Causes Of Abnormal Uterine Bleeding Research Articles

Alternative treatments of adenomyosis - an update in procedural management and clinical outcomes.

Adenomyosis is a common cause of abnormal uterine bleeding (AUB), dysmenorrhea, and pelvic pain. Definitive diagnosis and treatment have historically been by uterine histopathology at time of hysterectomy; however, advances in imaging have supported earlier diagnosis and subsequent conservative treatment. This review aims to update the evidence supporting the uterine-sparing, procedural management options with a focus on clinical outcomes. Uterine artery embolization (UAE), radiofrequency ablation (RFA), high-intensity focused ultrasound (HIFU), percutaneous microwave ablation (PMWA), and adenomyomectomy are minimally invasive interventions proven to be effective in reducing AUB and dysmenorrhea due to adenomyosis. Symptom improvement is associated with a decrease in uterine volume. Studies support the use of alternative treatment options given the overall low rates of symptom recurrence and reintervention. Combination therapy may be more effective than monotherapy. This review provides the current evidence for use of alternative treatment options for adenomyosis. Access to ablative therapies in the USA is limited and primarily off label, given lack of FDA approval. High-quality prospective and randomized controlled trials are needed in order to further delineate treatment comparisons, efficacy, safety, and ideal patient selection for these treatments. More data are needed to assess safety and utility in those desiring future fertility.

Adenomyosis and Abnormal Uterine Bleeding: Review of the Evidence.

Thomas Cullen described bleeding abnormalities and dysmenorrhea as the "expected" presentations of adenomyomas. Adenomyosis is included within the FIGO classification of structural causes of abnormal uterine bleeding (AUB). Nevertheless, this long-standing association has been questioned by some authors who reported a high incidence of adenomyosis in uteri removed for indications other than AUB or dysmenorrhea. Here, we examine evidence for the link between adenomyosis and AUB. A comprehensive Medline literature review of all publications to October 2023. Sixty-three articles were identified and included in the review. Despite a large body of studies, the available literature does not provide conclusive evidence of a link between adenomyosis and AUB. This is because of unsuitable study design, or poor characterization of the study population or of the inclusion or exclusion criteria. Additional challenges arise because of the lack of agreed criteria for diagnosing adenomyosis and the often absence of detailed assessment of menstrual blood loss. Adenomyosis often coexists with other conditions that have also been linked to similar symptoms, and many cases of adenomyosis are asymptomatic. Most of the existing literature and studies that addressed treatment outcome of adenomyosis started from the premise that a link between the condition and AUB had been proven. Yet, published information shows that aspects such a relationship is still uncertain. Further research is needed to address the relation between AUB and adenomyosis burden (or subtypes), distribution, and concomitant pathology.

Traits of intrauterine pathology management in the peri- and postmenopausal period

Increasing number of anovulatory cycles in the perimenopause, leading to relative hyperestrogenism, and persistent hypoestrogenism in postmenopause, increase the proliferative activity and change the endometrium morphology. That is associated with higher rates of intrauterine pathology. The prevalence of atypical hyperplasia and endometrial cancer in women of the peri- and postmenopausal periods reaches its maximum values. Therefore, one of the most important concepts of patient’s management is to exclude malignant and precancerous endometrial pathology. Significant hormonal changes leads to important confounders in diagnostic and therapeutic algorithms. It could lead to both hypo- and hyperdiagnosis. The review analyzes the main causes of abnormal uterine bleeding, the features of their clinical manifestation, taking into account probable iatrogenic causes, extrauterus and extragenital sources of spotting. This article reviews the principles of ultrasound examination, considering menstrual cycle phase, duration of menopause, hormone treatment, as well as indications for endometrial biopsy, in case of inconsistency of clinical presentation, ultrasound results, menopausal status and iatrogenic factors. We describe the relevant principles of medical correction, wait-and-see tactics and surgical treatment of abnormal uterine bleeding, both in the presence of organic pathology of the endometrium, and in its absence.

Abnormal Uterine Bleeding: A Pictorial Review on Differential Diagnosis and Not-So-Common Cases of Interventional Radiology Management.

