Endometritis

Endometritis is nowadays rare in developed countries and typically shows a subclinical or mild course; therefore, there are probably more cases of endometritis than diagnosed but they lack clinical relevance. In the fertile period of life it can be the reason for vaginal bleeding and infertility. The most common causes for non-specific endometritis are residual placental tissue after abortion or childbirth, intrauterine interventions, lesions within the uterine cavity, such as endometrial polyps, endometrial hyperplasia and neoplasms, intrauterine devices (IUD) and cervical stenosis. The histological detection of plasma cells in the endometrial stroma is required for the diagnosis of chronic endometritis. These can be detected immunohistochemically using anti-CD138 antibodies, which should be carried out particularly in cases of infertility with only slight inflammatory symptoms and few plasma cells. The use of an IUD containing progestin is frequently associated with an asymptomatic lymphoplasmacytic infiltration. After curettage or endometrial biopsy, an eosinophilic xanthogranulomatous or granulomatous endometritis and also a foreign body granuloma reaction can occur. Specific forms of endometritis, such as caused by tuberculosis, sarcoidosis, mycoplasma and herpes are very rare. Cytomegalovirus endometritis is associated with immunosuppression. Endometritis caused by infections with Chlamydia trachomatis is characterized by an extensive lymphoplasmacytic infiltration. The differential diagnoses of chronic endometritis include the very rare malignant lymphoma, which is usually characterized by a relatively monotonous cell infiltration.     

宫内膜活检或刮出物中子宫内膜间质肉瘤的诊断

目的：探讨宫内膜活检或刮出物诊断子宫内膜间质肉瘤的标准和鉴别诊断注意事项。方法：对９例临床和病理资料完整并经宫内膜活检或刮出物中确诊的子宫内膜间质肉瘤,对照其随后进行的子宫切除标本的蜡块,再次常规制片,ＨＥ染色,光镜进行对比观察。结果：９例宫内膜活检或刮宫标本中,有６例分化良好,酷似子宫内膜增生过长时的间质细胞。有３例分化差者,其中２例酷似恶性淋巴瘤,１例酷似多形肉瘤。９例均见簇状分布的子宫内膜螺     

A practical guide to the evaluation of benign endometrial conditions in biopsy and curettage material

Sampling of the endometrium, via biopsy or dilation and curettage, is an important diagnostic tool in a wide variety of clinical scenarios, ranging from infertility and abnormal uterine bleeding to cancer surveillance in high-risk populations. This review describes the most common methods for endometrial sampling used currently and discusses the issue of specimen adequacy from an evidence-based perspective. It also focuses on select benign conditions involving the endometrium in the setting of abnormal uterine bleeding, ranging from anatomic/structural lesions to patterns indicative of a dysfunctional menstrual cycle. The topic of endometrial sampling evaluation in the context of recurrent pregnancy loss is also discussed, with insights on documentation of endometrial changes during the ovulatory phase and the diagnosis of endometritis.     

Diagnosis of chronic endometritis in biopsies with stromal breakdown

Plasma cells are the hallmark of chronic endometritis but are not specific for upper tract infection. Plasma cells have also been noted in hormonally mediated endometrial disorders in association with gland architectural changes ("disordered proliferative" and "anovulatory" patterns), and stromal breakdown. We reviewed benign endometrial biopsies diagnosed at Beth Israel Deaconess Medical Center over a 2-year period described as disordered/anovulatory patterns +/- stromal breakdown. Cases were excluded if tissue was not available; women were younger than 50 years where most diagnoses were atrophic or cancer; or diagnoses were secretory, menstrual endometrium, or polyps. The remaining 61 cases were compared to 33 samples of unremarkable proliferative endometrium. Plasma cells were quantified on hematoxylin and eosin-stained sections and using a histochemical stain methyl green pyronin. The indication for biopsy was an abnormal pattern of bleeding in 34 cases, infertility workup in 7, incidental part of workup for pain, or other findings in 5. The majority of disordered proliferative endometrium had plasma cells (61% grade 1, 17% grade 2) all seen on methyl green pyronin staining only. Two thirds of proliferative endometrium with breakdown showed plasma cells (19% grade 1, 39% grade 2, 10 % grade 3). Plasma cells were rare in inactive endometrium and noted in only 18% of unremarkable proliferative endometrium, all grade 1. Plasma cells are commonly present in the endometrium of women with dysfunctional uterine bleeding and focal stromal breakdown. Given the lack of clinical evidence for infection, the inflammation likely represents a physiologic process.     

