Evaluation and Management of Abnormal Uterine Bleeding

Abnormal uterine bleeding (AUB) is a common condition that leads to increased health care costs and decreased quality of life. A systematic approach to AUB evaluation can simplify management and enhance women’s well-being. Abnormal uterine bleeding describes any variation from normal bleeding patterns in nonpregnant, reproductive-aged women beyond menarche lasting for at least 6 months. Ambiguous and inconsistent use of terminology and definitions to characterize AUB in the past decades necessitated a new, consensus-based approach to nomenclature and AUB evaluation. This led to the International Federation of Gynecology and Obstetrics (FIGO) System 1 in 2007, which standardized nomenclature, set parameters, and defined normal and abnormal bleeding based on the 5th to 95th percentile data from available large-scale epidemiologic studies. FIGO System 1, endorsed by several national and international societies, improved worldwide communication among educators, clinicians, and researchers. FIGO System 2, published in 2011, focused on classifications of AUB etiology into structural and nonstructural entities using the PALM-COEIN (polyp[s], adenomyosis, leiomyoma, malignancy, coagulopathy, ovulatory dysfunction, endometrial disorders, iatrogenic, and not yet classified) classification system. The PALM-COEIN classification is facilitated by a complete patient history combined with appropriate imaging, histopathologic analysis, or laboratory evaluation to ensure accurate diagnostic and treatment approaches to AUB. Herein we present the systematic evaluation of AUB.     

Less abnormal uterine bleeding with dabigatran than warfarin in women treated for acute venous thromboembolism

Essentials

• Factor Xa inhibitors cause more abnormal menstrual bleeding (AUB) than vitamin‐K antagonists (VKA).
• We analyzed data of AUB in women, evaluating dabigatran versus VKA.
• We observed a 41% lower risk of AUB in women on dabigatran compared to those on VKA.
• Our findings of lower AUB risk on dabigatran should be corroborated in future studies.

Summary

Introduction

Although direct oral anticoagulants (DOACs) are associated with a better safety profile than warfarin in patients with acute venous thromboembolism (VTE), direct factor Xa inhibitors involve a higher risk of abnormal uterine bleeding (AUB). We aimed to determine the risk of AUB during anticoagulation with dabigatran compared with warfarin.

Methods

Post‐hoc analysis of the pooled RE‐COVER studies and the RE‐MEDY trial. Incidences of AUB, based on a defined preferred terms search for adverse events, in female patients aged 18–50 years treated with dabigatran, were compared with those in women treated with warfarin.

Results

Of the 2964 women included in the above‐mentioned trials, 1280 women were in the relevant age category (18–50 years) and included in the current analysis. A total of 643 patients were randomized to treatment with dabigatran and 637 to treatment with warfarin. The overall rate of AUB was 8.1%, 5.9% for the women treated with dabigatran and 9.6% in those treated with warfarin, for an odds ratio for dabigatran‐treated patients of 0.59 (95% confidence interval [CI], 0.39–0.90; P = 0.015). In the dabigatran‐treated patients, three (0.5%) suffered major bleeding (MB) vs. five (0.8%) in the warfarin‐treated patients (HR, 0.65; 95% CI, 0.15–2.72). MB or non‐major relevant bleeding occurred in 30 (4.7%) patients randomized to receive dabigatran and 57 (8.9%) randomized to receive warfarin (HR, 0.53; 95% CI, 0.34–0.83). None of the bleeding events was fatal.

Conclusion

Dabigatran treatment was associated with a significantly (41%) lower risk of AUB than warfarin. Future studies in daily practice are needed to corroborate these findings.

     

Treatment of Heavy Menstrual Bleeding with the Estradiol Valerate and Dienogest Oral Contraceptive Pill

The new estradiol valerate and dienogest oral contraceptive pill recently received U.S. Food and Drug Administration (FDA) approval to treat heavy menstrual bleeding in women without diagnosed uterine conditions. This oral contraceptive formulation combines estradiol valerate, which is metabolically identical to natural estradiol, with the potent new progestin, dienogest. The four-phasic pill is effective for pregnancy prevention and leads to significantly decreased menstrual bleeding among women with heavy periods, and shorter and lighter periods among women with normal periods. Studies indicate that this formulation may be associated with decreased hepatic activation compared to contraceptive pills that contain ethinyl estradiol. However, whether these findings translate to a decreased risk of thrombotic events has not been determined, and the pill carries the same contraindications as all other combined hormonal contraceptives. At least 10–15% of women suffer from heavy menstrual bleeding, defined as ≥80 mL of blood loss per cycle. In large clinical trials of women with heavy menstrual bleeding, the estradiol valerate and dienogest pill decreased blood loss volume by a median of 81%. Women with heavy menstrual bleeding treated with this contraceptive pill can expect a significant reduction in bleeding after just one cycle of use. This therapy leads to a decrease in bleeding that may be greater than that achieved by different oral contraceptive pills or other medical therapies, including tranexamic acid and nonsteroidal anti-inflammatory drugs.     