Abnormal uterine bleeding (AUB) poses a multifaceted challenge in women's health, necessitating an integrated approach that addresses its diverse etiologies and clinical presentations. The International Federation of Gynecology and Obstetrics PALM-COEIN classification system provides a systematic approach to the diagnosis of AUB in non-pregnant women, based on clinical and imaging-based categorization of causes into structural (Polyps, Adenomyosis, Leiomyomas and Malignancy; PALM), and non-structural causes (Coagulopathies, Ovulatory disorders, primary Endometrial disorders, Iatrogenic and Not otherwise classified; COEIN). On the other hand, placental disorders, uterine rupture, ectopic pregnancy and retained products of conceptions are the main causes of uterine bleeding during pregnancy and in the peripartum period. Ultrasound is usually the first-line imaging technique for the differential diagnosis of causes of AUB. Computed Tomography may be useful if ultrasound findings are unclear, especially in emergency settings. Magnetic resonance imaging, when indicated, is an excellent second-line diagnostic tool for a better non-invasive characterization of the underlying cause of AUB. This pictorial review aims to illustrate the main causes of AUB from the point of view of diagnostic imaging and to show not-so-common cases that can be treated by means of interventional radiology.

Causes of abnormal uterine bleeding in women of 20–60 years of age based on polyp, adenomyosis, leiomyoma, malignancy, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not-yet-classified at a tertiary care hospital: A cross-sectional study

Abstract Background: Approximately 10%–25% of women are affected with abnormal uterine bleeding (AUB). It is essential to have a thorough understanding and knowledge about the disease, causative factors, pathophysiology, incidence and prevalence of various causative factors, clinical presentations, and diagnostic aids for an early prediction and diagnosis of disease to treat the condition at the earliest possible phase and with minimum morbidity and costs. Objective: The objective of this study was to study the causes of AUB women of 20–60 years of age based on polyp, adenomyosis, leiomyoma, malignancy, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not-yet-classified (PALM COEIN). Materials and Methods: It was a hospital-based prospective study among 136 patients with AUB aged 20–60 years. History, general and gynecological examination, and routine gynecological examination were done using speculum examination of the vagina and the cervix and a bimanual examination. Routine investigations and an ultrasonography were done. Some were subjected to PAP smear as a routine procedure. Results: Women aged 31–50 years and multiparous were most affected with AUB in 84.6% and 88.9% of cases, respectively. According to the International Federation of Gynecology and Obstetrics type classification, the most common type of presentation was heavy menstrual bleeding in 54% of cases. The most common presenting symptom was pain in the abdomen in 4.4%. The most common-related symptom was spasmodic dysmenorrhea in 36%. The most common clinical sign was pallor in 25%. The most common associated comorbidity was anemia in 49%. Leiomyoma was the most common ultrasound diagnosis of underlying pathology in 52.2%. The most common cause of AUB as per PALM COEIN was AUB leiomyoma in 52.2%. Conclusion: Our study shows that the causation of AUB was multifactorial (though in some cases, solitary lesions were found) involving the entire female reproductive system resulting in a single common presentation as AUB.

Clinicopathological Pattern of Endometrial Specimens in Women with Abnormal Uterine Bleeding and Ultrasonography Correlation.

