Menstrual Loss Research Articles

Randomised comparative trial of the levonorgestrel intrauterine system and mefenamic acid for the treatment of idiopathic menorrhagia: a multiple analysis using total menstrual fluid loss, menstrual blood loss and pictorial blood loss assessment charts

To compare the efficacy and tolerability of the levonorgestrel intrauterine system (LNG IUS) with mefenamic acid in the management of objective idiopathic menorrhagia. Phase III, Single centre, open, randomised, comparative, parallel group study. District General Hospital in the United Kingdom. Fifty-one women with objective menorrhagia. Twenty-five women randomised to receive the LNG IUS and 26 to oral mefenamic acid for six cycles. Change from baseline in menstrual blood loss (MBL), total menstrual fluid loss (TMFL) and pictorial blood loss assessment chart (PBAC) score at the third and sixth cycle of treatment. After six cycles the median menstrual blood loss was 5 mL in the LNG IUS group and 100 mL in the mefenamic acid group (P < 0.001). Median TMFL was 27 mL in the LNG IUS group and 157 mL in the mefenamic acid group (P < 0.001). Median PBAC score was 25 in the LNG IUS group and 159 in the mefenamic acid group. Changes in menstrual blood loss correlated strongly to changes in TMFL (r= 0.88) but PBAC correlated less well to blood loss and total fluid loss (r= 0.53 and r= 0.58). Both the LNG IUS and mefenamic acid significantly decreased menstrual blood loss, TMFL and PBAC scores. The LNG IUS produced greater reductions in all parameters than mefenamic acid. Comparison of the different measurements suggests that TMFL assessment may be an easier and a more relevant measure of symptom severity than menstrual blood loss.

A randomised controlled trial of microwave endometrial ablation without endometrial preparation in the outpatient setting: patient acceptability, treatment outcome and costs

To compare outpatient microwave endometrial ablation (MEA) in the postmenstrual phase to standard MEA treatment after drug preparation in a day case theatre environment. A randomised controlled trial. A large United Kingdom teaching hospital. Two hundred and ten women complaining of excessive menstrual loss. Two hundred and ten women with excessive menstrual loss were randomised. Ninety-seven women were treated as outpatients in the immediate post-menstrual phase and 100 were treated in an operating theatre after hormonal preparation. All procedures were commenced under local anaesthesia with or without conscious sedation. Analysis was by modified intention to treat. Primary outcome measures were satisfaction with treatment (measured at one year) and acceptability of treatment (measured at two weeks). Secondary outcome measures were menstrual outcome and financial cost. Significantly more women found treatment post-menses acceptable; 86 (89.5%) versus 76 (76.0%) [difference in proportions 13.6%, 95% CI (3.0%, 23.9%)]. Similar numbers in each arm were totally or generally satisfied with the treatment, 86 (92.5%) versus 84 (88.4%) [difference in proportions 4.1%, 95% CI (-4.7%, 12.9%)] while amenorrhoea rates at one year were comparable, 52 (55.9%) versus 60 (61.9%). [difference in proportions -5.9%, 95% CI (-19.8%, 7.6%)]. The mean health service costs were 124 pounds (95% CI 86-194 pounds) lower for the patients in the post-menses group. MEA performed under local anaesthesia (with or without conscious sedation) in the post-menstrual phase achieves high levels of satisfaction is very acceptable to patients and results in significantly reduced health service costs. Importantly menstrual outcomes are not affected by omission of drug preparation. There is now good evidence to support the use of MEA, without drug endometrial preparation, in the outpatient setting.

Thermal ablation performed in a primary care setting: the South Warwickshire Experience

To assess the feasibility of performing outpatient thermal ablation in a primary care setting. Prospective study. A small peripheral hospital in the UK used by local general practitioners and visiting hospital practitioners for its outpatient facilities. The area of South Warwickshire serves a population of 270,000. Two general practitioners were trained to perform outpatient thermal ablation using the Thermachoice thermal ablation system (Thermachoice II). The unit functioned autonomously with support from a local gynaecologist and radiologist, accepting referrals from hospital consultants and general practitioners. Severity of menstrual loss, premenstrual symptoms, dysmenorrhoea and quality of life assessed by visual analogue scales before treatment and at one month, two months, one year and two years. Eighty-seven women were treated. No major complications were encountered from the procedure. Reduction of menstrual loss or cure was reported by over 94% of women. Premenstrual syndrome (PMS) and symptoms of dysmenorrhoea were also improved by treatment. The majority of women were satisfied with the operation at one month (96%), two months (93%), one year (92%) and two years (94%). Thermal ablation is a simple procedure well suited to an outpatient setting. There are few complications as a result of the use of the thermal ablation catheters, and this study has shown that the procedure can be undertaken in a primary care setting with excellent results.

