Menstrual Loss Research Articles

Comprehensive Evaluation of Bleeding Disorders in Adolescents with Heavy Menstrual Bleeding

Introduction: Unpredictable, prolonged or heavy menstrual bleeding (HMB) is not unusual in many adolescents soon after menarche. Anovulation, owing to immaturity of the hypothalamic-pituitary-ovarian axis, is often the cause of HMB; however, it may coexist and mask an underlying bleeding disorder (BD). Retrospective data in adolescents with HMB suggest a prevalence of BDs from 10 to 62%. Prospective studies with uniform hemostatic evaluation and concurrent quality of life (QoL) assessments have not been performed. The incidence of BDs in adolescents, especially those with anovulatory bleeding, remains unknown. Methods: In this ongoing prospective cohort study (targeted n=200), 130 adolescents referred for HMB to multidisciplinary Young Women's Blood Disorders Clinics were enrolled. An assessment of menstrual loss using pictorial blood assessment chart (PBAC) and bleeding symptoms using ISTH-bleeding assessment tool (BAT) was undertaken. Participants underwent a comprehensive evaluation determined a priori, including assessment of hypermobility, standardized laboratory evaluation (prothrombin time, activated partial thromboplastin time, fibrinogen, thrombin time, von Willebrand disease (VWD) panel, whole blood platelet aggregation with ATP secretion, factor assays (FIX and FXIII), global hemostasis and hyperfibrinolysis using ROTEM, and a pelvic ultrasound (US). Patient reported outcomes for health related QoL(HR-QoL) was completed. Results: The mean age of participants was 14 (range 11-18) and mean age at menarche was 11.7 yrs. (range: 9-16). The mean PBAC score, before contraceptive initiation, was 504 (range: 100- 1200) and the mean ISTH BAT score was 3.8 (range: 1-8) in all participants. 62% had anovulatory menstrual bleeding. An inherited BD and/or bleeding risk was diagnosed in 24.6% (n=32); 9% (n=12) were diagnosed with VWD, 5% (n=6) with qualitative platelet dysfunction and 2 subjects were found to be hemophilia A (HA) carriers. Low VWF levels (VWF:Rco 30-50%) were detected in 9% (n=12). 15% had evidence of mild systemic hyperfibrinolysis (lysis 3-8% on ROTEM) but none met the criteria for further investigation for an inherited disorder of hyperfibrinolysis . Of those without BD, 2 were diagnosed to have VWF exon 28 polymorphism, and 3 were referred and ultimately diagnosed with hypermobility syndrome by Genetics. One was found to have endometriosis by laparoscopy and 3 were diagnosed with PCOS. Of those with BDs (all with low VWF), 3 were diagnosed with hypermobility syndrome (total 6) and 4 with PCOS (total 7). US was normal in all subjects. The PBAC scores were higher in BDs (634 vs. 410; SD ± 275 p=0.002), irrespective of the pattern of bleeding. No differences were found in the ISTH BAT scores (after excluding HA carriers) (3.6 vs. 4.8; SD ± 1.19, p=0.06), initial hbg or ferritin levels between the two groups. Only 6% (n=8) with BDs required ED visit and/or hospitalization for HMB vs. 14% (n=18) without a BD, of which majority had anovulatory bleeding. On multivariate logistic regression, no predictors of BDs were found. Adolescents with BDs had a decreased HR-QoL compared to those without a BD (QoL score 58 vs.87; SD± 12.5, p=<0.001) even after control of HMB and correction of anemia. Conclusions: Inherited BDs are common in adolescents with HMB, confer a decreased HR-QoL and can be associated with anovulatory bleeding. A comprehensive evaluation is required to unravel disorders causing HMB. In this ongoing study, at this time, no predictor of an inherited BD was found in adolescents with HMB. Data accrual from the fully powered, ongoing, prospective study may offer further data to develop an ideal tool with a scoring system to take into account all prevalent causes of HMB to accurately predict a BD in adolescents. Disclosures Zia: NHLBI K23: Research Funding. Journeycake:CSL: Consultancy; Biogen: Consultancy; Baxalta/Shire: Consultancy. Jain:Novo Nordisk: Honoraria; Bayer: Membership on an entity's Board of Directors or advisory committees; Biogen: Speakers Bureau. Sarode:CSL Behring: Consultancy, Honoraria.

