Management of Abnormal Uterine Bleeding on Anticoagulation: The Patient-Clinician Perspective.

Bleeding is a well-recognized side effect of anticoagulant therapy, which is used to treat venous thromboembolism (VTE) in individuals of all ages, including those of female sex, who commonly experience VTE as a complication of hormonal therapies and/or pregnancy. Heavy menstrual bleeding (HMB) is also extremely common in reproductive aged individuals of female sex. Despite these overlapping situations, relatively little attention has been paid to the impact of anticoagulant-associated HMB on treatment strategies and the patient experience. In this review, we summarize incidence and complications of HMB in anticoagulated individuals as well as management strategies for HMB in this population. We also address the patient experience, including the impact of HMB on quality of life and the impact of discontinuing hormonal therapies at the time of VTE diagnosis and anticoagulant initiation. We conclude by highlighting specific gaps related to the patient experience of anticoagulant-associated HMB in both the research and clinical settings.

Iatrogenic Bladder Injury During Laparoscopic Hysterectomy: A Case Report and Discussion of Anatomic Variations.

Hysterectomy, one of the most common surgical procedures performed in women worldwide, assumes a very important role in the definitive management of diverse gynecologic conditions. This case report presents a compelling instance of an iatrogenic bladder perforation that occurred during laparoscopically assisted vaginal hysterectomy in a 47-year-old woman with a high body mass index, extensive surgical history, and postural orthostatic tachycardia syndrome. Despite considerable preoperative planning and the use of minimally invasive techniques, the occurrence of physician-induced bladder perforation highlights the significance of understanding anatomical relationships and variations. The patient's previous abdominal surgeries including two cesarean sections, appendectomy, and cholecystectomy likely contributed to scar formation and adhesions, making dissection challenging. The case report and following discussion delve into anatomical variations, as well as the diagnosis and management of iatrogenic bladder injuries. The presented case serves as a valuable addition to the literature, contributing insights into the challenges and considerations surrounding urinary tract injuries during hysterectomy. This paper aims to review current research and guide practicing obstetricians and gynecologists in the management of intraoperative bladder injuries.

Prostaglandin Injection for Myoma Expulsion (PRIME): Case series of a novel approach to hysteroscopic resection of FIGO type 2 myomas.

OBJECTIVE: To evaluate the use of dilute carboprost tromethamine injection at the endometrium/myoma junction during hysteroscopy to facilitate myoma expulsion and removal in a single procedure. DESIGN: Case Series. SETTING: Single high-volume academic medical center. PARTICIPANTS: Seven patients aged 32-51 years old with FIGO type 2 uterine myomas and symptoms of abnormal uterine bleeding or infertility undergoing hysteroscopic resection with a morcellation device from November 2022 - July 2023. INTERVENTION: Dilute injection of carboprost tromethamine (10 mcg/mL) at time of hysteroscopic myomectomy. RESULTS: The main outcome measure was ability to complete the hysteroscopic myomectomy in a single procedure using a hysteroscopic morcellator. Secondary outcomes included total operative time, fluid deficit, and post-operative pharmacologic side effects and/or surgical complications. Among our seven patients, all had successful single procedure complete resections of myomas ranging from 0.9-4.6 cm in maximal diameter. Average operative time was 30 minutes, and average fluid deficit was approximately 839 mL. The carboprost dosages used ranged from 30-180 mcg. One patient experienced prolonged post-operative nausea and vomiting that resolved with anti-emetics. One patient experienced post-operative endometritis that improved with antibiotics. CONCLUSIONS: In this pilot study, injection of dilute carboprost intra-operatively facilitated one-step hysteroscopic myomectomy of FIGO 2 myomas, via enhanced extrusion of the intramural portion of the fibroid into the uterine cavity, with both short operative times and acceptable fluid deficits.

Contributing factors related to abnormal uterine bleeding in perimenopausal women: a case-control study.

