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Premenopausal vaginal bleeding, abnormal [keywords]
- 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.
- 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.
- ACR appropriateness criteria(®) on abnormal vaginal bleeding. [Journal Article]
- J Am Coll Radiol 2011 Jul; 8(7):460-8.
In evaluating a woman with abnormal vaginal bleeding, imaging cannot replace definitive histologic diagnosis but often plays an important role in screening, characterization of structural abnormalities, and directing appropriate patient care. Transvaginal ultrasound (TVUS) is generally the initial imaging modality of choice, with endometrial thickness a well-established predictor of endometrial disease in postmenopausal women. Endometrial thickness measurements of ≤5 mm and ≤4 mm have been advocated as appropriate upper threshold values to reasonably exclude endometrial carcinoma in postmenopausal women with vaginal bleeding; however, the best upper threshold endometrial thickness in the asymptomatic postmenopausal patient remains a subject of debate. Endometrial thickness in a premenopausal patient is a less reliable indicator of endometrial pathology since this may vary widely depending on the phase of menstrual cycle, and an upper threshold value for normal has not been well-established. Transabdominal ultrasound is generally an adjunct to TVUS and is most helpful when TVUS is not feasible or there is poor visualization of the endometrium. Hysterosonography may also allow for better delineation of both the endometrium and focal abnormalities in the endometrial cavity, leading to hysteroscopically directed biopsy or resection. Color and pulsed Doppler may provide additional characterization of a focal endometrial abnormality by demonstrating vascularity. MRI may also serve as an important problem-solving tool if the endometrium cannot be visualized on TVUS and hysterosonography is not possible, as well as for pretreatment planning of patients with suspected endometrial carcinoma. CT is generally not warranted for the evaluation of patients with abnormal bleeding, and an abnormal endometrium incidentally detected on CT should be further evaluated with TVUS.
- [An analysis on the clinicopathological characteristics of 79 cases atypical endometrial hyperplasia]. [English Abstract, Journal Article]
- Zhonghua Fu Chan Ke Za Zhi 2011 Jan; 46(1):19-23.
To explore the clinicopathological characteristics in atypical endometrial hyperplasia patients.A retrospective study was carried out on 79 cases with atypical endometrial hyperplasia patients admitted to Department of Gynecology, Peking University People's Hospital from Mar. 2007 to Jul. 2010. All patients were divided into two groups, hyperplasia group (merely atypical endometrial hyperplasia, 49 cases, 62%) and cancerization group (atypical endometrial hyperplasia accompanying endometrial carcinoma, 30 cases, 38%).The mean age of 79 cases were (50 ± 11) years old, while they were (50 ± 10) and (51 ± 11) years old for hyperplasia group and cancerization group, there were not difference (P = 0.994). The gravidity and delivery frequencies were also not differently between two groups. The rates of complicated other diseases were 47% (23/49) and 43% (13/30), which was not significantly different (P = 0.755). The body mass index (BMI) of cancerization group was higher than that of hyperplasia group [(27.9 ± 5.4) vs. (25.2 ± 2.9) kg/m², P = 0.024]. There were 50% (15/30) and 31% (15/49) menopause cases in two groups, respectively. Among them there were 13/15 and 8/15 cases showed vaginal bleeding. Among premenopausal patients, there were 12/15 and 68% (23/34) showed abnormal vaginal bleeding, but there were not significantly different between two groups (all P > 0.05). The uterine cavity mass found by ultrasonography in the cancerization group patients was more than that in hyperplasia group [73% (22/30) vs. 51% (25/49), P = 0.050]. There were 23 cases (29%), 44 cases (56%) and 12 cases (15%) were diagnosed by dilatation and curettage (D&G), hysteroscopy and hysterectomy, respectively. The rates of diagnosing atypical endometrial hyperplasia by D&G and hysteroscopy were 87% (21/23) and 93% (41/44), respectively. The rate of diagnosis of canceration were 6/12 and 12/16, respectively. While, the rate of missed diagnosis of canceration in the atypical endometrial hyperplasia patients by D&G and hysteroscopy were 6/13 and 19% (4/21), respectively. Which all did not shown significantly different (P > 0.05).Hysteroscopy or D&G should be chosen on those peri-menopausal patients with abnormal bleeding, while those atypical endometrial hyperplasia patients with high BMI and uterine cavity mass diagnosed with D&G and ultrasonography should consider the possibility of canceration.
- Ultrasound assessment of premenopausal bleeding. [Journal Article, Review]
- Obstet Gynecol Clin North Am 2011 Mar; 38(1):115-47, viii.
Vaginal bleeding is the most common cause of emergency care in the first trimester of pregnancy and accounts for the majority of premenopausal bleeding cases. Ultrasound evaluation combined with a quantitative beta human chorionic gonadotropin test is an established diagnostic tool to assess these patients. Spontaneous abortion because of genetic abnormalities is the most common cause of vaginal bleeding; ectopic pregnancy and gestational trophoblastic disease are other important causes and in all patients presenting with first trimester bleeding, ectopic pregnancy should be suspected and excluded, as it is associated with significant maternal morbidity and mortality. A thorough knowledge of the normal sonographic appearance of intrauterine gestation is essential to understand the manifestations of an abnormal gestation. Arteriovenous malformation of the uterus is a rare but important cause of vaginal bleeding in the first trimester, as it has to be differentiated from the more common retained products of conception, with which it is often mistaken.
- The levonorgestrel intrauterine system is an effective treatment in selected obese women with abnormal uterine bleeding. [Journal Article]
- J Minim Invasive Gynecol 2011 Jan-Feb; 18(1):75-80.
To evaluate the use of the levonorgestrel intrauterine system (LNG-IUS) in obese premenopausal women with abnormal uterine bleeding (AUB).Prospective observational study (Canadian Task Force Classification II-2).University-affiliated teaching hospital.Fifty-six obese women with body mass index (BMI) >30 kg/m(2).From January 2002 through September 2009, 56 obese patients (BMI >30 kg/m(2)) with abnormal uterine bleeding (AUB) were identified from the senior author's clinical practice (G.A.V.). After clinical assessment, including Papanicolaou smear, endometrial biopsy, and pelvic sonography, the LNG-IUS was placed to treat their AUB.The median and (range) for age, parity, and BMI were 42.5 years (20-64), 2 children (0-6), and 41.2 kg/m(2) (30-61), respectively. Many patients had additional comorbid conditions placing them at high risk for traditional medical or surgical therapies. The initial endometrial biopsy result was normal in 46 women (82.1%). Three women (5.4%) had inadequate sample, three (5.4%) had simple endometrial hyperplasia, two (3.6%) had complex endometrial hyperplasia without atypia, and two women (3.6%) had complex endometrial hyperplasia with atypia. After placement of the LNG-IUS, all women reported menstrual blood reduction at 3 and 6 months. The LNG-IUS was expelled in 2/56 patients (3.6%) and removed in 12 (21.4%), and a new device was inserted in 3/56 patients (5.4%). At median follow-up of 48 months (range 3-72), the satisfaction rate was 75%.In properly selected obese women with AUB, the LNG-IUS is an effective therapy in approximately 75% of cases.