Bleeding Patterns Research Articles

Tales from the clinic: Contraception and perimenopause.

Effective contraception consultations are essential to delivering high-quality perimenopause care and reducing unplanned pregnancies. Contraception can be used independently, or in conjunction with hormone replacement therapy (HRT). Newer contraception options provide enhanced opportunities to individualise perimenopause care. This paper provides case based contraception options, which reduce unplanned pregnancies, erratic perimenopausal bleeding patterns and estrogen deficiency symptoms. Clinicians must also be aware of the potential impact of vaginal preparations which may affect condom integrity. Formulary updates should enable a wide range of options for contraception choices in all settings and provider updates should include this vital topic.

Retraction: Puerperal and Menstrual Bleeding Patterns With Different Types of Contraceptive Device Fitted During Elective Cesarean Delivery

AbstractM. S. E. Elsedeek, “Puerperal and Menstrual Bleeding Patterns With Different Types of Contraceptive Device Fitted During Elective Cesarean Delivery,” International Journal of Gynecology & Obstetric 116, no. 1 (2012): 31–34, https://doi.org/10.1016/j.ijgo.2011.07.036.The above article, published online on 27 October 2011 in Wiley Online Library (wileyonlinelibrary.com), has been retracted by agreement between the journal Editor‐in‐Chief, Michael Geary; the International Federation of Gynecology and Obstetrics; and John Wiley & Sons Ltd. The retraction has been agreed following an investigation based on concerns raised by a third party. The editors found that the ANOVA results from Tables 1 and 2 could not be reproduced and the P‐values do not correspond to the summary data. Furthermore, several statistical results are internally inconsistent, reporting a number of F statistics which do not match the P‐values. The author was invited to comment on the concerns and provide supporting data but did not respond. Given the extent of the identified issues, the editors have lost confidence in the data presented.

Breast and endometrial safety of micronised progesterone versus norethisterone acetate in menopausal hormone therapy (PROBES): study protocol of a double-blind randomised controlled trial

IntroductionData suggest that micronised progesterone (mP) in menopausal hormone therapy is safer for the breast than synthetic progestins, while protection of the endometrium appears to be less effective. However, comparative...

Discontinuation of long-acting reversible contraception: a retrospective Dutch study in general practice

Background In the Netherlands, the use of long-acting reversible contraception (LARC) methods increases. Studies show high premature discontinuation rates of LARCs, but comprehensive insights into the Dutch situation remain limited. Aim The aim of this study is to determine (1) the rate and reasons of discontinuation of different types of LARC in the first 2.5 years of use and (2) what patient characteristics are associated with premature discontinuation. Design and setting Retrospective cohort study utilising data from a Dutch primary care research network. Methods We included all women who received a LARC between 2017 and 2019 with a 2.5-year follow-up period. We performed a descriptive analysis, Kaplan Meier and logistic regression analysis to answer the research questions. Results We included 642 women. In total, 166 women (25.9%) discontinued their LARC within 2.5 years. Discontinuation rates were 22% for levonorgestrel intra-uterine systems (LNG-IUS) 52 mg, 25% for LNG-IUS 19.5 mg, 39% for copper IUDs and 47% for subdermal implants. Common reasons for discontinuation were: alterations in bleeding pattern (68%), abdominal pain (32%), headache or mood fluctuation (24%) and a preference for natural contraceptive methods (23%). Factors associated with discontinuation for reasons other than pregnancy wish were: age between 30 and 34 years old (OR 5.1, 95% CI [1.26–20.48]) and a history of sexual, physical and/or psychological abuse (OR 3.16, 95% CI [1.60–6.23]). A high educational level (OR 0.33, 95% CI [0.12–0.89]) was associated with a lower risk of discontinuation. Conclusion The discontinuation rates of LARCs are high. Better counselling might prevent premature discontinuation.

Efficacy and uterine bleeding patterns in initiating goserelin therapy during different menstrual phases in patients with adenomyosis: a prospective cohortstudy.