Managing menorrhagia in primary care

Excessive menstrual loss is a major health-care problem. Every year in the UK, around 1 in 20 women aged between 30 and 49 years will consult their GP because of heavy menstrual bleeding, thus menorrhagia is a considerable burden on primary care resources and may ultimately lead to referral. Once a patient is referred, surgical intervention is highly likely. Effective medical treatments exist at a primary care level. Active education of good management of menorrhagia and promotion of effective medical management in primary care halves the number of referrals. Involving patients in the decision-making process may increase the effectiveness of treatment. To empower them to make informed choices, women need comprehensive and evidence-based information on menorrhagia and the treatment options available.

Managing menorrhagia: who and when to refer

GPs have different referral rates for menorrhagia despite the existence of authoritative explicit guidelines. Ideally a referral should be necessary, timely and effective. It is impractical to objectively measure menstrual loss in primary care. A woman is regarded as having menorrhagia if she perceives that the heaviness of her periods is interfering with her life, and affecting her overall well being. Practitioners use idiosyncratic criteria to assess patients, namely their personal and professional experience. Of women referred for menorrhagia, 27% did not actually perceive this to be the reason for their referral, illustrating the difficulty doctors have in assessing menstrual problems. Perceived patient pressure affects what a GP does and has great resource, and potential iatrogenic, implications. Inappropriate assessments of patients' expectations can result in actions deemed unnecessary by the doctor and unwanted by the patient. To maximise the benefit of the referral, the problem and reason for referral should be adequately communicated to the specialist. Reasons for referral are: 1 If serious pathology is suspected. 2 Failed medical treatment. 3 Patient choice. The decision to refer rests with the clinician in partnership with the patient. As with most decisions made in general practice, good communication skills are the key. Pressure to keep referral rates low should not stop access to a specialist. However using more adequate medical management and more detailed counselling and information, there is the potential for managing more women in primary care, to the benefit of women and health care resources.

The efficacy, side-effects and continuation rates in women with symptomatic endometriosis undergoing treatment with an intra-uterine administered progestogen (levonorgestrel): a 3 year follow-up

Side-effects and choice of drugs influence compliance during treatment for endometriosis. Progestogen administered by a device with a 5-year lifespan, has been shown to be an effective medical alternative with several advantages. The aims of this study were to investigate its efficacy, continuation rates and side-effects in women with endometriosis over a 3-year period. Thirty-four women with laparoscopically confirmed minimal to moderate symptomatic endometriosis offered insertion of an intrauterine device at diagnostic laparoscopy were followed up at 1, 3 and 6 months, and then every 6 months for 3 years. A symptom diary for side-effects, documentation of symptoms on a visual analogue scale (VAS), a verbal rating scale (VRS) and quantified menstrual loss using the pictorial blood loss chart was used to assess response to treatment. The continuation rates were respectively 85%, 68%, 62% and 56% at, 6, 12, 24 and 36 months. Discontinuation rates were highest at <12 months, and most of these were for irregular and intolerable bleeding and persistent pain. An improvement in symptoms was observed throughout the 36 months. The greatest changes in pain assessed by either the VAS or VRS were between the pretreatment scores and those after 12 months (7.7 +/- 1.3 versus 3.5 +/- 1.8 for VAS, P < 0.001; and 25 +/- 13.8 versus 14 +/- 9.4 for VRS, P < 0.002). The monthly quantified blood loss fell from 204 (196) pretreatment to 60 (50) at 12 months (P < 0.001) and then to 70 (30) after 36 months. The most common side-effects were bleeding irregularities (14.7%), one-sided abdominal pain (11.8%) and weight gain (8.8%). Intrauterine progestogen is effective in symptom control throughout the 3 years on the device, and discontinuation is greatest between 3 and 6 months. For those patients with improvement in symptoms, it is an acceptable long-term alternative.

