Perimenopausal abnormal uterine bleeding.

Abnormal uterine bleeding is a frequent symptom in the perimenopause. Causes are numerous, ranging from physiological reactions due to decreasing/unstable ovarian function to premalignant and malignant conditions. Benign findings such as endometrial polyps and myomas increase with age, leading to more abnormal uterine bleeding in the perimenopause. Cervical and vaginal causes of abnormal uterine bleeding should be excluded by speculum examination. Sexually transmitted diseases or pregnancy should be ruled out. Measurement of haemoglobin and iron levels, human chorion gonadotropin and thyroid hormones are relevant in selected cases. Transvaginal ultrasound is an ideal first step for the evaluation of perimenopausal abnormal uterine bleeding. Saline or gel contrast sonohysterography improves the diagnostic accuracy. Based on the ultrasound findings, invasive procedures such as endometrial biopsy or hysteroscopy can be planned. Once premalignant and malignant causes are excluded, the necessity for treatment can be evaluated in collaboration with the patient. Heavy menstrual bleeding causing anaemia will need immediate treatment. In less severe cases and in intermenstrual bleeding, expectant management can be considered. Hormonal treatment, such as oral progestogens, combined oral contraceptives or insertion of the levonorgestrel intrauterine system, may be a possibility if anovulatory bleeding is interfering with quality of life. The amount of bleeding can be reduced both by antifibrinolytic and non-steroidal anti-inflammatory drugs, progestogens and the levonorgestrel intrauterine system. Focal intrauterine lesions such as endometrial polyps or submucous myomas may require operative hysteroscopic procedures. Endometrial ablation or endometrial resection are good choices in selected cases, but some women will need a hysterectomy to treat their abnormal uterine bleeding in perimenopause.

Abnormal uterine bleeding due to uterine arteriovenous malformation in an early adolescent with intrauterine contraceptive device in situ.

We report a case of uterine arteriovenous malformation in an early adolescent who presented with heavy vaginal bleeding 2 months after termination of pregnancy with copper intrauterine contraceptive device (IUCD) insertion. The patient was admitted and had medical treatment, including blood transfusion and subsequently transcatheter embolisation of the arteriovenous malformation to control her bleeding. The IUCD was left in situ. Her symptoms completely resolved by 4 months post-procedure.

Therapeutic options for the management of abnormal uterine bleeding.

Just as the investigation of abnormal uterine bleeding (AUB) is approached systematically using the two FIGO systems for AUB in the reproductive years, treatment options can be considered similarly. Therapeutic options fall into two categories-medical and surgical-and while medical management is typically regarded as first-line therapy, there are several exceptions defined by the presenting cause or causes, mainly when infertility is a concurrent issue. In the early 1990s, up to 60% of women underwent a hysterectomy for the symptom of heavy menstrual bleeding (HMB), but this figure has decreased. The number of women undergoing a hysterectomy for benign disorders continues to decline, along with an increase in hysterectomies performed using minimally invasive techniques. Discussions about therapeutic options are tailored to the individual patient, and we include the risks and benefits of each option, including no management, to enable the patient to make an informed choice. The different types of treatment options and the factors affecting decision-making are considered in this article.

Abnormal uterine bleeding in reproductive age: a comparative analysis between the five Brazilian geographic regions.

OBJECTIVE: This study aimed to comparatively evaluate the presence of abnormal uterine bleeding and associated factors among women from the five official Brazilian geographic regions. METHODS: This is a cross-sectional, population-based, multicenter study of reproductive-age women from the five regions of Brazil. All participants answered questionnaires containing personal and socioeconomic data and information on uterine bleeding (self-perception and objective data). RESULTS: A total of 1,761 Brazilian women were included, 724 from the Southeast, 408 from the Northeast, 221 from the South, 213 from the North, and 195 from the Central-West. Considering women's self-perception, the prevalence of abnormal uterine bleeding was 37.56% in the North region, 39.46% in the Northeast, 21.54% in the Central-West, 29.56% in the Southeast, and 25.34% in the South (p<0.001). Abnormal uterine bleeding was more prevalent in the North and Northeast, where women had lower purchasing power, became pregnant more often, and were the only ones financially responsible for supporting the family more often (p<0.001). The menstrual cycle lasted <24 days in less than 20% of the women in all regions (p=NS). Among these, approximately 8 out of 10 women had never undergone treatment in four out of the five regions evaluated. More than half of the evaluated women reported a worsening of their quality of life during bleeding. CONCLUSION: The prevalence of abnormal uterine bleeding in Brazilian women was higher in the North and Northeast, followed by the Southeast, South, and Central-West regions. There was a worsening of quality of life during menstruation regardless of the woman's self-perception of abnormal uterine bleeding. Such results can direct the actions of health managers toward a better approach to abnormal bleeding.

