach to explore the added value of tests (hysteroscopy or ultrasonography) over and above history when predicting endometrial hyperplasia or cancer. This analytic strategy needs to be applied in larger datasets to draw clinical conclusions.

The female reproductive tract acts not only as a complex mediator of sperm function and selection but animal data suggests that it alters protein expression after exposure to sperm, implying two-way communication. We have used single-cell fluorescence imaging to observe [Ca2+]i signalling in human female reproductive tract cells upon initial contact with sperm and in sperm during binding and release events. Parallel experiments were also performed on a model human oviductal cell line, OE E6/E7 and a control, human foreskin fibroblasts. Upon exposure to sperm, tract cells generated [Ca2+]i signals through mobilisation of thapsigargin-sensitive intracellular Ca2+ stores. The percentage of significant [Ca2+]i responses varied in different anatomical regions of the female tract. Furthermore, [Ca2+]i signalling was observed upon exposure to sperm-conditioned media suggesting signalling factors may be shed or secreted by sperm. Human foreskin fibroblasts were unresponsive to sperm. Co-culture of sperm with tract explants induced post-translational modification of sperm proteins through NO-dependant S-nitrosylation. We have also provided initial evidence for [Ca2+]i alterations in sperm during binding to and detachment from oviductal explants. We conclude that sperm can elicit [Ca2+]i signals in female tract cells upon initial contact though mobilisation of intracellular Ca2+ stores. This may reflect events upstream of reported gene and protein expression changes. In addition, human sperm interaction with oviductal epithelium is likely to be important in modulating sperm function during migration and associated events through the female reproductive tract.

Previous studies have associated intracellular calcium ([Ca2+]i) oscillations in vascular smooth muscle cells (SMC) with vasomotion in multiple species. In normal and pre-eclamptic pregnancies, there is strong evidence to suggest that the intrauterine environment is hypoxic. The aim of this study was to investigate whether ATP and [Ca2+]i oscillations play a role in modulating vasomotion during hypoxia in human umbilical blood vessels. The results obtained from in vitro studies using firefly luciferase assay and quinacrine staining indicated that human umbilical artery and vein endothelial cell (HUAEC, HUVEC respectively) constitutively released ATP and, in HUVEC at least, the release was accentuated by hypoxia (7.6 mmHg O2, 30 min). This release is dependent on the PI3K/ROCK pathway, and on normal vesicular transport. Further, application of ATP to human umbilical artery SMC induced dose-dependent [Ca2+]i oscillations, which was mediated by P2Y4 receptor. Moreover, ex vivo data from freshly isolated umbilical artery rings showed that acute hypoxia increased the frequency of vasomotion. It is therefore proposed that the findings of the present study is important in the understanding of the behaviour of human umbilical vessels in normal pregnancy, but may also have implications in the pathophysiology of complicated pregnancy such as pre-eclampsia.

Advances in technology have led to the miniaturisation of hysteroscopes without compromising optical performance. This development has facilitated the routine use of diagnostic hysteroscopy in an outpatient setting without the need for general anaesthesia. Further developments have expanded hysteroscopy from a simply diagnostic intervention to an operative one with a plethora of hysteroscopic surgical procedures. The work in this thesis has adopted a mixed methodological approach to rigorously evaluate patient selection, feasibility and efficacy of office hysteroscopy. Based on the results of this thesis we recommend: 1) Women with recurrent PMB should be investigated with either hysteroscopy or saline infusion sonography. 2) Vaginoscopy should probably be used in preference to other techniques to introduce the hysteroscope into the uterine cavity. 3) Women who have a uterine cavity >9cm or dysmenorrhoea should be warned they are more likely to require further intervention after endometrial ablation. 4) There appears to be no difference between the effectiveness of bipolar radiofrequency ablation and thermal balloon ablation at five years of follow up. 5) Women who present with abnormal uterine bleeding and an endometrial polyp should have it removed. 6) The hysteroscopic morcellator should be used in preference to bipolar resection for endometrial polyp removal.

