Cesarean scar niche: An evolving concern in clinical practice.

Increasing cesarean section rates have led to an increased awareness of associated complications such as the formation of cesarean scar niche, defined as an indentation at the site of the cesarean scar with a depth of at least 2 mm, diagnosed by ultrasound or magnetic resonance imaging. The precise prevalence of cesarean scar niche is unclear. The cause of a cesarean scar niche appears to be multifactorial and likely a combination of technical factors (low incision location), anatomical factors (uterine retroflexion), and patient factors, which might impair healing (body mass index, smoking, maternal age). Most patients with cesarean scar niche are asymptomatic; however, women can present with postmenstrual bleeding, pelvic pain, and subfertility. In pregnancy, cesarean scar niches have been associated with placenta accreta spectrum disorder and uterine rupture. Treatment should be reserved for symptomatic women. Hormonal treatment using either the combined oral contraceptive pill or a progesterone-containing intrauterine device may address irregular vaginal bleeding. Surgical management should be reserved for those in whom hormonal manipulation has failed or is contraindicated. The aim of this review was to summarize current literature pertaining to the cause, prevalence, diagnosis, and symptoms of cesarean scar niche and to make recommendations for managing this relatively new condition.

The pathogenesis of abnormal uterine bleeding in myopathic uteri.

It has been suggested that impaired venous drainage and endometrial vascular ectasia (EMVE), secondary to increased intramural pressure, explains abnormal bleeding in fibroid uteri. Striking EMVE with extravasated red blood cells (ecchymosis) has also been seen in uteri with grossly obvious myometrial hyperplasia (MMH), suggesting that increased intramural pressure can cause EMVE in the absence of fibroids. EMVE with MMH may explain the century old association of clinically enlarged uteri with abnormal bleeding, and this same mechanism may be operative in myopathic uteri with grossly obvious adenomyosis. EMVE with associated thrombosis, ecchymosis, and/or stromal breakdown is commonly seen in random sections of hysterectomies for bleeding. EMVE may also be associated with endothelial hyperplasia, consistent with a reaction to endothelial injury due to impaired venous drainage. This further supports the theory that EMVE bleeds when thrombosis occurs, due to Virchow's Triad (stasis, endothelial injury, and hypercoagulability). EMVE may be "the lesion for which surgery was performed" in hysterectomies with otherwise unexplained bleeding.

Lesions of anogenital mammary-like glands: Four cases including novel pathologic and immunohistochemical observations.

Anogenital mammary-like glands, formerly described as ectopic breast tissue, are currently considered to be normal histologic components of the anogenital region. Anogenital mammary-like glands can give rise to many lesions identical to counterparts in the native female breast. We describe four cases of such lesions, including fibroadenoma, gynecomastia-like hyperplasia, and ectopic mammary-type tissue with a spectrum of usual ductal hyperplasia, apocrine metaplasia, adenosis, and pseudolactational change. All four cases occurred in young women (ages 29-38) who presented with vulvar or perianal masses. Similar to previously reported cases, these lesions shared histologic and immunohistochemical characteristics identical to native female breast lesions. Novel findings in our cases included (1) the first case of gynecomastia-like change to be reported in the perianal area of a female, (2) Immunohistochemical staining identifying a 3-layered epithelium characterized by a population of CK14 and CK5/6 positive and hormone receptor negative superficial luminal cells, and (3) diffuse, strong positivity for GATA3 in all cases. Our study adds to the literature on these rare lesions and highlights findings which may be useful in understanding the pathogenesis and improving the diagnosis of anogenital mammary-like gland lesions.

Risk assessment of endometrial cancer and endometrial intraepithelial neoplasia in women with abnormal bleeding and implications for clinical management algorithms.

