Cesarean scar isthmocele (CSI) is a defect in the anterior myometrial wall of the uterine isthmus, at the site of a previous cesarean scar, and can be associated with menorrhagia in the form of prolonged menstrual bleeding or spotting, dysmenorrhea, and/or secondary subfertility. We report a case of hysteroscopic morcellation of CSI with a subsequent successful pregnancy. A 37-year-old female with menorrhagia since cesarean delivery and secondary subfertility, with midcycle transvaginal sonogram (TVS) showing a CSI with associated endometrial cavity fluid (ECF) as well as a small endometrial polyp, underwent hysteroscopic revision of the CSI and polypectomy via a tissue removal system. Postoperatively, menorrhagia had resolved, and follow-up midcycle TVS imaging showed no ECF. The patient spontaneously conceived 3 months after surgery and achieved a successful pregnancy. The use of a hysteroscopic tissue removal system is a feasible approach to the revision of CSI. Larger studies are necessary in order to determine efficacy for fertility patients.

Capillary dried blood spot collection offers an excellent less invasive alternative to serum or plasma collection by venesection. This study aimed to generate reference ranges for four sex steroids in capillary whole blood samples collected from healthy premenopausal women as dried blood spots as a screening method to detect disorders of sex development. Using this method we evaluated variations according to age, body mass index, menstrual cycle, and hormonal contraceptive use. This cross-sectional, community-based study included 120 healthy premenopausal women aged 18-40 years, not pregnant or breastfeeding. Whole blood testosterone (T), androstenedione (A4), 17α hydroxyprogesterone (17OHP), and progesterone (P4) were measured by liquid chromatography-tandem mass spectrometry (LCMS) from dried filter paper blood spots. The median (95 % confidence limits) for T were 0.75 (0.28, 2.20) nmol/L, A4 2.69 (1.02, 6.03) nmol/L, 17OHP 1.62 (0.32, 8.52) nmol/L and P4 0.65 (0.18, 41.0) nmol/L. Age by 5-year interval was associated with a progressive reduction in A4 but not for other steroids. Menstrual variation was evident for 17OHP and P4 with increases in luteal phase with a small mid-cycle peak for A4 but no other consistent changes. All sex steroid concentrations were significantly lower in participants taking a systemic hormonal contraceptive (combined oral contraceptive or etonogestrel implant). None of the sex steroid concentrations varied significantly with body mass index. These data provide reference ranges for whole blood T, A4, 17OHP and P4 measured by LCMS from dried blood spots from healthy young adult premenopausal women. Small but significant variations were evident according to age, hormonal contraceptive use and menstrual cycle phase.

Background and Objectives: Menstrual changes, including altered cycle length and bleeding patterns, have been reported following COVID-19 vaccination. This study aimed to determine the prevalence and types of menstrual changes occurring after COVID-19 vaccination among female students and staff at a university in Saudi Arabia. Materials and Methods: A cross-sectional study was conducted among women aged 18-39 years who received at least one dose of a COVID-19 vaccine. Eligible participants, including university students and staff, were recruited between May 2022 and November 2022. Participants completed a questionnaire detailing their sociodemographic characteristics, general medical and reproductive history, and menstrual characteristics before and after vaccination. The prevalence of various menstrual changes (cycle length, bleeding days, flow, and mid-cycle spotting) was calculated. The demographic factors associated with menstrual changes were analyzed using chi-squared tests. Results: The 472 included participants had a mean age of 20.9 years, and 95.3% were unmarried. Changes in menstrual cycle characteristics after COVID-19 vaccination were reported by 54.7% of respondents overall. The most common change was in cycle length, followed by the number of menstruation days and bleeding flow. Menstrual changes were not associated with age, BMI, occupation, marital status, or medical history. Changes in intermenstrual bleeding were more frequently reported after the third dose of the Pfizer vaccine compared to the Moderna vaccine (p = 0.014). Conclusions: More than half of the recruited female students and staff reported menstrual changes following COVID-19 vaccination, with altered cycle length being the most common. The potential underlying mechanisms and implications of these menstrual alterations require further investigation. These findings provide evidence of the menstrual side effects of COVID-19 vaccines among women in Saudi Arabia.

Menstrual bleeding patterns are considered relevant indicators of reproductive health, though few studies have evaluated patterns among regularly menstruating premenopausal women. The authors evaluated self-reported bleeding patterns, incidence of spotting, and associations with reproductive hormones among 201 women in the BioCycle Study (2005-2007) with 2 consecutive cycles. Bleeding patterns were assessed by using daily questionnaires and pictograms. Marginal structural models were used to evaluate associations between endogenous hormone concentrations and subsequent total reported blood loss and bleeding length by weighted linear mixed-effects models and weighted parametric survival analysis models. Women bled for a median of 5 days (standard deviation: 1.5) during menstruation, with heavier bleeding during the first 3 days. Only 4.8% of women experienced midcycle bleeding. Increased levels of follicle-stimulating hormone (β = 0.20, 95% confidence interval: 0.13, 0.27) and progesterone (β = 0.06, 95% confidence interval: 0.03, 0.09) throughout the cycle were associated with heavier menstrual bleeding, and higher follicle-stimulating hormone levels were associated with longer menses. Bleeding duration and volume were reduced after anovulatory compared with ovulatory cycles (geometric mean blood loss: 29.6 vs. 47.2 mL; P = 0.07). Study findings suggest that detailed characterizations of bleeding patterns may provide more insight than previously thought as noninvasive markers for endocrine status in a given cycle.