There have been many breakthroughs in birth control technologies, many of which have been beneficial for women. However, many feminists who advocate reproductive freedom also warn that freedom for some might lead to further oppression for others. The case in point is the practice of tubal ligation in the United States. Conflict theory indicates that the field of medicine is a social structure that is based upon capitalistic ideology and serves to perpetuate inequality. Feminist theory argues that medicine systematically disempowers women and that notions of family are very narrowly defined. This study examined the prevalence of tubal ligation among women in the United States, specifically focusing on nonwhite and poor women in an effort to determine whether or not they are sterilized at higher rates than their white and nonpoor counterparts. Data from the National Survey for Family Growth (Cycle V) were examined using several bivariate crosstabulations, and three logistic regressions were run to see if living below the poverty level or being nonwhite had any effect on a woman's likelihood to have a tubal ligation. The results show that there is some indication that living below the poverty level and being nonwhite, among other variables including being counseled by a medical provider about tubal ligation, does increase the likelihood that a woman will have a tubal ligation.

Pre-eclampsia is a pregnancy-specific, multi-system disorder of placental origin. Affecting between 2-8% of women, it is one of the leading causes of both maternal and fetal morbidity and mortality in the United Kingdom. Although the disorder presents after 20 weeks gestation with the classic symptoms of hypertension and proteinuria, the pathological process(es) leading to this syndrome initiate early in the first trimester. In current clinical practice, prediction of those who will get the disease and those who will have a poor outcome once it develops is poor. This thesis focuses on novel ways to enhance the prediction of the development of pre-eclampsia and poor outcome once the syndrome manifests. Firstly, the current risk factors for pre-eclampsia were challenged. Racial variation in these risk factors has demonstrated the importance of considering maternal ethnicity when assessing the likelihood of developing the disease. Obese Black women were more likely to develop pre-eclampsia than obese white women (aOR 2.06 (95%CI 1.34-3.23) p=0.002). In the normal BMI group Black women were less likely to develop pre-eclampsia than White women (aOR 0.421 (95%CI 0.24-0.73) p<0.001). Younger (<20 years of age) Black women were less likely to develop pre-eclampsia than younger white women (aOR 0.628 (95%CI 0.49-0.83) p<0.001). Conversely, older (>35 years of age) Black women were more likely to develop pre-eclampsia than older White women (aOR 1.67 (95%CI 1.39-1.99) p<0.001). Secondly, first trimester maternal plasma studies have identified a cohort of potential disease (and pathophysiological) markers that may allow for the development of an early screening test for pre-eclampsia. The ratio of angiotensinogen to Kallikrein is raised in the first trimester of pregnancies that later develop pre-eclampsia (p<0.001). The receiver operator curve (ROC) for the ratio of angiotensinogen to kallikrein had an area under the curve (AUC) of 0.81 (SE=0.05). A cut-off value of >0.27 has a sensitivity of 0.9 (95% CI = 0.74 – 0.97), a specificity of 0.5 (95% CI = 0.24-0.65), positive predictive value (PPV) 0.63 (95%CI = 0.47-0.75) and negative predictive value (NPV) of 0.87 (95% CI = 0.53-0.96) in predicting the onset of preeclampsia. Common haematological and biochemical tests are presented as markers for both the development of the disease and poor outcome when it occurs. The ratio of Neutrophil to Lymphocyte (NLR) is raised in the first trimester of pregnancies that develop pre-eclampsia (p<0.001). The ROC of the ratio to Neutrophil to Lymphocyte has an AUC of 0.84 (95% CI = 0.85-0.95). A cut off value of 2.53 has a sensitivity of 0.92 (95%CI = 0.85-0.95), specificity of 0.6 (95%CI = 0.51-0.67), PPV 0.68 (95%CI = 0.6-0.74) NPV 0.87 (95%CI = 0.8-0.93) for predicting the onset of pre-eclampsia. At the time of diagnosis of pre-eclampsia, a raised NLR predicts poor maternal outcome and the need for a caesarean section due to fetal distress (p<0.05). In addition, a reduced level of bilirubin predicts both poor fetal and maternal outcome and the need for a caesarean section (p<0.05).