BACKGROUND: Most endometrial cancer cases are preceded by abnormal uterine bleeding, offering a potential opportunity for early detection and cure of endometrial cancer. Although clinical guidelines exist for diagnostic workup of abnormal uterine bleeding, consensus is lacking regarding optimal management for women with abnormal bleeding to diagnose endometrial cancer. OBJECTIVE: We report the baseline data from a prospective clinical cohort study of women referred for endometrial evaluation at the Mayo Clinic, designed to evaluate risk stratification in women at increased risk for endometrial cancer. Here, we introduce a risk-based approach to evaluate diagnostic tests and clinical management algorithms in a population of women with abnormal bleeding undergoing endometrial evaluation at the Mayo Clinic. STUDY DESIGN: A total of 1163 women aged ≥45 years were enrolled from February 2013 to May 2019. We evaluated baseline absolute risks and 95% confidence intervals of endometrial cancer and endometrial intraepithelial neoplasia according to clinical algorithms for diagnostic workup of women with postmenopausal bleeding (assessment of initial vs recurrent bleeding episode and endometrial thickness measured through transvaginal ultrasound). We also evaluated risks among women with postmenopausal bleeding according to baseline age (<60 vs 60+ years) as an alternative example. For this approach, biopsy would be conducted for all women aged 60+ years and those aged <60 years with an endometrial thickness of >4 mm. We assessed the clinical efficiency of each strategy by estimating the percentage of women who would be referred for endometrial biopsy, the percentage of cases detected and missed, and the ratio of biopsies per case detected. RESULTS: Among the 593 women with postmenopausal bleeding, 18 (3.0%) had endometrial intraepithelial neoplasia, and 47 (7.9%) had endometrial cancer, and among the 570 premenopausal women with abnormal bleeding, 8 (1.4%) had endometrial intraepithelial neoplasia, and 7 (1.2%) had endometrial cancer. Maximum risk was noted in women aged 60+ years (17.7%; 13.0%-22.3%), followed by those with recurrent bleeding (14.7%; 11.0%-18.3%). Among women with an initial bleeding episode for whom transvaginal ultrasound was recommended, endometrial thickness did not provide meaningful risk stratification: risks of endometrial cancer and endometrial intraepithelial neoplasia were nearly identical in women with an endometrial thickness of >4 mm (5.8%; 1.3%-10.3%) and ≤4 mm (3.6%; 0.9%-8.6%). In contrast, among those aged <60 years with an endometrial thickness of >4 mm, the risk of endometrial cancer and endometrial intraepithelial neoplasia was 8.4% (4.3%-12.5%), and in those with an endometrial thickness of ≤4 mm, the risk was 0% (0.0%-3.0%; P=.01). The most efficient strategy was to perform biopsy in all women aged 60+ years and among those aged <60 years with an endometrial thickness of >4 mm, with the lowest percentage referred to biopsy while still detecting all cases. CONCLUSION: Existing clinical recommendations for endometrial cancer detection in women with abnormal bleeding are not consistent with the underlying risk. Endometrial cancer risk factors such as age can provide important risk stratification compared with the assessment of recurrent bleeding. Future research will include a formal assessment of clinical and epidemiologic risk prediction models in our study population as well as validation of our findings in other populations.

Clinical Success Rate of Extensive Hysteroscopic Cesarean Scar Defect Excision and Correlation to Histologic Findings.