Abnormal uterine bleeding (AUB) refers to any symptomatic deviation from normal menstruation. AUB is a common gynecological disorder in non-pregnant women of reproductive age, accounting for approximately 33% of gynecological outpatient visits. The early diagnosis and management cause of AUB is important because of increased incidence of endometrial carcinoma with rapid growth. Transvaginal ultrasound is non-invasive imaging technique used to find endometrial carcinoma before referring patients for invasive techniques. Dilatation and curettage (D&C) and endometrial biopsy are surgical procedures that scrape the endometrial lining of the uterus for diagnosis and treatment. The aim of this study is to describe the clinicopathologic pattern of endometrial specimens in women with AUB and ultrasonographic correlation. Tissues from endometrial biopsy and curettage of 411 patients with AUB who referred to Shahid Mohammadi hospital were prospectively selected from 2021 to 2023. Patients were divided into three groups based on age and menstrual status including: premenopausal (18-39 years), perimenopausal (40-49 years) and postmenopausal (≥50 years). The results were correlated to patient's age and other data and evaluated with statistical analysis. During the two-year study period, a total of 411 endometrial specimens with clinical diagnosis of AUB were submitted and the results were analyzed. The youngest patient presenting with AUB was 21 years old, while the oldest was 77 years old. The most common complaint was menorrhagia in 201 (48.0%) out of 411 patients. The most common pathology finding in three groups was polyp in 100 (24.3%) cases. Hormonal effect was the next commonly observed pattern seen in 70 (17.0%) cases. P value was calculated as 0.003 which was significant using chi-square for the trend seen in age. Endometrial sampling is a useful tool for evaluation of women with AUB and referring patients for treatment. Histopathological evaluation of the endometrium is very useful in detecting the etiology of AUB. Transvaginal sonography has high sensitivity in detecting polyps.

Meclizine improves endometrial repair and reduces simulated menstrual bleeding in mice with induced adenomyosis

BackgroundAdenomyosis is one of the structural causes of abnormal uterine bleeding, which often presents as heavy menstrual bleeding (HMB). Mostly due to poor understanding of its pathophysiology, medical management of adenomyosis-induced HMB is still a challenge. We have previously reported that glycolysis is crucial to endometrial repair following menstruation and that suppressed glycolysis can cause HMB. Objective(s)To test the hypothesis that meclizine, a drug with excellent safety profile, alleviates HMB in mice with induced adenomyosis using a simulated menstruation model. Study DesignAdenomyosis was induced in 36 female C57BL/6 mice using endometrial-myometrial interface disruption. Three months after induction, the mice were randomly divided into three groups: low- and high-dose meclizine, and controls. Treatment with meclizine or vehicle started shortly before the simulated menstruation procedure and ended before progesterone withdrawal. The amount of blood loss was quantitated and uterine tissue was harvested for histological evaluation of the grade of endometrial repair. We performed immunohistochemistry analysis of 4 proteins critically involved in glycolysis, namely glucose transporter 1 (Glut1), hexokinase 2 (Hk2), 6-phosphofructo-2-kinase/fructose-2,6-biphosphatase 3 (Pfkfb3) and pyruvate kinase 2 (Pkm2). The extent of tissue fibrosis in both ectopic and eutopic endometrium was evaluated using Masson trichrome staining. ResultsIn mice with induced adenomyosis, meclizine accelerated endometrial repair in a dose-dependent manner and reduced the amount of menstrual bleeding. Meclizine administration raised endometrial immunoexpression of Hk2 and Pfkfb3 but not of Glut1 or Pkm2.The extent of endometrial fibrosis was reduced following the meclizine administration. Remarkably, these favorable changes were accompanied with suppression of lesional progression, as evidenced by the dose-dependent reduction in the extent of fibrosis (a surrogate for lesional progression). Conclusion(s)These encouraging results, taken together, suggest that glycolysis may be a promising therapeutic target and that meclizine may hold a therapeutic potential as a non-hormonal treatment for adenomyosis-induced HMB without exacerbating the disease.

