Improvement of laboratory markers of anaemia in the treatment of heavy menstrual bleeding with a 19.5-mg intrauterine device: a pilot study.

OBJECTIVES: To evaluate improvements in laboratory markers of anaemia (haemoglobin, haematocrit, serum iron, and ferritin) in women with subjective heavy menstrual bleeding (HMB) treated with the levonorgestrel 19.5-mg intrauterine device. MATERIALS AND METHODS: We conducted a pilot study at the Department of Obstetrics and Gynaecology, University of Campinas, Faculty of Medical Sciences, Campinas, SP, Brazil. We compared anaemia markers in 73 women aged 18-48 years suffering from HMB, one year after placement of the IUD. RESULTS: The mean age of participants was 30.0 years (range 24-38); more than half were white, and the mean body mass index (kg/m2) was 27.0. Twenty (27.4%) participants exited the study due to loss to follow-up (n = 12; 16.4%), expulsion (n = 7; 9.6%) and uterine perforation (n = 1; 1.4%). One-year post-IUD placement, amenorrhoea was reported by 10 (13.7%) women. According to intention-to-treat and per protocol analyses, the proportion of women with normal haemoglobin levels significantly improved (p = 0.014 in both analyses), as did haematocrit (p < 0.001 in both analyses) and serum iron (p = 0.003 in both analyses) compared to baseline evaluations. The proportion of women with normal ferritin levels also improved (p < 0.001) in both analyses using a cut-off of 15 ng/ml, though no significant difference was observed using a 30 ng/ml cut-off (p = 0.083 in both analyses). CONCLUSION: The levonorgestrel 19.5-mg IUD effectively improved laboratory markers of anaemia one year after placement in women with HMB.

Our results show that the levonorgestrel 19.5-mg IUD significantly improved anaemia markers in subjects with subjective HMB one year after insertion. The occurrence of expulsions emerged as a notable concern in this treatment group.

Predictors of diagnostic delays and loss to follow-up in women with von Willebrand disease: a single-center retrospective cohort study.

Background: Women with von Willebrand disease (VWD) often face diagnostic delays, leading to increased bleeds, stress, and healthcare use. The factors influencing these delays and their effects on gynecologic outcomes are not well understood. Objectives: This study aimed to 1) identify the prevalence and predictors of diagnostic delays and loss to follow-up in women with VWD and 2) determine how these delays affect severe gynecologic bleeding, emergency visits, transfusions, and hysterectomies. Methods: We conducted a single-center retrospective cohort study and included women aged ≥18 years diagnosed with VWD. Delayed diagnosis was defined as ≥3 bleeding events prior to VWD diagnosis, excluding easy bruising due to its subjectivity. Loss to follow-up was defined as ≥5 years since the last hematology visit. We used logistic regression for analysis. Results: Among 178 diagnosed women (median age, 27 years), 71 (40%) experienced ≥3 bleeding events before diagnosis. The median time from the first bleeding event to VWD diagnosis was 14.2 years. Severe bleeding events significantly predicted diagnostic delays (adjusted odds ratio, 3.1; 95% CI, 1.5-6.2). Fifty-four (30%) women were lost to follow-up, with remote era of initial bleed and VWD type identified as significant predictors. Delays were associated with increased risks of hysterectomies (odds ratio, 2.7; 95% CI, 1.2-6.3) and other gynecologic procedures. Conclusion: Delayed diagnosis and loss to follow-up in VWD are common even in a specialized Hemophilia Treatment Centre. Such delays lead to more severe bleeding and increased gynecologic interventions. Prompt diagnosis is paramount for better patient outcomes and reduced healthcare utilization.

Impact of demographic and clinical factors on elagolix plus add-back therapy effects on patient-reported nonbleeding symptoms in women with heavy menstrual bleeding and uterine fibroids: a post hoc analysis of data from two clinical trials.