STUDY OBJECTIVE: Cesarean scar defect (CSD) is often associated with postmenstrual bleeding, infertility, and pain. Hysteroscopic CSD repair was described in the past, mainly as excision of the proximal edge of the defect to allow continuous blood flow during menstruation. In this study we aimed to evaluate the efficacy of extensive hysteroscopic cesarean scar niche excision in symptomatic patients. DESIGN: A retrospective cohort study. PATIENTS: Symptomatic patients treated with hysteroscopic CSD excision who were considered eligible for the procedure when myometrial thickness of 2 mm or more was observed on sonohysterography. SETTING: Tertiary referral center. INTERVENTIONS: Extensive CSD excision was performed using a cutting loop and pure cutting current. The proximal and distal edges of the defect were resected. This was followed by resection of tissue at the base of the niche, until underling muscular tissue was evident. Tissue sampled from the base of the CSD was collected for histologic examination. Patients were followed for a minimum of 1 year after hysteroscopic CSD excision. Clinical information obtained included detailed obstetric history and preoperative and postoperative menstruation pattern. MEASUREMENTS AND MAIN RESULTS: Between 2011 and 2016, 95 patients underwent extensive hysteroscopic niche excision; 67 were included in the study, whereas the remaining were lost to follow-up. Patient mean age at the time of the procedure was 38 ± 5.5 years. Twenty-nine patients (43%) had a history of high-order repeat cesarean surgeries. Sixty-six patients (98.5%) presented with postmenstrual bleeding, 26 with secondary infertility (38.8%), and 2 with pelvic pain (2.9%). After hysteroscopic niche excision, 63.4% of patients reported significant improvement or resolution of postmenstrual bleeding. A statistically significant reduction in number of bleeding days per cycle (15.5 ± 4.8 vs 9.8 ± 4.7, p < .001) was also noted. Histologic evidence for myometrial tissue within the obtained samples was associated with better outcomes. A histologic specimen from patients who experienced significant improvement or resolution of postmenstrual bleeding was more likely to reveal myometrial tissue (p = .04). Of the 26 patients who suffered from infertility, 19 attempted to conceive spontaneously after CSD excision. Of those, 10 patients (52.6%) conceived and 9 delivered at least once (47.36%). CONCLUSION: Extensive hysteroscopic surgical excision of cesarean scar niche should be considered in symptomatic patients suffering from irregular menstrual bleeding. The quality of the excision at the apex of the niche could be associated with a higher success rate. The role of niche excision to overcome secondary infertility should be further evaluated.

Déficit de factor XI. A propósito de un caso / Acquired factor XI deficiency. A case reports

La deficiencia de factor XI es un trastorno hereditario de la coagulación en el que existe una reducción cuantitativa o cualitativa del factor XI debido a mutaciones en el gen F11. Es una entidad común entre los asquenazíes, que puede ser subestimada en los caucásicos. Puede debutar a cualquier edad con clínica variable e impredecible, existiendo escasa relación entre los niveles de actividad del factor XI y los síntomas hemorrágicos. Su diagnóstico se basa en la realización de un estudio de coagulación básico (alargamiento del tiempo parcial de tromboplastina activado [TTPA]) y la medición de los niveles del factor XI. Presentamos un caso con el objetivo de difundir esta entidad entre la comunidad pediátrica

Factor XI deficiency is a hereditary coagulation disorder with a quantitative and/or qualitative reduction of factor XI due to F11 gene mutations. This is a common entity in Ashkenazi community, which can be underestimated in Caucasians. It can debut at any age with variable and unpredictable symptoms, showing poor relation between factor XI activity levels and bleeding symptoms. It can be diagnosed after a basic coagulation exam (lengthening activated partial thromboplastin time [APTT]) and factor XI levels measure. We present a factor XI deficiency clinical case for spreading this entity to the pediatric community

Metrorrhagia iuvenilis and Premenstrual Syndrome as frequent problems of adolescent gynecology with aspects of diet therapy.

Painful menstruation, premenstrual syndrome and metrorrhagia iuvenilis are one of the most common problems related to the sexual cycle in adolescent girls. Metrorrhagia iuvenilis is acyclic bleeding that occurs in adolescents and lasts from over 10 days even up to 3 months. These bleeds are very abundant and have a tendency to relapse. They cause anemia, and severe cases can be life-threatening. Premenstrual Syndrome (PMS) is a cluster of somatic, emotional and behavioural symptoms occurring in the luteal phase of the menstrual cycle. The aetiology of PMS remains unknown. According to strict diagnostic criteria, an estimated 2.5-5% of girls and women are affected by PMS. However, some researchers maintain that the symptoms of PMS may be prevalent in as many as 40-80% of girls and women. This article it has been discussed premenstrual syndrome and metrorrhagia iuvenilis and aspects related to dietotherapy were included.

