Management Of Abnormal Uterine Bleeding Research Articles

Diagnosis and management of abnormal uterine bleeding in adolescence

During menarche and adolescence, abnormal uterine bleeding (AUB) may serve as a crucial indicator of a hidden bleeding disorder. When a young woman is suspected of having a bleeding disorder, the obstetrician-gynecologist should collaborate with a hemostasis specialist to arrange the necessary laboratory testing and determine the best course of action. The Italian Society for the Study of Hemostasis and Thrombosis and the Italian Society of Gynecology and Obstetrics jointly offer recommendations on the diagnosis and treatment of AUB. They also suggest diagnostic and therapeutic pathways to decrease diagnostic delay and improve treatment effectiveness and safety.

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

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

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

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

Ayurvedic Management of Abnormal Uterine Bleeding in Uterine Fibroid

Summary Abnormal uterine bleeding (AUB) is the most common gynecological problem and is often accompanied with uterine fibroid. Very limited options are available in biomedicine for the AUB. In this reported case, AUB associated with stasis dermatitis was managed on the line of treatment of Vataja Yonivyapada with satisfactory results. This is a case of AUB in uterine fibroid associated with stasis dermatitis in the left lower limb of a 39-year-old female. Gokshuradi Guggulu 750 mg, Shatavari Churna - 2 g, Gairika - 500 mg, and Mukta Shukti Pishti - 500 mg were given twice a day for 18 months, Pushyanuga Churna - 2 g, Chandraprabha Vati - 250 mg, and Arsha Kuthara Rasa 250 mg twice a day for 8 months, and Gokshura churna - 2 g twice a day for 14 months were given to her as oral medication. Jatyadi taila was applied locally twice a day on affected area for 17 months. Four sets of Anuvasana Basti (medicated oil enema), one set of Raktamokshana (therapeutic bloodletting) with Alabu, and three sets of Raktamokshana with Shringa were also adopted in 14 months of treatment duration. After 14 months of treatment, the size of the bulky uterus was reduced from 108 mm × 76 mm × 70 mm in May 2018 to 102 mm × 64 mm × 55 mm in May 2019 and from 7.0 to 6.6 mm in endometrium thickness. The fibroid was resolved, and abnormal bleeding was arrested. This case demonstrates that Ayurveda oral medication and Panchakarma based on the management of Vataja Yonivyapada may be useful in AUB associated with stasis dermatitis.

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

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

Impact of abnormal uterine bleeding care in premenopausal patients prior to endometrial malignancy diagnosis

BackgroundLiterature evaluating the management of abnormal uterine bleeding in premenopausal patients prior to endometrial malignancy diagnosis is lacking. ObjectiveTo evaluate predictors and consequences of inadequate evaluation and management of abnormal uterine bleeding and time to endometrial sampling in premenopausal patients prior to endometrial malignancy diagnosis.Study Design.This was a retrospective cohort study of premenopausal individuals with endometrioid endometrial cancer or atypical hyperplasia at a single institution from 2015 to 2020.. Complete noninvasive management encompassed pelvic exam, ultrasound, and progestin treatment before or in conjunction with the endometrial sampling of diagnosis. Multivariable logistic and ordinal odds models were used to evaluate predictors and outcomes. Results152 subjects were included, 80.3 % with cancer and 19.7 % with atypical hyperplasia. The majority of patients had anovulatory bleeding, obesityand recent health care. Only 20.4 % had complete nonvinvasive management, and only 12.5 % had complete noninvasive management or endometrial sampling within 2 months of presentation with abnormal bleeding. Class III obesity reduced the likelihood of complete assessment and increased time to sampling, while age 45 and up and parity reduced time to sampling. Most patients had partial workup but no progestin treatment and long intervals before endometrial sampling after presentation to a provider with abnormal bleeding. Incomplete workup correlated to worse cancer grade and stage. ConclusionDespite high clinical risk and health care contact, most patients had insufficient gynecologic management preceding a diagnosis of endometrial malignancy. Inadequate care correlated to worse oncologic outcomes and demonstrates missed opportunities for early detection and prevention of endometrial cancer.

Therapeutic options for the management of abnormal uterine bleeding.

