Comparison of Combined Bipolar Radiofrequency Impedance-Controlled Endometrial Ablation with Levonorgestrel Intrauterine System versus Bipolar Radiofrequency Endometrial Ablation Alone in Women with Abnormal Uterine Bleeding

Study ObjectiveThis study aims to evaluate the efficacy of the combination of bipolar radiofrequency impedance-controlled endometrial ablation (NovaSure; Hologic Inc., Bedford, MA) and levonorgestrel intrauterine system (LNG-IUS; Mirena; Schering AG, Berlin, Germany) placement in comparison with NovaSure endometrial ablation alone in patients with abnormal uterine bleeding (AUB).DesignA propensity score matching study.SettingBeijing Tiantan Hospital, Capital Medical University, Beijing, China.PatientsA retrospective study was conducted on 246 patients with AUB who underwent NovaSure endometrial ablation with (NovaSure+LNG-IUS group) or without (NovaSure group) LNG-IUS between January 2013 and August 2016. To overcome selection bias, propensity score matching was used to establish a 1:1 match between these 2 groups. Accordingly, 41 patients were included in each group.InterventionNovaSure endometrial ablation, immediately followed by LNG-IUS insertion in the NovaSure+LNG-IUS group, and NovaSure endometrial ablation alone in the control group.Measurements and Main ResultsFollow-up assessments performed at postablation months 6, 12, and 24 revealed the following: The rate of amenorrhea (78.05% vs 46.34%, 85.37% vs 53.65%, and 87.80% vs 58.54%, respectively; p <.005) and the rate of dysmenorrhea remission (100% vs 70.59%, 100% vs 64.70%, and 100% vs 64.70% [p <.05, p <.01, and p <.01], respectively) were significantly higher in the NovaSure+LNG-IUS group than in the NovaSure group. The rate of reinterventions was similar for both groups at postablation month 6. However, at postablation months 12 and 24, these rates were significantly lower in the NovaSure+LNG-IUS group than in the NovaSure group (0 vs 14.63% and 2.44% vs 21.95% [p <.05 and p <.01], respectively).ConclusionFor women with AUB, the combination of NovaSure endometrial ablation and LNG-IUS is more effective than NovaSure alone in achieving amenorrhea, alleviating dysmenorrhea and reducing reinterventions.     

Abnormal Uterine Bleeding in Women with Infertility

Purpose of Review

Abnormal uterine bleeding (AUB) is a common gynecologic complaint of reproductive-age women that necessitates careful evaluation due to potential underlying structural and systemic abnormalities. The majority of studies on AUB and infertility examine these topics separately, despite emerging evidence that many etiologies of AUB influence fertility. This review aims to provide an updated perspective on the diagnosis and management of AUB in the context of the infertility evaluation.

Recent Findings

The FIGO PALM-COEIN classification of AUB allows for the precise identification of systemic and structural causes to guide management. Pelvic ultrasound continues to be an accessible first-line imaging technique with high sensitivity for detecting structural etiologies of abnormal bleeding, particularly when used with color Doppler or 3D imaging. Notably, recent studies suggest that many of the endometrial pathologies that lead to AUB can also negatively impact endometrial receptivity, perhaps contributing to infertility in some women.

Summary

While the impact of systemic causes of AUB, such as ovulatory dysfunction, on infertility is widely recognized, the extents to which endometrial disorders and discrete structural lesions affect fertility are not entirely understood. More research is needed to assess the impact of structural abnormalities and their treatment on subsequent fertility outcomes in women with AUB.