Abnormal uterine bleeding (AUB) during the menopausal transition results in reproductive endocrine disorders and both physiological and pathological changes, substantially impacting women's health. This study aimed to investigate the factors influencing AUB in perimenopausal women. Between April 2021 and June 2022, 120 perimenopausal women with AUB in the menopausal transition, diagnosed and treated at the Gynaecology Department of Kunming Tongren Hospital, were included in the case group. Concurrently, women undergoing routine health examinations at the same hospital were randomly selected as the control group. Univariate and multivariate logistic regression analyses identified factors related to AUB. The univariate analysis revealed significant associations (P < 0.05) between AUB and several factors, including age, body mass index (BMI), age at menarche, gravidity, and intrauterine device (IUD) placement in perimenopausal women. The multivariate regression analysis indicated that the independent risk factors for AUB include benign endometrial lesions (odds ratio [OR] 5.243, 95% confidence interval [CI] 3.082-9.458, P < 0.001), endometrial thickness ≥ 10 mm (OR 1.573, 95% CI 0.984-3.287, P < 0.001), age ≥ 50 years (OR 2.045, 95% CI 1.035-4.762, P = 0.001), BMI ≥ 25 kg/m2 (OR 2.436, 95% CI 1.43-4.86, P = 0.002), and IUD placement (OR 2.458, 95% CI 1.253-4.406, P < 0.001). Abnormal uterine bleeding during the menopausal transition is associated with several factors, including age, BMI, and IUD placement, highlighting the importance of early screening for these risk factors in the diagnosis and treatment of AUB.

Incidental actinomycosis in a 44-year-old female during total abdominal hysterectomy for abnormal uterine bleeding: A case report.

Actinomycosis, a rare chronic bacterial infection caused by Actinomyces species, presents diagnostic challenges due to diverse clinical presentations. This report presents a case of peritoneal actinomycosis incidentally discovered during a total abdominal hysterectomy in a 44-year-old female with refractory abnormal uterine bleeding and a history of long-term intrauterine contraceptive device use. The patient presented with persistent abnormal uterine bleeding despite conservative management. Intraoperative findings during total abdominal hysterectomy revealed peritoneal involvement, prompting histopathological evaluation confirming actinomycosis. This case highlights diagnostic complexities associated with actinomycosis, emphasizing the significance of histopathological confirmation. Postoperative management with antibiotics demonstrated favorable outcomes, supporting their efficacy in treating actinomycosis. The case underscores the importance of considering uncommon infections in pelvic pathology, particularly in patients with prolonged intrauterine contraceptive device usage. It prompts further exploration of actinomycosis in relation to intrauterine contraceptive device use and highlights the need for timely intervention and histopathological confirmation for optimal patient care.

A Rare Case Report of Dedifferentiated Endometrioid Carcinoma.

Dedifferentiated endometrioid carcinoma (DEC) is an exceptionally rare subtype of endometrial cancer characterized by a high-grade component juxtaposed with a low-grade endometrioid adenocarcinoma. This case report presents a unique instance of dedifferentiated endometrioid carcinoma in a 64-year-old female patient who presented with post-menopausal bleeding and abdominal pain. Diagnostic evaluation including imaging studies and histopathological examination revealed a mixed tumor comprising both high-grade and low-grade components. Management involved a multidisciplinary approach including surgical resection followed by adjuvant chemotherapy and radiation therapy. They are frequently mislabeled as endometrioid carcinomas of International Federation of Gynecology and Obstetrics (FIGO) Grade 2 or Grade 3. It is crucial to correctly differentiate these instances from traditional endometrioid carcinomas. This case underscores the importance of early recognition and comprehensive management strategies tailored to the unique characteristics of dedifferentiated endometrioid carcinoma. We report this case due to its rarity and complexity in diagnosis.

Analysis of clinical data of different endometrial pathological types in perimenopausal women with abnormal uterine bleeding.