CLINICOPATHOLOGICAL EVALUATION OF ABNORMAL UTERINE BLEEDING IN PERIMENOPAUSAL WOMEN

Objective: Abnormal uterine bleeding (AUB) is defined as any bleeding from the uterus that is deviated from normal in terms of regularity, duration, frequency, and amount of blood loss. It interferes with the woman’s physical, emotional, social, and material quality of life. The prevalence of AUB ranges between 11% and 13% rising to 24% in perimenopausal women. The aim of this study is to analyze the demographic profile and risk factors of AUB in perimenopausal women, to classify the causes of AUB based on PALM-COEIN classification, and to correlate the clinical and sonological findings with post-operative histopathology findings. Methods: A cross-sectional study was conducted in the Department of Obstetrics and Gynecology at GIMSR hospital, Visakhapatnam, for 1 year from September 2022 to September 2023. A total of 151 perimenopausal women with complaints of AUB in the age group of 41–50 years who underwent hysterectomy were included in the study. Results: The most common clinical presentation was heavy menstrual bleeding (HMB) seen in 96 cases (63.5%). Clinically, the PALM component accounted for 61% of cases and the COEIN component accounted for 39% of cases. Ultrasonographically, the PALM component was detected in 76.8% of cases. We calculated the sensitivity, specificity, positive predictive value, and negative predictive value of ultrasound for detection of PALM lesions. Conclusion: Leiomyoma was the most common cause clinically, sonologically, and pathologically. Correlation was good for leiomyoma. USG has good specificity for diagnosis of AUB-A and AUB-P but low sensitivity.

Evaluating Trainees' Experiences with Intravenous Iron Use

Background: Iron deficiency (ID) and iron deficiency anemia (IDA) cause significant morbidity. Despite being a disease of high prevalence, affecting people with heart failure, chronic kidney disease, heavy menstrual bleeding, irritable bowel disease, hereditary hemorrhagic telangiectasia (HHT), and bariatric surgery, it has low healthcare priority. The World Health Organization (WHO) estimates 37% of people who are pregnant, and 30% of women 15-49 years of age worldwide are anemic. Fibroids, which are the leading cause of abnormal uterine bleeding, disproportionately impact people of color. ID and IDA cause fatigue, impaired cognitive function, and poor mental health, eroding quality of life and personal productivity. In addition, IDA has been associated with an increase in all-cause mortality is associated with an increased risk of arterial and venous thrombosis. Under-treatment of IDA results in avoidable hospitalizations, emergency room visits, blood transfusions, decreased HRQoL, and loss of personal productivity. Despite the significant impact ID and IDA can have on morbidity, mortality, and quality of life, intravenous iron remains underutilized. No study has been performed to date to assess provider practices, knowledge, and perceptions of intravenous iron use. This qualitative study aims to understand trainees' experiences with intravenous iron use in patients with ID and IDA. Methods: We conducted an inductive reflective thematic analysis of semi-structured qualitative interviews from five focus groups to understand trainees' experiences with and barriers to prescribing intravenous iron in patients with ID and IDA. Internal medicine residents from academic institutions across the country were recruited via snowball sampling. Chief residents from six internal medicine programs were contacted to disseminate sign up links to their residents; programs were chosen for geographic diversity. Results: Twenty-eight internal medicine residents responded and nineteen residents across five institutions participated (PGY levels 1-3). Thematic analysis of trainees' experiences of caring for patients with conditions characterized by iron deficiency resulted in three main themes: education, systemic factors, and practice pattern. Participants identified a wide range of conditions for which they consider administration of oral or intravenous iron. However, they generally expressed uncertainty as to whether evidence-based guidelines exist to guide their decision-making with the exception of intravenous iron administration in heart failure patients. In addition, systemic factors, such as setting, support staff, hospital formularies, order sets, and insurance status often impacted their decision to use intravenous iron. Conclusions: There is a wide variation among residents' practice patterns in regard to their comfort with prescribing intravenous iron. The ease or hesitancy with which they do so is greatly influenced by educational and systemic factors. By gaining a deeper understanding of the experiences of trainees we can lay the foundation to develop evidence-based guidelines and educational initiatives for conditions characterized by ID and IDA. Additionally, by identifying both institutional facilitators and barriers, we can cultivate system-based initiatives to improve access to intravenous iron. To assess this need on a larger scale, our next step involves developing a survey that will be widely distributed via national societies. While cost, insurance status, and need for specialty referral were identified as barriers for intravenous iron use, there was no explicit discussion of how these barriers may contribute to healthcare inequity for underserved populations.