Management of women with abnormal uterine bleeding: Clinical practice guidelines of the French National College of Gynaecologists and Obstetricians (CNGOF).

OBJECTIVE: To provide French guidelines for the management of women with abnormal uterine bleeding (AUB). DESIGN: A consensus committee of 26 experts was formed. A formal conflict-of-interest policy was developed at the beginning of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding (i.e. pharmaceutical or medical device companies). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. METHODS: The last guidelines from the Collège National des Gynécologues et Obstétriciens Français on the management of women with AUB were published in 2008. The literature seems now sufficient for an update. The committee studied questions within 7 fields (diagnosis; adolescents; idiopathic AUB; endometrial hyperplasia and polyps; type 0-2 fibroids; type 3 or higher fibroids; and adenomyosis). Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and evidence profiles were compiled. The GRADE® methodology was applied to the literature review and the formulation of recommendations. RESULTS: The experts' synthesis work and the application of the GRADE method resulted in 36 recommendations. Among the formalized recommendations, 19 are strong and 17 weak. No response was found in the literature for 14 questions. We chose to abstain from recommendations rather than providing advice based solely on expert clinical experience. CONCLUSIONS: The 36 recommendations make it possible to specify the diagnostic and therapeutic strategies for various clinical situations practitioners encounter, from the simplest to the most complex.

Vaginal Bleeding Before 20 Weeks Gestation.

Conditions that often present with vaginal bleeding before 20 weeks are common and can cause morbidity and mortality. Clinically stable patients can choose their management options. Clinically unstable patients require urgent procedural management: uterine aspiration, dilation and evacuation, or surgical removal of an ectopic pregnancy. Septic abortion requires prompt procedural management, intravenous antibiotics, and intravenous fluids. Available data on prognosis with expectant management of pre-viable rupture of membranes in the United States are poor for mothers and fetuses.

Presentation trends, characteristics and outcomes for women with early pregnancy bleeding in the emergency department: A 10-year data linkage study.

BACKGROUND: Women present to the emergency department (ED) with pregnancy complications including bleeding. They seek investigations, treatment and clear discharge and referral pathways. AIMS: The aim was to identify trends, characteristics, ED care and discharge pathways for women who present to the ED with early pregnancy bleeding. METHODS: Retrospective data (from 2011 to 2020) were extracted from a regional health district's databank. Data were processed, and deterministic linking was used to produce a final data set. Descriptive statistics were used to identify trends and characteristics. Linear and logistic regression models were used to identify factors that influence health service use, outcomes and discharge pathways. RESULTS: Over the 10 years, there have been almost 15 000 presentations to the ED for early pregnancy bleeding, from approximately 10 000 women, 0.97% of all ED presentations. The frequency of presentations increased by 19.6% over the study period. The average age of women who presented to the ED was 29.1 years, which increased from 28.5 years (2011) to 29.3 (2020). The median length of stay was less than 4 h, and most women were treated and discharged from the ED. One-third of presentations received neither ultrasound nor pathology, but health service costs increased by 330% from 2014 to 2020. CONCLUSIONS: Maternal age is increasing, as is the frequency of ED presentations for early pregnancy bleeding, and both factors increase demands on the ED. Findings from this study may inform strategies to improve current care models and improve quality and safety practices within the ED.

Short-term outcomes of uterine artery embolization for urgent or emergent abnormal uterine bleeding.

PURPOSE: To evaluate the outcomes of uterine artery embolization (UAE) for patients with urgent or emergent abnormal uterine bleeding (AUB). MATERIALS AND METHODS: Retrospective review of all patients from 1/2009-12/2020 who were treated urgently or emergently with UAE for AUB. Urgent and emergent cases were defined as those requiring inpatient admissions. Demographic data were collected for each patient including hospitalizations related to bleeding and length of stay (LOS) for each hospitalization. Hemostatic interventions other than UAE were collected. Hematologic data were collected before and after UAE including hemoglobin, hematocrit, and transfusion products. Data specific to the UAE procedure included complication rates, 30-day readmission, 30-day mortality, embolic agent, site of embolization, radiation dose, and procedure time. RESULTS: 52 patients (median age: 39) underwent 54 urgent or emergent UAE procedures. The most common indications for UAE were malignancy (28.8%), post-partum hemorrhage (21.2%), fibroids (15.4%), vascular anomalies (15.4%), and post-operative bleeding (9.6%). There were no procedure-related complications. Following UAE, 44 patients (84.6%) achieved clinical success and required no additional intervention. Packed red blood cell transfusion decreased from a mean of 5.7 to 1.7 units (p < 0.0001). Fresh frozen plasma transfusion decreased from a mean of 1.8 to 0.48 units (p = 0.012). 50% of patients received a transfusion prior to UAE, while only 15.4% were transfused post-procedure (p = 0.0001). CONCLUSIONS: Emergent or urgent UAE is a safe and effective procedure to control AUB hemorrhage secondary to a variety of etiologies.