Pathophysiology of endometrial bleeding

OBJECTIVES: To review the morphological and molecular events responsible for uterine bleeding in health and disease. METHODS: Review of pertinent literature focusing on the histology and pathophysiology of normal and abnormal uterine bleeding (AUB). RESULTS: The seat of normal menstrual bleeding is located in the upper two-thirds of the endometrial mucosa and is recognized by tissue necrosis, disruption of microvasculature, migratory leukocytes and platelet/fibrin thrombi in microvessels. The molecular events responsible for tissue and vascular breakdown are related to the release of proteolytic lysosomal enzymes of endometrial cell and inflammatory cell origin. In cases of AUB, tissue breakdown is located in the superficial layer (subsurface) of the endometrium. It is either focal (breakthrough bleeding) or diffuse (withdrawal bleeding). It is initiated by either chronic endometritis and/or microerosions or vascular fragility due to structural abnormalities of microvessels. Endometritis and microerosions occur in otherwise normal endometrium, polyps, submucosal leiomyomata, atrophy and cancer (organic causes). Primary vascular alterations are found in hyperestrogenic-type endometria, i.e. anovulatory dysfunctional uterine bleeding (DUB) and progestational-type endometrium, i.e. progestational contraceptives and combined, continuous hormonal replacement therapy (HRT) (non-organic causes). Ovulatory DUB and coagulation disorders are not appreciated histologically. These are related to impaired vasoconstriction and fibrinolysis and impaired coagulation factors, respectively. CONCLUSIONS: Histology may contribute to better understanding of the mechanisms of action that initiate, regulate and lead to AUB. Better insight may trigger in the development of therapeutic procedures that could either prevent or control vascular breakdown which results in unexpected uterine bleeding.     

Chlamydia trachomatis in the endometrium: can surgical pathologists identify plasma cells?

Chlamydia trachomatis infection is the most common bacterial sexually transmitted disease. The authors examined the relation between chronic endometritis, which they term plasma cell endometritis (PCE), and chlamydial infection using plasmid-based polymerase chain reaction (PCR) and immunohistochemical staining (IHC) of paraffin-embedded endometrial sections. C. trachomatis infection was detected in 5 (24%) of 21 cases of PCE and in 1 (4%) of histologically normal endometrium. The diagnosis of chronic endometritis (with plasma cells confirmed by methyl green pyronin staining) was correctly made in 74% of the cases originally diagnosed as PCE and in 23% of control cases originally diagnosed as normal. The authors conclude that the histopathologic finding of plasma cells in endometrial samples should encourage further examination for chlamydial infection.     

Plasma cell endometritis is associated with Chlamydia trachomatis infection.

The presence of plasma cells in endometrial tissue has been linked to Chlamydia trachomatis infection. The aim of our work was to determine the strength of the association between C trachomatis infection and plasma cell endometritis. C trachomatis infection was detected by polymerase chain reaction (PCR) or immunohistochemistry in 5 (24%) of 21 endometrial tissue samples with plasma cell endometritis and in 1 (4%) of 28 tissue samples with no evidence of plasma cell endometritis (P < .02). Patients with plasma cell endometritis were also more likely to have symptoms and signs consistent with upper genital tract chlamydial infection; thus there is an association between endometrial C trachomatis infection and the presence of plasma cells in the endometrium. The histopathologic finding of plasma cell endometritis should encourage further examination of the tissue sample for simultaneous chlamydial infection. Plasmid-based polymerase chain reaction and immunohistochemical staining of paraffin-embedded samples are useful methods for detecting C trachomatis in endometrial tissue.     