We carried out this study to explore the possibility of initiating goserelin therapy during the non-menstrual period in patients diagnosed with adenomyosis. 115 premenopausal adenomyosis patients were enrolled and divided into three groups based on their menstrual cycle phase during the initial outpatient visit: menstrual, follicular, and luteal. Each received a 3.6 mg subcutaneous dose of goserelin monthly for three months. The endpoints encompassed alterations in uterine volume, dysmenorrhea Numerical Rating Scale (NRS) score, CA125 level, hemoglobin (HGB) after a 12-week treatment course, and the occurrence and duration of uterine hemorrhage during the first treatment cycle. Analysis revealed that the timing of goserelin therapy initiation in the menstrual cycle did not significantly impact its effectiveness in reducing uterine size, alleviating pain, lowering CA125 levels, or improving hemoglobin concentrations. However, patients starting treatment during the luteal phase experienced increased uterine bleeding (reference: menstrual period, OR = 4.33, 95% CI 1.23-15.25, p = .023). The results suggested non-inferiority of goserelin therapy initiated during the non-menstrual period, but the uterine bleeding rate was higher in the luteal phase group. Therefore, goserelin treatment for outpatient adenomyosis patients should not be limited to starting during the menstrual period; it can also be initiated outside the menstrual period, providing more convenience for patients as most consultations occur outside the menstrual period. However, the use of goserelin during the luteal phase should be avoided to reduce the risk of exacerbated bleeding, especially in anemic patients with heavy menstrual bleeding. This study highlights the importance of individualizing treatment initiation based on the patient's health profile to optimize therapeutic outcomes and minimize adverse effects. ChiCTR2200059548.

Traumatic Middle Meningeal Artery Aneurysm: A Rare Cause of Recurrent Acute Epidural Hematoma. A Case Report

AbstractTraumatic middle meningeal artery aneurysm (TMMA) is a rare condition and a known cause of several different bleeding patterns after head injury. Once detected, they need to be treated as an emergency due to their potential for morbidity and mortality. Generally, recurrence does not occur in surgery for acute epidural hematoma if adequate hemostasis is achieved. Here, we report a case of atypical postoperative recurrence of an acute epidural hematoma, possibly due to the development and rupture of a TMMA. A 41-year-old man with left acute epidural hematoma after a head injury was referred to our hospital. Emergency craniotomy was performed immediately, and the hematoma was removed. The source of the bleeding was near the fracture site in the middle cranial fossa, and sufficient hemostasis was confirmed. However, a head computed tomography (CT) scan the next day revealed a recurrence of the acute epidural hematoma. Magnetic resonance (MR) angiogram showed an aneurysm with a diameter of approximately 4 mm in the left middle meningeal artery. The recurrence of the acute epidural hematoma appeared to be related to the formation and a rupture of a middle meningeal artery aneurysm, and to prevent subsequent rebleeding, the patient underwent reoperation, and the hematoma and aneurysm were removed. In surgery for acute epidural hematoma, recurrence can be prevented by removing the hematoma and ensuring hemostasis. Although conventional surgery was performed in this case, a repeat of epidural hematoma occurred. A postoperative middle meningeal artery aneurysm had been thought to have developed, ruptured, and caused a repeat epidural hematoma.In treating acute epidural hematoma, a TMMA development should be considered when an atypical clinical course occurs, such as a recurrence of postoperative bleeding.

Impact of Etonogestrel-releasing contraceptive implant use in cisgender women with Sickle cell disease