Just as the investigation of abnormal uterine bleeding (AUB) is approached systematically using the two FIGO systems for AUB in the reproductive years, treatment options can be considered similarly. Therapeutic options fall into two categories-medical and surgical-and while medical management is typically regarded as first-line therapy, there are several exceptions defined by the presenting cause or causes, mainly when infertility is a concurrent issue. In the early 1990s, up to 60% of women underwent a hysterectomy for the symptom of heavy menstrual bleeding (HMB), but this figure has decreased. The number of women undergoing a hysterectomy for benign disorders continues to decline, along with an increase in hysterectomies performed using minimally invasive techniques. Discussions about therapeutic options are tailored to the individual patient, and we include the risks and benefits of each option, including no management, to enable the patient to make an informed choice. The different types of treatment options and the factors affecting decision-making are considered in this article.

Abnormal uterine bleeding in anticoagulated patients by drug class: outcomes and management

Although abnormal uterine bleeding is a known adverse effect of anticoagulant drugs, true rates have not been widely studied. Society-backed recommendations and guidelines do not yet exist for prevention and management of abnormal uterine bleeding among anticoagulated patients. This study aimed to describe the incidence of new-onset abnormal uterine bleeding among patients receiving therapeutic anticoagulation by anticoagulant class, and to evaluate gynecologic treatment patterns. We conducted an institutional review board-waived retrospective chart review of female patients aged 18 to 55 years and prescribed therapeutic anticoagulants, including vitamin-K antagonists, low-molecular-weight heparins, and direct oral anticoagulants, in an urban hospital network from January 2015 through January 2020. We excluded patients with antecedent abnormal uterine bleeding and menopause. Associations between abnormal uterine bleeding, anticoagulant class, and other covariates were evaluated with Pearson chi-square and analysis-of-variance tests. The primary outcome, abnormal uterine bleeding odds by anticoagulant class, was modeled with logistic regression. Age, antiplatelet therapy, body mass index, and race were included in our multivariable model. Secondary outcomes included emergency department visits and treatment patterns. Of the 2479 patients who met the inclusion criteria, 645 were diagnosed with abnormal uterine bleeding after initiating therapeutic anticoagulation. After adjusting for age, race, body mass index, and concurrent use of antiplatelet therapy, those receiving all 3 classes of anticoagulants had higher odds of experiencing abnormal uterine bleeding (adjusted odds ratio, 2.63; confidence interval, 1.70-4.08; P<.001), whereas those taking only direct oral anticoagulants had the lowest odds (adjusted odds ratio, 0.70; confidence interval, 0.51-0.97; P=.032), with vitamin-K antagonists as the reference group. Race other than White was associated with higher odds of abnormal uterine bleeding, as was lower age. The most common hormone therapies used among patients with abnormal uterine bleeding were levonorgestrel intrauterine devices (7.6%; 49/645) and oral progestins (7.6%; 49/645). Sixty-eight patients (10.5%; 68/645) had an emergency department visit for abnormal uterine bleeding; 29.5% (190/645) of patients received a blood transfusion; 12.2% (79/645) began any pharmacologic therapy for bleeding; and 18.8% (121/645) underwent any gynecologic procedure. Abnormal uterine bleeding occurs frequently among patients on therapeutic anticoagulation. Incidence in this sample varied considerably by anticoagulant class and race; use of single-agent direct oral anticoagulation carried the lowest risk. Important sequelae such as bleeding-related emergency department visits, blood transfusions, and gynecologic procedures were common. Balancing bleeding and clotting risk in patients on therapeutic anticoagulation requires a nuanced approach and should involve collaborative management between hematologists and gynecologists.

Ormeloxifene: The Perfect Alternative for the First-line Management of Abnormal Uterine Bleeding

Ormeloxifene: The Perfect Alternative for the First-line Management of Abnormal Uterine Bleeding

To Study the Efficacy and Safety of Diosmin with Tranexamic Acid and Mefenamic Acid Versus only Tranexamic Acid and Mefenamic Acid in Medical Management of Abnormal Uterine Bleeding: A Randomized Controlled Trial.