Objective: To investigate the efficacy of elagolix plus add-back therapy (estradiol [1 mg] and norethindrone acetate [0.5 mg] once daily) on patient-reported nonbleeding symptoms and menstrual bleeding associated with uterine fibroids (UFs) across different subpopulations. Design: Post hoc analysis of two phase 3 clinical trials-Elaris UF-1 and UF-2. Setting: A total of 76 (UF-1) and 77 (UF-2) US clinical sites. Patients: Women (N = 591) with UFs and heavy menstrual bleeding. Interventions: Elagolix (300 mg) twice daily with add-back therapy (the indicated dose for UF-associated heavy menstrual bleeding) vs. placebo for 6 months. Main Outcome Measures: "Very much improved" or "much improved" change in nonbleeding symptoms (abdominal/pelvic pain, abdominal/pelvic pressure/cramping, back pain, and abdominal bloating) and menstrual bleeding measured using a Patient Global Impression of Change scale. Improvements were assessed in subpopulations stratified using baseline characteristics (age, race [self-reported], body mass index, and International Federation of Gynecology and Obstetrics fibroid classification). Results: Across subpopulations, differences favored elagolix plus add-back therapy (vs. placebo) for most symptoms at month 1 and all symptoms at months 3 as well as 6. In patients with characteristics commonly associated with high disease burden (age >40 years, Black/African American), those treated with elagolix plus add-back therapy reported significantly greater improvements vs. placebo at months 1-6 (P<.05) for all nonbleeding and bleeding symptoms (P≤.05). Conclusions: Premenopausal women with heavy menstrual bleeding and UFs receiving elagolix plus add-back therapy experienced significant improvements in nonbleeding as well as bleeding symptoms from months 1-6, regardless of baseline characteristics. Clinical Trial Registration Number: NCT02654054 and NCT02691494.

Abnormal Uterine Bleeding With Leiomyomas: A Case Report of Its Natural Course and Therapeutic Management.

Uterine fibroids (UFs), or leiomyomas, are common benign tumors affecting a significant proportion of women by the age of 50 years. While typically non-cancerous, UFs can severely impact the quality of life (QoL) through symptoms such as heavy menstrual bleeding (HMB) and pelvic pain. We report a case of a 45-year-old Hispanic female with a history of hypertension, diabetes, nephrolithiasis, and a solitary kidney, who presented with symptomatic UFs and an ovarian cyst. Despite initial pharmacological treatment with Ortho Micronor and Myfembree, the patient experienced persistent symptoms, prompting surgical intervention. A supracervical hysterectomy, bilateral salpingectomy, lysis of adhesions, and left ovarian cystectomy were performed, resulting in symptom relief and benign postoperative findings. This case report highlights the need for personalized treatment plans and comprehensive patient counseling to manage complex gynecological conditions effectively.

Cost-effectiveness of hysterectomy, first- and second-generation endometrial ablation, and levonorgestrel-releasing intrauterine device for treatment of heavy menstrual bleeding: a systematic review.

OBJECTIVES: This study aims to provide a clear understanding of the relative economic evaluation of hysterectomy, first- and second-generation endometrial ablation, and levonorgestrel-releasing intrauterine device for treatment of heavy menstrual bleeding. METHODS: The search was conducted without restriction until 5 October 2023 across online databases (PubMed, EMBASE, Scopus, Cochrane, and Web of Sciences) and economic evaluation databases. The review focused on studies that used the full economic evaluation approach to compare treatments. Review articles, editorials, conference abstracts, and non-English language articles were excluded. Included studies were evaluated for methodological quality using the QHES-checklist. The studies were analyzed using ICER. RESULTS: Out of 156 articles assessed for full-text evaluations, 23 publications were selected for qualitative analysis. Two studies deemed to be of low quality were excluded from the final analysis, while the majority of studies showcased high quality. The findings presented diverse perspectives on the most cost-effective treatment, with LNG-IUD frequently emerging as the preferred choice. CONCLUSION: There are diverse methodologies in economic evaluations, impacting reported health economic outcomes due to varying perspectives, time horizons, and modeling approaches. The review highlighted the need for further research to establish optimal HMB treatment strategies and to guide healthcare resource allocation.

The WeThrive App and Its Impact on Adolescents Who Menstruate: Qualitative Study.