Objective: Early detection and diagnosis are important for improving the therapeutic effect and quality of life in patients with endometrial cancer (EC). This study aimed to analyze the clinical data of different endometrial pathological types in perimenopausal women with abnormal uterine bleeding (AUB) in order to provide evidence for the prevention and early diagnosis of EC. Methods: A total of 462 perimenopausal women with AUB were enrolled in this prospective observational study. Endometrial biopsy was performed in patients with suspected endometrial lesions. According to the pathological examination results, the patients were divided into endometrial polyp group (EP) (n = 71), endometrial hyperplasia without atypia group (EH) (n = 59), atypical endometrial hyperplasia (AEH) (n = 36), and EC group (n = 27). The history risk factors and ultrasonic imaging characteristics of endometrium among the four groups were compared. Results: Twenty-seven women were diagnosed with EC (5.84%). The prevalence rate of AEH and EC in the group of 51- to 55-year-old women was significantly higher than that in the groups of 40- to 45-year-old women and of 46- to 50-year-old women (P < 0.05). The age, body mass index, and history of diabetes gradually increased with the development of endometrial pathological types. In addition, the correlation index of endometrial blood flow increased gradually, and the proportion of uneven endometrial echo, unclear endometrial-myometrial junction (EMJ), and ovarian cyst also increased gradually. However, no statistically significant difference was found when comparing endometrial thickness (ET) and endometrial volume (EV) among endometrial pathological groups (P > 0.05). The ET, EV, endometrial vascularization index, endometrial flow index, and vascularization flow index in the ovarian cyst group were significantly higher (P < 0.05), and the proportion of uneven endometrium echo and unclear EMJ were significantly higher compared with that in the non-ovarian cyst group (P < 0.05). Conclusions: The most common cause of perimenopausal women with AUB was benign endometrial lesions. However, women aged 51-55 years old with endometrial high risk factors and ovarian cyst should be alert to AEH and EC. Endometrial biopsy needs to be performed to determine endometrial malignancy in necessity.

Is there a difference in the clinical profile and outcome of women using levonorgestrel IUD for abnormal uterine bleeding and those using it for contraception?: A comparative cross-sectional study.

Objective: The most common indications for Levonorgestrel intrauterine device (LNG-IUD) are contraception and management of abnormal uterine bleeding (AUB). This study was conducted with the aim of exploring the differences in the clinical profile and outcome of women using LNG-IUD for contraception and AUB. Materials and Methods: This was a retrospective comparative cross-sectional study of women who underwent LNG-IUD (52 mg) between 2012 and 2017. Their electronic health records were reviewed until the last documented follow-up or until December 2021. Results: A total of 235 women had LNG-IUD with an age range of 21 to 62 years and a mean of (37.98 years±6.76). Of these women, 153/235 (65.1%) had it for contraception and 82/235 (34.89%) had it for AUB. The follow-up was 1-94 months with (mean ± SEM) follow-up for the AUB group of (21.48±2.31) months and for contraception group was (20.74±1.76) months (p-value of 0.80). There was a significant difference between the two groups in the age and body mass index (BMI), where women who had LNG-IUD for AUB were older (mean of 42.54±6.49 years, p-value <0.001) and had higher BMI (31.88±7.52 kg/m2, p-value =0.011). All LNG-IUDs that were indicated for contraception were inserted in an outpatient setting. However, 68.3% in the AUB, the insertion was in the operating theater in conjunction with hysteroscopy. After combining both expulsion and removal of LNG-IUD during the follow-up period, there was no significant difference between the 2 groups in the overall retention rate during the follow-up (p-value =0.998). Conclusion: this study shows that women using LNG-IUD for the management of AUB are older and have a higher BMI compared with those using it for contraception. AUB women experienced more expulsion compared with the contraception group, but there was no difference between the 2 groups in the overall survival/retention of LNG-IUD.

The role of hysteroscopy with morcellator without anesthesia in the management of abnormal uterine bleeding.