BackgroundSickle cell disease is a hereditary hemolytic anemia that exposes women to increased health risks especially in pregnancy, with serious implications for the woman and fetus. Acute pain episodes can occur multiple times per month and result in reduction of quality of life and disruption of her life. ObjectiveTo assess the clinical, including pain and metabolic parameters of women with sickle cell disease using etonogestrel-releasing contraceptive implants. MethodsWomen with sickle cell disease, aged 18–40 years, with reports of pain crises in the preceding 3 months were included and followed up for 12 months. Blood samples were collected to evaluate the blood count, reticulocytes, liver profile (alkaline phosphatase, gamma-glutamyl transferase, alanine aminotransferase, aspartate aminotransferase, and total bilirubin and its fractions), lipid profile, and lactate dehydrogenase levels before and 6 and 12 months after implant insertion. The following clinical variables were analyzed every 3 months: bleeding pattern, blood pressure, weight, body mass index, pain intensity (assessed using a visual analogic scale (VAS) from 0 to 10), and frequency of pain crises. ResultsTwenty-three women completed the study. There were no differences in laboratory variables between baseline and 6 and 12 months after implant insertion. Similarly, clinical variables did not differ, except for pain intensity (VAS pre-insertion = 8 vs. VAS 12 months post insertion = 4; p = 0.005) and frequency of pain crises (pre-insertion = 6 vs. 12 days/month post insertion = 0; p = 0.000). ConclusionsEtonogestrel-releasing contraceptive implants were associated with a reduction in the intensity and frequency of pain crises in women with sickle cell disease. Moreover, it was safety among these population due to no changes in laboratory parameters during the first 12 months of use.

Follow-Up Imaging in Angiography-Negative Spontaneous Subarachnoid Hemorrhage

BackgroundThe aim of this study was to assess the diagnostic yield of follow-up investigations in aneurysm negative SAH patients. Material and MethodsIn 109 (25%) of 435 patients with SAH and initial negative DSA, the diagnostic yield of repeat DSA and MRI of the brain and craniocervical junction was reviewed. ResultsOf the 109 patients with an initial negative DSA, 51 (47%) had perimesencephalic (PM), 54 (50%) had non-perimesencephalic (NPM) blood distribution, and 4 (3.7%) had CT-negative SAH. A delayed bleeding source was determined in 3 of 82 (3.7%) patients who underwent repeat DSA, and in 1/5 patients who underwent a third DSA. The bleeding patterns of these patients were all NPM (n=4). Repeat DSA did not identify a bleeding source in patients with PM-SAH. MRI of the brain and craniocervical junction after 2 days revealed a bleeding source in 1/105 patients (1%) in a CT-negative SAH. When all diagnostic modalities, including exploratory craniotomy and MRI of the spinal axis were considered, the rate of delayed diagnosis of the bleeding source was 6.4% (7/109). In addition to the bleeding pattern, patients with delayed diagnosis of the bleeding source were characterized by worse disease severity parameters, worse radiological grading scales, and more in-hospital complications than patients without delayed diagnosis of a bleeding source. ConclusionThe results of this study support the use of repeat DSA in patients with NPM-SAH, however, routine repeat DSA may not be indicated in PM-SAH patients. The routine use of MRI remains controversial.

Evaluation of the effectiveness of road safety measures and their impact on the pattern and distribution of extracranial and intracranial hemorrhages in fatal head injury cases in Uttar Pradesh, India

Introduction: In Uttar Pradesh, India, there are many fatal head injuries as a result of road traffic accidents (RTAs). Studying the pattern and distribution of intracranial hemorrhages, a frequent complication of severe head trauma might provide vital information on the efficacy of traffic safety regulations. To improve road safety tactics and lower fatal head injuries in Uttar Pradesh, this study intends to assess the effect of road safety measures on the frequency and distribution of intracranial hemorrhages in fatal head injury patients. Aim: This study’s objective is to assess the influence of current road safety initiatives on intracranial bleeding distribution and patterns in fatal head injury cases in Uttar Pradesh. Methodology: The 604 RTA cases with head injuries that were brought to the mortuary of the S.R.N. Hospital in Prayagraj for a medical-legal postmortem assessment over the course of a year, from April 2021 to March 2022, make up the entirety of this prospective study. Following receiving institutional ethical approval and informed consent, structured interviews with attendees utilizing a questionnaire were done to gather the data. Result: The results show that certain traffic safety measures have reduced the frequency of fatal head injuries in RTAs. A decreased incidence of intracranial hemorrhages was linked to improved traffic infrastructure, including well-planned junctions, pedestrian crossings, and distinct bicycle lanes. Similar results were shown in serious head injuries when traffic restrictions including speed limits, seat belt use, and helmet legislation were strictly enforced. Conclusion: There are still issues with fatal brain injuries from car accidents, despite some encouraging results. Safety legislation violations, a lack of public knowledge, and inadequate enforcement all contribute to the issue. Disadvantaged groups like walkers and users on two-wheelers continue to be especially susceptible. The results of this investigation offer important new understandings of the efficiency of traffic safety measures and their influence on the distribution and pattern of cerebral hemorrhages in Uttar Pradesh, India. The results point to the necessity of improved public education efforts and traffic safety laws. More research and focused interventions are required to address specific risk factors among various road user groups. This will result in a safer driving environment and a decline in catastrophic brain injuries.

