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Premenopausal vaginal bleeding, abnormal [keywords]
- Abnormal vaginal bleeding after epidural steroid injection: a paired observation cohort study. [Journal Article, Research Support, Non-U.S. Gov't]
- Am J Obstet Gynecol 2013 Sep; 209(3):206.e1-6.
The use of epidural steroid injections has increased dramatically, but knowledge of potential adverse effects is lacking. An association between steroid injection and subsequent abnormal vaginal bleeding has been suspected clinically, but evidence has been limited to anecdotal reports.Paired observational retrospective cohort study using electronic medical records from a large integrated health care system. Participants were all nonhysterectomized women who underwent epidural steroid injections in 2011. For each steroid injection, encounters for abnormal vaginal bleeding during the 60 days preceding and 60 days after the injection were compared as paired observations. For women found to have bleeding, medical records review was performed to examine menopausal status and bleeding evaluation outcomes.Among 8166 epidural steroid injection procedures performed on 6926 nonhysterectomized women, 201 (2.5%) procedures were followed by at least 1 outpatient visit for abnormal vaginal bleeding. Women were 2.8 times more likely to present with abnormal vaginal bleeding during the postinjection period compared with the preinjection period (P < .0001). Of the 197 women with postinjection bleeding, 137 (70%) were premenopausal and 60 (30%) were postmenopausal. Postinjection bleeding prompted endometrial biopsy evaluation in 103 (52%) cases, with benign findings for 100% of premenopausal women (59/59) and 95% of postmenopausal women (42/44).Epidural steroid injections are associated with subsequent abnormal vaginal bleeding for both premenopausal and postmenopausal women. Women undergoing epidural steroid injection should be advised of abnormal bleeding as a potential adverse effect and providers should be aware of this association when evaluating abnormal bleeding.
- Management of uterine bleeding during hematopoietic stem cell transplantation. [Case Reports, Journal Article, Research Support, N.I.H., Intramural]
- Obstet Gynecol 2013 Feb; 121(2 Pt 2 Suppl 1):424-7.
Hematopoietic stem cell transplant is an effective treatment strategy for a variety of hematologic disorders, but patients are at risk for dysfunctional coagulation and abnormal bleeding. Gynecologists are often consulted before transplant for management of abnormal uterine bleeding, which may be particularly challenging in this context.A premenopausal woman with MonoMAC (a rare adult-onset immunodeficiency syndrome characterized by monocytopenia and Mycobacterium avium complex infections resulting from mutations in GATA2, a crucial gene in early hematopoiesis) presented with pancytopenia, evolving leukemia, and recent strokes, necessitating anticoagulation. During preparation for hematopoietic stem cell transplant, she experienced prolonged menorrhagia requiring transfusions. Surgical therapy was contraindicated, and medical management was successful only when combined with balloon tamponade.Balloon tamponade may be a potentially life-saving adjunct to medical therapy for control of uterine hemorrhage before hematopoietic stem cell transplant.
- A new progestogen-only medical therapy for outpatient management of acute, abnormal uterine bleeding: a pilot study. [Clinical Trial, Journal Article]
- Am J Obstet Gynecol 2013 Jun; 208(6):499.e1-5.
The objective of this investigation was to study short-term efficacy and feasibility of a new progestogen-only treatment for outpatient management of acute abnormal uterine bleeding.This was a prospective, single-arm, pilot clinical trial of a progestogen-only bridging treatment for acute abnormal uterine bleeding in nonpregnant, premenopausal women in the Gynecologic Urgent Care Clinic at Harbor-UCLA Medical Center. Subjects were administered a depo-medroxyprogesterone acetate 150 mg intramuscular injection and given medroxyprogesterone acetate 20 mg to be taken orally every 8 hours for 3 days. The primary outcome measures included a percentage of women who stopped bleeding in 5 days, time to bleeding cessation, reduction in numbers of pads used, side effects, and patient satisfaction.All 48 women stopped bleeding within 5 days; 4 women had spotting only at the time of their last contact during the 5 day follow-up. Mean time to bleeding cessation was 2.6 days. Side effects were infrequent and patient satisfaction was high.Injection of depo-medroxyprogesterone acetate 150 mg intramuscularly combined with 3 days of oral medroxyprogesterone acetate 20 mg every 8 hours for 9 doses is an effective outpatient therapy for acute abnormal uterine bleeding.