Social and Cultural Issues of Menstruation and Abnormal Uterine Bleeding in Nepal

Practice difficulties during menstruation and abnormal uterine bleeding (AUB) are major global concerns. So, this review will explore the issues of cultural and social for menstruation and AUB in Nepal. Nearly one-third of menstruating girls and women were facing abnormal menstruation and uterine bleeding worldwide. All religions have negative views and enforce prohibitions on menstruation and abnormal uterine bleeding except Sikhism. AUB impacts women's living quality, sexuality, social engagement and participation, mental well-being, access to education and employment prospects, experiences of stigma and shame, as well as economic challenges. Menstruation restrictions are a routed problem in some parts, some religions, and castes, and very few menstruating women use disposable sanitary pads in Nepal. Awareness programs, educational intervention programs, and education on menstrual health help to rule out the causes of AUB, and legal implementation of these should be applied to the effort to overcome the issues.

An analytical study of hysteroscopic evaluation in patients with abnormal uterine bleeding, and its correlation with histopathology

Abnormal uterine bleeding (AUB) refers to bleeding that occurs outside of normal menstrual cycles and includes changes in the regularity, frequency, duration, or amount of bleeding during or between periods. AUB is a condition that causes significant impairment in women's health, impacting a substantial proportion of women in different stages of their reproductive life with 14-25% of women of reproductive age and up to 50% of women in the perimenopausal phase experience the effects of this condition. The present study was analytical observational study conducted in the Department of Obstetrics and Gynaecology for the period of 18 months. Prior to commencement, the study obtained approval from the ethics committee at the hospital, and 63 women aged 35 or above, who were experiencing abnormal uterine bleeding, willingly participated in the study by providing written consent.. Each patient underwent a thorough medical history and general systemic examination. They were also subjected to baseline investigations, transvaginal sonography, diagnostic hysteroscopy, and endometrial biopsy. The overall diagnostic accuracy of our study came out to be 90.48%. The correlation between Histopathological and Hysteroscopic findings of the endometrium and was found to be statistically significant (p<0.05). Hysteroscopy is a valuable diagnostic tool for identifying the underlying cause of AUB. Proper management of AUB will depend on several factors including the patient's age, fertility goals, and the results of the final histopathology. While hysteroscopy is a valuable tool for visualizing abnormalities in the uterine cavity, it is important to note that it is not a substitute for tissue diagnosis, which is considered the gold standard. Rather, hysteroscopy complements other diagnostic procedures by offering the advantage of direct visualization of any abnormalities within the uterine cavity.

Abnormal uterine bleeding (clinical lecture)

Abnormal uterine bleeding (AUB) not related to pregnancy has been one of the leading reasons for visiting a gynecologist for many years. The incidence of AUB is approximately 30% among patients of reproductive age and can increase to 70% during the perimenopausal period. Recurrent AUB leads to the development of iron deficiency anemia, significantly reducing the quality of life, and also resulting in additional costs for hygiene products.
 This clinical lecture provides a modern classification of AUB. It focuses on the main mechanisms of development of this pathology in adolescence and reproductive age. The causes of AUB are analyzed, and the classification, symptomatology, and clinical presentation of the studied conditions are presented. The lecture covers international criteria for pathologic uterine bleeding, clinical criteria for assessing bleeding severity according to MansfieldVodeJorgensen scale and estimation of blood loss volume according to Algover index. Detailed consideration is given to the issues of differential diagnosis, general principles of therapy, and indications for traditional, hormonal, and surgical hemostasis. The lecture also outlines the algorithm of diagnostic search for patients in the adolescent, reproductive, postmenopausal age groups, as well as for patients on the background of menopausal hormonal therapy.

Sonographic evaluation of abnormal uterine bleeding among non-pregnant women in Lagos, Southwest, Nigeria