Efficacy of Homoeopathy in the Management of Dysfunctional Uterine Bleeding: A Review

Background: Dysfunctional uterine bleeding (DUB) is a prevalent condition affecting women during their reproductive years. It is characterized by irregular or abnormal menstrual bleeding patterns and can significantly impact a woman's quality of life. Studies suggest it affects around 1 in 5 women during their reproductive years. Homoepathic approach can prove to be efficient in successfully treating and managing cases of DUB. Aims and Objectives: This study was aimed to critically evaluate the existing evidence on the efficacy of homoeopathy in treating DUB. Specific outcome parameters, therapeutic approach, criteria for assessment and treatment outcomes were noted and compared having variable impact in cases of DUB. Methods: A comprehensive literature search was conducted through databases like PubMed and Google Scholar. Search criteria was focused on targeting analysis from randomized controlled trials (RCTs), clinical studies, observational studies and case reports. Results: 6 articles having an in depth relation to action of homeopathy on DUB were identified. It included one(01) randomized controlled trial, one(01) experimental study, one(01) prospective and observational study, one(01) prospective clinical study and two(02) case reports. All studies were obtained from peer-reviewed journals. Conclusion: This study aimed at contributing valuable insights into the current state of knowledge regarding homoeopathy's role in managing DUB and exploring the need for enhanced value based research in the field of homoeopathy.

The direct effect of SARS-CoV-2 virus vaccination on human ovarian granulosa cells explains menstrual irregularities

Following administration of the SARS-CoV-2 vaccine, many women worldwide reported short-term menstrual irregularities. Although menstrual bleeding, “the fifth vital sign”, is experienced by more than 300 million people on any given day worldwide, these changes were only partially studied. Irregular periods are important well beyond fertility and the discomfort they impose; they are associated with the risk of cardiovascular morbidity, chronic diseases, and premature mortality. Pre-clinical examination of the vaccine polymeric envelope indicates its accumulation in the ovaries. The somatic endocrine cells of the ovarian follicle - the granulosa cells (GCs)—participate in the strict hypothalamic-pituitary-ovarian (HPO) feedback loop that governs the menstrual cycle via endocrine and paracrine regulators, as AMH and Inhibins. We aimed to unravel the direct effect of the COVID-19 vaccine on GCs and link their post-vaccine activity to changes in menstrual patterns. Human primary GCs exposed in-vitro to the Pfizer COVID-19 vaccine BNT162b2, demonstrated no change in their viability but altered mRNA transcripts, specifically of the regulatory key factors: InhibinB was upregulated, whereas AMH was downregulated. We further examined pre- and post-vaccination blood samples from individual women and found a 2–3 folds change in the post-vaccination FSH/InhibinB protein level ratio, compared to their pre-vaccination values. This altered expression of InhibinB could significantly impact the HPO axis in vaccinated women and may ultimately influence the endometrium cyclicity, manifested clinically by the commonly reported changes in menstrual bleeding patterns.

Clinical outcomes of post-placental insertion of Copper T380A and Multiload 375 contraceptive devices during cesarean section: a randomized clinical trial