- Long-term outcomes after intrauterine morcellation vs hysteroscopic resection of endometrial polyps. [Comparative Study, Journal Article]
- J Minim Invasive Gynecol 2013 Mar-Apr; 20(2):215-21.
To compare the long-term outcomes of intrauterine morcellation (IUM) of endometrial polyps vs a traditional operative polypectomy technique, hysteroscopic resection (HSR), and to identify factors predictive of recurrent abnormal uterine bleeding (AUB) after operative polypectomy.Retrospective cohort study (Canadian Task Force classification II-2).Minimally invasive gynecologic surgery practice in a tertiary care center.Women who underwent operative hysteroscopic polypectomy between January 1, 2004 and December 31, 2009.Intrauterine morcellation or HSR with evaluation and/or treatment of recurrent AUB after operative polypectomy.Of 311 patients (IUM group, 139; HSR group, 172), 167 (53.7%) had at least 1 gynecologic follow-up visit and 57 (18.4%) had recurrent AUB. Subsequent gynecologic clinic visit rates were similar between the 2 groups (HSR, 58.1%, vs IUM, 48.2%; p = .08). Recurrence of AUB within the first 4 years of follow-up was similar between the IUM and HSR groups (hazard ratio for HSR vs IUM, 1.12; 95% confidence interval, 0.64-1.98; p = .59). However, recurrence of endometrial polyps approached statistical significance (hazard ratio, 3.3; 95% confidence interval, 0.94-11.49; p = .06). Premenopausal status, history of hormone replacement therapy, multiparity, and polycystic ovarian syndrome were independently associated with AUB recurrence. There were no reports of inability to establish a histopathologic diagnosis among all pathology specimens evaluated.Compared with HSR, intrauterine morcellation may be associated with lower recurrence of endometrial polyps. However, the incidence of recurrent AUB is independent of polypectomy method.
- Hysteroscopic findings in women with menorrhagia. [Journal Article]
- J Minim Invasive Gynecol 2013 Mar-Apr; 20(2):209-14.
To describe the hysteroscopic findings in patients complaining of menorrhagia to establish any significant association between menorrhagia and benign/malignant intrauterine disorders.Prospective cohort study (Canadian Task Force classification II).University La Sapienza, Rome, Italy.One hundred eighteen premenopausal women undergoing office hysteroscopy for menorrhagia (group A) and 344 premenopausal patients undergoing office hysteroscopy for other indications (noncyclic abnormal uterine bleeding, infertility, ultrasonographic abnormalities, etc) (group B).Office hysteroscopy.Data on the prevalence of hysteroscopic findings (cervical polyps, endometrial polyps, submucous myomas, low-grade hyperplasia and high-grade hyperplasia/endometrial carcinoma) were compared between group A and group B. The total prevalence, as well as the prevalence of type 0 and type I myomas (totally or >50% intracavitary, respectively), and the mean number per patients with submucous myomas was significantly higher in group A compared with group B (p = .0001, p = .024, and p = .017, respectively). Multivariable logistic regression analysis showed a statistically significant association between age (odds ratio 4.15, 95% confidence interval 1.55-11.1 in the 40- to 49-year age group), presence of submucous myomas (odds ratio 2.76, 95% confidence interval 1.52-5.00), and menorrhagia.Menorrhagia seems to be associated with aging, the presence and number of submucous myomas, and with the degree of their intracavitary development.
- Clinicopathological changes of uterine leiomyomas after GnRH agonist therapy. [Journal Article]
- Clin Exp Obstet Gynecol 2012; 39(2):191-4.