Text mining in a literature review of abnormal uterine bleeding according to the FIGO classification.

AIM: Abnormal uterine bleeding, as proposed in 2007, is defined as unexpected uterine bleeding in women of reproductive age; the cause of the bleeding is categorized using the PALM-COEIN system. Identifying the diagnostic and treatment modalities for each cause might be intriguing. To summarize the options for abnormal uterine bleeding assessment, we employed text-mining analysis for each of its causes. METHODS: We analyzed abstracts based on PALM-COEIN from PubMed and Web of Science in March 2022. The literature was divided into categories; topics about the disorders were retrieved, and covalent network analysis was conducted to find information for evaluating abnormal uterine bleeding. RESULTS: Diagnostic approaches for PALM included histological and image analysis, including computerized tomography, magnetic resonance imaging, sonography, and hysteroscopy. The therapeutic approaches varied according to the cause. Diagnostic approaches for COEIN were mostly medical history interviews and blood sampling, and the therapeutic approaches for COEIN were ablation, hysteroscopy, and hormonal treatment. The PALM-COEIN classification co-occurrence search revealed each cause's diagnostic procedures, symptoms, and treatment procedures. CONCLUSION: Our text-mining methodology revealed comprehensive insights, important study themes, and clinical trends for abnormal uterine bleeding. A tailored approach to medical realities is required for treating abnormal uterine bleeding properly.

The Utility of Pelvic Ultrasounds in Adolescents Presenting to the Emergency Department with Abnormal Uterine Bleeding.

STUDY OBJECTIVE: To analyze what factors influence a provider's decision to order a pelvic ultrasound (PUS) in the emergency department (ED) for adolescents with abnormal uterine bleeding (AUB), to determine if endometrial stripe (EMS) measurements are used in treatment decisions, and to evaluate if treatment outcomes differ based on EMS thicknesses. METHODS: Retrospective chart review of patients aged 11-19 presenting to the ED with AUB from 2006 to 2018. Those receiving a PUS were divided into three EMS groups: ≤5 mm, 6-9 mm, and ≥10 mm. Outcomes were evaluated in admitted patients by progress notes indicating resolution of bleeding. Cross-tab, χ2, and logistic and linear regression analysis were performed. RESULTS: Of 258 adolescents meeting study criteria, 113 (43.8%) had a PUS. None had an abnormality. A PUS was more likely to be performed in patients with lower hemoglobin values (P < .003). Provider decision to order a PUS did not differ by age or bleeding duration (P > .1). Among those with a PUS, 67 (59%) received hormonal therapy (pill, progestin-only, IV estrogen). There were no significant differences in treatment choices based on EMS (P < .061) or, among the 44 admitted patients (17%), in the time it took bleeding to stop after initiating treatment (pill: P = .227, progestin-only: P = .211, IV estrogen: P = .229). CONCLUSION: In adolescents with AUB in the ED, performing a PUS was more common in those with low hemoglobin. EMS thickness did not appear to affect treatment decisions or inpatient outcomes. Larger studies are needed to confirm the current findings and determine if PUS is needed in the evaluation of AUB.

A Case of a Refractory Bleeding Giant Vaginal Wall Cavernous Hemangioma Successfully Managed with Sclerotherapy.

BACKGROUND Vaginal wall hemangiomas are extremely rare, benign, vascular tumors of the female genitalia. Most cases occur in childhood, but a few cases can be acquired; however, the mechanism of hemangioma formation remains unknown. Most hemangiomas involving female genital organs are small and asymptomatic. However, huge hemangiomas can cause irregular genital bleeding, infertility, and miscarriage. Surgical excision and embolization are the most common treatment options. We reveal that sclerotherapy achieved good outcomes in a patient with an intractable huge vaginal wall hemangioma. CASE REPORT A 71-year-old woman visited a local doctor with concerns of frequent urination. A ring pessary was inserted after a diagnosis of pelvic organ prolapse. However, symptoms did not improve, and the patient consulted another hospital. The previous physician diagnosed vaginal wall tumors and prolapse and performed a colporrhaphy. However, she was referred to our hospital with heavy intraoperative bleeding. Imaging examination revealed a huge hemangioma on the vaginal wall, which was histologically diagnosed as a cavernous hemangioma. Angiography revealed hemorrhage in the right peripheral vaginal artery. Owing to concerns regarding extensive vaginal wall necrosis caused by arterial embolization, sclerotherapy using monoethanolamine oleate was selected. Hemostasis was achieved 1 month after sclerotherapy, and postoperative imaging showed the lesion had shrunk in size. No recurrence of hemangioma was observed 19 months after surgery. CONCLUSIONS We report a case of a large vaginal wall intractable bleeding hemangioma. Sclerotherapy can be a suitable treatment option for large vaginal hemangiomas that are too extensive to be treated using surgery or arterial embolization.