Immunohistochemical characterization of endometrial leucocytes in endometritis

AIMS: Leucocytes are a normal and variable component of the endometrial stromal cell population. The aim of this study was to characterize endometrial leucocytes in established cases of endometritis in order to determine whether there are objective characteristics of the leucocyte infiltrate which would allow its identification as part of an inflammatory process rather then the normal physiological leucocyte infiltrate. METHODS AND RESULTS: We examined endometrial tissue from 79 cases of endometritis and 22 histologically normal controls. Leucocytes were characterized immunohistochemically for CD45, CD20, CD68, CD3 and CD56 and numbers were analysed semiquantitatively on a scale of 0-4. In many endometritis cases the overall number of leucocytes was increased. Furthermore, leucocytes were unusually distributed with a tendency to accumulate superficially beneath the endometrial surface. Whilst numbers of macrophages, T lymphocytes and endometrial granulated lymphocytes (uterine natural killer cells) did not differ between endometritis samples and controls, most endometritis cases contained a substantially increased number of B cells, which normally represent 1% or less of the endometrial leucocyte population. B lymphocytes were also observed in unusual locations such as intraepithelially and within glandular lumina. CONCLUSIONS: These results suggest that immunohistochemical characterization of endometrial leucocytes may be helpful in establishing a diagnosis of endometritis in equivocal cases.     

Endometrial micropolyps at fluid hysteroscopy suggest the existence of chronic endometritis

BACKGROUND: At fluid hysteroscopy the presence of endometrial micropolyps (less than 1 mm of size) is a frequent finding. Although their origin is still unknown, in our experience they are associated with stromal edema, endometrial thickening and periglandular hyperhaemia that suggest the existence of chronic endometritis. This study will aim to describe these lesions and evaluate their inflammatory significance by comparing hysteroscopic and histological findings. METHODS: 820 women underwent hysteroscopy and endometrial biopsy. Sensitivity, specificity, positive and negative predictive values and accuracy of the micropolyps presence for the diagnosis of chronic endometritis were calculated. RESULTS: Micropolyps were found in 96 cases (11.7% of all hysteroscopies); in 90 (93.7%) of these cases histology confirmed the presence of chronic endometritis. In women without micropolyps, chronic endometritis was significantly less frequent (78 cases, 10.8%) (P < 0.000001). The likelihood of chronic endometritis for women with micropolyps was very high (odds ratio 124.2, confidence interval 50.3-205.4). The sensitivity, specificity, positive and negative predictive values were 54%, 99%, 94% and 89%, respectively; the diagnostic accuracy was 90%. CONCLUSIONS: The presence of endometrial micropolyps at fluid hysteroscopy is significantly associated with endometrial inflammation and can be considered a reliable diagnostic sign for this pathology.     

The Mi15 monoclonal antibody (anti-syndecan-1) is a reliable marker for quantifying plasma cells in paraffin-embedded bone marrow biopsy specimens

Plasmocyte selective monoclonal antibodies (MAb) recognizing syndecan-1 have recently been described. They belong to a new cluster, CD138. Using the MAb MI15, we investigated the expression of syndecan-1 in routinely paraffin-embedded tissues. Nontumoral lymph nodes (25 cases) and bone marrow biopsy specimens (63 cases) showed strong membrane staining of plasma cells only, allowing accurate analysis of the nuclear structure. The MI15 positivity correlated with kappa and lambda light chain expression in the cytoplasm. The percentages of plasma cells calculated in bone marrow biopsy specimens after MI15 staining were, respectively, 2.1% (range, 1% to 4%) in normal bone marrows, 8.5% (range, 5 to 17) in reactive plasmocytosis, and 4.66% in monoclonal gammapathy of undetermined significance (MGUS) patients (range, 1 to 13), in the same range but slightly higher than those obtained on smears or on hematoxylin and eosin (H&E)-stained sections. In multiple myeloma (40 cases), all plasma cell types were marked, and Mi15 MAb gave additional information in 8 of 40 (20%) patients. In lymph nodes, Mi15 MAb reacted with Reed-Sternberg cells of classical Hodgkin's disease in 23 of 31 cases (74%) with variable intensity. In contrast, nodular lymphocyte predominance Hodgkin's disease (10 cases), most B cell lymphomas (88 of 107 cases) and all T cell lymphomas (30 cases) were negative. In B cell lymphomas, plasmocytomas (8 cases), plasmocytic lymphomas (2 cases), and 5 of 13 cases of immunoblastic lymphoma with plasmocytoid differentiation were stained. In lymphoplasmocytoid lymphomas (4 lymph nodes and 20 bone marrow biopsy specimens), only mature plasma cells were positive. Moreover, a wide distribution of syndecan-1 was observed in normal and tumoral epithelial tissues. Finally, Mi15 MAb appears to be a reliable marker for identifying and quantifying normal and tumoral plasma cells in paraffin-embedded bone marrow and lymph node samples.     

Karman's cannula and vacuum aspirator in gynecological practice.