Objective: To evaluate the feasibility of hysteroscopy with morcellator without anesthesia and the diagnostic accuracy of 2D, 3D and power Doppler transvaginal sonography (TVS) in patients with abnormal uterine bleeding (AUB). Material and Methods: This was a retrospective study including women with AUB. All patients underwent 2D, 3D and power Doppler TVS evaluation of the uterine cavity, and patients with suspicion on ultrasound (US) of endometrial pathology (EP) underwent hysteroscopy with morcellator without anesthesia. The painful symptomatology was assessed during the procedure using a visual analogue scale (VAS). Additionally, histological evaluation was performed. Results: A total of 182 women underwent US imaging, of whom 131 (72%) had hysteroscopy. 130/131 patients completed the hysteroscopic examination with good compliance (VAS <4). One patient (0.8%) was unable to complete the procedure due to nulliparity and cervical stenosis. Of the 130 patients the US diagnosis was confirmed in 120 (92.3%), while in 10 patients (7.7%) the hysteroscopic diagnosis was different from the US diagnosis. Histological examination confirmed benign endometrial polyps in 115/130 patients (88.5%), while premalignant conditions were diagnosed in 3/130 patients (2.3%) and malignant conditions in 2/130 (1.5%). Of the 10 patients with endometrial thickening, two were diagnosed with a malignant condition. Conclusion: This study confirmed the feasibility of managing patients with AUB and suspicion of EP using "see-and-treat" hysteroscopy with morcellator without anesthesia. This procedure has the potential to yield desired outcomes while minimizing pain and discomfort, presenting a feasible outpatient approach for both treating and preventing endometrial carcinoma without requiring anesthesia.

Manually driven versus motor driven hysteroscopic tissue removal system for polypectomy: Long-term results.

OBJECTIVE: The aim of this follow-up study is to compare a manually driven hysteroscopic tissue removal system (ResectrTM 9 Fr) with a motor driven system (TruclearTM) in terms of long-term clinical outcomes such as abnormal uterine bleeding and polyp recurrence. STUDY DESIGN: This is a follow-up of a multicenter randomized controlled trial comparing a manually and motor driven hysteroscopic tissue removal system for polypectomy. This prospective cohort study was performed at Ghent University Hospital (Ghent, Belgium) and Catharina Hospital Eindhoven (Eindhoven, the Netherlands). The trial was registered at Clinicaltrials.gov (Trial ID = NCT05337605, April 2022). Seventy-five women with abnormal uterine bleeding who participated in the randomized controlled trial and had pathological confirmation of the diagnosis of an endometrial polyp, were contacted. Fifty-five women (70.67 %) were willing to participate in this follow-up study. The primary outcome was the recurrence and/or persistence of abnormal uterine bleeding and the time to the recurrence of abnormal uterine bleeding. Secondary outcomes were polyp recurrence and time to polyp recurrence, symptom relief, satisfaction score regarding symptom relief and general satisfaction score regarding the surgical procedure. RESULTS: In the manually driven group, the mean time to the recurrence or persistence of abnormal uterine bleeding was 26 months (95 % CI 20 - 32). In the motor driven group, the mean time to the recurrence or persistence of abnormal uterine bleeding was 29 months (95 % CI 23- 34). A log-rank test showed a non-significant difference between both groups (P =.77). There was no significant difference in polyp recurrence (P =.22) or symptom relief between the two groups (P =.67). Additionally, the groups did not differ in satisfaction scores regarding symptoms or polypectomy (P =.16 and P =.61, respectively). CONCLUSION: This long-term follow-up study showed no statistically significant difference in the recurrence and persistence of abnormal uterine bleeding between a manually and motor driven hysteroscopic tissue removal system for polypectomy.

Predictive value of body mass index (BMI) and determination of optimum cut-off point in the diagnosis of endometrial hyperplasia in pre-menopausal women with abnormal uterine bleeding.

Background: The suitable BMI cut-off point in persons with endometrial cancer or hyperplasia with abnormal uterine bleeding was investigated in this study. Methods: This case-control research was conducted on 1470 women with abnormal uterine bleeding in Ayatollah Rouhani Hospital,Babol between 2010 and 2012, with 312 participants included in the study. In terms of uterine biopsy results, patients were split into six groups: simple hyperplasia without atypia, simple hyperplasia with atypia, complicated hyperplasia with atypia, complex hyperplasia without atypia, endometrial cancer, and normal persons. Results: The mean age and BMI of patients in these three groups were not significantly different (P equal to 0.081 and 0.435, respectively). The kind of disease exhibited a strong relationship with menstruation (P 0.001). The body mass index (BMI) values ​​did not have significant levels under the curve to determine the appropriate cut-off point in the diagnosis of hyperplasia plus endometrial cancer and endometrial cancer alone (P 0.380 and 0.124, respectively) and hyperplasia alone (P = 0.920). Based on logistic regression, age 50 years and older and irregular menstruation were significant with OR equal to 2.36 and 2.09 (P = 0.011) and HTN with OR equal to 0.44 (P = 0.026), respectively. Conclusion: BMI has little predictive value in the detection of endometrial cancer or hyperplasia, according to the findings, and other diagnostic and screening modalities should be utilized instead. The findings backed up the theory that old age and irregular menstruation are linked to an increased risk of endometrial cancer.