Gonadotrophin-releasing hormone agonist (GnRHa) has been commonly used for the medical treatment of prostate cancer, precocious puberty, endometriosis, adenomyosis and uterine leiomyomas. GnRHa therapy in cases of symptomatic uterine leiomyomas aims for the reduction of their size and remission of symptoms such as menometrorrhagia, causing a state of hypoestrogenemia. This is considered to be a helpful preoperative strategy in cases of large myomas, or anemia because of abnormal vaginal bleeding. The aim of this retrospective study was to examine the clinicopathological changes in uterine leiomyomas exposed to preoperative GnRHa therapy for two up to six months.The study group consisted of 10 premenopausal patients who were treated with GnRHa prior to surgery.In all cases the size of leiomyomas was reduced after GnRHa therapy. A microscopic review of the surgical specimens showed increased cellularity and ischemic type of necrosis.Morphological changes of uterine leiomyomas are often associated with preoperative GnRH agonist therapy. The differential diagnosis from uterine leiomyosarcomas includes absence of mitotic activity.
- Evaluation and management of abnormal uterine bleeding in premenopausal women. [Journal Article, Review]
- Am Fam Physician 2012 Jan 1; 85(1):35-43.
Up to 14 percent of women experience irregular or excessively heavy menstrual bleeding. This abnormal uterine bleeding generally can be divided into anovulatory and ovulatory patterns. Chronic anovulation can lead to irregular bleeding, prolonged unopposed estrogen stimulation of the endometrium, and increased risk of endometrial cancer. Causes include polycystic ovary syndrome, uncontrolled diabetes mellitus, thyroid dysfunction, hyperprolactinemia, and use of antipsychotics or antiepileptics. Women 35 years or older with recurrent anovulation, women younger than 35 years with risk factors for endometrial cancer, and women with excessive bleeding unresponsive to medical therapy should undergo endometrial biopsy. Treatment with combination oral contraceptives or progestins may regulate menstrual cycles. Histologic findings of hyperplasia without atypia may be treated with cyclic or continuous progestin. Women who have hyperplasia with atypia or adenocarcinoma should be referred to a gynecologist or gynecologic oncologist, respectively. Ovulatory abnormal uterine bleeding, or menorrhagia, may be caused by thyroid dysfunction, coagulation defects (most commonly von Willebrand disease), endometrial polyps, and submucosal fibroids. Transvaginal ultrasonography or saline infusion sonohysterography may be used to evaluate menorrhagia. The levonorgestrel-releasing intrauterine system is an effective treatment for menorrhagia. Oral progesterone for 21 days per month and nonsteroidal anti-inflammatory drugs are also effective. Tranexamic acid is approved by the U.S. Food and Drug Administration for the treatment of ovulatory bleeding, but is expensive. When clear structural causes are identified or medical management is ineffective, polypectomy, fibroidectomy, uterine artery embolization, and endometrial ablation may be considered. Hysterectomy is the most definitive treatment.
- Comparison of saline infusion sonohysterography and hysteroscopy in diagnosis of premenopausal women with abnormal uterine bleeding. [Comparative Study, Journal Article]
- Eur J Obstet Gynecol Reprod Biol 2012 Mar; 161(1):66-70.
The aim of this study was to compare the diagnostic effectiveness of transvaginal sonography (TVS), saline infusion sonohysterography (SIS), and diagnostic hysteroscopy (HS), with the pathologic specimen as a gold standard diagnostic method, in detecting endometrial pathology in premenopausal women with abnormal uterine bleeding.This prospective cohort study was conducted at Zeynep Kamil Education and Training Hospital, Istanbul, Turkey, and included 89 premenopausal women. All participants were examined first by TVS, further investigated with SIS and HS, and finally dilatation and curettage was performed when needed. The results obtained from these three methods were compared with the pathologic diagnoses. The positive and negative likelihood ratios (LR+ and LR-) of TVS, SIS and HS were calculated by comparison with the final pathological diagnosis. In addition, area under the curve (AUC) values were also calculated.Polypoid lesion was the most common abnormal pathology. LR+ and LR- of TVS, SIS, and HS were 3.13 and 0.15, 9.83 and 0.07, 13.7 and 0.02 respectively in detection of any abnormal pathology, and the AUCs of TVS, SIS, and HS were 0.804, 0.920, and 0.954 respectively. When the three procedures were compared with each other separately, HS had the best diagnostic accuracy, and the diagnostic accuracy of HS and SIS was superior to TVS (p(1)=0.000, p(2)=0.000). For the detection of polypoid lesions, HS was the most accurate diagnostic procedure (AUC=0.947), followed by SIS (AUC=0.894) and TVS (AUC=0.778).HS provides the most accurate diagnosis and allows treatment in the same session in premenopausal women with abnormal uterine bleeding.
