The prevalence of underlying bleeding disorders in patients with heavy menstrual bleeding with and without gynecologic abnormalities.

OBJECTIVE: The purpose of this study was to assess the prevalence of underlying bleeding disorders in women with heavy menstrual bleeding (HMB) with and without gynecologic abnormalities. STUDY DESIGN: We performed a single-center prospective cohort study of 112 consecutive patients who were referred for heavy menstrual bleeding. Control subjects were 28 healthy volunteers who reported no HMB. Patients and control subjects had hemostatic testing in the first week after menstruation. Patients underwent gynecologic evaluation. RESULTS: The median age was 42.5 years (range, 17-55 years) in patients and 40.0 years (range, 25-55 years) in control subjects. Forty-six percent of patients had anemia; the median pictorial bleeding assessment chart score was 271. Seven percent of the control subjects with a subjectively normal menstruation had anemia. Twenty-six percent of patients had gynecologic abnormalities, which was considered to explain HMB. Overall, we found an underlying bleeding disorder in 29% of the patients, which was comparable for unexplained and explained HMB (31% vs 27%; P = .75). We diagnosed 6 cases of Von Willebrand's disease, 4 cases of factor XI deficiency, and 1 case of factor VII deficiency. The only abnormalities that we found in control subjects were platelet aggregation defects (11% in control subjects vs 23% in patients). Patients had a significantly longer activated partial thromboplastin time compared with control subjects (26.5 vs 25.0 seconds; P = .001) that was caused by lower median levels of factor XI (100 vs 124 IU/dL; P < .001). CONCLUSION: Bleeding disorders play an equally important role in the cause of both unexplained and explained heavy menstrual bleeding. A novel finding is the occurrence of low, but not deficient, levels of factor XI.

Distinguishing benign and malignant pelvic masses: the value of different diagnostic methods in everyday clinical practice.

OBJECTIVE: To optimize referral to specialized gynaecologists for surgical treatment of ovarian cancer by improving preoperative discrimination between benign and malignant pelvic tumours. STUDY DESIGN: In a prospective multicentre study 143 patients with a pelvic mass were included. At several occasions during the diagnostic work-up the gynaecologist estimated the chance of malignancy (educated guess/expert opinion). MRI in the local setting was suggested for uncertain cases. All MRI images were reviewed by an expert radiologist. The datasheet designed for the study further allowed for determining the risk of malignancy index (RMI). RESULTS: The diagnostic accuracy of the gynaecologist's final estimation of the chance of malignancy and the calculated RMI were comparable (area under the ROC curve of 0.87 and 0.86). MRI did not improve the accuracy of the diagnostic work-up for the study population as a whole. Subgroup analysis did however show improved diagnostic accuracy in cases with an estimated chance of malignancy between 20 and 80% when the MRI was read by an expert radiologist. CONCLUSION: Patient selection for surgery of a pelvic mass should be based on the chance of malignancy as assigned by the referring gynaecologists. In case of uncertainty MRI improves diagnostic accuracy, when judged by an expert.

Routine evaluation and treatment of unexplained menorrhagia: do we consider haemostatic disorders?

OBJECTIVE: Unexplained menorrhagia can be caused by underlying bleeding disorders. The aim of this study was to investigate the current work-up of menorrhagia in routine gynaecological practice, with a special interest in haemostatic evaluation. Secondly, we investigated the outcome of individualized treatment in our centre. STUDY DESIGN: Retrospective medical chart review of 112 consecutive patients referred with menorrhagia to a general gynaecology clinic of a university teaching hospital in the Netherlands between January 2006 and January 2007. In April 2008 we performed a structured telephone interview evaluating the effectiveness of their therapy. RESULTS: We included 112 patients, whose median age was 42 years. Twenty-nine percent were anaemic (hemoglobin <12.0g/dL). Seventy-one (63%) had unexplained menorrhagia. Only two patients had haemostatic evaluation and neither had von Willebrand's disease. Forty percent (29/71) needed two or more different therapies, 17% (12/71) needed three different therapies and two patients needed a total of seven different therapies. Eight patients underwent hysterectomy, six of them after endometrial ablation. Most patients (80%) were successfully treated medically or surgically and were satisfied with their therapy during follow-up. Eleven patients declined therapy and accepted their heavy periods. CONCLUSION: Haemostatic evaluation in women with unexplained menorrhagia is uncommon in gynaecological practice in our centre. Although most of the patients were satisfied with their treatment, a significant number required hysterectomy and another important proportion had to accept their menorrhagia. We hypothesize that the identification of haemostatic disorders might improve care for these women.

Effects of a preovulatory single low dose of mifepristone on ovarian function.

OBJECTIVES: To investigate the effect of a single low dose of mifepristone on ovarian function, when administered in the preovulatory period. METHODS: Healthy women with regular menstrual cycles were studied during two consecutive menstrual cycles. Either mifepristone or placebo was given in a randomized double-blind order when the leading follicle reached a diameter between 15 and 17 mm. Daily ultrasound and serum hormone measurements were obtained until follicular collapse. Statistical analysis was performed using Wilcoxon signed-rank test. RESULTS: Eight women entered the study, although one woman had to be excluded afterwards from analysis because her LH surge had already appeared on the day of treatment. The LH surge was delayed from day 14 to 17 (P = 0.01). Mifepristone caused a 3-day delay in follicular collapse, occurring on day 16 in control cycles and on day 19 in mifepristone treatment cycles (P = 0.02). The median cycle length was 26 days in control cycles and 30 days in mifepristone treatment cycles (P = 0.03). Progesterone measurement 7 days after follicular collapse did not differ significantly between both cycles. CONCLUSIONS: A single 10-mg dose of mifepristone administered during the preovulatory phase of the cycle delays the LH surge and postpones ovulation.