Isthmocele: an overview of diagnosis and treatment.

An isthmocele, a cesarean scar defect or uterine niche, is any indentation representing myometrial discontinuity or a triangular anechoic defect in the anterior uterine wall, with the base communicating to the uterine cavity, at the site of a previous cesarean section scar. It can be classified as a small or large defect, depending on the wall thickness of the myometrial deficiency. Although usually asymptomatic, its primary symptom is abnormal or postmenstrual bleeding, and chronic pelvic pain may also occur. Infertility, placenta accrete or praevia, scar dehiscence, uterine rupture, and cesarean scar ectopic pregnancy may also appear as complications of this condition. The risk factors of isthmocele proven to date include retroflexed uterus and multiple cesarean sections. Nevertheless, factors such as a lower position of cesarean section, incomplete closure of the hysterotomy, early adhesions of the uterine wall and a genetic predisposition may also contribute to the development of a niche. As there are no definitive criteria for diagnosing an isthmocele, several imaging methods can be used to assess the integrity of the uterine wall and thus diagnose an isthmocele. However, transvaginal ultrasound and saline infusion sonohysterography emerge as specific, sensitive and cost-effective methods to diagnose isthmocele. The treatment includes clinical or surgical management, depending on the size of the defect, the presence of symptoms, the presence of secondary infertility and plans of childbearing. Surgical management includes minimally invasive approaches with sparing techniques such as hysteroscopic, laparoscopic or transvaginal procedures according to the defect size.

Isthmocele: an overview of diagnosis and treatment

SUMMARY An isthmocele, a cesarean scar defect or uterine niche, is any indentation representing myometrial discontinuity or a triangular anechoic defect in the anterior uterine wall, with the base communicating to the uterine cavity, at the site of a previous cesarean section scar. It can be classified as a small or large defect, depending on the wall thickness of the myometrial deficiency. Although usually asymptomatic, its primary symptom is abnormal or postmenstrual bleeding, and chronic pelvic pain may also occur. Infertility, placenta accrete or praevia, scar dehiscence, uterine rupture, and cesarean scar ectopic pregnancy may also appear as complications of this condition. The risk factors of isthmocele proven to date include retroflexed uterus and multiple cesarean sections. Nevertheless, factors such as a lower position of cesarean section, incomplete closure of the hysterotomy, early adhesions of the uterine wall and a genetic predisposition may also contribute to the development of a niche. As there are no definitive criteria for diagnosing an isthmocele, several imaging methods can be used to assess the integrity of the uterine wall and thus diagnose an isthmocele. However, transvaginal ultrasound and saline infusion sonohysterography emerge as specific, sensitive and cost-effective methods to diagnose isthmocele. The treatment includes clinical or surgical management, depending on the size of the defect, the presence of symptoms, the presence of secondary infertility and plans of childbearing. Surgical management includes minimally invasive approaches with sparing techniques such as hysteroscopic, laparoscopic or transvaginal procedures according to the defect size.

RESUMO A istmocele ou nicho uterino é representada por uma descontinuidade miometrial ou um defeito anecoico triangular na parede uterina anterior, com a base se comunicando com a cavidade uterina no local de uma cicatriz anterior de cesárea. O defeito pode ser classificado como pequeno ou grande, dependendo da espessura da parede miometrial deficiente. Embora geralmente assintomático, seu principal sintoma é o sangramento uterino anormal ou pós-menstrual; a dor pélvica crônica também pode ocorrer. Infertilidade, placenta acreta ou prévia, deiscência de cicatriz, ruptura uterina e gravidez ectópica em cicatriz de cesárea prévia também podem aparecer como complicações dessa condição. Os fatores de risco para desenvolvimento da istmocele comprovados até o momento incluem útero retroverso e múltiplas cesarianas. No entanto, fatores como localização mais inferior de uma cesárea prévia, fechamento incompleto da histerotomia, aderências precoces na parede uterina e predisposição genética também podem contribuir para o desenvolvimento de um nicho. Como não existem critérios definitivos para o diagnóstico de uma istmocele, vários métodos de imagem podem ser usados para avaliar a integridade da parede uterina e, assim, diagnosticar uma istmocele. Entretanto, ultrassonografia transvaginal e sono-histerografia com infusão salina surgem como métodos específicos, sensíveis e custo-efetivos para o diagnóstico de istmocele. O tratamento inclui manejo clínico ou cirúrgico, dependendo do tamanho do defeito, da presença de sintomas, da presença de infertilidade secundária e de planos de gravidez. O manejo cirúrgico inclui abordagens minimamente invasivas como histeroscopia, laparoscopia ou transvaginal, de acordo com o tamanho do defeito.