Maternal obesity increases the risk of numerous maternal and fetal complications of pregnancy. Women were recruited at booking for antenatal care. Each subject was examined in the first, Second and third trimester of pregnancy as well as twelve weeks post partum. Using non invasive techniques microvasular function was measured at each visit. Fasting bloods were taken. This assessment allowed us to observe microvascular function, inflammatory response, dislipidaemia and changes in fatty acid composition with advancing gestation and the degree of recovery in the post partum. By recruitment of women with varying body mass index (BMI) values we were able to examine the influence of maternal BMI on these responses to pregnancy.

Although global gene microarray studies have demonstrated the molecular heterogeneity of breast cancer (BC) and provided potential for clinical applications, the molecular subclassification of luminal/ER-positive tumours, which is the largest class of BC, remains unclear. Characterisation of luminal/ER-positive subtypes could have important implications in clinical decision-making and patient management. The patient study cohort is derived from a consecutive series of approximately 1902 cases of primary operable invasive breast carcinoma obtained from the Nottingham Tenovus Primary Breast Carcinoma Series, with patients presenting between 1986 and 1998. This is a well-characterized series of primary breast carcinoma that has been treated in a uniform way and previously used to study a wide range of proteins. Using gene microarray experiments in 128 frozen invasive BC derived from this series , 47,2 93 gene transcripts were analysed using a number of different bio-statistical models to identify a transcript signature for luminal/ER-positive BC, from which candidate genes were selected and that can be used to characterise ER-positive breast cancer. In addition, other biomarkers with strong relevance in ER-positive breast cancer were studied because the evidence strongly suggests an important role in the biology and molecular classification of ER-positive breast cancer. The selection criteria was based on published literature concentrating mainly on ER related pathways including ER coregulators (CARMI, PELPI), cellular proliferation (p27. TK1, cyclin B1), apoptosis (Bc12), Akt/PIK3 pathway (FOX03a), gene expression profiling (FOXA1, XBP1, TFF1) and endocrine resistance (CD71). Immunohistochemistry and high throughput tissue micro array technology were used to study the protein expression of 16 biomarkers with strong relevance to ER pathways in a well characterised consecutive series of invasive BC (n=1902) in addition to anther 9 markers that were available from the database of the breast cancer research group, University of Nottingham. The data were analysed using different clustering methods including K-means and Partitioning around Medoids. Kaplan Meier plots with Log-rank test (LR) were used to model clinical outcome. A transcript signature for ER positive BC was identified including RERG, GATA3 and other genes by a supervised classification analysis using 10-fold external cross-validation of the gene microarray data. Immunohistochemical validation studies confirmed their association with ER positive BC. Through a consensus approach using different clustering techniques applied to protein expression data 25 markers, three biological clusters (patient subclasses) in ER positive breast cancer showing significant difference in clinical outcome (LR= 28.185 & p<0.001) have been identified. Importantly, the poor prognosis cluster was significantly characterised by high tumour grade and frequent development of distant metastasis. In conclusion, our results emphasised the heterogeneity of luminal/ER-positive BC. Molecular profiling of breast cancer using protein biomarkers on TMAs can sub-classify ER-positive tumours into clinically and biologically relevant subgroups.