A randomised comparison of microwave endometrial ablation with transcervical resection of the endometrium; follow up at a minimum of five years

To compare long term outcomes following microwave endometrial ablation (MEA) or transcervical resection of the endometrium (TCRE). Follow up of a randomised controlled trial. Gynaecology department of a large UK teaching hospital. Two hundred and thirty-nine participants in a randomised comparison of MEA with TCRE. Collection of patient completed postal questionnaires and operative databank review. Women's satisfaction with and acceptability of treatment, menstrual symptoms, changes in health-related quality of life and additional treatments received. Two hundred and thirty-six of the original 263 women returned questionnaires (90%) after a minimum of five years post-treatment. Women allocated to MEA were significantly more likely to be totally or generally satisfied with treatment (86% vs 74%; difference 12%, 95% CI 2% to 23%), to find it acceptable (97% vs 91%; difference 6%, 95% CI 1% to 13%) and would recommend it (97% vs 89%; difference 8%, 95% CI 1% to 14%). Bleeding and pain scores were highly significantly reduced following both MEA and TCRE, achieving amenorrhoea rates of 65% and 69%, respectively. The hysterectomy rate after a minimum of five years was 16% in the MEA and 25% in the TCRE arm. Both techniques achieve significant and comparable improvements in menstrual symptoms, and health-related quality of life. While high rates of satisfaction with treatment and acceptability of treatment are achieved by TCRE, these are significantly lower than levels following MEA. These long term data, when combined with the trials' operative findings and known costs of both procedures, now inform us that MEA is a more effective and efficient treatment for heavy menstrual loss than TCRE.

Acceptability and clinical performance of a copper-containing frameless IUCD in Hong Kong

This is the first study conducted in Hong Kong to evaluate the acceptability and clinical performance of a copper-containing frameless intrauterine contraceptive device (IUCD; GyneFix/Ji Ni™). Sixty-two women chose to use the frameless IUCD for contraception. A learning curve was demonstrated in the insertion technique of this new device. Pain associated with insertion was acceptable. No pregnancy was reported during the 1-year trial period. Objectively, the amount of menstrual loss did not change and dysmenorrhea improved, but the duration of menstrual flow was slightly prolonged during the use of this device. However, there was a 10.7% request rate for removal of the device because of its side effects. The expulsion rate during the first year was 5.3%, and the continuation rate at the end of the first year was 76.7%. It was found that 85% of the 40 subjects interviewed upon the completion of the 1-year trial period wished to replace the same device after the product expiry date and that 92.5% would recommend this device to their friends. In summary, the clinical performance of the frameless IUCD was comparable to its framed counterparts. The device was considered acceptable to a majority of the women.

Outpatient thermal balloon ablation of the endometrium

To determine the feasibility and potential efficacy of thermal balloon ablation of the endometrium in the outpatient setting without the need for general anesthesia or conscious sedation. Prospective observational study. Outpatient hysteroscopy clinic in a university-affiliated teaching hospital. Fifty-three consecutively recruited women with menorrhagia that was unresponsive to medical treatment. Thermal balloon endometrial ablation using local anesthetic without conscious sedation. Procedure feasibility, change in menstrual symptoms, and patient satisfaction and quality of life (Menorrhagia Utility Scale and EuroQol) at 6-month follow-up. Thermal balloon ablation was successfully completed in 50 (94%) of 53 women. The three failed procedures consisted of one case in which the woman could not tolerate the procedure because of severe discomfort, one case of equipment failure, and one case in which the balloon catheter could not be inserted into the uterine cavity. Completed outcome questionnaires were returned by 49 (98%) of 50 treated women. Improvement in menstrual loss was experienced by 39 (80%) of 49 women, and satisfaction with the outcome of treatment on menstrual symptoms was reported by 33 (67%) of 49 women. Significantly higher condition-specific quality-of-life scores were associated with treatment satisfaction. Thermal balloon ablation of the endometrium is feasible in the outpatient setting. Improvement in menstrual symptoms and satisfaction with the outcome of treatment appear to be comparable to published inpatient data. Further studies are required to determine the cost-effectiveness of outpatient compared with inpatient thermal balloon therapy.