A case of functioning gonadotroph adenoma in a reproductive aged woman.

A 34-year-old woman presented our hospital with complaint of irregular menstruation and abnormal uterine bleeding lasting for a month. After her second parturition at the age of 27, her menstrual cycle had been regular, but it suddenly became irregular at the age of 30. Transvaginal ultrasound revealed the presence of ovarian mass, and the patient underwent diagnostic laparoscopic surgery. Bilateral ovaries temporally shrink after puncture but the size soon resumed. Gonadotropins were almost normal, but estradiol and PRL levels turned out to be elevated, and cabergoline treatment was initiated. After referral to our hospital, we found that the ovaries showed multifollicular appearance. Brain magnetic resonance imaging showed an 18-mm macroadenoma in the suprasellar area. To suppress the secretion of endogenous gonadotropins and estrogen, low-dose estrogen-progestin was prescribed. Surprisingly, the treatment temporarily reduced the size of the ovaries. The patient was referred to a neurosurgeon, and a functioning gonadotroph adenoma was suspected. After the resection of the pituitary tumor, her menstrual cycle became regular, and the size of bilateral ovaries became normal. We also noticed that her ovarian reserve judged by anti-Müllerian hormone had been almost diminished after the surgical treatment, probably reflecting the exhaustion of follicular pool. Women with multifollicular ovaries and elevated estradiol levels may have functioning gonadotroph adenomas, although the level of FSH is relatively normal, and ovarian reserve can be followed by measuring anti-Müllerian hormone.

Gynaecological and obstetrical bleeding in Caucasian women with congenital factor XI deficiency: Results from a twenty-year, retrospective, observational study.

INTRODUCTION: Factor XI (FXI) deficiency is a mild bleeding disorder, common among Ashkenazis, that may be underestimated in Caucasians. Management of FXI deficiency in women is a challenge, due to its unpredictable bleeding tendency and the little evidence available on this issue. OBJECTIVE: To describe gynaecological/obstetrical bleeding complications and to analyze the effectiveness and safety of the antihaemorrhagic treatment among women with FXI deficiency. MATERIAL AND METHODS: A retrospective, observational study of 214 Caucasian subjects with FXI deficiency collected during 20 years (1994-2014) without clinical selection. RESULTS: We identified 95 women with FXI deficiency. Any haemorrhagic event was communicated by 26/95 (27.4%), being abnormal uterine bleeding the most frequently found (12/95, 12.6%). Nine postpartum haemorrhages were recorded from 136 deliveries (6.6%) in 57 women. Four postsurgical bleeding complications were registered among 25 gynaecological surgeries (16%) in 20 women. Abnormal uterine bleeding, postpartum and postsurgical haemorrhages were related to both a positive bleeding history and FXI:C values ≤43.5%. Prophylaxis with fresh frozen plasma, used in 12/25 (48%) gynaecological surgeries, did not prevent from postoperative bleeding in three cases, but two developed severe adverse reactions. CONCLUSION: Women with FXI deficiency, especially those with a positive history of bleeding or FXI:C ≤43.5%, are at risk of developing gynaecological/obstetrical haemorrhages, most of them mild/moderate. Systematic prophylaxis has questionable effectiveness, but might cause severe side effects.

Biomarkers in abnormal uterine bleeding†.