     

Value of 3-Dimensional Sonohysterography for Detection of Intrauterine Lesions in Women with Abnormal Uterine Bleeding

Study ObjectiveTo compare 2-dimensional (2D) sonohysterography (SHG) and 3D-SHG with saline solution infusion vs diagnostic hysteroscopy for investigation of intrauterine lesions in perimenopausal and postmenopausal women with abnormal uterine bleeding.DesignComparative observational cross-sectional study (Canadian Task Force classification II-1).SettingUniversity hospital.PatientsFifty perimenopausal and 20 postmenopausal women with abnormal intrauterine bleeding with clinically or ultrasonically suspected intrauterine lesions.InterventionsConventional 2D- and 3D ultrasonography and 2D- and 3D-SHG with saline solution infusion followed by diagnostic hysteroscopy, and endometrial curettage or subsequent operative treatment (e.g., hysterectomy, myomectomy, or polypectomy). Ultrasonographic and hysteroscopic findings were compared with histopathologic findings.Measurements and Main ResultsFor 2D-SHG, sensitivity, specificity, positive predictive value, negative predictive value, overall accuracy, likelihood ratio for a positive result, and likelihood ratio for a negative result were 79%, 72%, 89%, 54%, 76%, 2.82, and 0.29, respectively, and for 3D-SHG, were 92%, 89%, 96%, 80%, 91%, 8.36, and 0.09, respectively; and for diagnostic hysteroscopy, were 94%, 89%, 96%, 84%, 93%, 8.55, and 0.07, respectively. Thus, 3D-SHG was superior to 2D SHG (p = .02) and comparable to diagnostic hysteroscopy (p = .75) for diagnosis of intrauterine lesions.Conclusion3D-SHG can be used in the initial investigation of intrauterine lesions in perimenopausal and postmenopausal women with abnormal uterine bleeding before resorting to invasive procedures such as diagnostic hysteroscopy. Further studies of computer-reconstructed 3D-SHG virtual hysteroscopy are recommended.     

Prediction of Occult Uterine Sarcoma before Hysterectomy for Women with Leiomyoma or Abnormal Bleeding

Study ObjectiveTo develop a risk prediction model for occult uterine sarcoma using preoperative clinical characteristics in women undergoing hysterectomy for presumed uterine leiomyomata.DesignCases of uterine sarcoma were identified from the electronic medical records. Age/race-matched controls were selected at a 2:1 ratio (controls:cases) from a cohort of 45 188 women who underwent hysterectomy for uterine leiomyomata or abnormal bleeding during the same time interval. Unadjusted conditional logistic regression was performed to identify risk factors for occult uterine sarcomas, defined as no preoperative suspicion for malignancy. A risk prediction model was developed using a weighted logistic regression model, and the performance of the model was assessed using the receiver operator characteristic curve and corresponding area under the curve.SettingA large integrated health care system in CaliforniaPatientsWomen 18 years of age and older who underwent a hysterectomy and were diagnosed with a uterine sarcoma and matched controls from 2006 to 2013.InterventionsNone.Measurements and Main ResultsThere were 117 cases of occult uterine sarcomas that met inclusion criteria during the study period. The final risk prediction model included age, race/ethnicity, number of myomas, uterine weight, uterine size increase, degree of pelvic pain, and recent history of blood transfusion. The risk prediction model showed high accuracy based on the receiver operating characteristic curve method (area under the curve = 0.83; 95% confidence interval, 0.77–0.90); however, the positive predictive values were low (0.048 or less) at all risk thresholds.ConclusionMultiple clinical features are associated with the presence of a uterine sarcoma, but when incorporated into a prediction model, they fail to provide significantly more information about women who may have an unrecognized sarcoma and only marginally improve the certainty about women who are not likely to have sarcoma.     

Social Vulnerability Index and Surgical Management of Abnormal Uterine Bleeding in Reproductive-age Women