Gonadotoxic therapies including radiotherapy and chemotherapy used to treat cancers are extremely damaging to germinal epithelium inducing transient or permanent azoospermia. Spermatogonial stem cells (SSCs) are the foundation of spermatogenesis. They represent the basis of a male fertility restoration strategy after treatment. This work presented herein addressed two critical aspects in this strategy; markers to identify and isolate human SSCs, and the kinetics of SSC recovery after chemotherapy. In chapter 2, the expression of various rodent SSC markers by undifferentiated human spermatogonia, which include SSCs, was examined by immunohistochemistry, and CD9 expression was detected in the basal compartment of human seminiferous tubules. After immunological sorting, human CD9 positive male gem cells showed 3 to 4-folds enrichment when transplanted into immune-deficient nude mice testes, confirming that CD9 is expressed on human putative human SSCs and can be used to enrich for this population. In chapter 3, I studied the contribution of SSC recovery to fertility recovery after chemotherapy in a mouse model, and provided functional evidence that the restoration kinetics of male fertility follows those of the SSC population after damage. I also addressed the question whether there is a critical SSC number to confer fertility and suggested a 30% of original SSC population as a threshold of the SSC population size required for the onset of male fertility restoration. Though the study did not identify a faithful physiological parameter related to male reproduction (sperm count, testis weight, testosterone level, Glial cell-derived neurotropic factor (GDNF) transcripts level in testes), which would allow for monitoring the degree of SSC recovery in a non-invasive manner, yet it paved the way for future efforts to predict the timing of male fertility restoration after chemotherapy. In conclusion, this work identified a new marker for human putative SSCs and proved it to be effective to enrich for this cell population. In addition, it provided functional evidence that restoration of male fertility results from that of SSC and identified for the first time a threshold level of SSC population size permitting recovery. / Les thérapies gonadotoxiques y compris la radiothérapie et de la chimiothérapie utilisées pour traiter les cancers sont extrêmement dommageable pour l' épithélium germinal, induisant l'azoospermie transitoire ou permanente. Les cellules souches germinales (CSG) sont à la base de la spermatogenèse. Elles représentent la base d'une stratégie de restauration de la fertilité masculine après traitement. Ce travail a porté sur deux aspects essentiels de cette stratégie; identifier des marqueurs pour isoler les CSG humains, et étudier la cinétique de la récupération des CSG après une chimiothérapie. Dans le chapitre 2, l'expression de différents marqueurs des CSG de rongeurs a été examinée dans les CSG humaine par immunohistochimie, et l'expression de CD9 a été détectée dans le compartiment basal des tubes séminifères de l'homme. Après un triage cellulaire immunologique, les cellules CD9 positives ont montré un enrichissement de trois à quatre lorsqu'elles sont transplantées dans les testicules des souris nude immunodéficientes, confirmant que CD9 est exprimé sur les CSG mâles et peut être utilisé pour enrichir cette population.Dans le chapitre 3, j'ai étudié la corrélation entre la cinétique de récupération des CSG et la restauration de la fertilité après une chimiothérapie chez un modèle de souris, et fourni une preuve fonctionnelle que la restauration de la fertilité masculine est parallèle à celui de la population CGS après l'insulte. J'ai également abordé la question de savoir si il y a un nombre critique de CSG pour récupérer la fertilité. Mes résultats suggèrent que 30% de la population d'origine CSG doit être seuil pour supporter la restauration de la fertilité masculine. Bien que l'étude n'a pas identifié un paramètre physiologique mesurable indicateur de la capacité reproductive des mâles pour l'apparition de la restauration de la fertilité masculine (nombre de spermatozoïdes, poids des testicules, niveau de testostérone, niveau de transcription du facteur neurotrope dérivé des cellules gliales (GDNF) dans les testicules), qui permettrait de surveiller le degré de récupération de la CSG, mais il a ouvert la voie à de futurs efforts. En conclusion, ce travail a identifié un nouveau marqueur des CSG humaines et il s'est avéré être efficace pour enrichir cette population cellulaire. En outre, il a fourni des preuves que la restauration fonctionnelle de la fertilité masculine est le résultat de la récupération des CSG, et a identifié pour la première fois un seuil de taille de la population CSG permettant la récupération de fertilité masculine.

