Heavy menstrual bleeding: a global survey of health care practitioners' perceptions.

OBJECTIVES: This study sought to assess the perceptions of health care practitioners (HCPs) regarding heavy menstrual bleeding (HMB). METHODS: We developed an online survey for HCPs administered in 10 countries (Brazil, Canada, China, France, Germany, Korea, Russia, Spain, UK and USA), in order to assess their perceptions regarding HMB. RESULTS: We received 1032 responses. Most HCPs considered more than 7 days of bleeding abnormal. There was a significant difference in the definition of HMB between countries (p < .001). Most HCPs measured menstrual blood loss by the number of sanitary pads or tampons needed, followed by the impact on patients' daily activities. The majority of HMB patients (61%) were diagnosed as having a non-structural disorder with no causative identifiable coagulopathy. Patient acceptance and compliance were each relevant for the treatment decisions of half of the HCPs. Treatment options for idiopathic HMB featured mainly oral contraceptives and the levonorgestrel-releasing intrauterine system. Surgery was mentioned as a treatment option for idiopathic HMB by 44% of HCPs. CONCLUSION: The definition of HMB and HCP perceptions of HMB regarding diagnostic and therapeutic issues varied between countries. Surgery was mentioned as a treatment for idiopathic HMB by nearly half of HCPs. Clinician education is greatly needed to improve the management of women with HMB.

Five-year follow-up of levonorgestrel-releasing intrauterine system versus thermal balloon ablation for the treatment of heavy menstrual bleeding: a randomized controlled trial.

BACKGROUND: The study was conducted to compare 5-year follow-up of levonorgestrel-releasing intrauterine system (LNG-IUS) or thermal balloon ablation (TBA) for the treatment of heavy menstrual bleeding (HMB). STUDY DESIGN: A prospective, randomized controlled trial comparing LNG-IUS (n=30) and TBA (n=28) was performed. Hysterectomy rates, hemoglobin level, bleeding pattern, well-being status and satisfaction rates were assessed. Comparisons between groups were performed by χ(2) test and by unpaired and paired t tests. RESULTS: After 5 years of follow-up, women treated with a TBA had higher rates of hysterectomy (24%) compared to the LNG-IUS group (3.7%) due to treatment failure (p=.039). Use of LNG-IUS resulted in higher mean hemoglobin (±SD) levels in comparison to the TBA group (14.1±0.3 vs 12.7±0.4 g/dL, p=.009). Menstrual blood loss was significantly higher in the TBA when compared to the LNG-IUS group (45.5% vs 0.0% p<.001). The psychological general well-being index scores were similar. Patient acceptability, perceived clinical improvement and overall satisfaction rates were significantly higher in women using LNG-IUS. CONCLUSION: Five-year follow-up of HMB treatment with LNG-IUS was associated with higher efficacy and satisfaction ratings compared to TBA.

Resources and procedures in the treatment of heavy menstrual bleeding with the levonorgestrel-releasing intrauterine system (LNG-IUS) or hysterectomy in Brazil.

BACKGROUND: Heavy menstrual bleeding (HMB) is the most common complaint of women seeking gynecological care. Treatments included surgical or medical options including hysterectomy and the levonorgestrel-releasing intrauterine system (LNG-IUS) due to the profound suppression of endometrial growth that intrauterine LNG exerts which results in amenorrhea or in a reduction of blood loss. OBJECTIVE: The study was conducted to evaluate the resources and procedures involved in inserting an LNG-IUS compared to performing hysterectomy in women with HMB in a public sector hospital in Brazil. STUDY DESIGN: Two cohorts of women were studied: women who accepted an LNG-IUS (n=124) and matched women who underwent hysterectomy on the same day (n=122). We evaluate the number of procedures carried out in each group of women, including those performed before the decision was made to insert an LNG-IUS or to perform hysterectomy, the insertion of the device itself and the surgical procedure, in addition to the procedures and complications registered up to 1 year after LNG-IUS insertion or hysterectomy. RESULTS: Age and the duration of HMB were significantly lower in the LNG-IUS acceptors than women at the hysterectomy group. The numbers of gynecological consultations and Pap smears were similar in both groups; however, women in the hysterectomy group also underwent laboratory tests, ultrasonography, chest X-ray and electrocardiogram. In the hysterectomy group, the main complications were hemorrhage (six), bladder/bowel perforation (four), complications with anesthesia (one), ureteral reimplantation required (one) and abdominal pain (two). At 1 year, HMB was controlled in 83.1% of women in the LNG-IUS group, and 106 women continued with the device. CONCLUSIONS: Both treatments were effective in HMB control. Fewer resources and complications were observed in LNG-IUS acceptors when compared to hysterectomy. The LNG-IUS represents a good strategy for reducing the number of hysterectomies and the resources required for women with HMB.

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.

A randomized prospective trial comparing the levonorgestrel-releasing intrauterine system with thermal balloon ablation for the treatment of heavy menstrual bleeding.