Study ObjectiveTo determine whether surgical management of abnormal uterine bleeding (AUB) is associated with social vulnerability index (SVI).DesignA retrospective cohort.SettingA total of 7 hospitals and 4 ambulatory surgery centers within a large New York health system.PatientsAll patients between 15 and 45 years of age who underwent either a hysterectomy or myomectomy for AUB between January 2019 and October 2021.InterventionsNone. Home addresses were linked to census tracts and SVI scores. SVI is composed of 4 themes that potentially influence a community's vulnerability to health stressors: socioeconomic status, household composition and disability, minority status and language, and housing type and transportation. Multiple logistic regression analyses were performed to evaluate the association between SVI and surgical procedure/approach, adjusting for age, race and ethnicity, marital status, insurance, language, body mass index, and previous abdominal surgery.Measurements and Main ResultsA total of 1628 patients were included. On performing regression analysis between SVI quarters and type of surgery, the odds of undergoing laparotomy for the hysterectomy group were not affected by SVI composite score both before and after adjusting for alternative factors (odds ratio [OR] and adjusted OR). Among those who had a myomectomy, individuals in SVI Q3 had 1.86 times (95% confidence interval, 1.27–2.72) higher odds of having a laparotomy than those in SVI Q1. Individuals in SVI Q4 had 1.74 times (95% confidence interval, 1.15–2.62) higher odds of having a laparotomy than those in SVI Q1. Although some unadjusted ORs were statistically significant in the myomectomy group, when adjusted for social, demographic, and economic factors, the results were not statistically significant.ConclusionPatients living in more vulnerable communities are less likely to have minimally invasive hysterectomy or myomectomy for the management of AUB. Neighborhood characteristics are independently associated with surgical procedure and approach.     

Use of the Levonorgestrel Intrauterine System to Treat Heavy Menstrual Bleeding in Adolescents and Young Adults with Inherited Bleeding Disorders and Ehlers-Danlos Syndrome

Study ObjectiveTo report on the rate of amenorrhea among adolescents and young adults with a bleeding diathesis after insertion of the 52-mg levonorgestrel intrauterine system (LNG-IUS)DesignRetrospective chart reviewSettingTertiary care, multidisciplinary Gynecology-Hematology clinic or Adolescent Gynecology clinicParticipantsThe cohort included 35 females aged 12–25 years presenting from January 2010 to January 2020 with heavy menstrual bleeding, 23 with an inherited blood disorder, and 12 with Ehlers-Danlos syndromeInterventionsThe 52-mg LNG-IUSMain Outcome MeasuresPrimary outcome was bleeding profile after LNG-IUS insertion. Secondary outcomes included rates of amenorrhea, intrauterine device (IUD) expulsion, IUD discontinuation, and unplanned pregnancy.ResultsMean age at menarche was 11.6 years, with mean age at insertion of 16.9 (range 11–23). Most participants were white (n = 26, 74.3%). Von Willebrand disease was present in 16 patients (45.7%) and Ehlers-Danlos syndrome in 12 (34.3%). Most (91.4%) had tried at least 1 hormonal regimen prior to LNG-IUS. Most participants (81.8%) reported improvement in bleeding, with 60.6% reporting spotting or amenorrhea. LNG-IUS expulsion occurred in 3 participants (9.1%) within the first 21 days, despite hemostatic agents at time of insertion. Mean continuation was 5.08 years (95% CI, 4.24–5.92), with 79% likelihood that participants kept their IUD in place for at least 2.5 years, and some up to 6 years.ConclusionThe 52-mg LNG-IUS is an effective treatment option for adolescents and young adults with heavy menstrual bleeding and a bleeding diathesis, with high rates of amenorrhea. Rates of IUD expulsion appeared higher during the first 30 days, but long-term continuation remained high.     

放置宫内节育器后出血与病毒感染的关系

采用病毒分离培养方法对１１３例放置宫内节育器（ＩＵＤ）后出血病例（ＩＵＤ出血组），放置ＩＵＤ无副作用的１０９例（ＩＵＤ正常组）、未放置ＩＵＤ正常妇女２４例（无ＩＵＤ正常组）及未放置ＩＵＤ异常子宫出血１１例（无ＩＵＤ异常出血组）的子宫内膜进行病毒分离。各组标本用兔肾细胞进行病毒分离，病毒阳性率依３次为５９．２９％、１９．２７％、１６．６７％、６３．６４％。分离出的病毒用多聚酶链反庆（ＰＣＲ）技术鉴定     

Use of the Levonorgestrel Intrauterine Device in an Adolescent with Type IV Vascular Ehlers-Danlos Syndrome and Heavy Menstrual Bleeding,a Case Report