Abnormal Contour Huge Uterine Fibroids

Uterine fibroids represent the most common large solid benign tumor of the female genital tract. This 35 years old lady, mother of one child represented to our clinic with a history of progressive abdominal swelling that had rapidly increased in the last two years. There were associated abdominal pain, easy fatigability, heavy menstrual loss and prolong secondary subfertility of about ten years. On examination abdomen was enlarged and the mass measuring about 25cm from xiphisternum, firm, irregular and fairly mobile. Pelvic ultrasound scan revealed features of huge multiple uterine fibroids and the size of the largest one was about 20x25cm,moderate bilateral hydro-nephrosis. Intraoperative findings were moderate pelvic adhesions, huge multiple fibroids and the largest measuring about 18x20cm. Total abdominal hysterectomy with preservation of both ovaries were done. Histopathological report confirmed benign leiomyoma with no evidence of malignancy.Medicine Today 2015 Vol.27(2): 49-50

The effectiveness of the levonorgestrel intrauterine system in obese women with heavy menstrual bleeding.

To evaluate the effectiveness of the levonorgestrel intrauterine system (LNG-IUS) in obese women with heavy menstrual bleeding in Counties Manukau Auckland area, New Zealand. Prospective observational study in a tertiary teaching hospital. Twenty women with heavy menstrual bleeding (HMB) who agreed to treatment with the LNG-IUS and had a body mass index (BMI) of >30kg/m2 were recruited between May and December 2014. The women completed two validated tools (Menstrual Impact Questionnaire and the Pictorial Bleeding Assessment Chart) at recruitment, 6 and 12months follow-up. Demographic, medical and laboratory variables were obtained from the relevant CMH databases. Data on side effects and satisfaction were obtained from the women at 12months. The median age (range) and BMI of the 20 women were 40.5years (27-52years) and 40.6kg/m2 (30-68), respectively. Three LNG-IUS were removed due to infection and pain and these women were subsequently booked for a hysterectomy. The reduction in menstrual loss was estimated at 19.7% per month (95% CI (12.5%, 26.2%); P<0.001), which translates to 73.2% per period of 6months (95% CI (55.3%, 83.9%)) and 92.8% per period of 12months (95% CI (80.0%, 97.4%)). The six items in the quality of life measure improved significantly in 14 women but only 12 women were satisfied with the treatment. The LNG-IUS was an effective treatment for 67% of obese women with heavy menstrual bleeding over a 12-month period, as assessed by the reduction in menstrual bleeding and the improvement in the quality of life measures.

Hepcidin is a Better Predictor of Iron Stores in Premenopausal Women than Blood Loss or Dietary Intake.

The relationship between dietary intake, circulating hepcidin and iron status in free-living premenopausal women has not been explored. This cross-sectional study aimed to identify dietary determinants of iron stores after accounting for blood loss and to determine whether iron intake predicts iron stores independently of hepcidin in a sample of Australian women. Three hundred thirty eight women aged 18–50 years were recruited. Total intake and food sources of iron were determined via food frequency questionnaire; the magnitude of menstrual losses was estimated by self-report; and blood donation volume was quantified using blood donation records and self-reported donation frequency. Serum samples were analysed for ferritin, hepcidin and C-reactive protein concentrations. Linear regression was used to investigate associations. Accounting for blood loss, each 1 mg/day increase in dietary iron was associated with a 3% increase in iron stores (p = 0.027); this association was not independent of hepcidin. Hepcidin was a more influential determinant of iron stores than blood loss and dietary factors combined (R2 of model including hepcidin = 0.65; R2 of model excluding hepcidin = 0.17, p for difference <0.001), and increased hepcidin diminished the positive association between iron intake and iron stores. Despite not being the biggest contributor to dietary iron intake, unprocessed meat was positively associated with iron stores, and each 10% increase in consumption was associated with a 1% increase in iron stores (p = 0.006). No other dietary factors were associated with iron stores. Interventions that reduce hepcidin production combined with dietary strategies to increase iron intake may be important means of improving iron status in women with depleted iron stores.

Menstrual loss of renal function: a case of mefenamic acid induced renal cortical necrosis.

Menstrual loss of renal function: a case of mefenamic acid induced renal cortical necrosis.

