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.

Effectiveness of high-intensity focused ultrasound combined with gonadotropin-releasing hormone agonist or combined with levonorgestrel-releasing intrauterine system for adenomyosis: A systematic review and meta-analysis.

Gonadotropin-Releasing Hormone Agonist (GnRH-a) and levonorgestrel releasing intrauterine system (LNG-IUS) are conventional conservative treatments for adenomyosis, and high-intensity focused ultrasound (HIFU) is a novel ablation technique. This study aimed to investigate the effectiveness of HIFU combined with GnRH-a or LNG-IUS for adenomyosis patients. In this systematic review and meta-analysis, Pubmed, Embase, Cochrane Library and Scopus databases were searched up to December 2021. Published studies comparing HIFU plus GnRH-a with HIFU plus LNG-IUS in adenomyosis patients were assessed for eligibility by two independent authors. Risk of bias tool was utilized for risk evaluation. We selected treatment effective rate of dysmenorrhea (pain during menstruation) as the primary outcome; effective rate of menorrhagia severity and reduction rate of adenomyotic lesion as the secondary outcomes. Adverse effects were assessed. Four studies with a total 729 patients were enrolled in the meta-analysis. HIFU plus LNG-IUS showed lower dysmenorrhea [within 6 months: risk ratio (RR) 0.88, 95% confidence interval (CI) 0.83-0.93, p < 0.00001; over 1 year: RR 0.73, 95% CI 0.65-0.82, p < 0.00001] and less menorrhagia severity (RR 0.63, 95% CI 0.60-0.66, p < 0.00001) than HIFU plus GnRH-a. Both groups demonstrated equal efficacy in adenomyotic lesion reduction rate (RR 1.03, 95% CI 0.97-1.09, p = 0.30). Adverse effects happened equally in both groups. Combination therapy of HIFU and LNG-IUS revealed better effectiveness in treating dysmenorrhea and menorrhagia than that of HIFU and GnRH-a. However, interpreting the conclusion should be approached with caution as a result of significant heterogeneity.

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.

Efficacy of intrauterine device procedural analgesics.

ABSTRACT: Nearly half of all pregnancies worldwide are unintended. Intrauterine devices are an effective, long-acting form of pregnancy prevention that require minimal maintenance, and also can be used in patients with menorrhagia. However, they are underused because of pain associated with their insertion. Topical and local anesthesia are good options for reducing procedural pain in select patients. IUD placement falls within the scope of practice for physician associates/assistants (PAs) practicing in family medicine, internal medicine, and women's health. PAs should be aware of these additional analgesia options available to patients in order to increase use of effective contraception.

Factors associated with dysmenorrhoea and menorrhagia improvement in patients with adenomyosis after uterine artery embolisation.

BACKGROUND: This study examined the improvement of dysmenorrhoea and menorrhagia after uterine artery embolisation (UAE) in women with symptomatic adenomyosis and identified factors that could predict the improvement of dysmenorrhoea and menorrhagia. METHODS: This retrospective study included women with adenomyosis who underwent bilateral UAE between December 2014 and December 2016. The percentage of the volume of the absence of contrast enhancement on T1-weighted images was evaluated 5-7 days after UAE. A receiver operating characteristic (ROC) analysis was used to determine a cut-off point and predict the improvement of dysmenorrhoea and menorrhagia. RESULTS: Forty-eight patients were included. At 24 and 36 months after UAE, the improvement rates for dysmenorrhoea and menorrhagia were 60.4% (29/48) and 85.7% (30/35), and the recurrence rates were 19.4% (7/36) and 9.1% (3/33), respectively. Only the percentage of the volume of the absence of contrast enhancement on T1-weighted images was associated with the improvement of dysmenorrhoea (p = 0.001, OR = 1.051; 95% CI: 1.02-1.08) and menorrhagia (p = 0.006, OR = 1.077; 95% CI: 1.021-1.136). When the cut-off value of the ROC analysis was 73.1%, sensitivity, specificity, positive predictive value, and negative predictive value for the improvement of dysmenorrhoea were 58.6%, 94.7%, 94.4%, and 60%, while they were 58.9%, 80%, 100%, 100%, and 45.5% for the improvement of dysmenorrhoea. CONCLUSION: Bilateral UAE for symptomatic adenomyosis led to good improvement of dysmenorrhoea and menorrhagia. The percentage of the volume of the absence of contrast enhancement on T1-weighted images of the uterus in postoperative magnetic resonance imaging might be associated with the improvement of dysmenorrhoea and menorrhagia.

