Premenopausal vaginal bleeding, abnormal [keywords]
- Complications Following Extended Freeze Endometrial Cryoablation in Uteri with Previous Uterine Incisions: A Case Report. [Case Reports, Journal Article]
- J Reprod Med 2015 Nov-Dec; 60(11-12):540-2.
Endometrial cryoablation causes cryonecrosis of the endometrial lining as treatment for abnormal uterine bleeding in premenopausal women who have no desire for future fertility. Extended freezes to potentially improve efficacy have been described in the literature, although no associated complications have been reported.We present 2 cases of ureteral stricture and sigmoid colon perforation in separate patients following extended freeze cryoendometrial ablation. Both patients had a preexisting uterine scar from prior cesarean section or myomectomy.Patients with a prior uterine incision may be at increased risk for complications from extended freeze endometrial cryoablation.
- Factors Influencing the Recurrence Potential of Benign Endometrial Polyps after Hysteroscopic Polypectomy. [Journal Article]
- PLoS One 2015; 10(12):e0144857.
An endometrial polyp is a frequently encountered gynecologic disease with abnormal uterine bleeding and infertility being the two common presenting problems, and hysteroscopic polypectomy is an effective method to remove them. The postoperative polyp recurrence might result in reappearance of abnormal uterine bleeding or infertility, whereas factors influencing the postoperative recurrence potential have limited data.This case-series report included 168 premenopausal women who suffered from endometrial polyps and underwent hysteroscopic polypectomy. All of them were awaiting a future pregnancy. Office hysteroscopy was done before and after hysteroscopic polypectomy, in which preoperative hysteroscopy examined the number, type, and location of endometrial polyps, and postoperative hysteroscopy checked the polyp recurrence. Surgical indications, either infertility or the presentation of abnormal uterine bleeding, and follow-up duration were recorded.Seventy-three out of 168 (43%) women had polyp recurrence after hysteroscopic polypectomy. Multivariate logistic regression analysis revealed that more endometrial polyps (P = 0.015) and longer duration of follow-up (P = 0.004) were significantly associated with an increased risk of postoperative polyp recurrence. The type of endometrial polyps was not correlated with polyp recurrence potential, whereas pedunculated type endometrial polyps were closely related to the presentation of abnormal uterine bleeding (P = 0.001).A higher number of endometrial polyps and longer follow-up duration are associated with a greater potential of polyp recurrence after hysteroscopic polypectomy.
- Hysterectomy risk in premenopausal-aged military veterans: associations with sexual assault and gynecologic symptoms. [Journal Article, Research Support, N.I.H., Extramural, Research Support, Non-U.S. Gov't]
- Am J Obstet Gynecol 2016 Mar; 214(3):352.e1-352.e13.
Several gynecological conditions associated with hysterectomy, including abnormal bleeding and pelvic pain, have been observed at increased rates in women who have experienced sexual assault. Previous findings have suggested that one of the unique health care needs for female military veterans may be an increased prevalence of hysterectomy and that this increase may partially be due to their higher risk of sexual assault history and posttraumatic stress disorder (PTSD). Although associations between trauma, PTSD, and gynecological symptoms have been identified, little work has been done to date to directly examine the relationship between sexual assault, PTSD, and hysterectomy within the rapidly growing female veteran population.The objective of the study was to assess the prevalence of hysterectomy in premenopausal-aged female veterans, compare with general population prevalence, and examine associations between hysterectomy and sexual assault, PTSD, and gynecological symptoms in this veteran population.We performed a computer-assisted telephone interview between July 2005 and August 2008 of 1004 female Veterans Affairs (VA)-enrolled veterans ≤ 52 years old from 2 Midwestern US Veterans Affairs medical centers and associated community-based outreach clinics. Within the veteran study population, associations between hysterectomy and sexual assault, PTSD, and gynecological symptoms were assessed with bivariate analyses using χ(2), Wilcoxon-Mann-Whitney, and Student t tests; multivariate logistic regression analyses were used to look for independent associations. Hysterectomy prevalence and ages were compared with large civilian populations represented in the Behavioral Risk Factor Surveillance System and American College of Surgeons National Surgical Quality Improvement Program databases from similar timeframes using χ(2) and Student t tests.Prevalence of hysterectomy was significantly higher (16.8% vs 13.3%, P = .0002), and mean age at hysterectomy was significantly lower (35 vs 43 years old, P < .0001) in this VA-enrolled sample of female veterans compared with civilian population-based data sets. Sixty-two percent of subjects had experienced attempted or completed sexual assault in their lifetimes. A history of completed lifetime sexual assault with vaginal penetration (LSA-V) was a significant risk factor for hysterectomy (age-adjusted odds ratio, 1.85), with those experiencing their first LSA-V in childhood or in military at particular risk. A history of PTSD was also associated with hysterectomy (age-adjusted odds ratio, 1.83), even when controlling for LSA-V. These associations were no longer significant when controlling for the increased rates of gynecological pain, abnormal gynecological bleeding, and pelvic inflammatory disease seen in those veterans with a history of LSA-V.Premenopausal-aged veterans may be at higher overall risk for hysterectomy, and for hysterectomy at younger ages, than their civilian counterparts. Veterans who have experienced completed sexual assault with vaginal penetration in childhood or in military and those with a history of PTSD may be at particularly high risk for hysterectomy, potentially related to their higher risk of gynecological symptoms. If confirmed in future studies, these findings have important implications for women's health care providers and policy makers within both the VA and civilian health care systems related to primary and secondary prevention, costs, and the potential for increased chronic disease and mortality.