Clinical analysis of uterine parameters evaluated by preoperative magnetic resonance imaging in patients treated by hysteroscopic approach with previous cesarean scar defect-related abnormal uterine bleeding: a retrospective cohort study.

Background: As the cesarean delivery rate continues to rise globally, the treatment of previous cesarean scar defects (PCSD) remains challenging. This study aimed to analyze the variables that may influence the clinical cure rate of patients with PCSD-related abnormal uterine bleeding (AUB) as determined by preoperative magnetic resonance imaging (MRI) following hysteroscopic therapy. Methods: Women who underwent hysteroscopic surgery for PCSD-related AUB at the Gynecology Department of Third Xiangya Hospital of Central South University from 2018 to 2022 were recruited to this retrospective cohort investigation. A total of 147 patients were enrolled in this study and underwent follow-up over 6 months. The significance of clinical characteristics linked to the clinical cure rate of AUB was examined by logistic regression. Results: There were 64 clinically cured (43.5%) and 83 non-clinically cured (56.5%) patients in the study. There were no significant differences in the age, menstrual duration, gravidity, parity, number of cesarean sections, time since the previous cesarean section, uterus position, width, depth, and thickness of the remaining muscle layer of the defect by MRI T2-weighted images (T2WI) before hysteroscopic surgery between the 2 groups. MRI T2WI of the myometrial thickness adjacent to the defect [P=0.038, odds ratio (OR) =2.095, 95% confidence interval (CI): 1.047-4.261] and the distance from the defect to the external cervical os (P=0.021, OR =2.254, 95% CI: 1.136-4.540) before hysteroscopic surgery are risk factors for the clinical cure rate. Conclusions: The myometrial thickness adjacent to the defect and the distance from the defect to the external cervical os in preoperative MRI are risk factors for clinical cure rate in patients with PCSD-related AUB after hysteroscopic treatment, which is helpful for evaluating the prognosis of disease.

Efficacy of Levonorgestrel Intrauterine System in the Management of Abnormal Uterine Bleeding: A Retrospective Analysis of a 100 Women.

Aim: Abnormal uterine bleeding (AUB) is a common gynaecological complaint affecting around 10-30% women during reproductive years. It adversely affects a woman's life, leading to psychological, medical, social and sexual problems. We aim to study the efficacy of a levonorgestrel intrauterine system (LNG-IUS) in 100 women suffering from AUB. Methodology: A retrospective study was carried out at a private nursing home in Mumbai over a period of 4 years. A total of 100 patients aged 30 years to 50 years (average age = 42.9 years) who underwent LNG-IUS insertion for abnormal uterine bleeding were studied. Cases were evaluated according to clinical findings, hemogram and transvaginal ultrasound. The women were called for follow-up at 1 week, 1 month, 6 months, 1 and 2 years to analyse type and amount of bleeding and development of amenorrhea. Results: At the end of 6 months, 75% patients experienced decreased menstrual blood loss. Five patients underwent removal of the LNG-IUS at the end of 6 months as they experienced no relief of symptoms. At the end of 2 years, 95% patients were fully satisfied with the LNG-IUS insertion. Conclusion: A levonorgestrel intrauterine system significantly reduces bleeding in menorrhagia due to benign causes and is found to be highly effective in the management of various gynaecological pathologies such as endometrial polyps, adenomyosis and endometrial hyperplasia when insertion perfomed after dilatation and curettage/polypectomy. It has proven to be superior to various surgical and other non-surgical treatment modalities.