This study examined the improvement of dysmenorrhoea and menorrhagia after uterine artery embolisation in women with symptomatic adenomyosis and identified factors that could predict the improvement of dysmenorrhoea and menorrhagia. This retrospective study included women with adenomyosis who underwent uterine artery embolisation. A total of 48 patients were included. Only the percentage of the volume of the absence of contrast enhancement on T1-weighted images was associated with improvement of dysmenorrhoea and menorrhagia. Bilateral uterine artery embolisation for symptomatic adenomyosis led to good improvement. The percentage of the volume of the absence of contrast enhancement on images in postoperative T1-weighted magnetic resonance imaging of the uterus might be associated with the improvement of dysmenorrhoea and menorrhagia.

Heavy Menstrual Bleeding in Adolescents with Joint Hypermobility Syndrome/Hypermobile-Type Ehlers-Danlos: A Review.

Heavy menstrual bleeding has a high prevalence and is well documented in adult patients with hypermobile-type Ehlers-Danlos syndrome, but there is limited research surrounding work-up and treatment for the adolescent population. Excessive menstrual blood loss can significantly interfere with emotional and physical quality of life. A provider should acquire a comprehensive medical and menstrual history and focused physical examination, as well as baseline laboratory studies, to determine the presence of anemia or underlying bleeding disorder. Use of a pictorial blood assessment chart may be considered to help quantify the amount of bleeding. Treatment to reduce heavy menstrual flow and referral to specialty care should be initiated swiftly to improve quality of life for this population. [Pediatr Ann. 2024;53(3):e104-e108.].

Adequate menstrual suppression in adolescents with inherited bleeding disorders often requires multiple treatment changes: Retrospective cohort study of a multidisciplinary clinic.

Heavy menstrual bleeding (HMB) is often the presenting symptom for females with inherited bleeding disorders (IBD). Multidisciplinary clinics leverage the expertise of hematologists and women's health specialists. This study characterizes the complexity of HMB management for adolescents with IBDs from a large multidisciplinary clinic. Adolescents often required multiple different menstrual suppression treatments, with only about 20% achieving acceptable suppression with their first treatment. Adolescents switched therapy most often for uncontrolled bleeding, followed by adverse effects, and patient preference. Given the difficulty in achieving adequate menstrual suppression, multidisciplinary clinics offer necessary expertise in accomplishing bleeding control with minimal adverse effects.

Aspectos éticos del uso del DIU Mirena(R) en el tratamiento de la hemorragia menstrual severa / Ethical aspects of the use of Mirena(R) IUD in the treatment of heavy menstrual bleeding

El dispositivo intrauterino liberador de levonorgestrel conocido como DIU Mirena(R) (20 mcg/24h), se considera hoy uno de los principales recursos en el tratamiento de la hemorragia menstrual severa. No obstante, debido a su efecto de prevención de la concepción y sobre todo a la sospecha de que también pueda poseer un efecto antiimplantatorio, existen fundadas dudas morales tanto en los profesionales como en las pacientes acerca de la licitud ética de su uso terapéutico. Este artículo presenta una revisión exhaustiva de la literatura para tratar de averiguar el mecanismo de acción del DIU Mirena(R), en orden a una valoración ética de su uso terapéutico atendiendo a estos dos efectos no deseados. Según la bibliografía más reciente, la modificación del factor cervical en las pacientes portadoras de DIU Mirena(R) parece impedir de modo consistente la penetración de los espermatozoides a través del cuello del útero, limitando de esta manera las posibilidades de concepción. En consecuencia, la probabilidad de inducir una pérdida embrionaria imputable al dispositivo parece ser prácticamente nula. Dado que no disponemos de alternativas terapéuticas que permitan conservar la fertilidad y tratar esta patología una vez que fracasan los tratamientos de primera línea, el efecto de prevención de la concepción en el uso del DIU Mirena(R), puede ser juzgado éticamente aceptable. No se puede concluir, asimismo, que tengan lugar pérdidas embrionarias atribuibles a su uso, que pudieran agravar su valoración moral