Medical intervention in adolescent menorrhagia

Objectives: To find out causative factors of adolescent menorrhagia and success of various treatments. Design: Descriptive cross sectional study Place &amp; duration of study: Lady Willingdon Hospital, Lahore from May 2004 to April 2005. Subject and methods: Fifty unmarried patients at 12-19 years with menorrhagia selected by non-probability convenience sampling. Blood loss was determined by duration of bleeding extending beyond seven days, passage of clots and presence of anaemia. Results: The most common cause of menorrhagia was DUB (92%) followed by bleeding and endocrinal disorder. Non-steroidal anti-inflammatory drug and antifibrinolytic agent produced 75% subjective improvement in complaints. However, combined oral contraceptive produced 66% improvement. Conclusion: NSAIDS and antifibrinolytic drugs were found to be effective in reducing menstrual loss and should be used as first line of treatment.

Von Willebrand Factor for Menorrhagia: A Survey and Literature Review

Von Willebrand Factor for Menorrhagia: A Survey and Literature Review

Transvaginal sonographic features of diffuse adenomyosis in 18-30-year-old nulligravid women without endometriosis: association with symptoms.

To investigate whether there are sonographic features of diffuse adenomyosis in 18-30-year-old nulligravid women without endometriosis and to examine their association with symptoms of dysmenorrhea and abnormal uterine bleeding. This was a prospective observational study including women referred from a gynecology outpatient center to our university hospital for ultrasound examination. Inclusion criteria were age between 18 and 30 years, regular menstrual cycle and nulligravid status. Exclusion criteria were a past or current history of endometriosis, fibroids, ovarian cysts or lesions, endometrial pathology, current use of hormonal treatments or medications that would affect the menstrual cycle, previous uterine surgery and history of infertility. Women underwent a detailed clinical assessment and a two- (2D) and three-dimensional (3D) transvaginal ultrasound (TVS) examination. 2D-TVS features associated with diffuse adenomyosis were predefined as: (1) heterogeneous myometrium; (2) hypoechoic striation in the myometrium; (3) myometrial anechoic lacunae or cysts; (4) asymmetrical myometrial thickening of the uterine walls with the presence of straight vessels, extending into the hypertrophic myometrium, on power Doppler examination. On 3D-TVS, endomyometrial junctional zone (JZ) was measured as the distance from the basal endometrium to the internal layer of the outer myometrium on coronal section at any level of the uterus, and the smallest (JZmin) and largest (JZmax) JZ thicknesses and their difference (JZdiff) were recorded. 3D-TVS evaluation was considered suggestive for adenomyosis when JZmax ≥ 8 mm and/or JZdiff ≥ 4 mm. The presence of associated symptomatology represented our main outcome: the amount of menstrual loss was assessed by a pictorial blood loss analysis chart (PBAC) and painful symptoms were evaluated using a visual analog scale (VAS). During the observation period, 205 women (median age, 24 (interquartile range, 23-27) years) were enrolled into the study and 156 met the inclusion criteria. According to the 2D-TVS criteria, diffuse adenomyosis was found in 53 (34.0%) women and asymmetrical myometrial thickening of the uterine walls was the most common sonographic feature observed. ANOVA showed a significant relationship between the number of 2D-TVS features of diffuse adenomyosis and VAS score for dysmenorrhea (P = 0.005) as well as PBAC score for menstrual loss (P = 0.03). 3D-TVS showed that women with 2D-TVS features of diffuse adenomyosis had a significantly higher value of JZmax (6.38 ± 2.30 mm, P < 0.001), JZmin (2.07 ± 0.43 mm, P = 0.002) and JZdiff (4.33 ± 1.99 mm, P < 0.001) than did women without these features. Women with sonographic features of diffuse adenomyosis were symptomatic in 83% of cases, reported dysmenorrhea in 79.2% and showed a higher incidence of heavy bleeding than did those without these features (18.9% vs 2.9%; P = 0.001). Sonographic features suggestive of diffuse adenomyosis may develop earlier in reproductive life than previously thought, and may occur in association with dysmenorrhea and abnormal uterine bleeding in nulligravid women. Their observation in these women should therefore warrant further gynecological investigation.

Endometrial ablation and steam vaporisation: the true first generation ablative technique.