BACKGROUND: Use of the levonorgestrel-releasing intrauterine system (LNG-IUS) was compared with thermal balloon ablation (TBA) for the treatment of heavy menstrual bleeding (HMB). STUDY DESIGN: A prospective randomized trial comparing the LNG-IUS (n=30 women) and TBA (n=28 women). RESULTS: Hemoglobin levels increased (p<.001) and blood loss was reduced (p<.001) in both groups after 1 year of treatment. Menstrual bleeding was less in the LNG-IUS group compared to the TBA group at 6 and 12 months of treatment (p=.035 and p=.048, respectively). Intermenstrual bleeding was significantly less in the TBA group at 6 months compared to the LNG-IUS group (p=.044); however, there was no significant difference at 12 months (p=.129). No difference was found in psychological aspects between pre- and posttreatment variables in either of the groups (p=.537). CONCLUSIONS: Both the LNG-IUS and TBA appear to be effective in controlling HMB; however, posttreatment uterine bleeding patterns are different.

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.

Menstrual blood loss in women using the frameless FibroPlant LNG-IUS.

BACKGROUND: This study was conducted to report on a menstrual blood loss (MBL) study and iron stores in women with and without heavy menstrual bleeding using the frameless FibroPlant levonorgestrel-releasing intrauterine system (LNG-IUS) for contraception. STUDY DESIGN: An open, prospective, noncomparative MBL study, using FibroPlant releasing 14 mcg of LNG/day for contraception. MBL was assessed by the quantitative alkaline hematin (QAH) technique. RESULTS: The MBL study was conducted in 40 heavy and normally menstruating Brazilian women seeking contraception. MBL was reduced from a mean baseline menstrual volume of 29.7 mL to a mean volume of 1.5 mL after 24 months, while ferritin values increased from a mean value of 31.1 ng/mL (at baseline) to a mean level of 72.5 ng/mL (after 24 months of use). Differences were highly significant (p<.0005). There were no significant differences between those who had normal menstrual bleeding and the heavy bleeders. The heavy bleeders had comparable MBL to the normal bleeders 3 months after insertion, and by 24 months post-insertion, their ferritin levels were comparable to those of the normal bleeders. Amenorrhea occurred in 80% of women out of 40 after 24 months of use. No pregnancies were recorded. CONCLUSION: The LNG-IUS is effective in reducing MBL in normally menstruating women as well as in women with heavy menstrual bleeding. The authors agree with the recommendations by the UK National Institute for Clinical Effectiveness and the new Finnish guidelines for heavy menstrual bleeding that the LNG-IUS should be positioned as first-line treatment prior to endometrial ablation or hysterectomy.

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)

Use of recombinant factor VIIa in the management of severe bleeding episodes in patients with Bernard-Soulier syndrome.

Bernard-Soulier syndrome (BSS) is a rare congenital platelet disorder characterized by defective platelet adhesion and manifested by spontaneous and often profuse bleeding. Recombinant factor VIIa (rFVIIa) is a haemostatic agent licensed for the treatment of bleeding episodes in patients with haemophilia and inhibitors, which may represent a low-risk alternative to existing therapies in the management of patients with BSS. Here, we describe the use of rFVIIa for the treatment of three severe bleeding episodes in two patients with BSS. Data were extracted by automated searching of the international, Internet-based registry http://www.haemostasis.com . Patient 1, a 24-year-old woman, was admitted with severe epistaxis and hypotension. The diagnosis of BSS was confirmed by macrothrombocytopenia, absence of ristocetin-induced platelet agglutination (RIPA) and absence of glycoprotein (GP) Ibalpha and IX on the platelet surface. Epsilon aminocaproic acid (EACA; two 50-mg/kg doses), packed red blood cells (PRBCs, 2 U) and platelets (30 U) failed to control the bleeding and, after 13 h, three bolus doses of rFVIIa (90 microg/kg body weight) and a third dose of EACA were administered; bleeding stopped after the third dose of rFVIIa. Patient 2, a 15-year-old girl, initially presented with severe menorrhagia. A lack of RIPA and severe deficiency of GPIbalpha on the platelet surface confirmed the diagnosis of BSS. EACA and fresh-frozen plasma did not control the haemorrhage, but two bolus doses of rFVIIa (98 microg/kg body weight) resulted in a marked decrease in bleeding. On second admission, patient 2 had severe epistaxis and mild menorrhagia. Two rFVIIa doses (98 and 122.5 microg/kg body weight) were given, and the bleeding stopped. No adverse events were reported in these cases. These three admissions highlight the potential of rFVIIa for the treatment of severe bleeds in patients with BSS.

Uterine artery embolization for the treatment of symptomatic myomas in Brazilian women.