BackgroundTo compare two types of intrauterine devices, namely Cu T380A IUD and Multiload 375 IUD, inserted immediately post-placental during cesarean section, with regard to expulsion rates and side effects.MethodsA randomized comparative clinical trial was carried out over 200 patients with 100 patients in each group. Transabdominal ultrasonography (US) was done on all patients before discharge to ensure the adequate position of the IUD in addition to casco speculum examination to assess the IUD threads, and then women were requested to attend a follow-up appointment at 6 weeks after delivery; gynecological examinations in addition to transvaginal sonography were done to measure the top-fundal distance that reflects the position of the IUD. The participants were instructed to report the pattern of bleeding during the puerperium, fever, or vaginal discharge.ResultsThe ultrasonographic assessment of IUD position before patient discharge (1st assessment) revealed that 18% of Cu T380A IUD users were displaced in comparison to 24% of Multiload 375 IUD, and such difference between both groups was not statistically significant (P = 0.3); furthermore, the ultrasonographic assessment of IUD position after 6 weeks (2nd assessment) revealed that 19% of Cu T380A IUD users were displaced in comparison to 30% of Multiload 375 IUD, and such difference between both groups was statistically significant (P = 0.047). In addition, none of the included patients in both groups suffered from fever after IUD insertion.ConclusionThe present study demonstrated that post-placental insertion of Multiload 375 IUCD results in significantly higher displacement compared to post-placental insertion of Cu T380A IUCD, as well as significantly more bleeding problems with Cu T380A IUCD as compared with Multiload 375 IUCD.Trial registrationThe study was registered prospectively on clinical trial.gov with trial registeration number NCT05624411 (Registered 22-October-2022, https://clinicaltrials.gov/study/NCT05624411).

Bleeding Outcomes of Direct Oral Anticoagulants and Vitamin K Antagonists for Acute Venous Thromboembolism: A Cross-Sectional Study.

Venous thromboembolism (VTE) is a widespread and significant cause of morbidity and mortality on a global scale. The primary objective of this cross-sectional study is to examine the impact of anticoagulant therapy on major organ hemorrhage events in patients diagnosed with acute venous thromboembolism (VTE). Specifically, this research compares the effects of vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs). This retrospective observational study examined the medical records of 46 patients who had been diagnosed with VTE and were receiving treatment with DOACs or VKAs. The documentation of patient characteristics encompassed demographic information, comorbidities, and treatment particulars. Within 30 days of hospital admission, the incidence of significant organ bleeding events, with an emphasis on gastrointestinal and intracranial hemorrhage, was the primary outcome evaluated. Overall, 46 patients with VTE who were treated with oral anticoagulation therapy participated in the study. Twenty-four and 22 patients were administered VKAs and DOACs, respectively. The similarity in baseline characteristics between the DOAC and VKA groups ensured that the analyses were well-matched. The examination of bleeding sites unveiled subtle variations, as the DOAC group exhibited a progressive increase in the incidence of intracranial bleeding (12, 55.5%), while the VKA group demonstrated a surge in upper gastrointestinal bleeding (12, 50%) as well. While lacking statistical significance, these observed patterns are consistent with prior research that indicates that DOACs may have a lower risk of catastrophic hemorrhage in comparison to VKAs. The overall in-hospital mortality rate for patients treated with VKA was 33.3% (n=8), while that treated with DOAC was 18.2% (n=4). These differences did not reach statistical significance (P>0.05). In a similar vein, the evaluation of mortality associated with hemorrhage revealed six (25%) in the group receiving VKA and three (13.6%) in the group receiving DOAC; the P value was not statistically significant (P>0.05). This study contributes valuable insights into bleeding outcomes associated with anticoagulant therapy for acute VTE. The nuanced differences in bleeding patterns highlight the complexity of anticoagulant selection, emphasizing the importance of considering bleeding site considerations. The comparable mortality rates support existing evidence regarding the favorable safety profile of DOACs.

Assessment of the phenotypic severity of hemophilia A: using rotational thromboelastometry (ROTEM) and APTT-clot waveform analysis