Abnormal uterine bleeding (AUB) is an extremely common problem and represents a clinical area of unmet need. It has clinical implications and a high cost for the healthcare system. The PALM-COEIN acronym proposed by FIGO may be used as a foundation of care; it improves the understanding of the causes of AUB, and in doing so facilitates effective history taking, examination, investigations, and management. Heavy menstrual bleeding, a subset of AUB, is a subjective diagnosis and should be managed in the context of improving the woman's quality of life. Available evidence suggests that there is poor satisfaction with standard treatment options often resulting in women opting for major surgery such as hysterectomy. Such women would benefit from a tailored approach, both for diagnosis and treatment, highlighting the deficiency of biomarkers in this area. This article focuses on the causes of AUB as per the PALM-COEIN acronym, the researched biomarkers in this area, and the potential pathogenetic mechanisms. In the future, these approaches may improve our understanding of AUB, thereby enabling us to direct women to most suitable current treatments and tailor investigative and treatment strategies to ensure best outcomes, in keeping with the principles of personalized or precision medicine.

Iatrogenic metrorrhagia after the use of itraconazole for onychomycosis.

We present first case report on itraconazole, a drug very commonly used for onychomycosis, used along with simvastatin that caused metrorrhagia. The suggested probable mechanism is the inhibition of steroidogenesis, especially estrogens that resulted in low-estrogen breakthrough bleeding. This article emphasizes the importance of drug interaction check prior the initiation of onychomycosis treatment.

[Gynecological emergencies: A prospective study about patients purpose of consultation and outcome]. / Urgences gynécologiques : étude prospective sur les motifs de consultation et devenir des patientes.

OBJECTIVES: Aiming to evaluate the profile type, complaint and outcome of patients consulting a gynecologic emergency unit in order to enhance "real" emergencies and improve their management. MATERIALS AND METHODS: We enrolled prospectively 308 women consulting to Reims teaching hospital gynecologic emergency unit from the 15th of May to the 25th of June 2013. RESULTS: Two hundred and fifty-seven women (83.4%) spontaneously consulted without previous medical examination. Two hundred and thirty-eight of them (77.3%) had already been through gynecologic emergency units and 99 (32.1%) had no regular follow-up. Pelvic pain and/or metrorragia were registered as main complaint for 219 patients (71.1%). Median age was thirty years old (±11) and an average forty-minute wait was recorded. Gynecologic ultrasound was the first exam to be performed after clinical examination for 255 patients (82.8%). Twenty-two (7.1%) were hospitalized for surgical procedures or medical care, respectively 10 (3.2%) and 12 (3.9%). Among 51 women addressed by another healthcare professional, 9 were hospitalized (17.6%) versus 12 hospitalized (4.7%) out of 257, when consulting without initial professional expertise. A significant relationship between hospitalizations and general practitioner consultation was found with an OR=4.34 (95%CI: 1.51-12.05, P=0.002). Main motive of consultation involving home treatment turned out to be on-going pregnancies (92 patients, 29.9%). CONCLUSION: A large majority of gynecologic hospital consultations, responsible for time waste and professional monopolizing, can be treated by general practitioners and could contribute to a better management of life-threatening emergencies.

Prospective evaluation of the impact of intermenstrual bleeding on natural fertility.