Successful treatment of radiation-induced vaginal soft tissue radionecrosis with HBO2.

Introduction: Radiation therapy to the pelvis can result in radiation-induced vaginal soft tissue necrosis. This significantly impacts quality of life. Studies evaluating the efficacy of HBO2 are limited. Methods: In this retrospective report, we reviewed the medical records of patients treated with once-daily HBO2 for radiation-induced vaginal soft tissue necrosis. We included females between the ages of 18 to 90 with history of pelvic cancer treated with radiotherapy and resultant soft tissue radionecrosis. Data collected included age, comorbid disease, cancer type, radiation dose, HBO2 treatment pressure, time, and total treatments. Primary outcome was improvement of radionecrosis; secondary outcomes were improvement of pelvic pain, reduction in need for analgesia, and improvement of vaginal bleeding. Results: Seven patients were identified, of which six received HBO2. One patient had a vaginal fistula. Four patients had documented improvement of radionecrosis. Four out of five patients with pelvic pain had resolution of their pain, with two patients no longer requiring opioid analgesia. Two patients who presented with vaginal bleeding showed improvement with one resolved and one significantly decreased requiring no further hospitalization or transfusion. One patient experienced no documented improvement in any of the measured outcomes. Conclusion: In this case series, five out of six (83%) patients treated with HBO2 for radiation-induced vaginal necrosis improved in at least one outcome measure. While the sample size is small, these results add to the data available that supports the use of HBO2 in suitable candidates without contraindications who have symptoms related to radiation-induced vaginal soft tissue necrosis.

Abnormal Uterine Bleeding.

Abnormal uterine bleeding is a common problem in premenopausal women and refers to uterine bleeding that is abnormal in frequency, duration, volume, and/or regularity. Etiologies can be classified using the PALM-COIEN system. Patients should receive a comprehensive history and physical with special attention to menstrual, sexual, and family history. Physical examination needs to include a pelvic examination with speculum and bimanual components. All patients need to have a pregnancy test and CBC with platelets. Treatments vary by etiology. Medical treatments include levonorgestrel intrauterine devices, oral contraceptive pills, and tranexamic acid. Surgical treatment options include endometrial ablation and hysterectomy.

Common Issues in Prenatal Care: First Trimester Bleeding.

Vaginal bleeding in the first trimester is a common concern during pregnancy. The amount of bleeding and associated symptoms, such as nausea and vomiting, can be of prognostic value. Timely evaluation with vital signs, physical examination, laboratory tests (eg, Rh factor, hemoglobin and possibly progesterone levels), and pelvic ultrasound (US) can distinguish among viable pregnancy, nonviable pregnancy, intrauterine pregnancy (IUP) of uncertain viability, and pregnancy of unknown location. Serial pelvic US can be obtained in patients with IUP of uncertain viability after 11 to 14 days, and in pregnancy of unknown location in as little as 48 hours. Quantitative human chorionic gonadotropin (hCG) levels are of minimal clinical utility after IUP is visualized on US. Serial quantitative hCG levels should be measured in patients with pregnancy of unknown location. After an early pregnancy loss has been identified, as long as the patient is hemodynamically stable, options include expectant, medical, and surgical management. The treatment plan can be guided by shared decision-making. Ectopic pregnancy can be managed surgically via laparoscopy, medically with methotrexate, or expectantly (in certain circumstances). Progesterone for patients with early pregnancy bleeding and no history of miscarriage likely is of no benefit.

Diagnosis and medical management of abnormal premenopausal and postmenopausal bleeding.