- Practice points in gynecardiology: Abnormal uterine bleeding in premenopausal women taking oral anticoagulant or antiplatelet therapy. [Journal Article, Review]
- Maturitas 2015 Dec; 82(4):355-9.
A growing number of premenopausal women are currently using antithrombotic and/or (dual) antiplatelet therapy for various cardiovascular indications. These may induce or exacerbate abnormal uterine bleeding and more awareness and knowledge among prescribers is required. Heavy and irregular menstrual bleeding is common in women in their forties and may have a variety of underlying causes that require different treatment options. Thus using anticoagulants in premenopausal women demands specific expertise and close collaboration between cardiovascular physicians and gynecologists. In this article we summarize the scope of the problem and provide practical recommendations for the care for young women taking anticoagulants and/or (dual) antiplatelet therapy. We also recommend that more safety data on uterine bleeding with novel anticoagulants in premenopausal women should be obtained.
- Levonorgestrel Intrauterine Device Placement in a Premenopausal Breast Cancer Patient with a Bicornuate Uterus. [Case Reports, Journal Article]
- J Minim Invasive Gynecol 2016 Jan; 23(1):133-5.
Young women with breast cancer face contraceptive challenges. Data are limited and conflicting on the use of the levonorgestrel intrauterine device (LNG-IUD) in this patient population. A 32-year-old nulligravid woman with a history of breast cancer on tamoxifen presented with new-onset vaginal bleeding. Further workup revealed a previously undiagnosed bicornuate uterus. She underwent hysteroscopy, dilation and curettage, and LNG-IUD placement in each uterine horn. Postoperative follow-up confirmed retention and proper placement of both IUDs. Pathology from the dilation and curettage was benign, and the abnormal uterine bleeding abated. LNG-IUD placement in a young patient with a personal history of breast cancer on tamoxifen and a bicornuate uterus is a safe and feasible alternative for contraception.
- Histopathological Findings of Endometrial Samples and its Correlation Between the Premenopausal and Postmenopausal Women in Abnormal Uterine Bleeding. [Comparative Study, Journal Article]
- Kathmandu Univ Med J (KUMJ) 2014 Oct-Dec; 12(48):275-8.
Abnormal uterine bleeding is considered as one of the most common problems among women. The therapy is incomplete without knowing the underlying pathology.To determine the types and frequency of endometrial pathologies in patients presenting with abnormal uterine bleeding at Dhulikhel Hospital Kathmandu university Hospital.This is retrospective study total 100 cases were included over a period of one year of Abnormal Uterine bleeding.Out of 100 cases of Abnormal uterine bleeding, 61% were due to non-organic cause with a commonest histopathological findings proliferative endometrium. 27% cases were due to organic cause with pregnancy related condition as most common finding. 12% were reported as inadequate. The rate of postmenopausal bleeding declined with increasing age in the postmenopausal period and endometritis was the predominant finding.There is an age specific association of Abnormal uterine bleeding with increased incidence in perimenopausal age group. Postmenopausal bleeding declined with increasing with endometritis the most common finding. Dilation and curettage is helpful to exclude other organic pathology. It is useful for diagnosis and to know pathological incidence of organic lesions in cases of Abnormal uterine bleeding prior to surgery.
- The medical management of abnormal uterine bleeding in reproductive-aged women. [Journal Article, Review]
- Am J Obstet Gynecol 2016 Jan; 214(1):31-44.