Endometrial ablative techniques have become an established method of treatment for women with menstrual disorders. The study by Sambrook et al. and the Mini Commentary by Munro comparing balloon ablation and microwave ablation (Sambrook et al., BJOG 747–53) was a timely reminder of the long history of innovation that has led to the current endometrial ablation techniques. The underlying premise, that burning or cauterising the endometrium might produce a reduction in menstrual loss, is one that appealed to clinicians even in the 19th century, and where the mortality for hysterectomy was so high, a viable alternative worth investigating. One of the leading investigators in the UK in this field was G. F. Blacker, who is described as an Obstetric Physician to the University College Hospital, London, although in possession of the FRCS as well as FRCP and MD. He wrote an extensive description of the history of the developments in the field up until that point and his experience of the procedure (Blacker, Br J Obstet Gynaecol 1902;488–511). He subsequently described the histological effects of vaporisation after 14 days in a woman undergoing the operation and subsequently having a vaginal hysterectomy for suspected malignancy (Blacker, Br J Obstet Gynaecol 1903;3:444–7). Although not the first to attempt ‘vaporisation of the uterus’, the modern revival of the procedure is credited by Blacker to Professor Senguireff of Moscow (Figure 1). His equipment and techniques were improved by Ludwig Pincus of Danzig, whose modifications Blacker employed (Figure 2). Pincus employed steam in two ways: atmocautery, which was the direct application of steam to the endometrium, and zestocautery, where the steam was used to heat a hollow intra-uterine metal tube. Modern endometrial ablation techniques could therefore be considered a form of zestocautery by this definintion. Interestingly, while considering that anaesthesia is preferable in the great majority of cases, Blacker did suggest that uterine vaporisation could be conducted without anaesthetic, and even commented that the procedure could be conducted as an outpatient procedure. This has only recently become a practical reality (Oláh et al., BJOG 2005;112;1117–20). In the description by Blacker, Pincus had the largest series of patients at the time. He collected 833 cases, of whom 749 were cured or benefitted from the procedure, with three deaths. At this time this mortality rate was about the same as that experienced for the operation of curettage. It seems suprising, therefore, that the procedure did not find a more widespread application at the time. However, there were other techniques available to clinicians willing to try them, and the new and fashionable power source, electricity, formed the basis for galvanic cauterisation (Braxton Hicks, Br Med J 1874;2:672–3). However, as the improvements in surgical technique and aseptic conditions were adopted, surgical mortality and morbidity fell rapidly at the beginning of the 20th century. The result was that most of the techniques of endometrial ablation were forgotten until the end of the 20th century, when endometrial resection rekindled an interest in this aspect of management. These early techniques of ‘steam vaporisation’, and galvanic cauterisation are the true ‘first generation’ endometrial ablation methods. None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Sigmoidouterine Fistula: Anal Menstruation as a Rare Presentation

Background: Anal menstruation due to sigmoidouterine fistula in the anterior wall of the uterus has not been reported so far. Case: A thirty year old female presented to us with periodical anal bleeding without natural menstrual loss one year after dilatation and curettage for 10 weeks’ gestation. Hysterosalpingography raised the doubt of a fistulous tract between the uterus and the bowel with the dye present in the bowel.MRI revealed thinning of the anterior wall of the retroverted uterus with colon adherent to its anterior surface. Excision of the fistula along with a segment of sigmoid colon was done in a single stage. Conclusion: High degree of suspicion and planned investigations are required to reach at the diagnosis of such a bizarre condition.

Microwave endometrial ablation versus thermal balloon endometrial ablation (MEATBall): 5‐year follow up of a randomised controlled trial

To compare long-term outcomes following microwave endometrial ablation (MEA™) and thermal balloon ablation (TBall). Follow up of a prospective, double-blind randomised controlled trial at 5years. A teaching hospital in the UK. A total of 320 women eligible for and requesting endometrial ablation. Eligible women were randomised in a 1:1 ratio to undergo MEA or Tball. Postal questionnaires were sent to participants at a minimum of 5years postoperatively to determine satisfaction with outcome, menstrual status, bleeding scores and quality of life measurement. Subsequent surgery was ascertained from the women and the hospital operative database. The primary outcome measure was overall satisfaction with treatment. Secondary outcomes included evaluation of menstrual loss, change in quality of life scores and subsequent surgery. Of the women originally randomised 217/314 (69.1%) returned questionnaires. Nonresponders were assumed to be treatment failures for data analysis. The primary outcome of satisfaction was similar in both groups (58% for MEA™ versus 53% for TBall, difference 5%; 95% CI -6 to 16%). Amenorrhoea rates were high following both techniques (51% versus 45%, difference 6%; 95% CI -5 to 17%). There was no significant difference in the hysterectomy rates between the two arms (9% versus 7%, difference 2%; 95% CI -5 to 9%). At 5years post-treatment there were no significant clinical differences in patient satisfaction, menstrual status, quality of life scores or hysterectomy rates between MEA™ and Thermachoice 3, thermal balloon ablation.