Abnormal uterine bleeding (AUB) is a common problem in reproductive age group and perimenopausal age group being responsible for many outpatient visits. Traditional management of AUB consists of giving mefenamic acid, tranexamic acid, or their combination with progestogens or hormonal intrauterine deviced levonorgestrel intrauterine system (LNG-IUS) for severe or nonresponsive cases. The objective of the current study was to study the efficacy and safety of adding diosmin along with tranexamic acid and mefenamic acid in reducing menstrual blood loss in AUB patients. It was a prospective double-blind randomized controlled trial in which 900 mg of diosmin was given once daily along with 500 mg tranexamic acid and 250 mg mefenamic acid during menstruation (Group I-92 patients), or only tranexamic acid and mefenamic acid during menstruation (Group II-92 patients). Mean age, parity, body mass index, and socioeconomic status were similar in the two groups. It was 35.68 years versus 36.78 years, 2.2 versus 2.3, 23.68 kg/m2 versus 24.62 kg/m2 respectively. Mean days of bleeding before this treatment were 6.8 versus 6.6 (P = 0.33) and were 3.5 versus 5.2 (P = 0.02) after treatment. There was a significant reduction in both groups as compared to before treatment (P = 0.021 in Group I, 0.027 in Group II) but the reduction was greater in Group I (P = 0.02). The amount of blood loss was 385 ml versus 390 ml (P = 0.7) before treatment which was significantly reduced in both groups to 68 ml versus 112 ml (P = 0.02 in Group I, 0.03 in Group II) with more decrease in Group I than in Group II (P = 0.01). Mean hemoglobin at beginning of the study was 8.4 versus 8.5 g/dl in Group I and Group II (P = 0.02) and significantly increased in both groups posttreatment to 10.9 and 9.8 g/dl in Group I and Group II (P = 0.012 in Group I, 0.011 in Group II) with increase being more in Group I than Group II (P = 0.03). Pictorial blood assessment chart score was 398 versus 406 (P = 0.35) before treatment and decreased significantly to 86.5 and 110.5 (P = 0.001 in Group I, 0.001 in Group II) with more decrease being in Group I than II (P = 0.01). There was significant decrease in dysmenorrhea with both treatments with no difference in the two groups. Various adverse effects such as nausea, vomiting, abdominal pain, diarrhea, constipation, and headache were equal in the two groups. Both the group's diosmin with tranexamic acid and mefenamic acid (Group I) and tranexamic acid and mefenamic acid (Group II) were efficacious in reducing menstrual blood loss, number of menstrual days and dysmenorrhea with effect being more by addition of diosmin. Adverse effects were equal in both the two groups.

Evaluation of four different methods of analgesia for pain relief in patients of dilatation &amp; curettage: A randomized comparative study

Introduction: Dilatation and curettage is a diagnostic procedure in management of abnormal uterine bleeding. In a developing country like India with dense population and limited resources it becomes a necessity to provide simple, effective, inexpensive and low-risk method of pain relief which can be used in an outpatient setup. So, this study was planned to determine an effective modality of pain relief for this procedure. Methods: This was a prospective, randomized, comparative study conducted among 140 patients. The patients were divided into 4 groups: Group A: Paracervical block Group B: Paracervical block with intrauterine lignocaine Group C: Intravenous diclofenac Group D: Intravenous diclofenac with intrauterine lignocaine Pain was analyzed using pain rating scale immediately and 30 min after the procedure. Patient was assessed 2 hourly after the procedure using PADSS score (post anaesthetic discharge scoring system scale) and patient was discharged if PADSS score is more than 9. Results: The patients were well matched in age, parity, weight, number of vaginal births, menopausal status and indications for intervention among the groups and no statistically significant differences were observed in the baseline characteristics. Patients in Group B (Paracervical block with intrauterine lignocaine) had significantly low pain score immediately (1.69±0.47)as well as 30 min after the procedure(2.37±0.49), followed by group D (intravenous diclofenac with intrauterine lignocaine 3.71±0.75, 4.51±0.65). Group A and Group C required rescue analgesic in 25 and 22 patients respectively. However, rescue analgesic was required in only 3 patients of group D Early discharge of the patient was observed in group using combination of paracervical block with intrauterine lignocaine which had maximum PADDS score (11.71±0.45 at 2 hours after the procedure). No serious adverse effects were observed during the study. Most common adverse effect observed was nausea and vomiting apart from other minor adverse effect like dizziness, light-headiness, nausea/vomiting, metallic taste and perioral numbness. Conclusion: Adequate intraoperative and postoperative analgesia is ensured when combination of analgesic/ anaesthetic agent is used. Maximum pain relief, as reflected by pain scores was in group using combination of paracervical block and intrauterine lignocaine which also had highest PADDS score that allowed early discharge of the patient.