BackgroundEhlers-Danlos syndrome (EDS) is a group of connective tissue disorders of altered collagen synthesis. People with vascular EDS are at increased risk for vascular and hollow viscous rupture. Heavy menstrual bleeding (HMB) is common among adolescents with EDS. The levonorgestrel intrauterine device (LNG-IUD) is an effective treatment option for HMB; however, its use in patients with vascular EDS has historically been avoided due to perceived risk of uterine rupture. This is the first known case report on use of the LNG-IUD in an adolescent with vascular EDS.CaseA 16-year-old female with vascular EDS and HMB underwent placement of the LNG-IUD. Placement of the device was performed in the operating room under ultrasound guidance. At the 6-month follow-up, the patient reported significant improvement in bleeding and high satisfaction. No complications were identified at the time of placement or follow-up.Summary and ConclusionLNG-IUD may be a safe and effective option for menstrual management in individuals with vascular EDS.     

The Utility of Routine Ultrasound in the Diagnosis and Management of Adolescents with Abnormal Uterine Bleeding

Study Objective

Despite the fact that most cases of abnormal uterine bleeding (AUB) in adolescence are due to an immature hypothalamic-pituitary-ovarian (HPO) axis, the current approach to investigating adolescents who present with AUB often includes pelvic ultrasound to exclude rare structural causes. The aim of this study was to determine whether an ultrasound ordered for the investigation of AUB in adolescents detects any significant anatomic pathology or alters diagnosis and management.

Intrauterine Device Outcomes in Young Women with Heavy Menstrual Bleeding: Comparing Patients with and without Inherited Bleeding Disorders

Study ObjectiveTo evaluate the use of intrauterine devices (IUDs) in two young women's hematology clinics and compare adverse events in adolescents with and without inherited bleeding disorders (BDs)DesignRetrospective multicenter cohort study from February 2014 through February 2020SettingYoung women's hematology clinics at Nationwide Children's Hospital in Columbus, Ohio, and Children's Medical Center in Dallas, TexasParticipantsFemale patients evaluated for heavy menstrual bleeding (HMB) who underwent IUD placementInterventions and Main Outcome MeasuresRates of IUD expulsion, malposition, and ongoing HMB requiring additional medical treatmentResultsWe identified 43 patients with BDs and 35 patients without BDs who underwent placement of an IUD for HMB. The mean age was 14.9 years (range 11.0-21.4 years) at the time of presentation and 15.8 years (range 11.0-21.4 years) at IUD placement. Those with BDs were younger at the time of IUD insertion. Most patients (90%) had previously failed other methods to control HMB. The annual rate of IUD adverse events was 0.25 per year of use, and all adverse events occurred in the first 20 months after placement. There were no significant differences in adverse IUD events in patients with and without BDs, although those without BDs requested IUD removal more frequently.ConclusionsIn this cohort of adolescent females, the presence of a BD was not associated with a higher IUD expulsion rate. IUD placement should be considered a first-line option for adolescents with BDs who experience HMB.     

Treatment of Ovulatory and Anovulatory Dysfunctional Uterine Bleeding with Oral Progestogens

Six anovulatory and 10 ovulatory women with dysfunctional uterine bleeding (DUB) were treated with cyclical oral progestogens (norethisterone or medroxyprogesterone acetate). Anovulatory women were treated from day 12-25 and ovulatory from day 5-25, in doses of 5-10mg 3 times daily. Measured menstrual blood loss was effectively reduced from control to treatment cycles in both anovulatory (control cycle 131ml; treatment 80 and 64ml) and ovulatory women (control cycles 110 and 113ml; treatment 76 and 71 ml). Three women with ovulatory DUB did not show a useful response. Duration of bleeding was reduced in both groups and the pattern of loss changed. These regimens are effective forms of management for most women with ovulatory or anovulatory DUB.     

A New Paradigm for Uterine Fibroid Treatment: Transcervical,Intrauterine Sonography-Guided Radiofrequency Ablation of Uterine Fibroids with the Sonata System

Purpose of Review

This article provides the current evidence related to transcervical radiofrequency ablation of uterine fibroids under integrated intrauterine sonography guidance (the Sonata System).