Validating a pencil-and-paper measure of perimenopausal menstrual blood loss

In the study presented here, we describe our efforts to develop and validate a new measurement tool for perimenopausal menstrual blood loss. We validate this simple-to-use, subjective pencil-and-paper scale, the Mansfield-Voda-Jorgensen Menstrual Bleeding Scale (MVJ), against an objective measure, the weight of used menstrual products. Thirty-one women from the Minneapolis-St. Paul, MN region saved all their used products over three menstrual cycles, storing them in airtight zip bags, and rated their menstrual fluid volume loss using the MVJ. The overall correlation between MVJ scores and log discharge rate was quite high (r = 0.683); all MVJ categories were statistically unique with the exception of categories "1" and "2." The overall fit, then, was particularly good at the heavy bleeding end of the scale. When five women with poor performance were removed, the correlations ranged from 0.480-0.894. The MVJ is a promising tool for identifying women with excessive menstrual bleeding. It is a simple-to-use, pencil-and-paper scale that offers an inexpensive and practical method to clinicians who work with perimenopausal women, the group most vulnerable to unnecessary worry and/or interventions when menorrhagia is incorrectly diagnosed.

Medical management of menstrual disorders

A vast majority of women experience menstrual disorders some time in their life. Complaints of excessive menstrual loss, in particular, have a substantial impact on gynecological services. It is estimated that 5% of women consult their physician with menstrual problems each year, and up to 30% of reproductive age women suffer from menorrhagia. Menorrhagia is defined as blood loss of more than 80 ml per cycle, but already lower amounts may result in iron-deficient anemia. Before starting the medication for heavy menstrual bleeding, the possible organic cause should be assessed, and the age, pregnancy desires, general health and patient preference should be considered. The combined oral contraceptive pills (COCPs), prostaglandin inhibitors and tranexamic acid are still recommended as the first line of therapy for menorrhagia, especially in nulliparous women. All of these also have the added advantage of relieving dysmenorrhea. Other drugs, such as danazol and gonadotropin-releasing hormone agonists (GnRHa), reduce menstrual blood loss effectively, but due to side effects, their use is limited to special cases. Luteal progestins are widely used for the treatment of heavy menstrual bleeding, but women with regular ovulatory cycles suffering from menorrhagia do not benefit from the treatment.

Bilateral Uterine Artery Ligation: An Effective Low-Technology Option in the Management of Symptomatic Uterine Fibroids

Objective: This pilot study was designed to determine the efficacy of uterine artery ligation by the vaginal route as a low-technology alternative to uterine artery embolisation in the management of symptomatic uterine fibroids. Methods: Both nulliparous and multiparous women who had symptoms of uterine leiomyomata such as menorrhagia, dysmenorrhoea and abdominal swelling were informed about a new approach for the treatment of fibroids and, after giving consent, were recruited for the study. Ultrasonic measurements of uterine and fibroid volumes were determined pre-operatively and at two, six, twelve and eighteen weeks after the procedure. The severity of menorrhagia, dysmenorrhoea and pelvic pain were documented pre-and post-operatively. All the patients had bilateral uterine artery ligation using the vaginal route. Results: Ten patients aged between 31 and 49 years of age were studied. The mean duration of surgery was 64 minutes. Mean duration of hospital stay was 48 hours. Mean estimated intraoperative blood loss was 262 millilitres. A 20.5% reduction in mean uterine volume was noted at six and twelve weeks post-surgery. The mean duration of menstrual flow was reduced from 23 days before surgery to 17.3 days at the immediate next cycle postoperatively. Subsequently, most patients noted more reductions, although one had a rebound increase. All patients had reduction in perceived pelvic pain and an improved sense of well-being. Conclusion: It is suggested that the favourable results documented from studies using uterine artery embolisation can be replicated using uterine artery ligation, which is a low-technology alternative. This is an ongoing study. Key Words: Uterus, Leiomyoma, Menstrual Loss, Artery Ligation. [Trop J Obstet Gynaecol, 2003, 20: 4-6]

Spontaneous expulsion of three large fibroids after uterine artery embolization

Objective To report a case of uneventful expulsion of huge fibroids after uterine artery embolization. Design Case report. Setting The Department of Obstetrics and Gynaecology of a university hospital. Patient(s) A 45-year-old woman who underwent uterine artery embolization for fibroids. Intervention(s) Transfemoral selective bilateral uterine artery catheterization and injection of 500–700 μm polyvinyl alcohol particles. Main outcome measure(s) Recovery of the patient. Result(s) The spontaneous expulsion of three fibroids on three different occasions over several months resulted in a significant reduction in menstrual loss and dysmenorrhea. Conclusion(s) Delivering fibroids or sections of fibroids may be a natural process after uterine artery embolization, therefore it is essential to warn women about the possible risk. Close follow-up is also essential. The size of the fibroids discharged did not require hysterectomy. Adequate antibiotic cover may be necessary to prevent sepsis.