BACKGROUND: Heavy menstrual bleeding (HMB) affects up to 37% of adolescents. Without recognition, HMB can lead to other medical conditions resulting in diminished health-related quality of life. WeThrive, a new mobile health (mHealth) app, implements the pictorial bleeding assessment chart to identify HMB, and the adolescent Menstrual Bleeding Questionnaire to measure the effects of HMB on adolescents' health-related quality of life. If HMB is identified, WeThrive will connect users to local clinics for further assessment of their menstrual bleeding with a health care provider. OBJECTIVE: This study aimed to describe adolescents' experiences using WeThrive app. METHODS: This qualitative study was approved by the local Research Ethics Board in Halifax, Nova Scotia, and informed consent was provided by all participants. Individual semistructured interviews were held via videoconference with adolescents younger than 18 years, who had at least 1 menstrual period and had used WeThrive at least once. Interview transcripts were thematically analyzed by 2 investigators (MP and NMN) independently, and the κ statistic was calculated to determine the strength of correlation in themes. RESULTS: Five adolescents (mean age 15.5, range 13-18 years), participated in the interviews. All participants stated that WeThrive helps them better understand their menstrual periods by predicting period onset, recognizing menstrual symptoms, and identifying HMB. Four themes were identified: (1) the importance of visual features and usability, (2) newly obtained knowledge using WeThrive, (3) feature use depends on menstrual health, and (4) trustworthiness. There was substantial agreement on the identified themes (κ=0.73). CONCLUSIONS: WeThrive is visually appealing, and trustworthy, and helps users better understand their menstrual periods, including identifying HMB. By identifying HMB early, WeThrive has the potential to improve the recognition of bleeding disorders and iron deficiency in adolescents. WeThrive is a useful tool to help adolescents better understand their menstrual periods.

Effects of management of heavy menstrual bleeding of patients undergoing haploidentical hematopoietic stem cell transplantation.

OBJECTIVE: To investigate the benefits of menstrual management in women undergoing hematopoietic stem cell transplantation (HSCT), in whom heavy menstrual bleeding (HMB) can be an underestimated bleeding complication. METHODS: This was a retrospective cohort study. Patients who had undergone HSCT in the Gynecological Endocrinology Clinic of Peking University People's Hospital were included over 10 years. The data of hematology and menstruation for all participants were collected. The management methods of the intervention group include gonadotropin-releasing hormone agonists (GnRHa), combined oral contraceptives (COC), or low-dose mifepristone. Patients who did not receive management were included in the control group. RESULTS: There were 112 patients included in the intervention group and 218 patients included in the control group. In all, 90.0%(297/330) of patients presented with HMB before HSCT. In the control group, 83.5%(182/218) of patients experienced menstruation in the laminar air-flow room (LAFR), whereas only 22.3%(25/112) did in the intervention group. After leaving the LAFR, the incidence of recurrent uterine bleeding was significantly reduced in the intervention group (17.9%(20/112/) versus 50.9%(111/218), p < 0.001). Patients who did not undergo menstrual management had a higher risk of bleeding than those who did (odds ratio 18.12, p < 0.001). CONCLUSION: Menstrual management significantly reduces the incidence of HMB in HSCT patients and acts as a protective factor to prevent menstrual bleeding in the LAFR.

Risk of heavy menstrual bleeding following COVID-19 vaccination: A nationwide case-control study.

BACKGROUND: COVID-19 vaccination has been inconsistently associated with an increased risk of heavy menstrual bleeding in previous studies. This study aimed to assess the risk of heavy menstrual bleeding requiring hospital care following COVID-19 vaccination according to the number of doses received and the time elapsed since vaccination. METHODS: Using comprehensive data of the French National Health Data System, we carried out a case-control study. Non-pregnant 15-50 years old women who had a hospital discharge diagnosis of heavy menstrual bleeding between May 12, 2021, and August 31, 2022 (cases) were randomly matched to up to 30 controls of same age, place of residence, social deprivation index, and contraceptive use profile at the date of case hospital admission (index date). Conditional logistic regression models were used to estimate the risk of hospital care for heavy menstrual bleeding associated with primary or booster doses and delay since last COVID-19 vaccination at index date, adjusting for socio-demographic characteristics, comorbidities, healthcare use indicators, and recent SARS-CoV-2 infection. RESULTS: A total of 4610 cases and 89,375 matched controls were included (median age, 42 years). Compared to unvaccinated women, the risk of hospital care for heavy menstrual bleeding was increased in those having received a last dose of primary vaccination in the preceding 1-3 months (Odds Ratio, 1.20 [95% confidence interval, 1.07-1.35]). This association was marked among women residing in the most deprived municipalities (1.28 [1.07-1.52]) and those who were not using hormonal contraception (1.28 [1.11-1.48]). Assuming a causal relationship, a total of 103 cases [54-196] were estimated to be attributable to primary vaccination in France. CONCLUSION: These findings provide evidence of an increased risk of heavy menstrual bleeding during the three-month period following primary COVID-19 mRNA vaccination. No increased risk was found beyond 3 months after primary vaccination nor following booster doses.