Recent Findings

Published data on the treatment of fibroids with the Sonata System has demonstrated significant median reductions in total (73.3%) and perfused (73.3%) uterine fibroid volume, menstrual bleeding (72.3%), symptom severity (62.5%), and improvements in health-related quality of life (127%) at 12 months post-ablation. A clinical trial under an FDA Investigational Device Exemption is in progress.

Summary

The Sonata System is a promising treatment modality for uterine fibroids. As an incisionless, minimally invasive treatment that does not require general anesthesia or hospitalization, it has the potential for redefining the current paradigm for management of symptomatic fibroids.

     

置IUD子宫异常出血者子宫内膜细菌和病毒感染的研究

本文研究了育龄妇女子宫内膜细菌及病毒感染与宫内节育器（ＩＵＤ）所致子宫异常出血的关系。结果表明。置ＩＵＤ有异常出血组细菌总感染率为１０．５％（厌氧菌感染８．８％，需氧菌感染１．７％），显著高于未置ＩＵＤ正常组，是置ＩＵＤ未出血组的３．６２倍。置ＩＵＤ有异常出血组病毒总感染率为２９．５％。（巨细胞病毒（ＣＭＶ）感染１２．５％，单纯疱疹病毒Ⅱ（ＨＳＶⅡ）感染１７％，显著高于置ＩＵＤ无异常出血组和未置ＩＵＤ正常组。置ＩＵＤ＜１２月有异常出血者的细菌感染率显著高于置ＩＵＤ＞１２月者；而病毒感染则反之。宫颈糜烂的程度与置ＩＵＤ子宫有异常出血者宫内感染有关。     

促性腺激素释放激素激动剂联合曼月乐治疗保守性手术后中重度子宫内膜异位症的疗效分析

目的:探讨促性腺激素释放激素激动剂(GnRHa)联合曼月乐治疗中重度子宫内膜异位症(EMs)保守性手术后的疗效。方法:选择腹腔镜保守性手术后中重度EMs、无生育要求的患者43例,随机分为2组,试验组23例,术后使用GnRHa联合曼月乐治疗,对照组20例,术后单纯使用GnRHa治疗。随访12个月,比较手术前、手术后3个月、6个月、9个月和12个月疼痛评分、CA125值和复发率。结果:试验组和对照组中,术后各时间点的疼痛评分均低于术前(P<0.05);试验组中术后各时间点的疼痛评分无统计学差异;对照组中术后12个月疼痛评分均高于术后3个月、6个月和9个月(P<0.05);在术后12个月试验组的疼痛评分低于对照组(P<0.05)。试验组和对照组中,术后各时间点CA125值均低于术前(P<0.05);试验组中术后各时间点CA125值无统计学差异。对照组中术后12个月CA125值均显著高于术后3个月、6个月和9个月(P<0.05)。术后12个月试验组的CA125低于对照组(P<0.05)。试验组的复发率为0.0%;对照组的复发率为15.0%。结论:GnRHa联合曼月乐治疗保守性手术后中、重度EMs,可以长时间缓解疼痛,降低术后复发率,是一种有效的巩固治疗方法。     

Levonorgestrel-Releasing Intrauterine System Alone as Primary Treatment in Young Women with Early Endometrial Cancer: Case Report

Young women with polycystic ovary syndrome (PCOS) are at increased risk of endometrial adenocarcinoma (EAC) through chronic unopposed estrogen production. We describe the first case, to our knowledge, of grade 1 endometrioid EAC arising in the context of complex atypical endometrial hyperplasia in a 26-year-old woman with thrombophilia and PCOS who wished to retain fertility potential and was treated using a levonorgestrel-releasing intrauterine system alone. At first follow-up biopsy, a single focus of complex hyperplasia without atypia was documented. All specimens sampled during subsequent follow-up demonstrated inactive endometrium with pseudodecidual changes, and no ultrasonographic or magnetic resonance (MR) images exhibiting myometrial invasion or endoabdominal spread were observed. This successful outcome suggests that insertion of a levonorgestrel-releasing intrauterine system is a treatment option in selected young women with early-stage EAC who are not candidates for systemic therapy and who wish to maintain fertility potential. Close histologic follow-up is required, and immediate surgery is mandatory if endometrial cancer persists.