Heavy menstrual bleeding

Heavy menstrual bleeding is defined as excessive menstrual blood loss which interferes with the woman's physical, emotional, social and material quality of life. A well-structured history is important in determining a possible cause, its impact on the quality of life, identifying co-morbidities, organising appropriate investigations and offering management choices. Investigations include blood tests, pelvic imaging, outpatient hysteroscopy and endometrial sampling. Management may be conservative (wait and watch), medical or surgical, depending on the patient's age, parity, cause of bleeding, the need for fertility preservation and the impact on the quality of life. In several instances, pharmacological treatment can be commenced without a physical examination if a non-structural and non-histological cause is suspected.     

Ulipristal acetate for the management of acute heavy menstrual bleeding without fibroids

Heavy menstrual bleeding is a common condition among women of childbearing age. Although hysterectomy was the usual approach in acute cases in the past, other minimally invasive therapies or pharmacological alternatives, such as the levonorgestrel intrauterine device have shown to be highly effective. This case report presents the case of a pluripathological patient with acute heavy menstrual bleeding and severe anemia, who was successfully managed with ulipristal acetate, a selective progesterone receptor modulator. Bleeding control was achieved in 6?d without side effects, avoiding the need for surgery. This report suggests that ulipristal acetate could be useful in the treatment of acute uterine bleeding even in a structurally normal uterus without fibroids.     

Cost-effectiveness analysis of levonorgestrel intrauterine system and thermal balloon ablation for heavy menstrual bleeding

Objective  To compare the cost-effectiveness of levonorgestrel intrauterine system (LNG-IUS) (Mirena^®; Schering Co., Turku, Finland) and thermal balloon ablation (Thermachoice™; Gynecare Inc., Menlo Park, CA, USA) for the treatment of heavy menstrual bleeding.
Design  An open, pragmatic, prospective randomised trial.
Setting  A menstrual disorders clinic at National Women's Hospital, Auckland, New Zealand.
Population  Seventy-nine women with self-defined heavy menstrual bleeding randomised to the LNG-IUS (40 women) or the thermal balloon ablation (39 women).
Methods  Decision tree modelling using primary source data was used to identify the incremental cost-effectiveness of the two treatments.
Main outcome measures  Direct and indirect costs of medical treatment, including treatment costs, subsequent medical procedures, lost income and medical treatment for failed procedures. The change in quality of life as assessed by the Short Form-36 (SF-36) measured between time of treatment and 24 months was the primary outcome measure. Economic modelling examined the expected cost and outcome for a woman entering each treatment. Sensitivity analysis explored the robustness of the results.
Results  The expected cost of treatment was $NZ1241 ($US869) for the LNG-IUS and $NZ2418 ($US1693) for the thermal balloon ablation. The LNG-IUS was associated with an increase of 15 points on the SF-36 scale, compared with 12 points for the thermal balloon ablation. Sensitivity analysis indicates that the results are robust to a 25% decrease in the price of the primary cost drivers and to variations in the rates of failed treatment between the conditions.
Conclusion  The LNG-IUS would appear to be cost-effective when compared with the thermal balloon ablation for treatment of heavy menstrual bleeding.     

Heavy menstrual bleeding management during the Covid pandemic

Heavy Menstrual Bleeding (HMB) is a common gynaecological presentation, which can affect girls and women throughout their reproductive years and cause significant health issues. This review discusses the most recent evidence-based management of HMB and strategies for providing safe and effective care during the Covid 19 pandemic. Thus protocols and recommendations for HMB, developed to tackle the Covid 19, could become the ‘new normal’ for both primary and secondary care. There is a need for administrative changes, improved technology and effective communication to adapt these new recommendations.     

The management of perimenopausal abnormal uterine bleeding

Abnormal uterine bleeding in the perimenopause is a common gynaecological disorder and may affect 20–50 % of all women. It may be the first sign of premalignant or malignant disease. All women require assessment by means of pelvic ultrasound and an endometrial biopsy to exclude sinister pathology, identify other causes, and plan appropriate treatment. Pharmacological treatment includes antifibrinolytics, non-steroidal anti-inflammatories, combined hormonal contraception, cyclical progestogens and the levonorgestrel intrauterine system (LNG – IUS). Second line treatments may include endometrial ablation, uterine artery embolization, myomectomy or hysterectomy depending on the nature of the pathology. Minimal access techniques though the hysteroscopic, laparoscopic/robotic or vaginal route are increasingly used as the preferred surgical options. Novel treatments, either pharmacological or in the outpatient setting are likely to have a significant contribution in the future.     