Retrospective study on the outcomes and satisfaction with endometrial ablation by bipolar energy (NovaSure®) for the treatment of heavy menstrual bleeding.

PURPOSE: To determine the effectiveness, safety, and participant satisfaction with endometrial ablation by bipolar energy (NovaSure®) in the treatment of heavy menstrual bleeding (HMB), and to investigate factors associated with poorer outcomes. METHODS: Multicenter retrospective observational study based on medical record review of the outcomes related to endometrial ablation by the bipolar-energy technique procedure to treat HMB in the setting of three university teaching hospitals in Spain. RESULTS: A total of 333 women were included in the study. Most bipolar-energy ablations were successful (85.12%; n = 269 out of 316), with amenorrhea the most frequent outcome (39.6%, n = 131 out of 316). The majority of participants had no complications (95.5%; n = 317 out of 332), and of those who did, only 2.1% were related to the technique. No further treatment was required for HMB in 82.8% of women (n = 274 out of 331), and surgery was avoided in 91.8%; only 5.9% of women underwent ablation-related hysterectomy. In women with previous transverse cesarean sections (CS), 91.0% avoided subsequent surgical treatment. Eighty-six percent of women (n = 221 out of 257) were satisfied with the procedure. CONCLUSION: Bipolar-energy ablation is very effective and safe for the treatment of HMB and yielded a high rate of participant satisfaction in our setting. The presence of comorbidities or previous CS may slightly reduce the effectiveness of the method, while performing concomitant surgery (mainly curettage) increases the rate of complications. Notably, despite the known increased risk of hysterectomy, most participants with previous CSs who underwent ablation avoided major surgery.

The Effect of the Levonorgestrel-Releasing Intrauterine System on Myometrial Blood Flow in Patients With Heavy Menstrual Bleeding.

Background Abnormal uterine bleeding constitutes a vexing issue among female patients, substantially impacting their quality of life. Surgical interventions, particularly hysterectomy, contribute to the psychological, physical, and financial burden on families and, by extension, the healthcare system. Levonorgestrel-releasing intrauterine system (LNG-IUS) represents a conservative management approach and emerges as a beneficial option for affected patients. The present study aims to elucidate color Doppler changes in the uterine artery pre- and post-LNG-IUS insertion. Objective The primary objectives encompass an investigation into the variations in Doppler indices (resistance index (RI) and pulsatility index (PI)) within the arcuate and radial branches of the uterine artery, as well as the assessment of endometrial thickness before LNG-IUD insertion, at three months, and six months post-insertion. Secondary outcomes include evaluating changes in pictorial blood assessment chart (PBAC) scores before insertion, at three months, and at six months after LNG-IUS insertion. Methods A cross-sectional study was conducted at the Department of Obstetrics and Gynecology at All India Institute Of Medical Sciences (AIIMS), Nagpur. A cohort of 25 women underwent LNG-IUS insertion. The endometrial cavity, RI, and PI of both arcuate and radial arteries were assessed before LNG-IUS insertion and at three and six months after insertion. Results The PI of the arcuate artery exhibited minimal alteration over the six-month duration, with a p-value of 0.43. Conversely, the RI demonstrated a statistically significant increase over the same period (p = 0.03). Conversely, the radial artery exhibited no statistically significant changes in either PI or RI (p = 0.39 or 0.13, respectively). Conclusion Following six months of LNG-IUS utilization, a substantial reduction in endometrial thickness and menstrual flow was observed, concomitant with an improvement in hemoglobin levels. Notably, the PI of both the arcuate and radial arteries demonstrated no significant change. Although the RI of the arcuate artery increased, its clinical relevance may be limited. Consequently, the observed reduction in menstrual bleeding cannot conclusively be ascribed to diminished blood flow in uterine arteries.