Context: Among women with a prior caesarean section, 82.2% will have another caesarean delivery. The Society of Obstetrics and Gynaecology of Canada (SOGC) recommends that physicians offer medically eligible women with a previous caesarean section a trial of labour, to attempt a vaginal delivery. With greater inclusion of the patient in medical decision-making, it is important to understand women's part in this decision-making process. Objectives: To describe women's decision-making by looking at: 1) whether the decision was reported as primarily physician- or patient-driven 2) women's reasons for repeat caesarean section, 3) women's main information sources. Methods: For one year women booked for a repeat elective caesarean section, who were eligible for a trial of labour according to the 2005 guidelines of the SOGC, were approached with the survey in hospital post-partum, and invited to participate in the study. Chart review was used to determine eligibility, and obtain other medical characteristics. Results: Most of the women (77 %) reported being involved in the decision about their caesarean section. However, almost a quarter reported wholly physician-driven decisions (23 %). The main reasons women selected for a caesarean section related to their previous birth experience, and the physician's recommendation. Women born outside of Canada, with less education or who were allophones, were less likely to report using certain information sources, such as the Internet, and to find the information in the hospital-provided pamphlet useful. All in all, the women who received less information were more likely to report solely physician-driven decisions. Conclusion: Although patient involvement in decision-making is the norm, some decisions for caesarean section are made without the patient. Women's concerns, such as fear of a failed vaginal delivery, play an important role in this decision-making. Overall, immigrant women may understand less about their birth options than their Canadian peers. Addressing these concerns during pre-natal counselling may aid more fully informed consent, help assuage women's fears of vaginal birth and may increase the number of women attempting a trial of labour. / Contexte : Parmi les femmes ayant déjà subi une césarienne, 82 % auront un autre accouchement par césarienne. La Société d'Obstétriques et Gynécologie du Canada (SOGC) conseille aux médecins d'offrir aux femmes éligibles l'option d'essayer un accouchement vaginal. Avec l'inclusion des patients dans les décisions médicales, il est important de comprendre le rôle des femmes dans ce processus de décision. Objectif : Décrire le processus de décision en évaluant : 1) si la décision vient premièrement du médecin ou du patient, 2) les raisons données par les femmes pour le choix d'une césarienne, 3) les principales sources d'information utilisées par les femmes. Méthodes : Au cours d'une année, les femmes enregistrées pour une césarienne, et éligible pour un accouchement vaginal selon le SOGC 2005, ont été approchées à l'hôpital postpartum et invitées à participer à l'étude. Le dossier médical a été utilisé pour déterminer l'éligibilité et d'autres caractéristiques médicales. Résultats : La majorité des femmes (77%) ont participé à la décision concernant le choix d'une césarienne, mais à peu près un quart (23 %) ont rapportée que la décision a été faite entièrement par le médecin. Les femmes ont indiqué que des raisons reliées aux peurs d'un accouchement vaginal, et aux recommandations du médecin, ont supporté le choix d'une césarienne. Les femmes nées ailleurs, avec moins de scolarité, ou allophones ont moins utilisé certaines sources d'informations, telles que l'Internet, et ont trouvé l'information dans le dépliant de l'hôpital moins utile. En général, les femmes ayant reçu moins d'information ont été plus susceptibles de rapporter une décision faite seulement par leur médecin. Conclusion : Bien qu'il y ait souvent la participation de la patiente dans le processus de décision, quelques décisions concernant le choix d'une césarienne sont faites sans la patiente. La peur d'un accouchement vaginal joue un rôle important dans la décision. Dans l'ensemble, les immigrantes pourraient moins bien comprendre leurs options d'accouchement que les femmes canadiennes. Considérer ces problèmes lors du suivi pré-natal pourrait aider au processus de consentement, soulager les peurs reliées à un accouchement vaginal, et peut-être augmenter l'acceptante d'un essai d'accouchement vaginal.