Enhanced Diagnostic Efficiency of Endometrial Carcinogenesis and Progression in Women with Abnormal Uterine Bleeding through Peripheral Blood Cytokine Testing: A Multicenter Retrospective Cohort Study.

Objective: This study aimed to evaluate the role of plasma cytokine detection in endometrial cancer screening and tumor progression assessment in patients with abnormal uterine bleeding. Methods: In this multicenter retrospective cohort study of 287 patients with abnormal uterine bleeding, comprehensive clinical information and laboratory assessments, including cytokines, routine blood tests, and tumor markers, were performed. Associations between the clinical indicators and endometrial carcinogenesis/progression were evaluated. The independent risk factors for endometrial cancer and endometrial cancer with deep myometrial invasion were analyzed using multivariate binary logistic regression. Additionally, a diagnostic model was used to evaluate the predictive efficacy of these identified risk factors. Results: In patients with abnormal uterine bleeding, low IL-4 and high IL-8 levels were independent risk factors for endometrial cancer (p < 0.05). Combining IL-4, IL-8, CA125, and menopausal status improved the accuracy of assessing endometrial cancer risk. The area under curve of the model is 0.816. High IL-6 and IL-8 levels were independent risk factors for deep myometrial invasion in patients with endometrial cancer (p < 0.05). Similarly, combining IL-6, IL-8, and Monocyte counts enhanced the accuracy of assessing endometrial cancer risk with deep myometrial invasion. The area under curve of the model is 0.753. Conclusions: Cytokines such as IL-4, IL-8, and IL-6 can serve as markers for monitoring endometrial cancer and its progression in women with abnormal uterine bleeding.

Innovative Ultrasound Criteria for the Diagnosis of Adenomyosis and Correlation with Symptoms: A Retrospective Re-Evaluation.

The 2022 Delphi revision of the MUSA (Morphological Uterus Sonographic Assessment) criteria for the ultrasound diagnosis of adenomyosis divides the ultrasound signs for diagnosis into direct and indirect ones, considering the presence of at least one direct sign as a mandatory criterion. This study aimed to reclassify the patients referred to the Pelvic Pain specialist outpatient clinic of the Gynecological Clinic of Udine according to the new criteria, evaluating the number of overdiagnoses and the possible correlation between the direct and indirect signs and the patients' symptoms. 62 patients affected by adenomyosis were retrospectively recruited. The patients were then re-evaluated by ultrasound and clinically. At least one direct sign of adenomyosis was found in 52 patients, while 16% of the population examined did not present any. There was no statistically significant difference between patients presenting direct signs and those presenting none for the symptoms considered. According to the new criteria, 16% of the patients examined were not affected by adenomyosis; applying the new consensus to symptomatic patients could increase false negatives. In a population of symptomatic patients, the diagnosis of adenomyosis is still highly probable even without direct ultrasound signs, given the clinical symptoms and having ruled out other causes of such symptoms.

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.

Colouterine Fistula as a Rare Cause of Postmenopausal Abnormal Uterine Bleeding: A Case Report.

Postmenopausal abnormal uterine bleeding is a common clinical problem addressed in gynaecological practice and should prompt clinical investigation due to the significant prevalence of malignant and premalignant lesions of the endometrium in this age group. Nevertheless, other causes should be considered, since its diagnostic and therapeutic management may differ considerably. Here, we present a case of a colouterine fistula due to chronic diverticulitis presenting with postmenopausal abnormal uterine bleeding. This is an infrequent occurrence and is caused by the rupture of a diverticular abscess into the uterine wall, resulting in an inflammatory adhesion of the colon and uterus, with necrosis and subsequent fistula formation. The clinical presentation is variable and may include abdominal pain, gastrointestinal tract symptoms, vaginal discharge, and abnormal uterine bleeding. The laboratory and imaging techniques may be not completely conclusive and definitive diagnosis can be made intraoperatively. There are different treatment options, with en bloc resection and primary anastomosis being used most often, allowing complete treatment. The prognosis for a colouterine fistula secondary to diverticulitis is excellent after surgery. This case highlights the importance of clinical suspicion of an unusual cause of uterine bleeding and an effective and multidisciplinary approach that allowed complete surgical treatment and patient recovery.