Abnormal uterine bleeding (AUB) is the direct cause of a significant healthcare burden for women and society at large. Around 30% of women will experience AUB during their reproductive years, prompting them to seek medical attention. Abnormal Uterine Bleeding can significantly impact their quality of life, often causing frequent work absences and potentially requiring surgical treatment. It's crucial to accurately diagnose the underlying cause of AUB in this age group to ensure proper and effective management. This study aims to evaluate AUB among non-pregnant women in Lagos using transvaginal ultrasound. A descriptive cross-sectional study of 152 non-pregnant women of reproductive age (16 to 55 years) with abnormal uterine bleeding for a period of five months. A purposive sampling technique was used to recruit the subjects. Data was analysed using SPSS version 20.0. Sonographic evaluation reveals positive findings in 97 cases (63.8%) out of 152 cases studied. Seventy cases (46%) had structural abnormalities with the highest being Leiomyoma (41.4%), followed by Adenomyosis (3.9%), and Endometrial Polyp (0.6%). The age group 26 – 35 years presented most with abnormal uterine bleeding cases (48.6%). The major clinical history was absent menstrual bleeding with findings depicting normal endometrium. There was a positive and moderate correlation between age and parity of subjects with AUB. The study found that Transvaginal ultrasound effectively identifies AUB's structural causes. It is recommended as the initial assessment method due to its safety, affordability, and widespread availability in healthcare settings.

Exploring risk factors and management strategies for endometrial premalignant/malignant lesions in women with abnormal uterine bleeding: A retrospective cohort study

Background/Aim: Abnormal uterine bleeding (AUB) in women can often be attributed to a range of underlying factors, including endometrial premalignant and malignant lesions. However, despite the prevalence and potential severity of these lesions, the specific risk factors contributing to their development have not been fully explained. This study aims to explore the risk factors linked to these lesions and to elucidate the corresponding management strategies, filling a crucial gap in our understanding of the underlying causes of AUB. Methods: This retrospective cohort study was conducted among women presenting with AUB and undergoing endometrial biopsy at a gynecology clinic between July 2018 and January 2022. We recorded patients' demographic and clinical characteristics, ultrasonographic findings, and histopathological results of endometrial biopsies. Excluded from the study were patients under 30 years old, pregnant women, those with biopsy results from another center, individuals diagnosed with cancers other than endometrial cancer, cases of insufficient endometrial biopsies, and patients with missing data. The included patients were categorized into two groups: benign and premalignant/malignant, based on histopathological results, and subsequently compared using clinicodemographic findings. Logistic regression analysis was conducted to identify significant risk factors for premalignant/malignant endometrial lesions. We assessed the predictive capacity of endometrial thickness (ET) for premalignant/malignant lesions through receiver operating characteristic (ROC) analysis. Results: A total of 391 patients were analyzed, with a mean age of 50.9 (7.7) years. Among these patients, 89.3% (n=349) were classified as benign, while 10.7% (n=42) exhibited premalignant/malignant lesions. The premalignant/malignant group displayed higher age and BMI compared to the benign group (55.83 [10.55] vs 50.3 [7.6], P<0.001 and 29.17 [3.40] vs 27.73 [3.67], P=0.018, respectively). Logistic regression analysis identified age, BMI, and ET as significant risk factors associated with premalignant/malignant endometrial lesions. ROC analysis for predicting premalignant/malignant lesions using ET yielded cut-off values of 10.5 mm for premenopausal women (sensitivity 62.5%, specificity 58.7%, AUC [95% CI]: 0.688 [0.56-0.80], P =0.012) and 8.5 mm for postmenopausal women (sensitivity 88.5%, specificity 70.2%, AUC [95% CI]: 0.854 [0.78-0.92]; P<0.001). Conclusion: In summary, our findings shed light on the pivotal role of age, BMI, ET, and menopausal status in tailoring management strategies for patients with AUB, underscoring the importance of individualized approaches in enhancing patient care. However, definitive conclusions warrant multi-center prospective investigations to validate these findings in a larger population.

Therapeutic Carbohydrate Restriction as a Metabolic Modality for the Prevention and Treatment of Abnormal Uterine Bleeding.

Therapeutic carbohydrate restriction diets have been becoming increasingly popular over the years, resulting in dramatic weight loss and an improvement in metabolic disorders. Obesity, insulin resistance, and diabetes are the risk factors for many gynecologic morbidities such as uterine leiomyoma, endometrial polyps, and polycystic ovarian syndrome. There is evidence suggesting that the pathogenesis of cardiovascular disease is similar to that seen in many causes of abnormal uterine bleeding. We aim to explain how cardiovascular disease risk factor reduction with the use of therapeutic carbohydrate restriction may prevent and potentially treat these gynecologic disorders.