The levonorgestrel-releasing intrauterine device known as Mirena IUD(R) (20 mcg/24h) is nowadays considered among the leading resources in the treatment of heavy menstrual bleeding. Nonetheless, due to either its effect of prevention of conception and especially to the possibility that it may also have an anti-implantation effect, there is a founded concern on whether its therapeutic use may be ethically licit. This article engages in an exhaustive literature review in order to ascertain the mechanism of action of Mirena(R) IUD, in view of an ethical evaluation of its therapeutic use, keeping in mind those two unwanted effects. According to the most recent bibliography, the modification of the cervical mucus in patients carrying Mirena(R) IUD seems to consistently impede the spermatozoa penetration through the cervix, thus keeping down the probability of conception. Therefore, the likelihood of inducing an embryonic loss that can be ascribed to the device seems to be virtually nil. Given that there are no therapeutic alternatives that respect fertility as they address the pathology once the first-line treatments have failed, the prevention of fertilization effect of Mirena(R) IUD may be judged as ethically acceptable. Moreover one cannot conclude that the embryonic loss that might aggravate the moral evaluation of its use actually takes place

Adherence to SEGO recommendations on heavy menstrual bleeding (SMA-UR Study) / Seguimiento de las recomendaciones SEGO sobre el Sangrado Menstrual Abundante (Estudio SMA-UR)

Objective: Heavy menstrual bleeding is one of the most common frequent gynecological disorders in women of reproductive age. It affects quality of life, and in Western countries, is one of the most frequent causes of anemia. The aim of this study was to analyze adherence to the current recommendations of the Spanish Society of Gynecology and Obstetrics on the diagnosis and treatment of heavy menstrual bleeding in patients attending the emergency department. Material and methods: Observational, retrospective, and prospective study performed in routine clinical practice. The study population comprised 98 women diagnosed with heavy menstrual bleeding in the absence of any organic cause attending a gynecological visit scheduled after an emergency department visit due to abnormal menstrual bleeding. Results: Adherence to the Spanish Society of Gynecology and Obstetrics heavy menstrual bleeding recommendations was good for most factors, such as the usual/current bleeding characteristics (80.5% and 86.6%, respectively), gynecological and family history (92.7%), physical examination (92.7%), and diagnostic tests (92.7%), although less favorable for laboratory tests (58.5%) and initiation of treatment and regimen (39.0%). Conclusions: Most of the recommendations in the guidelines were applied, except for laboratory tests, initiation of treatment, and treatment regimen, which were followed to a lesser extent

Objetivo: el sangrado menstrual abundante es una de las alteraciones ginecológicas más frecuentes en las mujeres en edad reproductiva. Afecta a la calidad de vida y es, en los países occidentales, una de las causas más frecuentes de anemia. El objetivo del presente estudio es analizar el seguimiento de las recomendaciones vigentes de la Sociedad Española de Ginecología y Obstetricia en el manejo diagnóstico y terapéutico del sangrado menstrual abundante en pacientes que acuden a urgencias. Material y metodos: estudio observacional, de seguimiento retrospectivo y prospectivo según práctica clínica habitual. Se incluyeron un total de 98 mujeres diagnosticadas de sangrado menstrual abundante sin causa orgánica visitadas en una consulta ginecológica tras haber acudido a urgencias por alteraciones del sangrado. Resultados: se siguieron las recomendaciones de la Sociedad Española de Ginecología y Obstetricia en el manejo del sangrado menstrual abundante de forma mayoritaria para las evaluaciones de las características del sangrado habitual/actual (80,5% y 86,6%, respectivamente), valoración de antecedentes ginecológicos y familiares (92,7%), exploración física (92,7%) y pruebas diagnósticas (92,7%), mientras que se realizó en menor medida en lo relativo a la evaluación de pruebas de laboratorio (58,5%) e instauración de tratamiento y pauta (39,0%) de acuerdo a las guías. Conclusiones: se siguieron las recomendaciones para la mayoría de las evaluaciones, excepto en lo relativo a las pruebas de laboratorio e instauración de tratamiento y pauta de seguimiento de acuerdo a las guías, que se realizaron en menor medida