Is adenomyosis associated with menorrhagia?

Is the presence of adenomyosis associated with menorrhagia? There was no significant association between adenomyosis and menorrhagia, but there was a significant positive correlation between the severity of adenomyosis on ultrasound and the amount of menstrual loss estimated using pictorial blood loss assessment charts. There is no consensus in the literature with regards to the association between adenomyosis and menorrhagia. Previous studies have been limited to retrospective studies of highly selected populations which mainly included women who underwent hysterectomy. There are no large prospective studies evaluating the association between adenomyosis and menorrhagia, either in the general population of women or in a general gynaecology clinic setting. This was a prospective observational study set in the general gynaecology clinic of a university teaching hospital between January 2009 and January 2010. There were 714 consecutive premenopausal women who attended the clinic and underwent structured clinical and transvaginal ultrasound examination in accordance with the study protocol. Morphological features of adenomyosis were systematically recorded on ultrasound scan. Menorrhagia was determined subjectively by direct questioning and objectively by completion of pictorial blood loss analysis charts. A diagnosis of adenomyosis was made in 157/714 women [22.0% (95% CI: 19.1-25.2%)]. Multivariable analysis showed significant associations between submucous fibroids [OR 5.60 (95% CI: 2.69-11.6)], any fibroids [OR 1.53 (95% CI: 0.91-2.58)] and endometrial polyps [OR 2.81 (95% CI: 1.15-11.7)] and menorrhagia. There were also significant associations between increasing gravidity and BMI and menorrhagia (P < 0.01). There was no significant association between adenomyosis and menorrhagia in the study population, when adenomyosis was assessed as a binary outcome. When severity of adenomyosis was assessed by counting the number of morphological features of adenomyosis in each woman, we found a significant 22% increase in menstrual loss for each additional feature of adenomyosis [OR 1.21 (95% CI: 1.04-1.40)]. A classification of severity of adenomyosis based on the number of ultrasound features present is a novel concept that should be prospectively evaluated in different populations. A better understanding of the relationship between adenomyosis and menorrhagia can help improve counselling of women regarding the significance of this common condition and facilitate future studies assessing the effectiveness of different conservative treatments protocols. The authors have no competing interests. The study was not supported by an external grant.

TMPRSS6 rs855791 polymorphism influences the susceptibility to iron deficiency anemia in women at reproductive age.

Background: Genome-wide-association studies have identified the TMPRSS6 polymorphism rs855791 has the strongest association with red blood cell indices or iron parameters in general population. Whether this genetic variant influences the susceptibility of iron deficiency anemia (IDA) in women with menstruation has not been well studied.Methods: In this case-control study, we enrolled 67 women with IDA and 107 healthy volunteers, and analyzed their complete blood counts, rs855791 genotypes, and menstrual amounts. Menstrual blood loss was evaluated with a pictorial blood-loss assessment chart.Results: There were significantly fewer rs855791 C homozygotes in the IDA group than in the healthy group (11.9% vs. 25.2%, p = 0.03). The odds ratio (OR) of C homozygotes having IDA versus non-CC subjects having IDA was 0.4 (95% CI, 0.17 - 0.95, p = 0.04). When the analysis was confined to study subjects with menorrhagia, this difference became more prominent (9.6% vs. 28.6%, p = 0.01; OR, 0.27, 95% CI, 0.09 - 0.77, p = 0.01). For women with non-CC genotypes, there was an inverse correlation between hemoglobin levels and menstrual loss (p < 0.001); however, this association was not found for those with genotypes CC (p = 0.15).Conclusions: Our study suggests homozygosity for TMPRSS6 rs855791 C genotype has a protective role against IDA in women at reproductive age, especially in those with menorrhagia.