Abnormal uterine bleeding is a common reason for presentation to health-care providers: it is estimated that one woman in three will present to a care provider with abnormal uterine bleeding (AUB) during the reproductive years, and that at least one woman in 10 will experience postmenopausal bleeding. Although there are some variations in national guidelines for investigation, diagnosis and management of premenopausal AUB, there are far more areas of agreement than disagreement. A comprehensive literature search was undertaken to review national and international guidelines regarding investigation, diagnosis and management of AUB in both premenopausal and postmenopausal women. Areas of controversy are identified, and latest evidence reviewed. Although efforts to reduce hysterectomies for premenopausal AUB through medical management have largely been successful, there are areas where more research is necessary to guide optimal investigation and management. Many countries have well-defined guidelines for investigation and management of premenopausal AUB: there are fewer well-developed guidelines for investigation and management of postmenopausal bleeding. There is a paucity of evidence-based data on management of unscheduled bleeding on menopausal hormone therapy.

About uterine enhanced myometrial vascularity: Doppler ultrasound could reduce misdiagnosed life-threatening vaginal bleeding after pregnancy and guide the management.

Enhanced myometrial vascularity is a rare entity in which an abnormal communication between vessels of the myometrial wall, potentially derived from all pregnancies, increases bleeding risk. Spontaneous regression is possible, but often, it is not foreseeable in which cases it's better to adopt a waiting behaviour and in which others a treatment is required. We reported three cases of enhanced myometrial vascularity: two occurring after vaginal delivery, and the third one after a scar pregnancy. The first case was successfully treated by embolization, the second one was subjected to curettage complicated by uterine perforation; the third one underwent embolization as well, but subsequently required hysterctomy for persistent methrorragia. As we treated these similar cases in three different ways, we decided to perform a mini review of the literature in the aftermath. Considering literature data, we strongly believe that the detection of peak systolic speed by colour-Doppler ultrasound together with a careful evaluation of clinical symptoms, could be a good guide to the best treatment of each patient.

Emergency department visits and emergency-to-inpatient admissions for abnormal uterine bleeding in the USA nationwide.

BACKGROUND: Abnormal uterine bleeding (AUB) is a common but understudied gynaecological problem, and data are lacking on emergency department (ED) visits and associated ED-to-inpatient admissions for AUB. This project aims to further understanding of the burden of AUB on patients and the healthcare system by establishing the number and characteristics of women with AUB in the ED and evaluating predictors of AUB-related inpatient hospitalisation in the USA. METHODS: This is a cross-sectional study of women presenting to the ED with non-malignant AUB in the 2016 US Nationwide Emergency Department Sample (NEDS). Clinical, demographic and hospital system factors were evaluated. χ2 and Mann-Whitney tests were used to compare the proportion of visits with each characteristic, resulting in inpatient admission versus discharge from the ED. Multivariable logistic regression models were used to analyse predictors of AUB in the ED and of AUB-related hospitalisations. RESULTS: There were 1.03 million AUB-related visits in the 2016 NEDS, of which 11.2% resulted in inpatient admission. Clinical as well as demographic and hospital system factors influenced ED disposition. Women with AUB tended to be of reproductive age, be underinsured, live in lower income and urban areas, and present to urban and public hospitals. However, older age, higher income, better insurance, presentation to private hospitals and rural residence predicted inpatient admission. CONCLUSIONS: Our study highlights the ED as an essential place of care for women with AUB while also demonstrating the importance of access to outpatient gynaecology services as some AUB-related ED visits may be preventable with outpatient care. The significant demographic and hospital system differences, as well as expected clinical differences, between women with AUB admitted to inpatient and women discharged from the ED imply structural biases impacting AUB-related ED care and add to the deepening understanding of health disparities.

Interventions to improve access to care for abnormal uterine bleeding: A systematic scoping review.

BACKGROUND: Women with abnormal uterine bleeding (AUB) experience barriers to accessing healthcare services. OBJECTIVES: To identify and describe the evidence on interventions to improve healthcare access of women with AUB. SEARCH STRATEGY: A systematic search of databases including Medline, CINAHL, EMBASE, Scopus, and Cochrane register for clinical trials on February 26, 2021. SELECTION CRITERIA: Studies including women with AUB and investigating an intervention to improve access at the levels of individual patient, community, organization, health system, or medical education. DATA COLLECTION AND ANALYSIS: Data extraction and descriptive analysis of the country, study design, settings, participant characteristics, intervention, outcome measures, and key findings. MAIN RESULTS: We identified 20 studies and most interventions (13 studies) targeted organizational changes. Creating a multidisciplinary team, bringing services together and developing a care pathway improved the availability of services. Management of AUB in an outpatient setting improved the affordability. The use of decision aids improved patient engagement in consultations. There is a lack of interventions at an individual or community level targeting health literacy, health beliefs, social acceptability, and opportunity to reach and pay for services. CONCLUSIONS: Community-based culturally-adapted interventions focusing on access to women with different socio-economic and cultural backgrounds should be investigated.