OBJECTIVE: To evaluate the impact of an episode of intermenstrual bleeding on the probability of conception in a menstrual cycle (fecundability). DESIGN: Prospective, time-to-pregnancy cohort study. SETTING: Community-based cohort. PATIENT(S): Women trying to conceive, ages 30 to 44 years, without known infertility. INTERVENTION(S): Not applicable. MAIN OUTCOME MEASURE(S): Current cycle and subsequent cycle fecundability. RESULT(S): A total of 549 women provided 1,552 complete cycles for analysis. Intermenstrual and luteal bleeding were reported in 36% and 34% of cycles, respectively. Ninety-three percent of all intermenstrual bleeding was luteal. Cycles in which women had intermenstrual bleeding or luteal bleeding were statistically significantly less likely to result in conception (fecundability ratio [FR] 0.23; 95% confidence interval [CI], 0.16-0.34; and FR 0.22; 95% CI, 0.14-0.33). Women with an episode of intermenstrual and luteal bleeding had a statistically significant increase in the probability of pregnancy in the subsequent cycle (FR 1.61; 95% CI, 1.15-2.25; and FR 2.01; 95% CI, 1.52-2.87, respectively). CONCLUSION(S): Intermenstrual bleeding statistically significantly decreases the odds of conceiving in that cycle but does not appear to negatively impact a woman's immediate future reproductive potential. CLINICAL TRIAL REGISTRATION NUMBER: NCT01028365.

[Correlation Study on Syndrome Types of Chinese Medicine in Dysfunctional Uterine Bleeding Patients and Serum Sex Hormones].

Objective To observe the correlation between serum sex hormone levels and different syndrome types of Chinese medicine (CM) in dysfunctional uterine bleeding (DUB) patients. Methods Totally 532 DUB patients were classified into 10 different syndrome types according to syndrome typing theories of CM, including Gan-depression transforming heat syndrome, Shen deficiency blood sta- sis syndrome, Shen-yin deficiency syndrome, Pi-Shen deficiency syndrome, qi and yin deficiency syndrome, qi and blood deficiency syndrome, Pi deficiency syndrome, qi stagnation blood stasis syndrome, damp-heat syndrome, yin deficiency blood heat syndrome. Besides, 6 serum levels of sex hormone were measured including follicular stimulating hormone (FSH) , luteinizing hormone (LH) , estradiol (E2) , progesterone (P) , testerone (T) , and prolactin (PRL) in patients with different syndrome types. Correlation study between syndrome types and sex hormones were performed using Logistic regression analysis. Results The distributions of DUB in CM were sequenced from high to low as uterine bleeding, menostaxis, preceded menstrual cycle, intermenstrual bleeding, and menorrhagia. The distributions of syndrome types were sequenced from high to low as yin deficiency blood heat syndrome, qi and blood deficiency syndrome, qi stagnation blood stasis syndrome, Shen-yin deficiency syndrome, Pi-Shen deficiency syndrome, Gan-depression transforming heat syndrome, Pi deficiency syndrome, Shen deficiency blood stasis syndrome, qi and yin deficiency syndrome, damp-heat syndrome. PRL level was positively correlated with Gan-depression transforming heat syndrome in the ratio of 1. 117 (P <0. 05). FSH level was positively correlated with Shen-yin deficiency syndrome in the ratio of 1. 327 (P <0. 05). LH level was positively correlated with Pi-Shen deficiency syndrome in the ratio of 1.342 (P <0.05). Conclusions DUB patients with various syndrome types of CM had different levels of sex hormones, with certain-laws manifested. Positive correlation existed between PRL level and Gan-depression transforming heat syn- drome, FSH level and Shen-yin deficiency syndrome, LH level and Pi-Shen deficiency syndrome.

Sangramento uterino anormal: proposta de abordagem do Grupo Heavy Menstrual Bleeding: Evidence-Based Learning for Best Practice (HELP) / Heavy menstrual bleeding: management proposal of the Heavy Menstrual Bleeding: Evidence-Based Learning for Best Practice Group (HELP)