Driving improvement of diagnosis and awareness of heavy menstrual bleeding in women among physicians.

INTRODUCTION: A number of barriers in care exist for women/girls with bleeding disorders. Little progress has been made to overcome them, particularly regarding levels of awareness of healthcare professionals (HCPs) and women/girls. AIM: To evaluate awareness and perception of heavy menstrual bleeding (HMB) and bleeding disorders among HCPs and women/girls. METHODS: A three-part qualitative study was conducted, including HCPs and women/girls from over seven countries. Part 1 included eleven 60-min interviews with experts discussing HMB diagnostic barriers, which were further assessed in surveys among 6099 women/girls, 353 general practitioners (GPs), and 426 obstetricians and gynaecologists (OB/GYNs) during Part 2. Part 3 included three 1.5-2-h workshops with 20 clinicians and patient representatives covering HMB knowledge, criteria defining HMB and HCP resourcing for diagnosis. RESULTS: Many HCPs do not conduct certain investigations for women/girls presenting with HMB, and 22% of GPs lack confidence in the management of HMB. Only 8% of GPs use screening tools to evaluate menstrual blood loss, and 13% of GPs and 15% of OB/GYNs assess underlying bleeding disorders. Seventy-six percent of menstruating women/girls believed they could recognise HMB symptoms 'well'. However, 23% of these women/girls would not seek medical advice for abnormal/prolonged menstruation disrupting their lives. Disruptions were reported in 34% of women/girls from the general population and 61% of women with at-risk symptoms of HMB. CONCLUSION: Many women/girls and HCPs have limited awareness of important HMB indicators. There is a need for standardized clinical criteria to promote efficient diagnoses and management.

The Impact of Menstrual Disorders on Sleep Quality in Adolescents: An Observational Study.

STUDY OBJECTIVE: Premenstrual syndrome (PMS), dysmenorrhea, and abnormal uterine bleeding are frequent gynecological problems in adolescent girls. Studies show that sleep disorders and menstrual cycle irregularities are common conditions and indicate that they may occur together. Studies on the relationship between sleep quality and menstruation are mostly available for late adolescents (17 years and older) and young adult age groups. Our study aims to evaluate this relationship in adolescents aged 12-18. METHODS: A survey study was structured and consisted of 4 sections. The first section includes anthropometric measurements and medical history of the participants; the second section includes "menstruation and menstruation symptoms history"; the third section includes "The Sleep Quality Scale and Sleep Variable Questionnaire"; and the fourth section includes the "Premenstrual Syndrome Assessment Scale" (PMSAS). Our survey was applied to those who visited the adolescent medicine outpatient clinic. RESULTS: The Sleep Quality Scale score was significantly lower in those with high PMSAS scores (P < .001). The participants who had dysmenorrhea and experienced other symptoms during menstruation had significantly lower SQS scores and sleep efficiency (SE) (P < .001). There was no significant difference between heavy menstrual bleeding, defined as lasting more than 7 days, requiring more than 5-6 pads/tampons per day, and SE/quality (P > .05). CONCLUSION: According to our study, dysmenorrhea and the presence of PMS may negatively affect the sleep quality of adolescents. Health professionals dealing with young people should take into account the effects of menstrual problems on sleep quality and offer appropriate support/treatment options.

High prevalence of dysfunctional uterine bleeding in candidates for metabolic/bariatric surgery: increased endometrial cancer risk?