A double-blind randomized trial comparing the Cavaterm ™ and the NovaSure ™ endometrial ablation systems for the treatment of dysfunctional uterine bleeding

Objective To compare two second-generation endometrial ablation systems in women with dysfunctional uterine bleeding (DUB) who want conservative surgical treatment. Design A double-blind, randomized trial. Setting A minimal access gynecological surgery unit in northeast England. Patient(s) Fifty-seven women diagnosed with DUB were recruited, with 55 undergoing surgery and completing 12-month follow-up. Intervention(s) Thirty-seven women underwent a NovaSure ™ endometrial ablation, and 18 had a Cavaterm ™ endometrial ablation. Clinical and quality of life data were collected 6 and 12 months after treatment. Main outcome measure(s) Amenorrhea, menstrual change, quality of life, sexual activity, patient satisfaction, and procedure acceptability. Result(s) Amenorrhea, hypomenorrhea, eumenorrhea, and menorrhagia rates for the Cavaterm ™ and Novasure ™ groups at 12 months were 2/18 (11%) vs. 16/37 (43%); 11/18 (61%) vs. 10/37 (27%); 5/18 (27%) vs. 6/37 (16%); and 0/18 vs. 5/37 (13%), respectively. At 12 months, 83% and 92% of women were either satisfied or very satisfied in the Cavaterm ™ or Novasure ™ groups, respectively. There were no major complications in either group. Conclusion(s) Both the Cavaterm ™ and the Novasure ™ endometrial ablation systems are effective in reducing menstrual loss in women with DUB and achieve high rates of patient satisfaction. The Novasure ™ system achieved a statistically significantly higher rate of amenorrhea in this study.

Use of Health Services Associated With Increased Menstrual Loss in the United States

Obstetrical & Gynecological Survey: June 2003 - Volume 58 - Issue 6 - p 386-387 doi: 10.1097/01.OGX.0000070131.32332.8F

Endoscopic management of fibromyomata

Surgical endoscopy has been successfully utilised in most gynaecological conditions with reported benefits which include small scars, reduced hospital stay and early return to normal duties. Myomectomy with uterine conservation has been popularised since the 1930s. The relationship between symptoms, such as menorrhagia and the presence of uterine myomata, has still not been fully evaluated although it appears that there is a causal relationship when sub-mucous fibroids are present. In recent years, laparoscopy has been proposed as the access of choice to remove fibroids up to 10 cm in diameter. Concern and debate continue over the integrity of the scar produced and its strength in a future pregnancy. Pre-operative investigation to assess myoma position within the uterus varies from simple pelvic ultrasound, saline infusion sonography to magnetic resonance imaging (MRI). The technique of laparoscopic myomectomy also varies and different approaches are discussed here-in. Newer non-surgical techniques, such as uterine artery embolisation (UAE), are addressed. The true value of this approach is yet to be assessed as there are no randomised control trials (RCTs) comparing it with myomectomy. Hysteroscopic resection of sub-mucous fibroids is associated with a decrease in menstrual loss. A recent publication using truly evidenced-based medicine questions the accepted surgical tradition of treating fibroids even greater than 16-gestational weeks in size [Aust. N.Z. J. Obstet. Gynaecol. 2001 (41) 125].

Use of health services associated with increased menstrual loss in the United States

Objective: The study was conducted to estimate the effect of abnormal uterine bleeding on health care use. Study design: Data were taken from the National Health Interview Survey 1999, a nationwide representative sample of the civilian noninstitutionalized population of the United States. The participants who were eligible for the study were 3133 women aged between 18 and 64 years who reported having a natural menstrual period in the last 12 months and in the last 3 months, never having taken medication containing estrogen (except past use of oral contraceptives), and never been told they had reproductive cancer. From these, 328 women were excluded—5 women because they were more than 64 years old and 323 because of the imprecision of their answers related to their menstrual flow. Analysis was performed with the data from 2805 women: 373 having self-described heavy flow and 2432 having normal flow. Results: Age, family size, insurance coverage, perception of health, and flow of menstrual periods are associated with the majority of questions used to measure health care use (P ≤ .05). The odds ratios related to the flow of menstrual periods were all equal to or higher than 1.45 (P ≤ .05), which indicates that women who have a heavier flow are at least 1.45 times as likely to use health care as are women who have a lighter or normal flow. Conclusion: Women having heavy flow of menstrual bleeding are more likely to use health care than women having a normal flow. (Am J Obstet Gynecol 2003;188:343-8.)