Revisión: Actualización en el tratamiento del sangrado menstrual abundante / Review: An update on the treatment of heavy menstrual bleeding

El sangrado menstrual abundante (SMA) es un trastorno con un gran impacto en la mujer que conlleva un empeoramiento de su calidad de vida. Los objetivos que persigue su tratamiento incluyen la corrección de la anemia, la disminución de la cantidad de sangrado, la prevención de recurrencias y de las consecuencias a largo plazo de la anovulación, y la mejora de la calidad de vida de la mujer. La elección del tratamiento debe basarse en la decisión de la mujer tras conocer las ventajas y efectos adversos de las diferentes opciones, teniendo en cuenta sus deseos reproductivos y preferencias personales. El tratamiento farmacológico debe considerarse cuando no se hayan identificado anomalías estructurales como causa del SMA. El tratamiento farmacológico no hormonal, es de primera elección en pacientes con SMA con ciclos ovulatorios, con deseos genésicos o con limitaciones al tratamiento hormonal; incluye los aintiinflamatorios no esteroideos y los antibibrinolíticos (especialmente ácido tranexámico). El tratamiento farmacológico hormonal es la opción más adecuada ante alteraciones de la ovulación que causan SMA. En España tienen indicación específica el DIU-LNG, de primera elección en mujeres que no planean un embarazo, y un combinado cuatrifásico con valerato de estradiol y dienogest (VE2-DNG) oral. Los SMA de causa orgánica requieren el abordaje quirúrgico de los procesos patológicos que los provocan. Las opciones terapéuticas que han demostrado eficacia son la ablación endometrial y la resección endometrial (mínimamente invasivas pero no siempre completamente exitosas) y la histerectomía (cirugía mayor). En la presente revisión se analizan todas ellas

Heavy menstrual bleeding (HMB) is a disorder with a major impact on the woman which is associated with a worsening of their quality of life. The objectives pursued with its treatment are correction of anemia, decrease of the amount of bleeding, prevention of recurrence and long-term consequences of anovulation, and improving the quality of life of women. The choice of treatment should be based on the decision of the woman after knowing the benefits and adverse effects of different options, taking into account their reproductive desires and personal preferences. Drug therapy should be considered when structural abnormalities have not been identified as the cause of HMB. Non-hormonal drug treatment is the first choice in patients with HMB with ovulatory cycles, with reproductive desires or limitations to hormone treatment; It includes non-steroidal anti-inflammatories and antifibrinolytics (especially tranexamic acid). The hormonal drug treatment is the best option in HMB caused by ovulation disorders. In Spain, the LNG-IUD has this specific indication, of first choice in women who may become pregnant, and an oral quadriphasic combined with estradiol valerate and dienogest (VE2-DNG). The HMB with organic cause require the surgical approach of the pathological processes that cause them. The treatment options that have proven efficacy are endometrial ablation and endometrial resection (minimally invasive but not always completely successful) and hysterectomy (major surgery). In this paper, we analyze all of them

Degeneration of Leiomyoma in Patients Referred for Uterine Fibroid Embolization: Incidence, Imaging Features and Clinical Characteristics

PURPOSE: Imaging features and clinical characteristics of degenerated leiomyoma in patients referred for uterine fibroid embolization (UFE) were analyzed to assess the incidence of degenerated leiomyoma. MATERIALS AND METHODS: Patients referred for UFE between 2008 and 2009 were retrospectively analyzed (n=276). Patients ranged in age from 27 to 51 years (mean 38.0 years). All patients underwent screening MRI with contrast enhancement. Medical histories and clinical symptoms were evaluated. RESULTS: Among the 276 patients who underwent MRI, 14 (5.1%) showed degenerated leiomyomas. Symptoms were abdominal pain (n=4, 26.7%), menorrhagia (n=5, 35.7%) and bulk-related symptoms (n=5, 35.7%) and no symptoms (n=5, 35.7%). Of the 14 patients with degenerated leiomyomas, 5 (42.9%) had a history of pregnancy in the past two years. For T1-weighted imaging (T1WI), a high signal intensity (SI) of the leiomyoma was the most common finding (n=9, 64.3%) and a hyperintense rim (n=4, 28.6%) was the second most common. On T2-weighted imaging (T2WI), a low SI of the leiomyoma was found in six patients (42.9%), a high SI in four (28.6%) and a heterogeneous SI in four (28.6%) patients. Conservative management was performed in 11 (78.6%) patients, surgery in 3 (21.4%) and uterine artery embolization in one (7.1%) patient. CONCLUSION: The incidence of degeneration of leiomyoma in patients referred for UFE was 5.1%. Patients presented with variable clinical symptoms with or without a history of pregnancy. MR imaging showed a high SI on T1WI and various SIs on T2WI without contrast enhancement. An understanding of the degeneration of leiomyomata is essential when considering UFE.