Validation of a new menstrual pictogram (superabsorbent polymer-c version) for use with ultraslim towels that contain superabsorbent polymers

To validate the menstrual pictogram (superabsorbent polymer-c version) for Always Ultra-slim feminine towels containing superabsorbent polymers. Prospective, multicenter, evaluator-blinded study. Three gynecology research clinics in the United Kingdom. Women with self-perceived light, normal, or heavy menstrual periods who had not previously used a graphical method to assess their menstrual loss. One hundred twenty-two women were asked to complete the menstrual pictogram throughout two menstrual periods and collect their feminine towels for measurements of menstrual blood loss (MBL) by the alkaline hematin method and total menstrual fluid loss (MFL) by fluid weight. Agreement of menstrual pictogram MBL and MFL scores with alkaline hematin and towel weight, respectively. The percentage blood fraction was determined at various volumes of menstrual discharge. Alkaline hematin and fluid weight were highly correlated (r = .97). However, the percentage blood fraction progressively increased with total MFL and MBL score. After correction for this incremental rise in blood fraction, the menstrual pictogram gave a sensitivity of 82% and a specificity of 92% for a diagnosis of heavy menstrual bleeding. The menstrual pictogram (superabsorbent polymer-c version) provides a simple means of measuring MBL in the clinical setting.

Hemorrhage-Adjusted Iron Requirements, Hematinics and Hepcidin Define Hereditary Hemorrhagic Telangiectasia as a Model of Hemorrhagic Iron Deficiency

BackgroundIron deficiency anemia remains a major global health problem. Higher iron demands provide the potential for a targeted preventative approach before anemia develops. The primary study objective was to develop and validate a metric that stratifies recommended dietary iron intake to compensate for patient-specific non-menstrual hemorrhagic losses. The secondary objective was to examine whether iron deficiency can be attributed to under-replacement of epistaxis (nosebleed) hemorrhagic iron losses in hereditary hemorrhagic telangiectasia (HHT).Methodology/Principal FindingsThe hemorrhage adjusted iron requirement (HAIR) sums the recommended dietary allowance, and iron required to replace additional quantified hemorrhagic losses, based on the pre-menopausal increment to compensate for menstrual losses (formula provided). In a study population of 50 HHT patients completing concurrent dietary and nosebleed questionnaires, 43/50 (86%) met their recommended dietary allowance, but only 10/50 (20%) met their HAIR. Higher HAIR was a powerful predictor of lower hemoglobin (p = 0.009), lower mean corpuscular hemoglobin content (p<0.001), lower log-transformed serum iron (p = 0.009), and higher log-transformed red cell distribution width (p<0.001). There was no evidence of generalised abnormalities in iron handling Ferritin and ferritin2 explained 60% of the hepcidin variance (p<0.001), and the mean hepcidinferritin ratio was similar to reported controls. Iron supplement use increased the proportion of individuals meeting their HAIR, and blunted associations between HAIR and hematinic indices. Once adjusted for supplement use however, reciprocal relationships between HAIR and hemoglobin/serum iron persisted. Of 568 individuals using iron tablets, most reported problems completing the course. For patients with hereditary hemorrhagic telangiectasia, persistent anemia was reported three-times more frequently if iron tablets caused diarrhea or needed to be stopped.Conclusions/significanceHAIR values, providing an indication of individuals’ iron requirements, may be a useful tool in prevention, assessment and management of iron deficiency. Iron deficiency in HHT can be explained by under-replacement of nosebleed hemorrhagic iron losses.

Iron-dependent erythropoiesis in women with excessive menstrual blood losses and women with normal menses

In women of fertile age, iron loss consequent to excessive menstrual discharge is by far the most frequent cause of iron-deficient anemia. However, the relationship between menstrual discharge and iron loss is poorly understood. In this prospective study, total menstrual and iron losses were assayed in a large cohort of non-anemic women and women with excessive menstrual blood losses (menorrhagia) in order to provide data useful for intervention. One hundred and five Caucasian women aged 20-45 years were recruited. Blood cell count and serum ferritin (SF) levels were determined in each case before menses. Menstrual fluid losses (MFL) were determined using a standardized pads' weight method. Hematin concentration was assayed by a variant of the Alkaline Hematin Method from which iron concentration was calculated. Mean SF levels were 36.2 (range 8.6-100) ng/ml in healthy women and 6.4 (range 5-14) ng/ml in patients with menorrhagia. Median values of iron lost/cycle were 0.87 mg in healthy women and 5.2 mg in patients with menorrhagia (ranges 0.102-2.569 and 1.634-8.665 mg, respectively, p < 0.001). In women with menorrhagia, iron lost/cycle strongly correlated (0.789, p < 0.001) with MFL. In conclusion, healthy women with normal menses lose, on average, 1 mg iron/cycle. Average iron losses in patients with menorrhagia are, at least in our cohort, on average, five-to-six times higher than normal. Most women with menorrhagia had totally depleted iron stores. Indirect, quantitative evaluation of iron lost with menses may be useful to assess the risk of developing iron-deficient anemia in individual patients.