Social Vulnerability Index and Surgical Management of Abnormal Uterine Bleeding in Reproductive-Age Women

(Abstracted from J Minim Invasive Gynecol 2022;29:1104–1109) Abnormal uterine bleeding (AUB) is common and affects 10% to 50% of reproductive-age women. A large number of nonmedical factors in the social and physical environment have a strong effect on health outcomes in patients with AUB and other disorders/diseases.

Levonorgestrel Intrauterine System (MIRENA): Initial Experience in the Management of Abnormal Uterine Bleeding

Introduction: The Levonorgestrel intrauterine system (MIRENA) is a long acting contraceptive device act by releasing progesterone into the uterus It is also efficient in medical management of abnormal uterine bleeding. Levonorgestrel intrauterine system is best option for those ladies who want to avoid surgery in cases of abnormal uterine bleeding.&#x0D; Aims: To assess the effectiveness of MIRENA in abnormal uterine bleeding.&#x0D; Methods: This is a hospital based cross sectional study done at the department of obstetrics and gynecology in ladies with history of abnormal uterine bleeding. The study was done from January 2020 to January 2022 for a period of two years. Data were collected, recorded in standard Proforma and analyzed by using EESPPS version 17.&#x0D; Results: Majority of patients were multipara of age group 35-40 yrs. Mirena caused decrease in heavy menstrual blood loss by 2.4% in 4month of use and 47.6% by one year. After one year of use 83.3% patient had better compliance, 9.5% had expulsion, and only 7.1% had to undergo hysterectomy.&#x0D; Conclusion: Mirena is the best alternative in the medical management of abnormal uterine bleeding with good patient compliance reducing the rate of hysterectomy.

Real-world Safety and Effectiveness Analysis of Norethisterone in the Management of Abnormal Uterine Bleeding

Real-world Safety and Effectiveness Analysis of Norethisterone in the Management of Abnormal Uterine Bleeding

Telemedicine in the Evaluation and Management of Abnormal Uterine Bleeding: A Practical Approach

Telemedicine in the Evaluation and Management of Abnormal Uterine Bleeding: A Practical Approach

Social Vulnerability Index and Surgical Management of Abnormal Uterine Bleeding in Reproductive-age Women

To determine whether surgical management of abnormal uterine bleeding (AUB) is associated with social vulnerability index (SVI). A retrospective cohort. A total of 7 hospitals and 4 ambulatory surgery centers within a large New York health system. All patients between 15 and 45 years of age who underwent either a hysterectomy or myomectomy for AUB between January 2019 and October 2021. None. Home addresses were linked to census tracts and SVI scores. SVI is composed of 4 themes that potentially influence a community's vulnerability to health stressors: socioeconomic status, household composition and disability, minority status and language, and housing type and transportation. Multiple logistic regression analyses were performed to evaluate the association between SVI and surgical procedure/approach, adjusting for age, race and ethnicity, marital status, insurance, language, body mass index, and previous abdominal surgery. A total of 1628 patients were included. On performing regression analysis between SVI quarters and type of surgery, the odds of undergoing laparotomy for the hysterectomy group were not affected by SVI composite score both before and after adjusting for alternative factors (odds ratio [OR] and adjusted OR). Among those who had a myomectomy, individuals in SVI Q3 had 1.86 times (95% confidence interval, 1.27-2.72) higher odds of having a laparotomy than those in SVI Q1. Individuals in SVI Q4 had 1.74 times (95% confidence interval, 1.15-2.62) higher odds of having a laparotomy than those in SVI Q1. Although some unadjusted ORs were statistically significant in the myomectomy group, when adjusted for social, demographic, and economic factors, the results were not statistically significant. Patients living in more vulnerable communities are less likely to have minimally invasive hysterectomy or myomectomy for the management of AUB. Neighborhood characteristics are independently associated with surgical procedure and approach.