The charts of 340 patients who underwent an endometrial suction procedure using Karman''s cannula and syringe were reviewed. The therapeutic uses of this instrument were for the treatment of chronic endometritis (18.6%), the evacuation of incomplete or missed abortion (14.6%) and hydatidiform mole (0.8%), and the retrieval of the missing tail of an intrauterine contraceptive device (1.2%). Its diagnostic indications include: the investigation of infertility (55.3%), dysfunctional uterine bleeding (8.7%), and postcoital bleeding (0.8%). The diagnostic yield of the instrument was 96.6%. Transient postoperative abdominal pain occurred in 65.9% of the cases while cervical dilatation preceded aspiration in 12.9% of the cases with cervical stenosis. The advantages of the instrument are discussed and its usefulness in everyday gynecological practice highlighted.     

超声和宫腔镜检查在219例绝经后子宫出血中的诊断价值

目的探讨宫腔镜及B超检查在绝经后子宫出血病因中的诊断价值。方法对我院2001年8月至2011年8月219例绝经后子宫出血妇女的临床资料及宫腔镜检查的病理结果进行回顾性分析。结果以病理诊断为基础,宫腔镜诊断子宫内膜增生症、子宫内膜炎、子宫粘膜下肌瘤、子宫内膜息肉、子宫内膜癌与病理诊断的符合率分别为60.8%（48/79）、91.9%（34/37）、90.9%（20/22）、93.1%（27/29）、80.0%（20/25）,超声检查的符合率分别为48.1%（38/79）、35.1%（13/37）、59.1%（13/22）、65.5%（19/29）、44.0%（11/25）。宫腔镜诊断与病理诊断的符合率为78.1%（171/219）,明显高于超声诊断与病理诊断的符合率48.9%（107/219）（χ2=40.334,P=0.01）。结论绝经后子宫出血的患者最佳诊断方法是,先做超声检查了解子宫及盆腔情况,再宫腔镜检查后行分段诊刮术做组织病理学检查确诊。     

Limitations of the criteria used to diagnose histologic endometritis in epidemiologic pelvic inflammatory disease research

While endometrial neutrophils and plasma cells are criteria used to diagnose histologic endometritis in epidemiologic pelvic inflammatory disease (PID) research, plasma cell misidentification and nonspecificity may limit the accuracy of these criteria. Herein, we examined: (1) the identification of endometrial plasma cells with conventional methyl green pyronin-based methodology versus plasma cell-specific (CD138) immunostaining, (2) the prevalence of endometrial plasma cells among women at low risk for PID, and (3) endometrial leukocyte subpopulations among women diagnosed with acute or chronic histologic endometritis by conventional criteria. We observed an absence of CD138⁺ cells in 25% of endometrial biopsies in which plasma cells had been identified by conventional methodology, while additional immunohistochemical analyses revealed indistinguishable inflammatory infiltrates among women diagnosed with acute or chronic endometritis by conventional criteria. Among women considered at lower risk for PID development, flow cytometric analyses detected plasma cells in 30% of endometrial biopsy specimens, suggesting that these cells, even when accurately identified, only nonspecifically identify upper genital tract inflammatory processes. Combined, our findings underscore the limitations of the criteria used to diagnose histologic endometritis in PID-related research and suggest that satisfactory understanding of PID pathogenesis, treatment, and prevention is hindered by continued use of these criteria.     

The comparative evaluation of uterine and cervical mucosa cytology with endometrial histopathology in cows

Reproductive tract abnormalities especially in the uterus and ovaries of cows often results in infertility. The object of this study was to determine the relationship between the cytology of uterine and cervical mucosa and endometrial histopathology in normal and endometritic cows. In this study, the genital tracts of 131 slaughtered cows were collected. According to macroscopic appearances and histopathological evaluation, reproductive tracts were divided into normal and abnormal. Cytological samples were obtained from the discharges of cervical mucosa and uterine fluid that were collected by wet cotton swab and gentle aspiration. Differential cellular counts were carried on Giemsa stained smears of the mucosa. Comparison of cell densities of normal cows with endometritic cows showed significant differences (P<0.05) in the macrophage presence both by swab (0.00±0.00) and aspiration (0.16±0.55) methods. Comparison of cell densities in different grades of endometritis showed a significant difference (P<0.05) in the neutrophil percentage in cervical mucosa between the swabbing and aspiration methods. In this study, there were no significant differences in cell densities between the two collection methods in cows affected with either acute or chronic endometritis. However, there was significant difference in the neutrophil density in aspirated cervical mucosa compared to the swab collection in cows affected with subacute endometritis. Cytological methods can be useful for the diagnosis of clinical and subclinical endometritis of cows.     