Utilidad del dispositivo intrauterino con levonorgestrel en la leio­miomatosis uterina asociada a hipermenorrea / Levonorgestrel intrauterine device in uterine leiomyomatosis-related hypermenorrhea

Objetivos: Determinar los beneficios de la inserción del dispositivo intrauterino (DIU) con levonorgestrel en leiomiomatosis uterina asociada a hipermenorrea. Diseño: Estudio descriptivo, retrospectivo. Participantes: Mujeres con leiomiomatosis uterina e hipermenorrea. Intervenciones: A 15 pacientes con leiomiomatosis uterina e hipermenorrea se les insertó DIU-levonorgestrel como una alternativa al manejo quirúrgico usual. Se incluyó pacientes con leiomiomas entre 2 y 5 centímetros de diámetro promedio que no fueran intracavitarios y con un número máximo de 4, con un seguimiento a 12 meses. Principales medidas de resultados: Reducción del tamaño del leiomioma y del volumen menstrual. Resultados: Una paciente expulsó el dispositivo al tercer mes de su inserción. En 8 de las 14 restantes (57,1%) se redujo el tamaño promedio del leiomioma entre 25 y 50% con respecto al tamaño inicial; en 5 de las pacientes (35,7%) el tamaño permaneció igual y en una (7,1%) creció. El volumen menstrual disminuyó de manera estadísticamente significativa en 85,7% (12 de las 14 pacientes) e incluso dos de las de este grupo entraron en amenorrea. Solo una paciente (7,1%) reportó aumento del volumen menstrual. Conclusiones: El grupo de estudio es pequeño, pero puede servir para considerar al DIU-levonorgestrel como una alternativa al manejo quirúrgico de pacientes con leiomiomas asociados a hipermenorrea.

Objectives: To determine benefits of levonorgestrel intrauterine device (IUD) in uterine leiomyomatosis associated with hypermenorrhea. Design: Descriptive, retrospective study. Participants: Women with uterine leyomiomatosis and hypermenorrhea. Interventions: Levonorgestrel IUD was applied to 15 patients with uterine leiomyomatosis and hypermenorrhea as an alternative to usual surgical treatment. Patients with 2 to 5 cm average diameter leiomyomas not localized within the cavity were included, at most 4 in number, and followed for 12 months. Main outcome measures: Reduction of both leiomyoma size and menstrual volume. Results: One patient expelled the IUD at 3 months from insertion. In 8 of the remaining 14 (57,1%) there was reduction of the leiomyoma size between 25 and 50% in relation to the original size; in 5 patients (35,7%) the size remained the same and in one (7,1%) it grew. Menstrual volume decreased statistically significant in 85,7% (12 of the 14 patients) including amenorrhea in two. Only one patient (7,1%) reported increase in menstrual volume. Conclusions: The study group was small but may serve for considering levonorgestrel IUD as an alternative to surgical treatment in patients with leiomyomata associated to hypermenorrhea.

Efectos beneficiosos no anticonceptivos de la píldora anticonceptiva / No disponible

El primer objetivo del uso de un anticonceptivo oral combinado (AOC) es el de evitar un embarazo. En ocasiones el AOC se asocia a efectos secundarios, pero cada día se conocen mejor los efectos beneficiosos no anticonceptivos del mismo. Existe evidencia de una buena calidad que asocia el uso de AOC con la mejoría de la dismenorrea, la disminución del sangrado menstrual y la mejoría del síndrome premenstrual. También se sabe que el uso de AOC protege frente a la enfermedad inflamatoria pélvica (EIP) y el embarazo ectópico, reduce la pérdida mineral ósea y es eficaz en el tratamiento del acné leve y moderado. Además, la AOC disminuye la incidencia de cáncer de ovario y cáncer de endometrio. Conocer estos efectos beneficiosos resulta de interés tanto para los profesionales sanitarios como para las mujeres (AU)