In the treatment of women with abnormal uterine bleeding, once a thorough history, physical examination, and indicated imaging studies are performed and all significant structural causes are excluded, medical management is the first-line approach. Determining the acuity of the bleeding, the patient's medical history, assessing risk factors, and establishing a diagnosis will individualize their medical regimen. In acute abnormal uterine bleeding with a normal uterus, parenteral estrogen, a multidose combined oral contraceptive regimen, a multidose progestin-only regimen, and tranexamic acid are all viable options, given the appropriate clinical scenario. Heavy menstrual bleeding can be treated with a levonorgestrel-releasing intrauterine system, combined oral contraceptives, continuous oral progestins, and tranexamic acid with high efficacy. Nonsteroidal antiinflammatory drugs may be utilized with hormonal methods and tranexamic acid to decrease menstrual bleeding. Gonadotropin-releasing hormone agonists are indicated in patients with leiomyoma and abnormal uterine bleeding in preparation for surgical interventions. In women with inherited bleeding disorders all hormonal methods as well as tranexamic acid can be used to treat abnormal uterine bleeding. Women on anticoagulation therapy should consider using progestin-only methods as well as a gonadotropin-releasing hormone agonist to treat their heavy menstrual bleeding. Given these myriad options for medical treatment of abnormal uterine bleeding, many patients may avoid surgical intervention.
- Experience of hysteroscopy indications and complications in 5,474 cases. [Journal Article]
- Clin Exp Obstet Gynecol 2014; 41(4):451-4.
To evaluate the indications, intraoperative diagnoses, and complication rates of both diagnostic and operative hysteroscopic procedures.Five thousand four hundred seventy-four (5474) hysteroscopic procedures performed in the department of gynecologic endoscopy unit between May 2005 and December 2012 were retrospectively analyzed from the archives. Indications, intraoperative diagnosis, and complications of all gynecological endoscopic procedures are recorded.Abnormal uterine bleeding in premenopausal and postmenopausal women was the most frequent indication for diagnostic hysteroscopies in 1,887 (40%) cases. The most common preoperative indication for operative hysteroscopy was endometrial polyps in 469 (55.7%) cases and submucous leiomyomas in 151 (17.9%) cases. In this series, the most common complication was uterine perforation which occured in 15 (0.27%) out of 5,474 cases and the rate for diagnostic hysteroscopy and operative hysteroscopy was 0.06% and 1%, respectively.Hysteroscopy is a safe and effective minimally invasive procedure with very low complication rate.
- Predictors of malignancy in endometrial polyps: a multi-institutional cohort study. [Journal Article, Multicenter Study]
- Eur J Gynaecol Oncol 2014; 35(4):382-6.
The risk of endometrial cancer in women with endometrial polyps (EPs) has been reported to vary between 0.3% and 4.8%. There is a lack of data about the management of asymptomatic women with incidental diagnosis of EPs. In the present study the authors correlated demographic and clinical characteristics with histopathological features of the EPs hysteroscopically removed.An observational multi-institutional cohort study was conducted from February 2010 to December 2012 to identify all the premenopausal and postmenopausal women consecutively undergoing hysteroscopic polypectomy. The data of women were reviewed and clinical features were related to histopathologic results.The patients recruited were 813. The mean age was 52.5 years (range 22-87). The results showed a correlation between older age, high body mass index (BMI) and obesity, postmenopausal state, abnormal uterine bleeding (AUB), hypertension, and risk of malignant EPs. On multivariable analysis, the correlation remained only for age (OR 1.08, 95% CI 1.03 - 1.14) and AUB (OR 3.53, 95% CI 1.87 - 6.65).Older patients in postmenopausal status with AUB, a high BMI, and hypertension are at higher risk for premalignant and malignant polyps. In these patients a surgical approach should be used, consisting in hysteroscopical removing of the polyp.
- Committee Opinion No. 601: Tamoxifen and uterine cancer. [Journal Article]
- Obstet Gynecol 2014 Jun; 123(6):1394-7.
Tamoxifen, a nonsteroidal antiestrogen agent, is widely used as adjunctive therapy for women with breast cancer, and it has been approved by the U.S. Food and Drug Administration for adjuvant treatment of breast cancer, treatment of metastatic breast cancer, and reduction in breast cancer incidence in high-risk women. Tamoxifen use may be extended to 10 years based on new data demonstrating additional benefit. Women taking tamoxifen should be informed about the risks of endometrial proliferation, endometrial hyperplasia, endometrial cancer, and uterine sarcomas, and any abnormal vaginal bleeding, bloody vaginal discharge, staining, or spotting should be investigated. Postmenopausal women taking tamoxifen should be closely monitored for symptoms of endometrial hyperplasia or cancer. Premenopausal women treated with tamoxifen have no known increased risk of uterine cancer and require no additional monitoring beyond routine gynecologic care. Unless the patient has been identified to be at high risk of endometrial cancer, routine endometrial surveillance has not proved to be effective in increasing the early detection of endometrial cancer in women using tamoxifen and is not recommended. If atypical endometrial hyperplasia develops, appropriate gynecologic management should be instituted, and the use of tamoxifen should be reassessed.