BACKGROUND: Endometrial cancer (EC) is the strongest obesity-associated malignancy and the fastest-growing cancer in young women. Early identification of EC and other endometrial pathology (malignant and nonmalignant) in women with severe obesity may improve treatment options and uterine preservation. Screening for endometrial pathology using abnormal or postmenopausal uterine bleeding (APUB) as a surrogate in women pursuing metabolic/bariatric surgery may be clinically beneficial, but data supporting this effort are limited. OBJECTIVE: To develop and institute a screening program for APUB as a surrogate for endometrial pathology in bariatric surgery candidates. SETTING: Two, academic metabolic/bariatric surgery programs in Louisiana, United States. METHODS: The Modified SAMANTA is a 10-item questionnaire that was implemented to identify patients with APUB, specifically combining tools designed to identify anovulatory/postmenopausal and heavy menstrual bleeding. Demographic (age, race), body mass index, and questionnaire data were analyzed with respect to positive screening using data from March 2021 through May 2023. RESULTS: Of 1371 eligible women presenting for surgical evaluation, 664 (48.4%) positive screens were identified and referred for gynecologic evaluation to rule out endometrial hyperplasia/cancer or other endometrial pathology. The likelihood of positive screening for APUB was associated with increasing BMI (P = .001) and Black/African American race (P = .003), as well as increasing SAMANTA score (P < .001). In contrast, risk of positive screening was negatively associated with increasing age (P < .001). CONCLUSIONS: Women presenting for metabolic/bariatric surgery have a high prevalence of APUB and, given this dysfunctional bleeding and concurrent obesity, are at greater risk for underlying EC. Potential risk factors for APUB, given their associations with screening positive, include increased body mass index, younger age, and Black/African American race. Standardized screening with appropriate gynecologic referral should be a routine part of the overall evaluation for women with severe obesity.

Patients' motives and considerations on treatment decision-making for heavy menstrual bleeding: a qualitative study.

BACKGROUND: Several treatment modalities for heavy menstrual bleeding are available. However, many women report being unsatisfied in their search for an appropriate and effective treatment. The aim of this study is to gain insights in the experienced impact of heavy menstrual bleeding and the motives and considerations of women during the decision-making process for treating heavy menstrual bleeding. METHODS: An interpretative qualitative study was performed, using in-depth interviews. In total, 14 semi-structured interviews were conducted with patients who consulted a physician for treatment of heavy menstrual bleeding. Participants were recruited via the Netherlands Patients Federation (N = 10) or via the outpatient clinic in the Máxima Medical Center (N = 4). The interviews were conducted by phone or online between February 2020 and March 2021. In the interviews three topics were addressed: (1) participant's experience with heavy menstrual bleeding, (2) experience with patient journey of treatment decision-making and (3) elaborating on alternative treatments for heavy menstrual bleeding. A thematic analysis was conducted. RESULTS: Fourteen participants aged between 30 and 59 years old were interviewed. Three main themes emerged; "Considerations in taking the (next) step to seek help", "Various sources of information can contribute, confuse or frighten decision-making process" and "A physician's understanding and a relationship of trust are needed to guide the decision-making process". CONCLUSION: Our results show that women's considerations and decision making strongly depend on the obtained information and experience, the relationship with the physician, the influence of the social environment, the pre-visit expectations/desires, the fear of treatment complications and uncertainty of the effect of the treatment. It is a physicians role to create a trusting and open atmosphere during consultation. Patient-centered communication is helpful to share knowledge, and gain insights into a patient's hopes, fears and worries.

Incidence and Impact on Quality of Life of Heavy Menstrual Bleeding in Women on Oral Anticoagulant Therapy.

INTRODUCTION: Heavy menstrual bleeding affects up to two thirds of women on oral anticoagulation. The rates of heavy menstrual bleeding, its impact on quality of life and associated risk factors in women attending anticoagulation clinics in South Africa are largely unknown. MATERIALS AND METHODS: A prospective cohort study was performed over an eight-month period in women on Warfarin (n = 30) and Rivaroxaban (n = 27) for a median [interquartile range] duration of 15.5 [78.0] months attending an anticoagulation clinic in Johannesburg, South Africa. Heavy menstrual bleeding was assessed over one menstrual cycle using the validated pictorial blood loss assessment charts (PBAC) and the menstrual bleeding questionnaire (MBQ). RESULTS: In this population of predominantly African ethnicity, with a median age of 39 [8] years, 39 (68.4%) women experienced heavy menstrual bleeding, defined as a PBAC score of >100. Median cycle length on anticoagulation and MBQ scores were significantly higher among women with a PBAC score of >100 (p > 0.05). Univariate analysis identified Rivaroxaban as a risk factor for heavy menstrual bleeding (OR 5.03, 95% CI 1.40-18.12). Heavy menstrual bleeding required treatment in 29 (74.4%) women which included management of iron deficiency, anti-fibrinolytics, modification of anticoagulation and hormonal contraception. CONCLUSION: Heavy menstrual bleeding was associated with a considerable negative impact on quality of life. This was most significant for women on Rivaroxaban as compared to Warfarin. It is essential to monitor and appropriately treat heavy menstrual bleeding in at risk women on anticoagulant treatment.