A new menstrual pictogram for use with feminine products that contain superabsorbent polymers

To determine whether the menstrual pictogram (the superabsorbent polymer-c or SAP-c version) can reliably estimate blood and total menstrual fluid volumes on prestained Always Ultra slim feminine towels (Proctor & Gamble) that contain superabsorbent polymers. Randomized blinded study using simulated menstrual fluid (SMF: 50% blood, 50% saline mixture). Gynecology research clinic. 12 premenopausal women with regular menstrual cycles who had not previously used a graphical method to assess menstrual loss. None. Assignment of 135 prestained towels containing known volumes of 0.5-25.0 mL of SMF to five pictorial icons of the menstrual pictogram, and correlation of pictogram scores to blood recovered from towels by the alkaline hematin method and total fluid applied to towels by measurement of soiled towel weight. There was a high level of agreement between individual scores. For 112 (83%) of 135 towels, the participants' readings either completely concurred or differed by only a single icon. There was a statistically significant correlation between the volume of blood applied (SMF/2) and that recovered by alkaline hematin, and volume of fluid applied and soiled towel weight. The menstrual pictogram (SAP-c version) is a potential diagnostic tool for heavy menstrual bleeding and would be suitable for testing in a clinical trial.

English

BACKGROUND: Anemia continues to be a major public health problem worldwide, particularly in the developing country settings. The prevalence of anemia in females is disproportionately high in the developing countries mainly due to poverty, inadequate diet, malaria and other parasitic infection, poor access to health services and repeated pregnancy. AIM: The aim of this study is to find out the prevalence of anemia, in school going adolescent females in the age group of 12-15yrs in a village school and to know the prevalence of iron deficiency in both the anemic and non anemic school going adolescent females in a village school. MATERIAL AND METHODS: Present study is carried out in the Department of Pathology, Rural Medical College in Maharashtra situated in Central India. A secondary school in the neighborhood, having hundred girl students in the age group of 12-15years studying in VI to IX standard was selected. Screening for anemia and iron deficiency was done by: 1.Complete blood count: done by automatic cell counter i.e. Coulter for hemoglobin concentration.2.Estimation of serum ferritin concentration: was done by ELISA. RESULT: 63 of 100 girl students had hemoglobin levels less than 12 gm%. Anemia (hemoglobin <12 gm %) was present in 63% (63 out of 100) girls. Out of 63 girls who were anemic, 50 girls had reduced serum ferritin. Since the total number of students was 100, thus the prevalence of iron deficiency anemia was 50%. CONCLUSION: Iron deficiency is the major cause of anemia and most common nutritional disorder in our country and remains a formidable health challenge. Females in the period of later school age and early adolescence are prone to develop iron deficiency because, the nutrient requirements are high as the reserves are being laid for the subsequent rapid pubertal growth spurt, menstrual loss and also due to limited dietary iron intake

Kosttilskudd med jern ved jernmangel

A low supply of iron in the diet may result in iron deficiency and mild iron-deficiency anaemia in healthy individuals. Women are more susceptible than men because of menstrual iron loss. We compared the effect of a low dose of iron, administered as a dietary supplement, with a high pharmacological dose of iron to otherwise healthy individuals with iron deficiency and mild iron deficiency anaemia. In a randomised, double-blind trial conducted in 2000-2001, 73 women and three men with iron deficiency received either 27.6 mg of iron consisting of ferrous fumarate enriched with 13% haem iron, or 100 mg ferrosulphate daily for 12 weeks. Blood samples were analysed four times in the course of the treatment. The median ferritin value rose by 13 and 7 μg/l in the high-dose and low-dose group, respectively. The increase in ferritin was significantly higher in the high-dose than in the low dose group ( < 0.001). There was no statistically significant difference between the groups in the change in Hb, serum-iron or serum-iron binding capacity. The median haemoglobin value increased by 0.4 g/100 ml in both groups. Gastrointestinal side effects were experienced by 58% in the high-dose group and 35% in the low-dose group. Four subjects in the high-dose group and one in the low-dose group broke off the treatment because of side effects. A supplement of low-dose iron is enough to increase iron stores in cases of nutritional iron deficiency in healthy individuals and to optimise haemoglobin. High-dose iron caused the largest increase in iron stores. Low-dose iron resulted in the least side effects.