Laparoscopic hysterectomy in chronic renal failure patients with abnormal uterine bleeding

Background: Chronic renal failure (CRF) in women is frequently accompanied by endocrine disturbances leading to abnormal uterine bleeding (AUB). Recurrence of AUB is the most significant problem following current treatment approaches. Laparoscopic hysterectomy (LH) might be taken into consideration for patients who no longer want to preserve their fertility; however, these patients are in high-risk groups for minimally invasive surgery. Our goal was to determine whether LH is a good option for the treatment of AUB in patients with CRF when the associated risks are carefully managed.

Material and methods: This study included five patients who underwent LH for abnormal uterine bleeding between 2013 and 2016. Enhanced perioperative management and techniques were adopted to allow LH with minimized risks to the patient.

Results: All patients underwent LH successfully, without organ failure, heavy infection or abdominal cavity bleeding during the perioperative period. Operation times ranged from 95 to 152?min (mean time 117.6?min). The mean intraoperative blood loss was 24?ml. No recurrence was observed during the 18?months follow-up period.

Conclusion: For CRF patients with AUB who no longer want to preserve their fertility, hysterectomy may be a better option, not only to permanently resolve the problem, but also to remove the risk of future uterine lesions. The improved protocols minimized the specific risks of laparoscopy arising from the patient’s coexisting medical problems, making LH a feasible treatment approach in CRF patients with AUB.     

Non-surgical management of heavy menstrual bleeding

Hysterectomy is the commonest treatment for women with heavy menstrual bleeding. However, it is a major operation and should only be considered as a last resort. This article looks at alternative pharmacological treatments, as outlined in new NICE clinical guidance, and how nurses can improve the management of heavy menstrual bleeding.     

The effect of frankincense (Boswellia serrata,oleoresin) and ginger (Zingiber officinale,rhizoma) on heavy menstrual bleeding: A randomized,placebo-controlled,clinical trial

ObjectivesTo evaluate the effect of frankincense (Boswellia serrata, oleoresin) and ginger (Zingiber officinale, rhizoma) as complementary treatments for heavy menstrual bleeding (HMB) among women of reproductive age.DesignRandomized, placebo-controlled, clinical trial.SettingGynecology outpatient clinics.InterventionsPatients with HMB (n = 102) were randomly assigned to three groups. All patients received ibuprofen (200 mg) and either frankincense (300 mg), ginger (300 mg), or a placebo, which contains 200 mg anhydrous lactose as the filling agent and was similar in appearance to the two other drugs. Patients received the medications three times a day for seven days of the menstrual cycle, starting from the first bleeding day and this was repeated for two consecutive menstrual cycles.Main outcome measuresAmount and duration of menstrual bleeding and quality of life (QOL).ResultsDuration of menstrual bleeding was decreased in the frankincense (−1.77 ± 2.47 days, P = 0.003) and ginger (−1.8 ± 1.79 days, P = 0.001) groups, but not in the placebo group (−0.52 ± 1.86 days, P = 0.42). Amount of menstrual bleeding was decreased in all (P < 0.05), with no difference among the study groups (P > 0.05). More improvement in QOL was observed in the frankincense (−25.7 ± 3.1; P < 0.001) and ginger (−29.2 ± 3.7: P < 0.001) groups compared to the placebo group (−15.07 ± 3.52; P < 0.001) and between the groups, differences were statistically significant (P = 0.02).ConclusionsGinger and frankincense seem to be effective complementary treatments for HMB. Further studies with a larger sample size and longer follow-up are warranted in this regard.     

Evaluation and management of abnormal uterine bleeding in premenopausal women

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.     