BackgroundHemophilia A (HA) is an X-linked inherited bleeding disorder caused by reduced factor VIII (FVIII) levels. Approximately 10–15% of patients with severe HA (SHA) do not present with the anticipated bleeding pattern. Here, we assessed the phenotypic severity of hemophilia A using rotational thromboelastometry (ROTEM) and activated partial thromboplastin time-clot waveform analysis (APTT-CWA).MethodsPatients diagnosed with hemophilia A were enrolled. Clinical phenotype assignment was performed according to the published literature, and patients were classified into four phenotypic subgroups. The whole blood sample was first run on ROTEM in INTEM mode using platelet-poor plasma, APTT was run, and the APTT-CWA graph was simultaneously recorded.ResultsA total of 66 patients were recruited for this study. Statistically significant differences were observed between the four phenotypically categorized groups using ROTEM and APTT-CWA. On comparing patients with mild/moderate-to-severe phenotypes (Group II) with SHA without inhibitors (Group IV), no significant difference was found for all parameters of ROTEM or APTT-CWA. The MCF, MA30, MAXV, and Alpha angle values using ROTEM were found to be the lowest in patients with SHA with inhibitors, which helped differentiate them from those with SHA without inhibitors. However, these two groups could not be differentiated using the APTT-CWA parameters.ConclusionROTEM can be used to distinguish patients with SHA with inhibitors from those with SHA without inhibitors using a combination of parameters with high sensitivity and specificity. However, APTT-CWA cannot be used to differentiate these patient groups.

Occult endometrial cancer in women undergoing hysterectomy for benign indications: a retrospective cohort study in a tertiary hospital in China.

To evaluate the feasibility of further reducing the incidence of occult endometrial cancer in women undergoing hysterectomy for benign gynecological indications. Patients who underwent hysterectomies for presumed benign gynecologic conditions at Peking Union Medical College Hospital were retrospectively identified. Patients with occult endometrial cancer, which was defined as endometrial cancer diagnosed on postoperative histopathology with no preoperative confirmed malignancy, were selected. 24/7558 (0.32%; 95% CI 0.20-0.47%) patients undergoing hysterectomy for benign indications had occult endometrial cancer. Asymptomatic patients with normal endometrial imaging all tended to have favorable pathology. Heavy menstrual bleeding was the most overlooked AUB pattern in the premenopausal group. In the postmenopausal group, all the patients with serous adenocarcinoma or G3 endometrioid adenocarcinoma histology/stage T1b disease/LVSI space invasion had a history of persistent or recurrent PMB ≥ 6months and/or an intracavitary lesion > 20mm in diameter. 3/4 of the samples of the postmenopausal patients did not have adequate endometrium for evaluation. To further reduce the incidence of occult endometrial cancer, physicians should focus on the patient's bleeding pattern and actively implement endometrial sampling whenever indicated. Transvaginal ultrasonography is a valuable preoperative evaluation. Hysteroscopy with directed biopsy is the preferred procedure in postmenopausal patients.

Clinicopathological Evaluation of Thyroid Dysfunction in Women with Abnormal Uterine Bleeding

Introduction: Abnormal uterine bleeding describes any variation from normal bleeding patterns in nonpregnant, reproductive-aged women beyond menarche lasting for at least 6 months. Regular cyclic menstruation results the choreographed relationship between the endometrium and its regulating factors. Any type of disturbance between the regulatory mechanism of pituitary ovarian axis or pelvic diseases results in abnormal uterine bleeding. Thyroid hormones play a key role in the menstrual and reproductive function of women. It is recognized universally that menstrual disturbances may accompany clinical alterations in thyroid function. Objectives: To evaluate the thyroid dysfunction in patients with abnormal uterine bleeding. Materials and Methods: This cross sectional study was conducted in Department of obstetrics & gynaecology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Shahbag, Dhaka from April 2023 to December 2023. Women with abnormal uterine bleeding were included in the study. Sample was selected by purposive sampling. Sample size was 100. Detail demographic data were collected from the informant and recorded in structured case report form. Clinical examination and relevant investigation were done meticulously. Data was collected by using a semi-structured questionnaire. Data was processed and analysed with the help of computer program SPSS and Microsoft excel. Quantitative data expressed as mean and standard deviation and qualitative data as frequency and percentage. Result was presented in the form of tables, pie chart, graphs, bar diagrams, histogram & charts etc. Results: In this study, the maximum numbers of cases (43.0%) were between 26-35 years age group. Mean age was 29.57 ± 8.27 years. Large numbers of respondents came from urban area (58%). On evaluation of types & causes of AUB, maximum patient belongs to AUB-L (leiomyoma) group (53%) followed by AUB-A (adenomyosis) (28%); AUB-P (polyp) (8%); AUB-O (ovulatory) (9%) and AUB-M (malignancy) (2%). Present study showed that prevalence of thyroid disorders is 26% in AUB patients. The prevalence of Hypothyroidism was 18% and Hyperthyroidism was 8%. Thyroid dysfunction is associated with menstrual abnormalities in females of all age groups. Conclusion: Abnormal uterine bleeding has a strong association with thyroid disorders. The most common type of disorder is subclinical hypothyroidism. Thus, all patient of AUB must be evaluated for thyroid dysfunction. Medicine Today 2023 Vol.36 (1): 1-6