The first objective of using a combined oral contraceptive(COC) is that of avoiding pregnancy. COC is sometimes associated to side effects, but its non-contraceptive beneficial effects are becoming known day by day. There is evidence of the good quality associated to the use of COC with the improvement of dysmenorrhea, decrease of menstrual bleeding and improvement of premenstrual syndrome. It is also known that the use of COC protects against pelvic inflammatory disease (PID), and ectopic pregnancy, reduces bone mineral loss and is effective in the treatment of mild and moderate acne. Furthermore, COC decreases the incidence of ovarian cancer and endometrial cancer. Knowing these beneficial effects is of interest, both for the health care professionals and for women (AU)

Tratamiento de anemia aguda grave por hemorragia vaginal en la testigo de Jehová: a propósito de dos casos / Treating severe acute anemia due to vaginal bleeding in the Jehova’s Witness: a report of 2 cases

Los Testigos de Jehová (TJ) no aceptan la transfusiónsanguínea ni la administración de derivados hemáticosdebido a sus creencias religiosas. En situaciones de anemiaextrema, con riesgo vital para el paciente, si ésterechaza la transfusión puede producirse un grave conflictoético y legal, enfrentándose el principio de autonomíadel paciente, que implica la libertad para rechazaro aceptar un tratamiento médico, y el deber delmédico de salvaguardar la vida del paciente utilizandotodos los medios a su alcance. Presentamos dos casos deanemia grave, uno por menorragia y otro por hemorragiapuerperal, en mujeres TJ. Debemos conocer los tratamientosalternativos a la transfusión de hemoderivados(en nuestras dos pacientes fueron eficaces), y sabercómo actuar ante una situación crítica inesperada eneste tipo de pacientes. En la menorragia, el tratamientohormonal es efectivo cuando la mujer quiere preservarla fertilidad y evitar la cirugía (ablación endometrial ehisterectomía); en la hemorragia postparto refractariaal tratamiento conservador, la embolización selectiva delos vasos sangrantes puede evitar la necesidad de actitudesterapéuticas más agresivas como la histerectomíaobstétrica(AU)

For reasons of religious belief, Jehova’s Witnesses donot accept blood transfusions or the infusion of bloodproducts. In situations in which severe, life-threateninganemia develops, patient refusal to receive a transfusioncan create serious ethical and legal problems. Theprinciple of patient autonomy, which implies the freedomto accept or reject treatment, comes into conflict with thephysician’s obligation to safeguard the patient’s life usingall means possible. We report 2 cases of severe anemia inJehova’s Witnesses. One was due to menorrhagia and theother to postpartum bleeding. The physician should beaware of alternatives to infusion of blood products andknow how to cope with an unexpected critical event inthese patients. The measures we took were effective in ourpatients. In the case of menorrhagia, hormone treatmentis effective when the woman wishes to preserve the abilityto conceive and avoid surgery (endometrial ablation andhysterectomy). In postpartum bleeding refractory toconservative treatment, selective embolization of bleedingvessels may make it unnecessary to resort to moreaggressive treatment, such as obstetric hysterectomy(AU)

Sangramento uterino anormal / Abnormal uterine bleeding

O sangramento uterino anormal é um distúrbio frequente que pode ocorrer em qualquer idade entre a menarca e a menopausa, mas concentra-se principalmente em seus extremos, logo após a menarca e no período perimenopausa, quando ocorrem alterações no eixo hipotálamo-hipófise-ovário, que levam com muita frequência à anovulação. O sangramento uterino disfuncional, considerado diagnóstico de exclusão, pode ser ovulatório ou anovulatório. O manejo do quadro pressupõe que o sangramento agudo seja coibido e que se evite a recidiva; para tanto, é fundamental que se estabeleça o diagnóstico etiológico. Os autores fazem uma revisão objetiva sobre o assunto, dando ênfase ao diagnóstico e tratamento da doença.