青春期复发性黏膜下子宫肌瘤一例

子宫肌瘤是最常见的子宫良性肿瘤,多见于30~50岁的女性,在青少年中较为少见。该文报道了1例16岁青少年女性复发性黏膜下子宫肌瘤的诊治经过,患者因异常子宫出血行宫腔镜下子宫肌瘤切除术,术后未规律随访,患者于术后18个月再次因异常子宫出血入院,经阴道超声检查见宫腔5.2 cm×4.6 cm×3.8 cm占位,再次行宫腔镜下子宫肌瘤部分切除术,术后病理活组织检查提示为黏膜下子宫肌瘤。该病例的诊治经过提示,在青少年子宫肌瘤复发的诊治过程中,需与肌瘤肉瘤变鉴别,同时需尽可能保留患者生育能力,重视术后随访。     

围绝经期异常子宫出血诊断和治疗专家共识

围绝经期异常子宫出血(abnormal uterine bleeding, AUB)主要与卵巢功能衰退有关。卵巢衰退后常处于无排卵状态, 可能引起月经异常, 同时也是子宫内膜良、恶性病变的诱发因素。多数AUB会使患者不适, 并对其生活质量产生重大影响, 需要及时干预。随着诊断手段的不断丰富和规范化, 越来越多的AUB在门诊即得到了快速诊断。围绝经期异常子宫出血需针对病因进行规范化、个体化治疗。AUB的病因包括结构性改变和无结构性改变。无结构性改变者常需进行药物干预, 如孕激素、口服避孕药(尤其是短效口服避孕药)、放置左炔诺孕酮宫内缓释系统以及抗纤维蛋白溶解药物, 还可辅以微创治疗如宫腔镜手术和子宫内膜消融术等, 这使得很多AUB患者避免或推迟了子宫切除手术。     

经阴道超声测量对绝经后子宫内膜癌的诊断价值

目的:评价经阴道超声测量对绝经后子宫内膜癌的诊断价值。方法:选择因经阴道超声提示宫腔占位行宫腔镜检查术绝经后妇女520例,分析绝经后子宫内膜癌患者的相关特征。以病理诊断结果为金标准,评价经阴道超声和宫腔镜诊断子宫内膜癌的灵敏度和特异度。以ROC曲线下面积确定经阴道超声测量宫腔占位大小诊断绝经后子宫内膜癌的最佳临界值。结果:绝经后阴道流血(postmenopausal bleeding,PMB)、宫腔占位大及宫腔积液多与绝经后子宫内膜癌相关,而年龄、绝经年龄、绝经时间、内膜厚度与绝经后子宫内膜癌无关。伴PMB妇女的子宫内膜癌发生率是无PMB妇女的6.4倍。宫腔镜诊断绝经后子宫内膜癌的准确性高于经阴道超声。超声测量宫腔占位大小诊断无PMB子宫内膜癌的最佳临界值为14.5mm,此时阳性预测值为10.75%、阴性预测值为99.14%。超声测量宫腔占位大小诊断伴PMB绝经后子宫内膜癌的最佳临界值为18.5mm,此时阳性预测值为55.56%、阴性预测值为91.94%。结论:对于无PMB的妇女,经阴道超声测量宫腔占位大于14.5mm作为行宫腔镜检查的指征较合理;而对于经阴道超声发现宫腔占位且伴PMB的妇女,子宫内膜癌发生率较高,建议均行宫腔镜检查。     

Long-term effects of laparoscopic sterilization on menstruation.

The menstrual changes after laparoscopic sterilization were assessed in 200 women and compared with changes after conventional tubal ligation. About one third of the patients after laparoscopy had longer and heavier periods, but those women who were using oral contraception before operation fared worst. The reason for the menstrual changes may not be due to operation alone. There was no significant difference between laparoscopy and laparotomy in terms of increase in heavy bleeding or number of days of bleeding.     

Menorrhagia and bleeding disorders in adolescent females

In women, von Willebrand disease (VWD) is the most common inherited bleeding disorder. Since VWD and other inherited bleeding disorders are autosomal disorders, they affect women and men. Menorrhagia, or heavy menstrual bleeding (HMB), is the most common symptom of women with bleeding disorder experience. Objectively, it is defined as bleeding that lasts for more than seven days or results in the loss of more than 80 ml of blood per menstrual cycle. The prevalence of menorrhagia in a woman with a bleeding disorder ranges from 32 to 100% in patients with VWD, from 5 to 98% in patients with a platelet dysfunction and from 35 to 70% in women with a rare factor deficiency. A detailed history and a careful physical exam are the first steps towards a diagnosis in adolescents, adding a PBAC>100 increased the sensitivity of the screening tool further to 95%. Laboratory testing should be made at the time of menstrual bleeding in an effort to capture the lowest level of VWF:Ag and FVIII:C. Treatment options for menorrhagia in VWD: (1) antifibrinolytic therapy with tranexamic acid, (2) the non-transfusional agent desmopressin (DDAVP), (3) purified blood products that contain factor VIII and VWF concentrated from plasma and (4) hormonal preparations.     