Priorities for contraceptive method and service delivery attributes among adolescent girls and young women in Kenya: a qualitative study.

Despite increasing global commitment to meeting the family planning needs of adolescent girls and young women (AGYW), there is limited research on how they prioritize contraceptive method and service delivery characteristics. In this qualitative study, we examine the specific elements that drive the contraceptive choices of Kenyan AGYW, and apply our findings to the development of attributes and levels for a discrete choice experiment (DCE). Our four-stage approach included data collection, data reduction, removing inappropriate attributes, and optimizing wording. Between June-October 2021, we conducted in-depth interviews with 30 sexually-active 15-24 year-old AGYW in Kisumu county, Kenya who were non-pregnant and desired to delay pregnancy. Interviews focused on priorities for contraceptive attributes, how AGYW make trade-offs between among these attributes, and the influences of preferences on contraceptive choice. Translated transcripts were qualitatively coded and analyzed with a constant comparative approach to identify key concepts. We developed and iteratively revised a list of attributes and levels, and pre-tested draft DCE choice tasks using cognitive interviews with an additional 15 AGYW to optimize comprehension and relevance. In-depth interview participants' median age was 18, 70% were current students, and 93% had a primary sexual partner. AGYW named a variety of priorities and preferences related to choosing and accessing contraceptive methods, which we distilled into six key themes: side effects; effectiveness; user control; privacy; source of services; and cost. Bleeding pattern was top of mind for participants; amenorrhea was generally considered an intolerable side effect. Many participants felt more strongly about privacy than effectiveness, though some prioritized duration of use and minimizing chance of pregnancy above other contraceptive characteristics. Most AGYW preferred a clinic setting for access, as they desired contraceptive counseling from a provider, but pharmacies were considered preferable for reasons of privacy. We selected, refined, and pre-tested 7 DCE attributes, each with 2-4 levels. Identifying AGYW preferences for contraceptive method and service delivery characteristics is essential to developing innovative strategies to meet their unique SRH needs. DCE methods may provide valuable quantitative perspectives to guide and tailor contraceptive counseling and service delivery interventions for AGYW who want to use contraception.

The association between BMI and continuity of etonogestrel (ENG)-releasing implant.

The etonogestrel-releasing implant is a long-acting reversible contraception that is recommended by the Food and Drug Administration for 3 years and has been proven to be highly effective and convenient. Adverse effects including irregular bleeding patterns, weight gain, and acne are reported to be the main reasons for treatment discontinuation. The aim of this study is to learn the association between body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters) and the incidence of side effects and adherence to treatment. This is a retrospective cohort study, conducted at a single university-affiliated medical clinic, including all women who underwent etonogestrel-releasing implant (Nexplanon®; New Jersey, USA, Organon USA Inc., Merck and Co) insertion between January 2019 and December 2021. Cases where abnormalities were reported during the insertion procedure or missing data were excluded from the study. Information on patients' demographic, medical history, obstetric and gynecological history, and follow-up was collected from electronic medical files. The primary outcome was defined as the rate of implant removal in the different obesity classes. Data are presented as median and interquartile range. The study was approved by institutional review board. The study population included 1318 women, of whom 466 (35%) requested early removal of the implant. Women's demographic and clinical characteristics were comparable between women who requested early removal and those with full-length treatment. The median time for early removal was 12 (6-20) months from insertion. Irregular bleeding was the most frequent reason for early removal in both groups and was more than twice as prevalent in the early removal group (239 [51.29%] vs 193 [22%], P = 0.001). The early removal group had fewer obese women (BMI ≥30) compared with women who had full-length treatment (163 [31.8%] vs 350 [68.2%], P = 0.03), with comparable rates of class 3 obesity women (BMI ≥40) (P = 0.68). Multi-regression logistic analysis including age, BMI, parity and side effects found that the presence of side effects is the only independent predictor significantly associated with early implant removal (B = 1.74, P = 0.04). Continuation of etonogestrel-releasing implant contraception treatment was associated with the presence of side effects that were more often reported in non-obese women. BMI was not found to be a significant factor influencing adherence to treatment.