- Management of menorrhagia associated with chemotherapy-induced thrombocytopenia in women with hematologic malignancy. [Journal Article, Review]
- Pharmacotherapy 2011 Nov; 31(11):1092-110.
Abnormal uterine bleeding in women with a blood dyscrasia, such as leukemia, or who experience thrombocytopenia secondary to myelosuppressive chemotherapy is a clinical condition associated with significant morbidity. Consequently, effective management is necessary to prevent adverse outcomes. Prevention of menorrhagia, defined as heavy regular menstrual cycles with more than 80 ml of blood loss/cycle or a cycle duration longer than 7 days, in this patient population is the goal of therapy. Gonadotropin-releasing hormone analogs (e.g., leuprolide) are promising therapies that have been shown to decrease vaginal bleeding during periods of thrombocytopenia and to have minimal adverse effects other than those associated with gonadal inhibition. In patients who experience menorrhagia despite preventive therapies, or in patients who have thrombocytopenia and menorrhagia at diagnosis, treatment is indicated. For these women, treatment options may include platelet transfusions, antifibrinolytic therapy (e.g., tranexamic acid), continuous high-dose oral contraceptives, cyclic progestins, or other therapies for more refractory patients such as danazol, desmopressin, and recombinant factor VIIa. Hormonal therapies are often the mainstay of therapy in women with menorrhagia secondary to thrombocytopenia, but data for these agents are sparse. The most robust data for the treatment of menorrhagia are for tranexamic acid. Most women receiving tranexamic acid in randomized trials experienced meaningful reductions in menstrual bleeding, and this translated into improved quality of life; however, these trials were not performed in patients with cancer. Further clinical trials are warranted to evaluate both preventive and therapeutic agents for menorrhagia in premenopausal women with cancer who are receiving myelosuppressive chemotherapy.
- Clinicopathologic insight of simultaneously detected primary endometrial and ovarian carcinomas. [Journal Article]
- Arch Gynecol Obstet 2012 Mar; 285(3):817-21.
To evaluate the clinicopathologic features in patients with synchronous primary carcinomas of the ovary and endometrium.Clinical information and pathologic details were collected and analyzed from 30 women with synchronous endometrial and ovarian cancers.Median age at diagnosis was 51 years. Abnormal uterine bleeding was the most common presenting symptom (50%). More than half (53%) of the patients were premenopausal and 37% never had a pregnancy. Stage I disease was observed in 90 (27/30) and 73% (22/30) of the patients with endometrial and ovarian cancer, respectively. Endometrioid type was the most frequently observed histology for synchronous endometrial and ovarian cancer (n = 18/30, 60%). All patients were surgically staged and adjuvant treatment was considered when required according to our protocols. The mean follow-up period was 6.6 years (SD = 3.0 years), and the cumulative event-free rate for 5 years was 84.2% (SE 7.3%). No significant differences in the survival rates were found according to the histological subtype (p = 0.513). Women with synchronous primary cancers of the endometrium and ovary were generally younger than those developing either one of the above mentioned adenocarcinomas. They appeared to have a favorable prognosis with an estimated overall survival of 84.2% in 5 years.A gynecologist should always keep in mind the possibility of double primary carcinomas of the endometrium and ovary in a young, premenopausal, nulliparous woman presenting with abnormal uterine bleeding and prompt the patient for further evaluation.