Endometrial glandular and stromal breakdown, part 2: cytomorphology of papillary metaplastic changes

Careful cytomorphologic evaluation of abnormal endometrial lesions has made accurate and reproducible microscopic assessment possible. Histopathology of patients with dysfunctional uterine bleeding due to an anovulatory cycle usually contain endometrial glandular and stromal breakdown (EGBD) and papillary metaplasia on the endometrial surface epithelium, if an appropriate sample has been collected. We often recognized abnormal cell clumps in the cytological smears with EGBD cases. They were composed of metaplastic cells, and some irregular small projection figures were observed from the margins of the cell clumps. We describe the quantitation of metaplastic clumps with irregular protrusions (MCIP) in endometrial endocyte samples. The current study presents the cytomorphological characteristics of the metaplastic changes recognized in EGBD cases. During a 7-yr period, 144 cases for which histopathological diagnoses were obtained following endometrial curettage, after collecting a direct endometrial sample using the endocyte. The material comprised 49 cases of normal proliferative endometrium (NPE) (patients aged 28-51, average 39.9), 32 cases of EGBD (patients aged 30-67, average 49.6), and 63 cases of endometrial hyperplasia without atypia (EH) (patients aged 35-65, average 47.7). The following points were investigated: (1) the occurrence of metaplastic cells; (2) the occurrence and the frequency of MCIP; and (3) the occurrence of MCIP that contains condensed stromal clusters. Metaplastic cells were seen in 93.8% of the EGBD cases. Cytomorphologic pattern identified with MCIP was 90.6%, and its frequency showed 16.1%. The occurrence of MCIP that contain condensed stromal clusters (93.1%) showed a strong association in comparison with other lesions, such as NPE and EH. Our data appear to indicate that the appearance of MCIP with condensed stromal clusters originated from the papillary metaplasia, which occurred on the endometrial surface epithelium. The cytologic observation of those cells may be a useful indicator for providing the nature of EGBD endometrium.     

Transvaginal sonography of the endometrium in women with postmenopausal bleeding

Objective: The purpose of this study was to determine the value of screening transvaginal ultrasonography for the evaluation of endometrial abnormalities in women with postmenopausal bleeding. Materials and methods: 250 women with postmenopausal bleeding underwent transvaginal ultrasonographic examinations before undergoing dilatation and curettage. Women who had any pelvic symptoms or were on hormone replacement therapy were excluded. Results: In 151 women, the histologic diagnosis was atrophic endometrium. In these patients, the mean endometrial thickness was 3.4 ± 1.2 mm. In 24 patients with endometrial carcinoma, the mean endometrial thickness was 16.5 ± 6.2 mm. The measurement included both endometrial layers (i.e. double layer). Thirty six cases of other pelvic pathologic conditions were discovered on ultra sonography. Conclusions: We believe that is reasonable to have a cutoff limit for normal postmenopausal endometrium at 5 mm. Endovaginal ultrasound is a valuable diagnostic instrument, as sensitive as dilatation and curettage, for detecting pathological conditions in the uterine mucosa.     

Quantitative study of uterine curettage in the menstrual cycle.

The histological appearances in 114 endometrial curettings from cases of dysfunctional bleeding have been analysed quantitatively by the method of Dunnill and Whitehead (1972) and Risdon and Keeling (1974). As applied to this type of specimen, the technique provides indices of both tubular volume and tubular surface to volume ratio. The histological diagnosis of endometrial hyperplasia is made from the increase in stromal and epithelial elements and the change in the pattern of the glands. These changes, on some occasions, can be difficult to detect. Quantitative analysis can be used to distinguish minor degrees of abnormal endometrial hyperplasia, in comparing serial endometrial changes in a given patient, and in comparing different menstrual cycles in dysfunctional uterine bleeding. Endometrial biopsies were collected and put in categories according to the clinical diagnosis. These biopsies were then examined morphometrically to find the volume/glandular surface and glandular/volume ratio. A significant change in these ratios was found.     