Aneurysmal subarachnoid haemorrhage: Volumetric quantification of the blood distribution pattern to accurately predict the ruptured aneurysm location

BackgroundIn spontaneous subarachnoid haemorrhage (SAH) accurate determination of the bleeding source is paramount to guide treatment. Traditionally, the bleeding pattern has been used to predict the aneurysm location. Here, we have tested a software-based tool, which quantifies the volume of intracranial blood and stratifies it according to the regional distribution, to predict the location of the ruptured aneurysm. MethodsA consecutive series of SAH patients admitted to a single tertiary centre between 2012–2018, within 72 h of onset, harbouring a single intracranial aneurysm. A semi-automatized method of blood quantification, based on the relative density increase, was applied to initial non-contrast CTs. Five regions were used to define the bleeding patterns and to correlate them with aneurysm location: perimesencephalic, interhemispheric, right/left hemisphere and intraventricular. Results68 patients were included for analysis. There was a strong association between the distribution of blood and the aneurysm location (p < 0.001). In particular: ACom and interhemispheric fissure (p < 0.001), MCA and ipsilateral hemisphere (p < 0.001), ICA and ipsilateral hemisphere and perimesencephalic cisterns (p < 0.001), PCom and hemispheric, perimesencephalic and intraventricular (p = 0.019), and PICA and perimesencephalic and intraventricular (p < 0.001). The internal diagnostic value was high (AUROC ≥ 0.900) for these locations. ConclusionRegional automatised volumetry seems a reliable and objective tool to quantify and describe the distribution of blood within the subarachnoid spaces. This tool accurately predicts the location of the ruptured aneurysm; its use may be prospectively considered in the emergency setting when speed and simplicity are attained.

Assessing the uterine bleeding profile in women using a subcutaneous contraceptive implant containing etonogestrel: Real-life clinical practice

Introduction. Pregnancy planning is one of the leading areas in the population reproductive health care, in particular preventing and reducing the number of abortions.Aim. To evaluate the uterine bleeding profile and other adverse events associated with the use of an etonogestrel subcutaneous contraceptive implant (Implanon NXT®). Materials and methods. We analysed medical records of female patients (n = 153) who used Implanon NXT® in the period from 2013 to 2023, records of adverse events, uterine bleeding, bleeding management techniques and reasons given by women for discontinuing the use of implants.Results. The median duration of uterine bleeding episodes ranged from 7 to 13 days within a three-year period of use of Implanon NXT®. During the first 3 months, the proportion of women with prolonged bleeding was higher as compared to all other observation periods and gradually decreased during the first year of use of the drug from 41.2 to 15.8%. 40 patients with complaints of unsatisfactory uterine bleeding patterns required adjustment of drug dosages; 14 women continued to use Implanon NXT® after adjustment of drug dosages and repeated visits. 17.0% (n = 26) of patients required early removal of the implant. Due to pregnancy planning, the implant was removed early in 13% (n = 20) of patients. The most common adverse events included functional ovarian cysts, mastalgia, increased appetite, decreased libido, dizziness, acne; most of them were transient and did not require any management, and were not considered the reason for implant removal.Conclusion. The number of uterine bleeding episodes in patients using the etonogestrel implant was comparable to the normal menstrual cycle. Some women had changes in the uterine bleeding patterns, such as amenorrhea, frequent and prolonged bleeding, which reduced the duration of use of this contraception method. At the same time, combined oral contraceptives were the most effective as compared to other drugs used in correction regimens.