Abnormal uterine bleeding is a clinical problem wich may occur at any time during the reproductive years; however, it is most prevalent during perimenarche and perimenopause, when women tend to have anovularoty cycles. Disfunctional uterine bleeding is a prevalent disease that affects women from adolescence to menopause. The treatment should control the acute bleeding and avoid the recidive. The etiological diagnosis is fundamental for this purpose. The authors make an objective review about dysfunctional uterine bleeding herein, focusing on the diagnosis and treatment of the disease.

Heavy menstrual bleeding: assessment and management - update information

This guideline covers assessing and managing heavy menstrual bleeding (menorrhagia). It aims to help healthcare professionals investigate the cause of heavy periods that are affecting a woman's quality of life and to offer the right treatments, taking into account the woman's priorities and preferences. This guideline includes updated recommendations on: investigations for the cause of heavy menstrual bleeding; and management of heavy menstrual bleeding. It also includes recommendations on: history, physical examination and tests; and information for women.

Estudio aleatorizado del dispositivo liberador de levonorgestrel frente a resección endometrial para el tratamiento de la menorragia / Levonorgestrel intrauterine system versus endometrial resection for the treatment of menorrhagia: a randomized study

Objetivo: Tratamiento de la menorragia mediante resección endometrial y dispositivo liberador de levonorgestrel (LNG-IUS). Material y métodos: Estudio aleatorizado; en 25 pacientes se realiza una resección endometrial y en 25 se coloca un LNG-IUS, con un seguimiento a 12 meses. Las variables estudiadas fueron la concentración de hemoglobina, el patrón de sangrado menstrual y el grado de satisfacción. Resultados: En ambos grupos se incrementó la hemoglobina y el patrón de sangrado más frecuente fue el de amenorrea o hipomenorrea. El spotting fue el síntoma adverso más común para el LNG-IUS. El grado de satisfacción fue del 94% en el grupo de resección y el 86% en el de LNG-IUS. Conclusiones: Ambos tratamientos son efectivos para reducir el sangrado menstrual

Objective: To asses the efficacy of endometrial resection and the levonorgestrel intrauterine system (LNG-IUS) in the treatment of menorrhagia. Material and methods: Fifty women were randomized to either insertion of a LNG-IUS or endometrial resection. Hemoglobin levels, menstrual bleeding patterns and degree of satisfaction were evaluated during a 12-month follow-up. Results: Hemoglobin levels increased in both groups. The most frequent bleeding patterns were amenorrhea and hypomenorrhea. The most common adverse effect in the LNG-IUS group was the presence of spotting. Ninety-four percent of the patients in the resection group and 86% of those in the LNG-IUS group were satisfied with the treatment. Conclusions: Both treatments were effective in reducing menstrual blood loss

Histerectomía laparoscópica. Revisión de 71 casos. Descripción de la técnica. Análisis de resultados y complicaciones / Laparoscopic hysterectomy: Revision of 71 cases. Description o the technique, analysis of results and complications

El objetivo de este trabajo es analizar los primeros 71 casos de Histerectomía Laparoscópica (HTL) y Anexohisterectomía Laparoscópica (AHTL) realizados en el Servicio de Ginecología de Clínica G³emes de Luján (AU)

Fisiopatologia, diagnóstico e tratamento da menorragia na adolescência / Menorrhagia in adolescence: phisiopathology, diagnosis and treatment

A menorragia é um problema ginecológico comum em adolescentes. Os dois primeiros anos pós-menarca geralmente säo anovulatórios e a maioria dos casos de sangramento excessiva resulta da imaturidade do eixo hipotálamo-hipófise-ovário. Entretanto, o diagnóstico diferencial deve incluir coagulopatias, tireoidopatias e Síndrome de Ovários Policísticos, entre outros. A fisiopatologia do sangramento excessivo ainda näo está bem definida mas acredita-se que alteraçöes hemostáticas e hormonais estejam envolvidas. Para o diagnóstico da etiologia da menorragia, a história menstrual e a idade ginecológica (tempo decorrido desde a menarca) säo fundamentais. Um hemograma e uma ecografia transvaginal podem auxiliar bastante. O tratamento pode variar desde a tranqüilizaçäo e acompanhamento da adolescente, até a terapia medicamentosa agressiva. O tratamento cirúrgico é incomum