Contemporary evaluation of women and girls with abnormal uterine bleeding: FIGO Systems 1 and 2.

Abnormal uterine bleeding (AUB) is common, often debilitating, and may affect over 50% of reproductive-aged women and girls. Whereas AUB is a collection of symptoms that include intermenstrual bleeding and abnormalities in period duration, cycle length, and regularity, it is heavy menstrual bleeding (HMB) that is most contributory to iron deficiency and related anemia. It is apparent that AUB, in general, and HMB, in particular, remain underrecognized and underreported. FIGO created two systems for assessing and classifying AUB. FIGO System 1 defines the bleeding pattern using four primary descriptors: frequency, duration, regularity, and flow volume. FIGO System 2 provides a structured classification system of possible causes of AUB, using the acronym PALM-COEIN. "PALM" refers to structural causes of AUB (Polyp, Adenomyosis, Leiomyoma, Malignancy), and "COEI" refers to nonstructural causes (Coagulopathy, Ovulatory dysfunction, Endometrial, and Iatrogenic). The "N" is reserved for those entities that are currently not otherwise classified. Using FIGO System 1 as a gateway to FIGO System 2 streamlines the investigation of reproductive-aged women and girls with AUB. Understanding the pathogenesis of the FIGO System 2 "PALM-COEIN" causes helps interpret investigations and the onward management of AUB. Numerous evidence gaps exist concerning AUB; however, if researchers and trialists universally adopt FIGO Systems 1 and 2 for the assessment and diagnosis of AUB, clear translatable research findings can be applied globally.

Correlation between Manual Vacuum Aspiration and Endometrial Cell Sampler in Abnormal Uterine Bleeding

Objective: Office endometrial biopsy using an endometrial cell sampler is an accepted method of obtaining endometrial tissue for histopathologic evaluation in women with abnormal uterine bleeding (AUB). Manual vacuum aspiration (MVA) is considered an alternative method, but data specific to the use of MVA is limited. This study aimed to evaluate the efficacy of MVA compared to endometrial cell sampler for diagnosing causes of AUB. Materials and Methods: This prospective study enrolled women aged ≥35 years who presented with AUB during August 2015 to June 2016. For each patient, endometrial biopsy using an endometrial cell sampler was first performed followed by MVA. Correlation of endometrial histopathology between methods were analyzed using Kappa statistic. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were evaluated. Results: Of the 162 patients enrolled, the data from 151 women were analyzed. Correspondence of histopathologic finding between tissue obtained from endometrial cell sampler and MVA was 72.8% (Kappa: 0.51). Correspondence of histopathologic finding between tissue obtained from MVA and the final most severe pathology used for treatment decision was 84.1% (Kappa: 0.72). MVA diagnosed all cases of malignancy, but endometrial cell sampler missed one case of malignancy. The overall sensitivity, specificity, PPV, and NPV of MVA was 84.5%, 100%, 100%, and 91.2%, respectively. Conclusion: The histopathologic findings of MVA were in good agreement with those of endometrial cell sampler, and MVA had high accuracy for diagnosing endometrial pathology. MVA is suggested as a reliable alternative procedure for endometrial biopsy in women with AUB.