O Sangramento Uterino Anormal (SUA) representa um problema de saúde pública complexo que pode acometer 1/3 das mulheres em todo o mundo. Apresenta um impacto negativo importante na qualidade de vida de mulheres e associa-se a elevados custos econômicos diretos e indiretos. Trata-se de uma condição desafiadora tanto para as mulheres afetadas quanto para os profissionais de saúde. A nomenclatura atribuída ao SUA é confusa e faltam ainda recomendações diagnósticas e terapêuticas padronizadas. Foi criado o grupo Heavy Menstrual Bleeding: Evidence-based Learning for Best Practice (HELP) com proposta abordar os aspectos inconclusivos do SUA. Foram avaliados 134 documentos, incluindo 121 artigos científicos e 14 revisões de medicamentos, para desenvolvimento dos protocolos HELP. Foram elaborados protocolos simplificados referentes ao diagnóstico e tratamento do SUA, visando contribuir de forma mais eficaz com os médicos em seus diferentes cenários de atuação. O roteiro diagnóstico sugerido, compreendendo perguntas chaves e ações específicas, sinaliza para indicação de métodos propedêuticos adicionais. O tratamento proposto visa reduzir a perda do sangue menstrual e melhorar de a qualidade de vida das pacientes.(AU)

Abnormal uterine bleeding (AUB) is a complex public health problem that can affect one third of women worldwide. It has a significant negative impact on quality of life of women and is associated with high direct and indirect economic costs. It is a challenging condition for both the women affected and for the health professionals. The nomenclature assigned to the AUB is confusing and still miss diagnostic and therapeutic recommendations standardized. The Heavy Menstrual Bleeding: Evidence-based Learning for Best Practice Group (HELP) was created with the proposal to address the inconclusive aspects of AUB. The group evaluated 134 documents, including 121 scientific articles and 14 reviews of drugs for the development of protocols HELP. Simplified protocols were drawn up relating to the diagnosis and treatment of AUB, to contribute more effectively with doctors at different scenarios of operation. The script diagnostic suggested, comprising keys questions and specific actions, can indicate additional diagnostic methods. The proposed treatment aims to reduce the loss of menstrual blood and improve the quality of life of patients.(AU)

A national survey of gynecologists on current practice patterns for management of abnormal uterine bleeding in South Korea.

OBJECTIVE: To evaluate practice patterns of gynecologists in the management of abnormal uterine bleeding (AUB) in South Korea. METHODS: Between February 24 and March 12, 2014, a cross-sectional survey was performed through face-to-face interviews with 100 gynecologists selected through quota sampling reflecting regions and hospital types. Through the use of a questionnaire, the level of awareness and practice patterns regarding diagnosis and management of AUB were evaluated. RESULTS: Among 100 respondents, 60 reported that they had not previously heard of the International Federation of Gynecology and Obstetrics (FIGO) classification system. The standardization of AUB terminology was reported to be necessary or very necessary by 70 respondents. Pelvic ultrasonography would be used for diagnosis by 99 physicians. The most common first-line AUB treatment was combined oral contraceptives: 55 respondents would use them for heavy menstrual bleeding, 56 for intermenstrual bleeding, and 56 for polycystic ovary syndrome. Combined oral contraceptives were the preferred follow-up medication: 30 would use them for heavy menstrual bleeding, 24 for intermenstrual bleeding, and 52 for polycystic ovary syndrome. CONCLUSION: Despite implementation of the FIGO AUB classification system and guidelines, awareness and use among gynecologists in South Korea remains low.

Transvaginal ultrasonography and hysteroscopy as predictors of endometrial polyps in postmenopause.

The study compared ultrasound and ambulatorial hysteroscopy as diagnostic methods detecting endometrial polyps in postmenopause women. 281 women aged 41-82 years who underwent ambulatorial hysteroscopy were analyzed for presence of uterine bleeding and/or altered transvaginal ultrasound (endometrial thickness ≥5 mm). Ultrasonography detected endometrial polyps in 22.8% of patients and endometrial thickening in the other 59.8%. Hysteroscopy diagnosed endometrial polyps in 80.8%. Ultrasonography showed sensitivity of 88.7%, specificity of 25.4%, positive predictive value of 81.7%, negative predictive value of 37.5% and accuracy of 75.4% in diagnosing endometrial polyps. Hysteroscopy showed 96.4% sensitivity, 74.6% specificity, 93.4% positive predictive value, 84.6% negative predictive value and 91.8% accuracy. Hysteroscopy demonstrated more accuracy than ultrasonography, which is not sufficient for accurate diagnosis.