CONTEXT: Uterine myomas are benign tumors that mostly occur in women of reproductive age at a frequency ranging from 20 to 25%. The symptoms are increased menstrual flow, pain and compressive signs. New treatments have been proposed and uterine artery embolization is one of them. OBJECTIVE: To evaluate the effects of treatment by embolization of the uterine artery, in women with symptomatic myomas. Uterine and dominant myoma volumes and the major symptoms were evaluated before treatment and 12 weeks later. TYPE OF STUDY: Open clinical trial. SETTING: A tertiary-care women's hospital. PARTICIPANTS: The study was conducted on 32 women with symptomatic single or multiple myomas of the uterine body, seen at the outpatient unit from May 2000 to September 2001. MAIN MEASUREMENTS: The patients were submitted to gynecological examination and abdominal and endovaginal pelvic ultrasonography, and the examinations were repeated 12 weeks after the first procedure. Uterine artery embolization using PVA (polyvinyl alcohol) particles of 355-700 was performed by catheterization of the right femoral artery in 30 women and by bilateral catheterization in two. RESULTS: Before embolization, the mean uterine volume of the 32 women was 455 cm and the mean volume of the dominant myoma was 150 cm . Twelve weeks after embolization, the mean uterine volume was 256 cm and the mean volume of the dominant myoma was 91 cm , with p < 0.01 in both cases. Twelve weeks after the treatment, all the women answered a questionnaire, which showed that 71% had improvement in menstrual regularity, 90% decreased menstrual volume and 81% shortened menstrual duration. The most frequent immediate post-procedure symptoms, established as complications, were pain (100%) and fatigue (34%). One woman had myoma degeneration and was submitted to myomectomy. CONCLUSION: The significant reduction in uterine and dominant myoma volume confirms the validity of the treatment of symptomatic myomas by the technique of uterine artery embolization in Brazilian women. There was significant reduction in menstrual flow and duration, as well as better cycle regularity in the women studied. The few adverse effects observed in the sample studied mainly involved pain immediately after embolization.

Therapeutic use of levonorgestrel-releasing intrauterine system in women with menorrhagia: a pilot study(1).

The objective of this study was to evaluate the efficacy and performance, for up to 1 year, of an intrauterine system releasing 20 microg/day of levonorgestrel (LNG-IUS, Mirena) in the treatment of women with menorrhagia. It was a descriptive, prospective, non-comparative study. A 20 microg/day LNG-releasing-IUS was inserted on any day during bleeding to 44 women (between 24 and 49 years of age) who presented with menorrhagia after medical therapies had failed. Menstrual patterns were assessed, and hemoglobin concentrations were measured before LNG-IUS was inserted and at 3, 6, 9, and 12 months of use. The most common bleeding pattern at 3 months after insertion was spotting, and after 6, 9, and 12 months the majority of women presented with amenorrhea or oligomenorrhea. Three women requested removal of the LNG-IUS because of spotting, and six women expelled it spontaneously. Hemoglobin levels were improved from 102 g/L to 123 and 128 g/L at 3 and 12 months, respectively, after insertion of the LNG-IUS (p < 0.01). At 12 months 79.5% of participants continued the use of LNG-IUS. In conclusion, LNG-IUS was an effective treatment for three out of four women with menorrhagia and could be an alternative treatment for women with menorrhagia who are either contraindicated for or refuse hysterectomy or endometrial ablation.

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

Transcervical resection of the endometrium (TCRE) using the rollerball resectoscope - abstract

Objective: To assess the efficacy of transcervical resection of the endometrium using the rollerball resectoscope in Jamaican women complaining of menorrhagia. Methods: From January 1st 1994 to December 31st 1994, 16 women underwent TCRE using a 27 fr CIRCON-ACMI uterine resectoscope with a rollerball electrode and 5 per cent dextrose/water as the irrigation medium. All patients had previous diagnostic hysteroscopy with endometrial sampling that demonstrated benign pathology. Details of operative time, fluid absorption and complications were recorded on prepared forms. Menstrual status was enquired at follow-up visits at 1, 3 and 6 months after the procedure. Results: The average operative time was 43 minutes and the average fluid absorption 308 ml. Complications included endometritis in 2 patients and one uterine perforation. Eight patients were amenorrheic at the 1st visit and remained so at 6 months, 2 women reported spotting to 3 months followed by amenorrhea. A further 3 continued to menstruate but with reduced loss. The remaining 3 were not satisfied and 2 chose hysterectomy. Conclusion: TCRE using the rollerball resectoscope can be an alternative therapy for women with menorrhagia, however, complications need to be addressed by proper patient selection, skilled training in operative hysteroscopy and a larger study population followed long term (AU)

[Menometrorrhagia in adolescence]. / Menometrorragia en la adolescencia.

Forty-six patients with the diagnosis of menometrorrhagia, currently under control in the infantile and adolescent unit of Obstetrics and Gynecology Hospital del Salvador. We emphasize that uterine hemorrhage is a frequent emergency during adolescence requiring fully studies. Medical treatment using different hormonal schemes solve the majority of menometrorrhagias. Only a small group require a D & C using the virginal approach. Patients should be controlled during various cycles once bleeding is stopped to avoid relapse and future problems related with anovulation, endometrial hyperplasia or fertility problems.