Sistema intrauterino de liberación de levonorgestrel en el tratamiento de la hemorragia uterina disfuncional

Summary Introduction: Dysfunctional uterine bleeding is a common gynaecological condition for which medical treatment is often ineffective, and a large number of women undergo surgery. Objective: To assess the effect of a levonorgestrel releasing intrauterine device in the management of menorrhagia. Material and methods: The study included 47 premenopausal women with menorhagia. Menstrual loss was estimated with a pictographic chart and the measurement of serum haemoglobin and ferritin levels preinsertion and at six and twelve months postinsertion. We also evaluated the degree of satisfaction with the treatment. Results: Menstrual blood loss was significantly reduced after six months (70%) and after twelve months the reduction was 78%. There was a significant increase in serum ferritin during the first year. The degree of satisfaction was high. The degree of satisfaction was high. Conclusion: The levonorgestrel releasing intrauterine device is an effective nonsurgical treatment for the management of dysfunctional uterine bleeding and seems to be an important alternative to oral medication.

Numerical methods for estimating iron requirements from population data.

The estimation of iron requirements is crucial for nutrition and food policy. The traditional methods for estimating iron requirements are balance methods based on iron intakes and excretions and factorial methods based on estimated iron absorption rates and estimated iron losses from body compartments. As an alternative, numerical methods for estimating iron requirements from population data of iron status were developed. The iron status data reported by Satoh (1991) were used in the sixth edition of Recommended Dietary Allowances for Japanese. The menstrual iron losses in Japanese premenopausal women were estimated from the literature to calculate total iron losses as the sum of basal iron losses and menstrual iron losses. The use of this alternative method is illustrated by analyzing the same population data comprising the prevalence of iron deficiency and the distribution of iron intake. The estimated average requirements were affected by the form of distribution function, the relative standard deviation of requirements, and the correlation coefficient between iron intakes and requirements. We conclude that numerical methods can be very useful for estimating iron requirements and to elucidate dietary recommendations of iron. These methods may contribute to determining requirements of other nutrients as well as iron.

Endoscopic Evaluation of the Upper Gastrointestinal Tract is Worthwhile in Premenopausal Women with Iron-Deficiency Anaemia Irrespective of Menstrual Flow

Background: In premenopausal women, iron-deficiency anaemia is common and menstrual flow is often held responsible, but it is not clear whether these women should be submitted to gastrointestinal (GI) evaluation. We aim to prospectively investigate whether premenopausal women with iron-deficiency anaemia benefit from GI evaluation regardless of menstrual flow. Methods: The study population comprised 59 consecutive premenopausal women with iron-deficiency anaemia. Excluded were women with obvious or suspected causes of anaemia and those ≤21 years. Heavy menstrual loss was not considered an exclusion criterion. All subjects had: complete blood count, ferritin, non-invasive testing by faecal occult blood (FOB), 13C-urea breath test (13C-UBT), anti-tissue transglutaminase antibodies (tTG) and gastrin levels. Gastroscopy with antral (n = 3), corporal (n = 3) and duodenal (n = 2) biopsies was performed in women with positive 13C-UBT or tTG titre or hypergastrinaemia. Results: Heavy menstrual loss was present in 50.8%. Non-invasive tests were positive in 40/59 (67.8%): 30 had positive 13C-UBT, 12 had hypergastrinaemia, 7 had positive tTG and 3 had positive FOB. Women tested positive were similar to those tested negative as far as concerned age, haemoglobin and ferritin levels and heavy menstrual flow (55% versus 42.1%). All 40 women tested positive underwent gastroscopy with biopsies. Four (10%) had bleeding-associated lesions and 34 (85%) had non-bleeding-associated lesions. As regards upper GI findings, no differences were observed between women with normal and those with heavy menstrual flow. No lower GI tract lesions were detected in the three women with positive FOB. Conclusions: Our data suggest that premenopausal women with iron-deficiency anaemia benefit from endoscopic evaluation of the upper GI tract irrespective of menstrual flow.