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Vaginal bleeding, abnormal premenopausal increased or irregular [keywords]
- 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.
- Uterine angioleiomyoma causing severe abnormal uterine bleeding. [Case Reports, Journal Article]
- Clin Exp Obstet Gynecol 2014; 41(1):102-4.
Angioleiomyoma or angiomyoma or vascular leiomyoma is an unusual benign mesenchymal neoplasm. The authors present a rare case of large uterine angioleiomyoma causing severe abnormal uterine bleeding.The patient, a 53-year-old, gravida 2, para 2, premenopausal Greek woman presented with a complaint of severe abnormal uterine bleeding. On gynecologic examination there was a palpable pelvic mass. Preoperative computer tomography (CT) of the abdomen and pelvis revealed an intra-abdominal mass 25 x 15 cm with abnormally increased vascularization. She underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy, total omentectomy and elective pelvic lymph node dissection. Histopathology revealed uterine angioleiomyoma. Follow up 84 months after initial surgery showed no evidence of recurrence.Despite the type of surgery, patients with uterine angioleiomyoma have very low risk of recurrence and excellent prognosis.
- 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.
- Classification of hysteroscopical images using texture and vessel descriptors. [Journal Article]
- Med Biol Eng Comput 2013 Aug; 51(8):859-67.
In recent years, hysteroscopy, used as an outpatient office procedure, in combination with endometrial biopsy, has demonstrated its great potential as the method of first choice in the diagnosis of various gynecological abnormalities including abnormal uterine bleeding (AUB) and endometrial cancer (CA). In patients suffering with AUB, the blood vessels of the endometrium are hypertrophic, whereas in the case of CA vascularization is irregular or anarchic. In this paper, a methodology for the classification of hysteroscopical images of endometrium using vessel and texture features is presented. A total of 28 patients with abnormal uterine bleeding, 10 patients with endometrial cancer and 39 subjects with no pathological condition were imaged. 16 of the patients with AUB were premenopausal and 12 postmenopausal, all with CA were postmenopausal, and all with no pathological condition were premenopausal. All images were examined for the appearance of endometrial vessels and non-vascular structures. For each image, 167 texture and vessel's features were initially extracted, which were reduced after feature selection in only 4 features. The images were classified into three categories using artificial neural networks and the reported classification accuracy was 91.2 %, while the specificity and sensitivity were 83.8 and 93.6 % respectively.
- 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.
- Premenopausal bleeding: When should the endometrium be investigated?--A retrospective non-comparative study of 3006 women. [Journal Article]
- Eur J Obstet Gynecol Reprod Biol 2010 Jan; 148(1):86-9.
There is lack of consensus amongst professional organizations as regards the cut-off age for endometrial sampling of premenopausal women presenting with abnormal uterine bleeding (AUB) to exclude endometrial hyperplasia or carcinoma. Therefore we conducted this study to quantify the prevalence of hyperplasia and carcinoma in different age categories in premenopausal women with AUB to identify the appropriate cut-off age for endometrial sampling.A retrospective review of the histopathology reports of endometrial samples taken from 3006 women presenting with AUB and aged from > or =30 to < or =50 years at Ipswich Hospital, UK, from 1 January 1998 to 31 December 2007. Women were divided into three subgroups according to age; group 1: 30 to < or =40 (n=862), group 2: 40 to < or =45 (n=1035) and group 3: 45 to < or =50 (n=1109).Logistic regression revealed that the prevalence of atypical hyperplasia (OR: 3.85; 95% CI: 1.75, 8.49; p=0.01) and carcinoma (OR: 4.03; 95% CI: 1.54, 10.5; p=0.04) was significantly higher in women in group 3 when compared to younger women. There was no statistically significant difference as regards simple and complex hyperplasia in the different age categories. All but one of the women (n=23) who had complex atypical hyperplasia or carcinoma under the age of 45 years, presented with irregular rather than cyclical heavy menstrual bleeding.Our study, the largest in the literature, suggests using the age 45 years as a cut-off for sampling the endometrium in all women with AUB. However, irregular menstrual bleeding justifies investigating women regardless of their age.
- Prevalence of endometrial polyps and abnormal uterine bleeding in a Danish population aged 20-74 years. [Journal Article, Research Support, Non-U.S. Gov't]
- Ultrasound Obstet Gynecol 2009 Jan; 33(1):102-8.