Reproductive concepts and practices among observant Orthodox Jews may Lead to Halachic subfertility in a significant portion of couples. According to Halachah [the Jewish code of law) sexual activity may not take place during the time a woman menstruates (Niddah) as well as for a full week thereafter (7 days of cleanliness). Coitus is allowed to resume after the woman has immersed herself in a ritual bath (mikvah). In the case of unexpected spotting or bleeding (Zavah), the woman should consult a rabbi and a doctor to determine the origin of the blood. Uterine bleeding entails that intercourse is forbidden for a minimum of 5 initial days plus 7 days thereafter. In practice, any minute bleeding or spotting, regardless of timing during the menstrual cycle, renders the woman ritually impure and invokes the stringencies of Niddah rulings. Even a physiologic occurrence such as midcycle ovulatory bleeding or spotting renders the woman Zavah and prohibits sexual intercourse at the optimal time for conception. The inability to conceive in this halachically mandated time period is not due to a biologic fault but rather to social, cultural and religious norms as defined by the rabbinate. Medically lengthening the pre-ovulatory phase is a common practice, as shortening the count of days of ritual impurity is often seen as nonnegotiable. Ethical issues concerning the role of the physician and the safety of such treatments are discussed.

Differences in the age at natural menopause were examined using a retrospective population sample of 289 naturally menopausal women. The mean age at natural menopause was 46.70 +/- 5.44 years. Earlier menopause occurred in women living in semiurban areas, divorced/separated and less educated women, and women who were younger at: first marriage, widowhood, divorce/separation and first or last full-term pregnancy. Later menopause occurred in women who had: irregular menstrual periods before 25 years, dysmenorrhoea and mid-cycle spotting. Duration of oral contraceptives use, weight and body mass index were significantly positively correlated with age at natural menopause. Multiple regression analyses indicated that age at last full-term pregnancy, residence, pattern of menstrual cessation and duration of oral contraceptive use were the significant predictors of the end of menstrual activity.

The mechanisms responsible for Norplant implants-induced menstrual irregularities remain poorly understood. It is unclear whether local changes in endometrial haemostasis are involved. The aim of the present study was to examine the immunohistochemical staining for von Willebrand factor (vWF) in endometrial biopsies taken from 37 women exposed to Norplant implants for 3-12 months and to compare it with 73 controls at various phases of the normal menstrual cycle. The vWF staining intensity was quantified by subjective scoring and by objective computerised colour image analysis. Results from the Norplant implants group were additionally correlated with their bleeding patterns, endometrial histology, and plasma oestradiol (E2) and progesterone (P4) levels. No differences were found between control and Norplant implants subjects in the localization of vWF staining, which was specifically confined to the endothelium of endometrial blood vessels. vWF staining intensity in Norplant implants endometrium was significantly lower than in controls during mid cycle, and reached a mean (+/- SE) level (subjective staining score 2.05 +/- 0.13, n = 37) in the range of the early proliferative and mid secretory phase normal endometrium; nevertheless, it remained significantly higher than that of menstrual and late secretory phase normal endometrium. No significant variations in vWF staining could be related to either the histology of the endometrium or the bleeding pattern of the users. Correlation of vWF staining with either serum E2 or serum P4 prior to biopsy, or to the number of days of Norplant implants exposure revealed no significant relationships. However, vWF staining was positively correlated (r = 0.419, P < 0.01) to the number of bleeding/spotting days within a 90-day reference period prior to biopsies being taken. These results demonstrate that there are major differences in the mechanism responsible for normal menstruation and Norplant implants-induced intermenstrual bleeding and spotting, and show that menstrual disturbances associated with the use of Norplant implants are unlikely to be due to changes in vWF levels in endometrial endothelial cells.

Endometrial carcinoma is the most frequent malignancy of the female reproductive tract, and irregular vaginal bleeding is the most common presenting symptom. Endometrial carcinoma is found most commonly among postmenopausal women and is associated with obesity, nulliparity, and anovulation. Oral contraceptive (OC) use and tobacco smoking have been reported to protect against endometrial carcinoma. Irregular vaginal bleeding is a common side effect of OC therapy. We report the case of an obese, premenopausal nulliparous woman with normal menses who developed menometrorrhagia and was then found to have endometrial carcinoma despite her youth and her use of both tobacco and combination OC.

Effective cycle control was demonstrated based on two multicenter, 2-year studies of the triphasic oral contraceptive (OC) agent containing the new progestin norgestimate. The estrogen in this OC is ethinyl estradiol. These open-label Phase III studies were conducted in the United States by 33 investigators at 33 sites who treated a total of 1,783 subjects, healthy women 17 to 38 years of age with menstrual cycle characteristics considered to be within the normal range. The norgestimate/ethinyl estradiol preparation was taken for up to 24 cycles. Follow-up information was collected 3 to 4 months post-treatment. Bleeding pattern analyses were based on 27,970 valid cycles. Normal cyclic bleeding patterns were experienced by most of the women during the study; only minimal and statistically and clinically insignificant variations in menstrual flow, dysmenorrhea, and premenstrual tension occurred. There was a low incidence of failed withdrawal bleeding in single cycles (less than 1.0% after cycle 6). There were no cases of amenorrhea, defined as two consecutive cycles of missed withdrawal flow. The incidence of breakthrough bleeding or spotting was highest during the initial treatment cycles and diminished with continued use of the formulation. The mean incidence of breakthrough bleeding was 2.36% in cycles 13 to 24. Apart from somewhat higher initial percentages among women new to oral contraception, the pattern of midcycle bleeding or spotting was similar to that of all women studied. Effective long-term cycle control was demonstrated in women who used this OC agent.