Comparison of transvaginal ultrasonography and saline infusion sonohysterography in evaluating the endometrial cavity in pre- and postmenopausal women with abnormal uterine bleeding

OBJECTIVE: To compare the diagnostic accuracy of transvaginal ultrasonography (TVUS) and saline infusion sonohysterography (SIS) of the endometrial cavity in pre- and postmenopausal women with abnormal uterine bleeding. DESIGN: In a prospective study, TVUS and concurrent SIS findings of 100 pre- and 33 postmenopausal women were recorded. The pathological diagnoses of the specimens, obtained by means of dilatation and curettage, hysteroscopy, and hysterectomy, were taken as reference and compared with the results of TVUS and SIS. RESULTS: When TVUS and SIS findings were compared with pathological results, the sensitivity and specificity of TVUS in diagnosing endometrial pathologies were 83% and 70.6%, respectively, whereas the sensitivity and specificity of SIS were 97.7% and 82.4%, respectively. The sensitivity and specificity of SIS in the diagnosis of endometrial polyps were 100% and 91.8%, respectively, and in the diagnosis of fibroids were 95% and 100%, respectively. CONCLUSION: SIS is more accurate than TVUS alone in the evaluation of the endometrial cavity in women with abnormal uterine bleeding.     

Müllerian adenosarcomas of the uterus with sex cord-like elements. A clinicopathologic analysis of eight cases

Eight cases of uterine müllerian adenosarcoma with sex cord-like elements (SCEs) occurred in patients 22-85 years of age (median, 41) who presented with abnormal uterine bleeding. Seven patients had hysterectomy; one had curettage and radiation only. The polypoid endometrial tumors were composed of adenosarcoma admixed with SCEs; the latter accounted for 5-50% of the tumor. The SCEs were multifocal in six cases and formed a solitary mass at the base of the adenosarcoma in the remaining two cases. Benign-appearing epithelial-type cells, often containing abundant eosinophilic or foamy, lipid-rich cytoplasm, were arranged in solid nests, trabeculae, and solid or hollow tubules. Myometrial invasion was observed microscopically in six cases. Of seven patients with postoperative follow-up information, six were alive with no evidence of recurrent tumor at postoperative intervals of 3-11 years. The patient treated only by curettage and radiation had persistent intrauterine tumor at 7 months and died of an unrelated illness at 16 months. This study indicates that occasional uterine adenosarcomas contain SCEs similar to those described in endometrial stromal tumors and uterine tumors resembling ovarian sex cord tumors. The clinical and pathologic features of these tumors are otherwise similar to those of typical uterine adenosarcomas.     

Current treatment of dysfunctional uterine bleeding

OBJECTIVES: We performed a review of the treatment modalities for dysfunctional uterine bleeding. METHODS: Dysfunctional uterine bleeding can be treated medically or surgically. Medical treatment consists of anti-fibrinolytic tranexamic acid, non-steroidal anti-inflammatory drugs, the combined contraception pill, progestogen, danazol, or analogues of gonadotrophin releasing hormone. The levonorgestrel releasing intra uterine device is developed for contraception, but is also effective in the treatment of dysfunctional uterine bleeding. Surgical treatment includes endometrial ablation of the first and second-generation, and hysterectomy. This review contains current available evidence on the effectiveness of these therapies. RESULTS: Antifibrinolytic tranexamic acid is the most effective medical therapy to treat dysfunctional uterine bleeding. In general medical therapy is not as effective as endometrial resection in terms of patient satisfaction and health related quality of life. The levonorgestrel releasing intra uterine device is an effective treatment for dysfunctional uterine bleeding. No difference in quality of life was observed in patients treated with a levonorgestrel releasing intra uterine device as compared to hysterectomy. Ablation techniques of the first generation are effective and safe when used by trained surgeons, but have a learning curve. Ablation techniques of the second generation are effective, but long-term follow-up data are not available. Similarly, there are no large randomised controlled trials comparing the levonorgestrel releasing intra uterine device to first and second-generation ablation techniques. Hysterectomy, the traditional standard of care, has a relatively high complication rate, but it generates a high satisfaction rate and good health related quality of life scores. CONCLUSION: Since none of the treatments for dysfunctional bleeding is superior to one of the others, and since all treatments have their advantages and disadvantages, counselling of patients with dysfunctional bleeding should incorporate medical approach, levonorgestrel releasing IUD, endometrial ablation and hysterectomy.