To estimate the prevalence of endometrial polyps and to investigate associated abnormal uterine bleeding in a Danish population aged 20-74 years.This was a study of a random selection of women from the Danish Civil Registration System: 1660 women were invited of whom 686 were included (429 pre- and 257 postmenopausal). AUB was assessed by a validated questionnaire. The women underwent transvaginal sonography (TVS) and saline contrast sonohysterography (SCSH). Hysteroscopic resection was performed in cases with suspected focal intrauterine pathology. Full evaluation was performed in 619 women (two failures of TVS and 60 failures of SCSH, in two women SCSH was contraindicated (endometrial cancer), in two women hysteroscopy was contraindicated, and one polyp was lost before histology). World Health Organization histopathological criteria were used for diagnosing true endometrial polyps.On final diagnosis there were 48 women with polyps, eight with submucosal myomas, four with other benign findings and one with polypoidal growing endometrial cancer. Complex hyperplasia without atypia was diagnosed in two women with polyps. The prevalence of endometrial polyps was 7.8% (48/619; 95% CI, 5.6-9.9%). The prevalence was influenced significantly by age (P<0.005); in women below the age of 30 years, the prevalence was 0.9%. Polyps were diagnosed in 5.8% of pre- and 11.8% of postmenopausal women (P<0.01). Thirty-nine (82%) of the women who had histopathologically verified polyps were asymptomatic. In asymptomatic premenopausal women the prevalence of polyps was 7.6%, while it was 13% in asymptomatic postmenopausal women. AUB, in particular intermenstrual bleeding, was more frequent among women without polyps (38%). By ultrasound examination, submucosal myomas were diagnosed in 4.2% (26/622; 95% CI, 2.6-5.8%) and intramural myomas in 11.1% (76/684; 95% CI, 8.8-13.5%) of women. Polyps were diagnosed in 2% of oral-contraceptive and 25% of hormone-therapy users.The overall prevalence of endometrial polyps was 7.8% and the prevalence increased with age. Polyps were rare (0.9%) in women below the age of 30 years. Surprisingly, AUB was less frequent among women with polyps than among those without polyps.
- The impact of alternative treatment for abnormal uterine bleeding on hysterectomy rates in a tertiary referral center. [Journal Article]
- J Minim Invasive Gynecol 2009 Jan-Feb; 16(1):47-51.
The purpose of this study was to estimate the influence of alternatives to hysterectomy for abnormal uterine bleeding (AUB) on hysterectomy rates.Retrospective cohort study. Canadian Task Force II-2.University hospital.Premenopausal patients with AUB.Medical records of all premenopausal patients treated for AUB in our university clinic between January 1, 1995, and December 31, 2004, were reviewed. Patients were identified based on (specific) diagnostic and therapy codes used in the registry system of the hospital. The total number of placements of levonorgestrel-releasing intrauterine device (LNG-IUD), hysteroscopic surgery, and hysterectomies performed/year was estimated. In addition, the course of treatment of each patient was assessed.A total of 640 patients received surgery and 246 LNG-IUDs were placed. The proportion of endometrial ablations decreased significantly over time (p <.001), whereas hysteroscopic polyp or myoma removal (p =.030) and insertion of LNG-IUD (p <.001) both increased. The proportion of patients receiving hysterectomy for AUB as their first therapy decreased significantly (p =.005) from 40.6% to 31.4%, although the total number of patients receiving hysterectomy remained similar (p =.449). The 5-year intervention-free percentage for LNG-IUD was 70.6% (SD = 3.3%), for hysteroscopic polyp or myoma removal 75.5% (SD = 3.3%), and for endometrial ablation 78.0% (SD = 4.3%; p =.067).Despite the introduction of alternative therapies, the total hysterectomy rate in the management of AUB did not decrease in our clinic.
- The use of non-three-layer ultrasound in biopsy recommendation for premenopausal women. [Journal Article]
- Acta Obstet Gynecol Scand 2008; 87(11):1155-61.
To evaluate diagnostic accuracy and timing of abnormal transvaginal ultrasonography for the recommendation of endometrial biopsy among premenopausal patients with abnormal uterine bleeding.Two-hundred and thirteen transvaginal ultrasonograms of premenopausal women with abnormal uterine bleeding were retrospectively evaluated.'Abnormal' ultrasonography was defined as either non-three-layer appearance during the proliferative phase or thickening > or =15 mm during the secretory/unknown phase. Findings were assessed on the basis of the histological diagnosis of the biopsies taken as the reference standard. Accuracy of the defined criteria with their likelihood ratio for detection of an endometrial disease was calculated.Abnormal histopathologic findings were detected in 147 (69%) of 213 patients. 'Abnormal' transvaginal ultrasonography criteria could detect disease states in 90.3% of patients with a sensitivity of 94.6% and a specificity of 77.2% (p<0.01). Sensitivity and specificity increased to 97.1 and 84.4% for ultrasonography conducted during the proliferative phase and were 60 and 61.9% for the secretory/unknown phase, respectively. Better results were clearly found for ultrasonograms obtained during the proliferative phase (p<0.01). The inclusion of post-biopsy proliferative phase transvaginal ultrasonography data of the following cycle resulted in a sensitivity of 95.2% and a specificity of 89.4%.The application of transvaginal ultrasonography using non-three-layer criteria is a highly accurate first step for the selection of premenopausal patients with abnormal uterine bleeding, which may reduce the number of unnecessary endometrial biopsies by approximately 25%. Proliferative phase evaluation is preferable.