宫腔镜电切术前负压吸宫及术后电熨联合治疗异常子宫出血

目的：探讨宫腔镜电切除术前负压吸宫及术后电熨联合治疗异常子宫出血的疗效及预后。方法：选择有手术指征的异常子宫出血患者87例,采用被动式连续灌流宫腔电切镜行子宫内膜切除40例,肌瘤切除33例,肌瘤及内膜切除3例,息肉切除5例,息肉及内膜切除6例。结果：手术均顺利完成。术后随访3－11个月,总有效率96．6％,其中单纯子宫肌瘤及息肉切除术者,术后月经均减少或恢复正常;49例子宫内膜切除术同时切除肌瘤、息肉者,57．1％无月经,32．7％月经减少,4．1％月经正常,对痛经治愈率为100％,59列术前贫血者术后58例恢复正常,纠正贫血有效率为98．3％。术后并发症为3．4％,宫腔粘连并积血1例,月经无改善2例。结论：宫腔镜电切术前负压吸宫可薄化子宫内薄,电切术后滚球电极电熨切面可灭活由于电切深度不够或宫角处遗漏的内膜,与宫腔镜电切术联合应用可提高手术成功率,减少术后复发率,长期疗效尚待观察。     

Tranexamic Acid: a new option for heavy menstrual bleeding

Heavy menstrual bleeding, or menorrhagia, af ects approximately one-third of women. Treatments have included nonsteroidal anti-inflammatories and oral contraceptives, although neither is approved by the Food and Drug Administration (FDA) specifically for this use. Lysteda® (tranexamic acid) has recently been approved as a treatment for heavy menstrual bleeding. This article gives a background on menorrhagia and describes treatment with tranexamic acid, including its implications for nurses.     

Lifting the curse

Adenomyosis is a condition most women have never heard of. Yet it can cause severe menstrual cramping and heavy bleeding.     

Abnormal vaginal bleeding

The complaint of abnormal vaginal bleeding in a non‐pregnant patient is not a common presentation to a general ED. However, the bleeding may in itself be significant or it may be a harbinger of serious underlying pathology. A systematic approach to diagnosis is required. An initial approach to vaginal bleeding can be to categorize the bleeding by the anatomical site. This article discusses some of the common causes of upper tract or uterine bleeding and outlines the basic approach to diagnosis and management.     

中医验方结合戊酸雌二醇治疗月经中期出血的临床研究

目的　探讨中医验方结合口服戊酸雌二醇对月经中期出血、消除腹痛的疗效。方法　运用中医验方结合口服戊酸雌二醇和单用戊酸雌二醇 ,分析两组与未用药时的发病期及发病间期。结果　中西结合治疗组发病期缩短、发病间期延长 ,P <0 0 5 ;中西结合治疗组的显著有效率高于西药治疗组 ,P <0 0 5。结论　中医验方与口服戊酸雌二醇配合使用疗效显著 ,可作为月经中期出血的常规治疗方案     

Abnormal uterine bleeding

Disorders of the menstrual cycle are common problems in ambulatory medicine. Abnormal uterine bleeding describes bleeding that is excessive or outside the normal menstrual cycle. In the premenopausal woman, the differential diagnosis is broad, and pregnancy must always be considered. Determining whether the bleeding is ovulatory or anovulatory is a central part of the evaluation, as anovulation is one of the most common causes of abnormal uterine bleeding. In patients with anovulatory bleeding, the goal of treatment is to minimize blood loss and prevent complications from chronic unopposed estrogen. In women with oligomenorrhea or amenorrhea, after establishing the etiology, it is necessary to maintain adequate estrogen to support bone health. In the peri- and postmenopausal population, because the incidence of endometrial hyperplasia and malignancy rises, it is important to have a low threshold for endometrial assessment.