An Approach to the “Untransfusable” Patient

AbstractAbstract 4385The multiply alloimmunized patient poses a difficult predicament for clinicians, the hospital blood bank and duty hematologist. Whilst parallels may be drawn between patient blood management strategies used in the setting of blood refusal, others are unique to alloimmunization. There is limited literature guiding the management of the multiply alloimmunized patient requiring transfusion.We describe a 54-year-old lady who presented with symptomatic anaemia due to a delayed haemolytic transfusion reaction from an unidentifiable antibody. She had been transfused 2 units of red cells 13 days earlier in the setting of gastrointestinal bleeding. At this time she was found to have an anti- Fya antibody and was transfused with Rh matched, K negative, Fy(a-) and indirect anti-globulin test (IAT) cross-match compatible red cells. Her history included previous transfusions in the setting of bleeding, but no pregnancies. On admission hemoglobin (Hb) was 69 g/L [115 – 165], reticulocyte count 237× 109/L [20 – 100], bilirubin 33 μmol/L [<20] and haptoglobin <0.1 g/L [0.3 – 2.0]. Her blood film showed moderate polychromasia and nucleated red cells. A direct antiglobulin test was weakly positive (3/12) for IgG and C3d. Antibody investigations revealed a weakly positive auto-control and a new unidentifiable antibody. Subsequent testing identified 2 heterozygous mutations in exon 13 of the Lutheran gene: 1742A>T, encoding Gln581Leu and a silent 1671C>T, not affecting Ser557. These mutations are 2 out of the 3 mutations describing the LU- 13 genotype1. Our patient lacks the third mutation 1340C>T previously described.The patient's Hb dropped to 42 g/L and her treatment included bed-rest, intravenous iron, intramuscular vitamin B12, oral folate and erythropoietin. Whilst she had no active gastrointestinal bleeding she was given pantoprazole infusions and had a capsule endoscopy. She had a history of menorrhagia so was started on norethisterone and tranexamic acid to suppress menstrual loss. No first degree relatives were available for directed donation. She was transfused with 1 unit of IAT cross match compatible red cells together with 100mg prednisolone orally daily and 1g/kg intravenous immunoglobulin in an attempt to suppress immune haemolysis. She tolerated the transfusion well; however there was no increment in her Hb. Avoidance of unnecessary blood testing and pediatric collection tubes were used to reduce phlebotomy related loss. Over the next 10 days her Hb incremented without further transfusion to 78 g/L and had normalized by 4 weeks. Due to the need for future gastrointestinal surgery, on recovery of her Hb she had 5 autologous units of blood collected and frozen. Patient blood management strategies in the patient where the risk of potentially significant haemolytic reactions to transfusion is high must focus on minimizing blood loss, maximizing tissue oxygenation, promoting erythropoiesis and reducing metabolic needs. Approaches to lessen blood loss include early radiologic or surgical intervention to stop active bleeding, cessation or reversal of anticoagulants or aspirin and avoidance of medications or supplements associated with increased bleeding risk. Reducing phlebotomy-based blood loss includes minimizing the number of blood tests, using pediatric collection tubes and point of care devices. In our patient we investigated for ongoing bleeding sources, utilised proton pump inhibitors and used hormonal control for cessation of menstruation. Erythropoiesis was stimulated by the delivery of iron, folate, vitamin B12 and erythropoietin. Early investigation for associated coagulopathy or thrombocytopenia and early treatment with vitamin K, fresh frozen plasma and cryoprecipitate ensures that red cell volume is optimised.In a patient with multiple alloantibodies, the hospital blood bank should screen their inventory of donated red cells and consult with local and regional blood authorities. The blood typing of family members may allow for identification of potential donors. In the acute setting with an unstable haemorrhaging patient, the decision to transfuse the least incompatible blood may need to be considered. Long-term management plans may include autologous unit collection and identification of alloantibodies at a molecular level. Disclosures:No relevant conflicts of interest to declare.