Evaluation of Radiofrequency Endometrial Ablation: A 17-year Canadian Experience

The purpose of this study was to better elucidate radiofrequency endometrial ablation (REA) durability by assessing the probability of failure as defined by need for postablation hysterectomy. Age at index REA, duration from REA until hysterectomy, and REA failure (REAF) risk factors were analyzed. A retrospective cohort study was conducted using patient data between April 1, 2002, and March 31, 2019. REAF cases were identified using operative procedure codes. Cox proportional hazard regression assessed the effect of age at index REA on time to postablation hysterectomy. Kaplan-Meier survival curve evaluated timing of postablation hysterectomy, stratified by age at index REA. This study was conducted at Regina General Hospital in Regina, Saskatchewan, Canada. Patient population included those who were 21 years of age or older, were premenopausal, and had a history of heavy menstrual bleeding at the time of REA. The intervention under investigation was REA. The overall probability of postablation hysterectomy was 22.6%. The probabilities of postablation hysterectomy were 36.1% for women younger than 30 years (n=128), 28% for women 30 to 34.9 years old (n=528), 29.6% for women 35 to 39.9 years old (n=1152), and 17.6% for women 40 years and older (n=2221). Characteristics associated with REAF included tubal occlusion, cesarean section, dysmenorrhea, and chronic pelvic pain (p <.01) among women younger than 40 years. Leiomyomas accounted for higher failure rates in women 40 years and older (p <.01). Postablation hysterectomy is more likely to occur in women younger than 40 years. REA can be considered in women aged 30 to 39.9 years old, who have no known REAF risk factors. Women younger than 40 years with REAF risk factors will experience higher rates of hysterectomy. Thus, the decision to proceed with REA should be individualized with careful consideration for the underlying causes of abnormal uterine bleeding, while respecting patient autonomy.

Histopathologic study of endometrium in cases of abnormal uterine bleeding

Background: Abnormal uterine bleeding is one of the most common presenting symptoms among women visiting the gynecology outpatient department. Sonography and endometrial biopsy are the usual methods of evaluation; rarely, invasive procedures like hysteroscopy may be needed. Endometrial sampling can be used as a first step in the evaluation. This study was done to analyze the histopathology of the endometrium and to evaluate the causes of abnormal uterine bleeding. Materials and Methods: Endometrial samples were obtained using dilation and curettage from 50 women presenting to the gynaecology outpatient department with abnormal uterine bleeding symptoms in a medical college hospital. Results: Among the 50 cases, 21 were found to have endometrial hyperplasia (72.4%); 24 were diagnosed to have an organic lesion (48%). The endometrium was found to be in the proliferative phase in the majority of the cases (40%). The most common age group was 31-40 years and simple cystic hyperplasia was the commonest endometrial pattern. Single-parity women were most commonly affected and they showed a secretory endometrium under microscopy. Conclusions: Endometrial sampling should be carried out in every patient with abnormal uterine bleeding to study the histopathology of the endometrium and to evaluate the causes of the disease.

Perimenopausal abnormal uterine bleeding

Abnormal uterine bleeding is a very frequent symptom in the perimenopause. The causes are numerous ranging from physiological reactions due to decreasing/instable ovarian function to premalignant and malignant conditions. Benign findings such as endometrial polyps and myomas are increasing with age, leading to more abnormal uterine bleeding in the perimenopause. Cervical and vaginal causes of abnormal uterine bleeding should also be excluded by speculum examination. Sexually transmitted diseases should be ruled out in the perimenopausal women in new relationships. Measurement of hemoglobine, human chorion gonadotropine and thyreoid hormones are relevant in selected cases. Transvaginal ultrasound is the primary diagnostic tool in perimenopausal abnormal uterine bleeding. Saline or gel contrast sonohysterography improves the diagnostic accuracy. Based on the findings by ultrasound, more invasive procedures such as blind 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 individual woman. Severe heavy menstrual bleeding causing anaemia will need immediate treatment. In less severe cases and in intermenstrual bleeding expectant management can be considered. Hormonal medical treatment e.g., progestins or insertion of levonorgestrel-releasing intrauterine system (LNG-IUS) is a possibility in case of anovulatory bleeding interfering with the quality of life. The amount of bleeding can be reduced both by antifibrinolytic and non-steroidal anti-inflammatory drugs and LNG-IUS. In case of focal intrauterine lesions, such as endometrial polyps or submucous myomas, operative hysteroscopic procedures are warranted in the treatment of abnormal uterine bleeding. Other minimally invasive procedures, such as endometrial ablation or endometrial resection, is a good choice in selected cases, but some women will need a hysterectomy as a definite treatment of abnormal uterine bleeding in perimenopause.