热球子宫内膜去除术治疗异常子宫出血的远期疗效分析

目的应用TB型热球子宫内膜去除系统（Thermablate EAS）实施热球子宫内膜去除术,评估其治疗异常子宫出血的远期疗效及其安全性。方法对2005年1月至2007年3月123例应用TB型热球子宫内膜去除系统治疗异常子宫出血的患者进行远期随访,观察术后2年及5～8年的有效率、闭经率、痛经缓解率、二次手术率及并发症等。结果 116例患者完成随访,平均随访（84.1±7.9）个月,其中术前非绝经期患者98例,绝经期患者18例。术后2年及5～8年随访总有效率为96.6%、94.8%;闭经率38.8%、68.4%;痛经缓解率93.3%、95.5%;二次手术率2.6%、6.9%;术后5～8年随访总满意率96.5%。其中二者有效率、痛经缓解率及二次手术率比较差异均无统计学意义（P=0.52、P=1.0、P=0.12）,闭经率差异有统计学意义（P=0.00）。术中术后无球囊破裂、临近组织损伤、术后妊娠、子宫内膜去除-输卵管绝育综合征等并发症出现。结论TB型热球子宫内膜去除术治疗异常子宫出血安全、有效,可显著缓解痛经症状,远期疗效稳定,在临床值得推广应用。     

The management of perimenopausal abnormal uterine bleeding

Abnormal uterine bleeding around the time of the menopause is common and may be a sign of premalignancy such as endometrial hyperplasia or even endometrial carcinoma. All such women therefore need uterine assessment, which may include transvaginal scan combined with endometrial biopsy, hysteroscopy or a sonohysterogram. Having excluded (pre) cancer, treatment can then be offered. Medical treatment options include tranexamic acid to reduce blood loss, low-dose contraceptive pills, the levonorgestrel intra-uterine device and cyclic progestins. Surgical options include resecting sub-mucus fibroids hysteroscopically, endometrial ablation and hysterectomy.     

The management of perimenopausal menstrual symptoms

Abnormal bleeding around the time of the menopause is common and may be a sign of premalignancy such as endometrial hyperplasia or even endometrial carcinoma. As such all will need uterine assessment which may include transvaginal scan combined with endometrial biopsy, hysteroscopy or a sonohysterogram. Having excluded (pre) cancer, treatment can then be offered. Medical treatment options include tranexamic acid to reduce blood loss, low-dose contraceptive Pills, the levonorgestrel intra-uterine device and cyclic progestins. Surgical options include resecting sub-mucus fibroids hysteroscopically, endometrial ablation and hysterectomy.     

An overview of hysteroscopy and hysteroscopic surgery

Hysteroscopy allows direct visualization of the uterine and endocervical cavities. Recent innovations in endoscopic techniques have increased the accessibility of diagnostic and therapeutic procedures. However, hysteroscopic surgery should be performed by an appropriately trained gynaecologist to ensure safe practice and good patient outcomes. This review discusses the basic principles required to undertake diagnostic and operative hysteroscopic surgery, discuss the newer procedures available and highlight the current evidence behind the use of hysteroscopic surgery in the clinical setting.     

诺舒子宫内膜去除术治疗异常子宫出血的预后影响因素分析#br#

Objective?To investigate the prognostic factors of NovaSure endometrial ablation in the treatment of abnormal uterine bleeding (AUB). Methods?A retrospective analysis was performed on 201 patients with AUB who underwent NovaSure endometrial ablation in our hospital from January 1, 2011 to December 31, 2018. We analyze the amenorrhea rate and the rate of reintervention at different time points after operation. Cox regression model was used to investigate the factors that influenced the outcome (amenorrhea rate) and treatment failure (reintervention rate). Results?The amenorrhea rate was 67.66%, 70.27%, 76.32%, 75.83%, 78.82% at 1, 2, 3, 4 and 5~8 years after NovaSure operation respectively. The re-intervention rate was 6.47%, 10.27%, 14.47%, 15.00%, 18.82%, respectively.  Multivariate analysis by Cox regression model was used to study the prognostic factors .AUB patients with the history of cesarean section (P=0.026, HR=0.588, 95%CI: 0.368~0.938) or the cases combined with adenomyosis (P=0.007, HR=0.424, 95% CI: 0.227~0.792) can reduce the rate of amenorrhea, which affected the curative effect of NovaSure operation. AUB patients with dysmenorrhea history (P=0.008, HR=3.239, 95% CI: 1.356~7.736) or combined with adenomyosis (P<0.0001, HR=4.952, 95% CI: 2.297~10.678) or with thicker endometrial (thickness>10 mm, P=0.021, HR=2.413, 95% CI: 1.139~5.111) can increase the postoperative re-intervention rate, which are the risk factors for failure of NovaSure operation. Conclusion?The history of cesarean section and adenomyosis can reduce the rate of amenorrhea, which affected the curative effect of NovaSure operation; Dysmenorrhea, adenomyosis and endometrial thickness 10 mm can increase the postoperative re-intervention rate and were the risk factors of NovaSure operation failure.     

Vascular dysfunction as a cause of endometrial bleeding

Introduction.?Heavy menstrual bleeding (HMB) and the spotting and bleeding (S/B) associated with the use of hormonal contraceptives are distinct entities affecting endometrial vasculature and hemostasis.

Materials and methods.?An overview of the major etiologies and potential treatments for each condition is provided.

Results.?HMB is potentially caused by several different hemostatic dysfunctions. Combination oral contraceptives, levonorgestrel-releasing intrauterine system, non-steroidal anti-inflammatory drugs, and anti-fibrinolytics all have been shown to have some degree of efficacy in treating HMB. The basic cause of HMB is unknown in the majority of cases. Endometrial S/B related to hormonal contraceptives is a common occurrence and may well have a common etiology in altered angiogenesis resulting in abnormal blood vessels with fragile vessel walls. There is no effective treatment for this problem.