Highly Differentiated Follicular Thyroid Carcinoma Arising from Struma Ovarii at the Time of Hysterectomy

We present the case of a 43-year-old Gravida 2 Para 2 0 0 2 referred for surgical management of abnormal uterine bleeding with an 11 cm myoma uterus on ultrasound. Endometrial biopsy demonstrated an endometrium without hyperplasia or malignancy. She had a history of left salpingo-oophorectomy for struma ovarii 3 years earlier, which involved ovarian cyst drainage and removal through mini-laparotomy without a specimen retrieval bag.

Role of Transvaginal Ultrasound in Management of Abnormal Uterine Bleeding

Aim: To evaluate the transvaginal ultrasound in management of abnormal uterine bleeding. Place and duration of study: Department of Radiology, Ghulam Muhammad Mahar Medical College Hospital Sukkur from 1st July 2021 to 31st December 2021. Methodology: In this prospective study one hundred patients were enrolled. The patients were scrutinized on bases of their abnormal uterine bleeding and underwent transvaginal ultrasound. The clinical and demographic information was recorded and the sonographic results were evaluated. Results: There was no significant difference of age with the number of their births. Menorrhagia was observed in 13% while 57(57%) had metrorrhagia and 30% were having menometrorrhagia. The abnormal uterine bleeding diagnosis was made and it was seen that 61% leiomyoma, 22% polyp, 12% adenomyosis and 5% endometrial adenocarcinoma cases were presented respectively. Within these cases endometrial adenocarcinoma had transvaginal scan sensitivity of 100% followed by leiomyoma as 93% transvaginal scan sensitivity in cases. Conclusion: Transvaginal ultrasound is an efficient way of managing abnormal uterine bleeding. Keywords: Uterine bleeding, Transvaginal, Ultrasonography

Abnormal uterine bleeding in adolescents

Abnormal uterine bleeding (AUB) is a common diagnosis in the adolescent female population. In recent years, changes have been made to standardize nomenclature, evaluation and management of AUB in adolescents. The terms "abnormal uterine bleeding" and "heavy menstrual bleeding" have replaced terms including "dysfunctional uterine bleeding," "menorrhagia," "metrorrhagia", and "menometrorrhagia." Due to a high prevalence of these diagnoses in this population and resulting effects on quality of life, clinicians should understand and practice current evidence-based care, yet variability continues to exist. Evaluation should be focused on common etiologies of AUB in adolescents, namely non-structural causes, rather than those etiologies more common in adult females. The aim of this article is to review the existing definition, etiologies, pathophysiology, evaluation and management of AUB in adolescent females, with an emphasis on current universally accepted nomenclature and guidelines for use in clinical care.

Diagnostic hysteroscopy is a better method for diagnosis and management of abnormal uterine bleeding than traditional methods – An Indian perspective

Introduction: Abnormal uterine bleeding (AUB) is one of the common problems affecting at least one fourth women in reproductive age group. Currently transabdominal and transvaginal sonography is the most commonly used primary screening modality, whereas uterine dilatation and curettage (D&amp;C) is most the commonly used technique for diagnosis and obtain uterine biopsy. However they have various disadvantages. Diagnostic hysteroscopy and biopsy is gradually emerging as the gold standard for AUB. This study evaluates the role of hysteroscopy in diagnosing various intrauterine pathologies. Materials and methods: This study was a hospital record based retrospective observational study. Data of 172 patients who underwent hysteroscopy for AUB were included and hysteroscopic diagnosis was compared with final histopathology to find out the sensitivity, specificity and positive predictive value of hysteroscopy for diagnosing various common intrauterine pathology. Results: Results show that hysteroscopy has high sensitivity and specificity for diagnosis of intrauterine pathology. The study results are in concordance with the findings in few other similar studies. Conclusion: The authors recommend preferring use of this technique over traditional D&amp;C for both diagnostic and therapeutic indications in AUB. Keywords: metrorrhagia, hysteroscopy; uterine; dilatation; curettage