Review of interventions and effectiveness for heavy menstrual bleeding in women with moderate and severe von Willebrand disease.

INTRODUCTION: Women with VWD have an increased risk of gynaecological complications due to haemostatic challenges of menstruation. AIM: Review gynecological bleeding symptoms and their management in women with moderate-severe VWD. MATERIALS AND METHODS: Retrospective cohort analysis of prospectively collected data for women with moderate and severe VWD attending a joint multidisciplinary clinic between January 2010 and December 2020. Data was collected from electronic patient records on response to treatment options using PBAC, quality of life (QoL) assessment using SF-36 scores, haemoglobin and ferritin in comparison to pre-treatment values. RESULTS: Of the 67 women managed in the clinic; all reported heavy menstrual bleeding (HMB). Combination therapy with concurrent hormonal agents and tranexamic acid was required in 80% of women. There was an overall 64% improvement in PBAC scores in the first year, reflecting on QoL with 35% improvement in SF-36 score and correction of anaemia in 21% of cases. The cumulative effect of continued treatment culminated in greater reduction of blood loss, with an overall 71% improvement in PBAC scores by 5 years. One in 10 women required surgical treatment for a gynaecological pathology. Non-compliance was the cause of excessive unscheduled bleeding in 50% of adolescents. After 3 years, one in five women experienced a relapse of symptom, of whom 46% became perimenopausal and 54% discontinued hormonal treatments due to concerns about fertility, hair loss and weight gain. CONCLUSION: Management of HMB requires careful monitoring and follow-up by MDT with close collaboration between the gynaecology team and HTC. Control of HMB often requires a combination therapy.

A novel hypothesis-generating approach for detecting phenotypic associations using epigenetic data.

Aim: Hypotheses about what phenotypes to include in causal analyses, that in turn can have clinical and policy implications, can be guided by hypothesis-free approaches leveraging the epigenome, for example.Materials & methods: Minimally adjusted epigenome-wide association studies (EWAS) using ALSPAC data were performed for example conditions, dysmenorrhea and heavy menstrual bleeding (HMB). Differentially methylated CpGs were searched in the EWAS Catalog and associated traits identified. Traits were compared between those with and without the example conditions in ALSPAC.Results: Seven CpG sites were associated with dysmenorrhea and two with HMB. Smoking and adverse childhood experience score were associated with both conditions in the hypothesis-testing phase.Conclusion: Hypothesis-generating EWAS can help identify associations for future analyses.

To inform policy and improve clinical practice, it is important that researchers who study people's health find out which traits might increase the risk of illness. However, it can be difficult to know which traits should be looked at. In this study, we wanted to look for traits that might increase the risk of painful and heavy periods, using data about the switches that turn our genes on and off. There are some people in the Children of the 90s study that have data on gene switches. We compared all the switches between those with and without painful or heavy periods. For painful periods, we found links with seven switches and for heavy periods, we found two. We then used another data source, called the EWAS Catalog, to see which traits were associated with these switches. The traits we found included body size, smoking and child abuse. Finally, when using data on traits from the wider Children of the 90s group, we found that smoking and more difficult childhoods were some of the traits related to painful and heavy periods. A good thing about this approach is that we could find new traits that might increase the risk of painful or heavy periods; these should be looked at in future studies.

Standardizing the evaluation and management of iron deficiency anemia secondary to heavy menstrual bleeding in the emergency department.

BACKGROUND: Comprehensive guidelines for the management of iron deficiency anemia (IDA) in adolescents with heavy menstrual bleeding (HMB) presenting to the emergency department (ED) are lacking, leading to variability in care. We aimed to standardize the evaluation and management of these patients through the development and implementation of an evidence-based algorithm using quality improvement methodology. METHODS: Baseline data of the target population identified variability across four key measures of clinical management: therapy choice and administration, laboratory evaluation, hematology service consultation, and patient disposition. Literature review and consensus from pediatric hematology and gynecology providers informed a draft algorithm that was refined in an iterative multidisciplinary process. From December 2022 to July 2023, we aimed to achieve a 25% relative increase in patients to receive optimal management per the algorithm, while using sequential Plan-Do-Study-Act (PDSA) cycles. Process measures focusing on provider documentation and balancing measures, such as ED length of stay, were assessed concurrently. RESULTS: Forty-nine patients were evaluated during four PDSA cycles. Improvement of ≥40% above baseline regarding recommended therapy administration was achieved across four PDSA cycles. Adherence to recommended therapy choice improved from 57% (baseline) to 100%, minimal laboratory evaluation from 14% to 83%, hematology consultation from 36% to 100%, and appropriate disposition from 71% to 100%. ED length of stay remained stable. CONCLUSION: Implementation of a standardized algorithm for management of IDA secondary to HMB in adolescents in the ED increased adherence to evidence-based patient care.