Ultrasound finding of endometrial polyp and factors increasing risk of malignancy.

This article presents a comprehensive review of factors that increase the risk of malignancy in ultrasound findings of an endometrial polyp. We collected original studies, reviews, and meta-analyses that dealt with the topic of endometrial polyps and the risk of developing endometrial cancer. Each presumed risk factor was analysed individually. According to searched studies, abnormal uterine bleeding, old age, and body mass index are valid risk factors for developing endometrial cancer in endometrial polyps. Lynch syndrome patients are also in a high-risk group for endometrial cancer. On the other hand, the number of polyps, their size, diabetes mellitus, hypertension, and positive family history are factors with inconclusive results. There are either not enough data or different results among several studies.

Systematic review and meta-analysis of the etiology of heavy menstrual bleeding in 2,770 adolescent females.

BACKGROUND: Adolescent heavy menstrual bleeding(HMB), menorrhagia or abnormal uterine bleeding commonly occur in adolescent women. The differential diagnosis can be challenging. The pneumonic: PALM-COEIN (polyp, adenomyosis, leiomyoma, malignancy and hyperplasia, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not yet classified), is commonly used but it does not stratify as to the likelihood of a disorder. We have sought to develop a probability-based differential diagnosis for Adolescent HMB, menorrhagia or abnormal uterine bleeding. METHODS: A comprehensive literature search was conducted using PubMed, EMBASE, and SCOPUS databases. Case series describing adolescents from 10-19 years of age with HMB, menorrhagia or abnormal uterine bleeding was acceptable if: more than 10 patients were included; editorials, case reports, and secondary sources such as review articles, or book chapters were excluded. No language filter was used, but an English abstract was required. The etiology of HMB, menorrhagia or abnormal uterine bleeding, and the country of origin was extracted from articles that met inclusion criteria. Cumulative rate estimates were determined by Bayesian probability modeling. RESULTS: Seventeen full text articles were reviewed in detail; 2,770 patients were included. The most frequent causes of HMB were Ovarian Uterine Disorders (23.7%; 95% CredI 22-25.5%), Coagulation Disorders (19.4%; 95% CredI 17.8-21.1%), and Platelet Disorders (6.23%; 95% CredI 5.27-7.27%) with 45.9% (95% CredI 43.8-47.%9) of the cases of indeterminate origin. CONCLUSIONS: The leading causes of HMB in healthy adolescent females were varied. The sub-analysis identified distinct etiologies, suggesting that multiple factors must be considered in the evaluation of HMB. While PALM-COEIN (polyp, adenomyosis, leiomyoma, malignancy and hyperplasia, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not yet classified) provides us with a comprehensive picture of the possible causes of HMB in females, this systematic review assigns probabilities to the etiologies of HMB in adolescent females, providing physicians with a more focused and efficient pathway to diagnosis.

Disseminated Anaplastic Lymphoma Kinase (ALK)-Positive T-cell Lymphoma Involving the Uterus and Cervix: A Case Report.

Primary or secondary non-Hodgkin lymphomas (NHLs) involving the female gynecologic tract are rare. T-cell subtypes are further rare and portend a worse prognosis. We present a case of a 23-year-old female presenting with a cervical mass accompanied by constitutional symptoms and abnormal vaginal bleeding. Immunohistochemistry studies revealed the presence of disseminated T-cell non-Hodgkin lymphoma that was anaplastic lymphoma kinase (ALK)-positive. The patient demonstrated a complete response to systemic chemotherapy initially and again after the relapse of the disease one year after diagnosis. To our knowledge, this is the first case of an ALK-positive T-cell lymphoma with secondary involvement of the uterus and cervix; all previously published cases of this histologic subtype in the gynecologic tract describe primary disease of the vagina. This case emphasizes the importance of immunohistochemistry studies inclusive of T-cell and B-cell markers when evaluating biopsies from cervical tumors to render the appropriate diagnosis and guide systemic therapy.