Conclusions.?Medical therapy for HMB is limited and effective for reducing blood loss during menstruation. There is no effective treatment for the S/B associated with hormonal contraceptives.     

左炔诺孕酮宫内缓释系统与热球子宫内膜去除术治疗月经过多的疗效比较

目的评价左炔诺孕酮宫内缓释系统（LNG—IUS）与热球子宫内膜去除术（TBA）治疗月经过多的近期和远期疗效及安全性。方法将77例月经过多患者采用随机数字表法分为LNG—IUS组（39例）和TBA组（38例）,治疗后随访36个月,观察两组患者的疗效、血红蛋白（Hb）、性激素水平、安全性及卫生经济学指标。结果①LNG—IUS组患者治疗前月经失血图（PBAC）评分和经期分别是（258．32±72．75）分和（10．90±2．37）d,治疗后3、6个月分别是（76．10±21．26）分、（9．52±1．61）d和（61．62±17．27）分、（8．32±1．33）d;TBA组治疗前分别是（254．89±67．18）分和（11．19±2．11）d,治疗后3、6个月分别是（58．94±44．09）分、（9．52±1．61）d和（52．83±31．56）分、（8．32±1.33）d,两组治疗前后比较,差异均有统计学意义（P〈0．05）;且LNG—IUS组治疗后12、24及36个月PBAC评分和经期少于TBA组（P〈0．05）。②LNG—IUS组和TBA组患者治疗后6个月Hb分别是（111．68±7．58）g／L和（114．22土6．22）g／L,均较治疗前[（87．90±6．42）g／L及（88．50±5．60）g／L）]明显升高（P〈0．05）,但与治疗后12个月Hb[（116．16±4．29）g／L,（114．16±4．32）g／L）]比较,差异无统计学意义（P〉0．05）。③两组患者治疗前及治疗后6、12个月性激素水平无明显变化（P〉0．05）。④LNG—IUS组和TBA组治疗后6个月阴道不规则出血率分别为72．41％（21／29）和13．89％（5／36）,两组比较,差异有统计学意义（P〈0．05）。两组阴道排液率分别为10．34％（3／29）和44．44％（16／36）,两组比较,差异有统计学意义（P〈0．05）。两组均无大出血、宫腔积脓等并发症。结论LNG—IUS与TBA均可有效改善月经过多,纠正贫血,且安全、简单易行;TBA治疗月经过多的近期疗效较LNG—IUS确切,依从性更好。     

Trichloroacetic acid for the treatment of dysfunctional uterine bleeding: a pilot prospective clinical trial

Objective

The aim of the trial was to assess the safety and efficacy of tricholoroacetic acid for the treatment of dysfunctional uterine bleeding using topical versus intrauterine instillation.

Study design

In a pilot prospective randomized clinical trial, seventy women were randomly allocated to one of two groups. In Group I, the patients were subjected to intrauterine instillation of 95% tricholoroacetic acid. Group II underwent dilatation and curettage before topical application of 95% tricholoroacetic acid.

Results

The groups were similar regarding baseline clinical characteristics. There was a satisfactory clinical reduction of menstrual flow (amenorrhea, hypomenorrhea and eumenorrhea) at a rate of 97.1% (Group I) and 85.7% (Group II) at 6 months. A significant increase was observed in the mean haemoglobin value at 3 and 6 months in both treatment groups (P < 0.05).Group I showed a significant increase in haemoglobin level compared to Group II (P < 0.05) and a significant reduction of the endometrial thickness compared to Group II (2.21 ± 0.41 versus 3.03 ± 3.37).

Conclusion

Trichloroacetic acid use for treating dysfunctional uterine bleeding seems to be efficient and safe, especially in women who do not require conception. Trichloroacetic acid intrauterine instillation is associated with longer duration of reduced menstrual bleeding than topical application.     

子宫内膜消融术治疗良性病变所致子宫出血疗效的研究

目的探讨超声引导下子宫内膜消融术在良性疾病导致的异常子宫出血中的治疗效果。方法 应用自凝刀对114例患者在超声监护下行子宫内膜射频消融术,术后定期随访,观察疗效。结果自凝刀子宫内膜消融术治疗子宫出血平均（12.32±4.51）min,96例治愈,18例有效,总有效率100%,无严重并发症。结论超声引导下子宫内膜消融术治疗子宫异常出血是一种安全、疗效好、简单、快速的治疗方法。     

Re-definition and re-classification of menstrual disorders

Historically, the terminology used for abnormal uterine bleeding has been inconsistent and confusing. The Fédération Internationale de Gynécologie et d'Obstétrique (FIGO) has recently approved new definitions and a standardized classification system for menstrual disorders and other contributors to the problem of abnormal uterine bleeding. This article describes the need for these changes and aims to encourage their use in routine clinical practice, medical education and scientific research, with the hope that they will lead to improved reproductive healthcare for women.