A quick method to customize pictorial blood assessment tools towards better measurement: Method development and validation.

OBJECTIVE: Identification of heavy menstrual bleeding (HMB) cases in primary care settings is often done by using pictorial blood assessment charts (PBAC). The study aims to highlight the challenge of assessing blood loss, to develop a standardized method to efficiently customize a patient-reported pictorial chart, to validate the tool produced with our proposed method, and to demonstrate the feasibility of using PBACs in settings where resources are scarce. MATERIALS AND METHODS: Using blood samples and feedback from 21 women aged 30-51 years, we followed guidelines suggested in the literature, developed a method to produce PBACs for regular, long and night sizes, and had 9 participants testuse them. Linear regression analysis was performed to determine the correlation between participants' scores and menstrual blood weight. RESULTS: The study demonstrated the feasibility of customizing product-sensitive and size-specific pictorial charts by adopting essential steps including collecting menstrual blood with menstrual cups, employing fluid application techniques, and using sanitary pads as icons for easy identification. Linear regression analyses of score versus blood weight showed that the recorded blood weight was around 95% of the scored values (R2 = 0.9428, 0.947, and 0.9508, respectively; p < 0.001). CONCLUSION: Valid patient-reported PBACs created by the proposed method provides an innovative women's healthcare solution to assist HMB identification and reduce health expenditure by preventing risks for HMB related complications in varying economic and technological contexts. Women's participation in tracking menstrual abnormalities may improve health literacy.

Menstrual blood loss is an independent determinant of hemoglobin and ferritin levels in premenopausal blood donors.

INTRODUCTION: To prevent blood donors from developing iron deficiency (ferritin <15 µg/L) and subsequent anemia (hemoglobin <120 g/L), blood services rely on information about known risk factors, including the donor's sex and age. For example, while Finnish women are able to donate whole blood with a minimum donation interval of 91 days, women in the 18 to 25-year-old age group are recommended to donate no more than once per year. Menstrual blood loss is not accounted for in blood donation interval recommendations, despite being a known risk factor of iron deficiency. We aim to investigate to what extent menstrual bleeding is associated with ferritin and hemoglobin levels in female blood donors, and quantify the association of other menstruation-related variables not currently accounted for by blood services (i.e., use of hormonal contraception, heavy menstrual bleeding) with iron deficiency or anemia. MATERIAL AND METHODS: The study population consisted of 473 premenopausal and 491 postmenopausal Dutch whole blood donors. Exclusion criteria were current pregnancy, BMI ≥50, ferritin ≥200, pictorial blood assessment chart (PBAC) ≥400, and age <18 or ≥70 years. Menstrual blood loss was quantified using a PBAC, a semiquantitative method to evaluate the number of used menstrual products and the degree of staining. We identified predictors of log(ferritin)/hemoglobin and iron deficiency/anemia using Bayesian linear and logistic regression models and quantified the average percentage of variance in log(ferritin) and hemoglobin explained by the covariates. RESULTS: Menstrual blood loss accounted for most of the explained variance in hemoglobin (8%) and second only to the number of days since last donation for ferritin (8%). Heavy menstrual bleeding (PBAC ≥150, OR = 3.56 [1.45-8.85], prevalence 13%) was associated with anemia, and use of levonorgestrel-releasing intrauterine device was negatively associated with iron deficiency (OR = 0.06 [0.01-0.44]). After statistical control for menstrual blood loss, age was not associated with iron status. CONCLUSIONS: Menstrual blood loss and blood donation were the most important determinants of iron status in premenopausal women. Thus, results suggest that accounting for menstrual blood loss in donation interval guidelines may benefit blood donors.