ACOG Practice Bulletin. Diagnosis of abnormal uterine bleeding in reproductive-aged women.
... These structural alterations and vascular fragility lead to breakdown and bleeding. (20) (21) Etiology of DUB (23) ...
... In adolescents, DUB most frequently occurs as a result of persistent anovulation due to the immaturity or dysregulation of the hypothalamic-pituitary-ovarian axis and represents normal physiology. (23) ...
... DUB most frequently occurs as a result of anovulatory cycles (eg, PCOS), use of hormonal contraception, and endometrial hyperplasia. (23) ...
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... The duration of normal menstrual flow is generally 4.5-8 days and the menstrual cycle typically lasts 21-35 days. 12 Typical blood loss during menstruation is 30 ml and abnormal blood loss is considered any blood loss greater than 80 ml. Cycle length varies most during the years succeeding menarche and during perimenopause (typically age > 40 years) because of the high prevalence of anovulatory cycles during these periods. 2 Almost 30% of women of reproductive age will look for medical assistance due to HMB. 13 The initial evaluation of women with AUB includes a detailed medical history and physical examination, and laboratory and imaging tests where this is needed. ...
... Cycle length varies most during the years succeeding menarche and during perimenopause (typically age > 40 years) because of the high prevalence of anovulatory cycles during these periods. 2 Almost 30% of women of reproductive age will look for medical assistance due to HMB. 13 The initial evaluation of women with AUB includes a detailed medical history and physical examination, and laboratory and imaging tests where this is needed. 12 Signs that may evoke a systemic cause of the genital bleeding should also be examined (coagulation disorders, thyroid dysfunction, prolactin levels) as well as family history of malignancy, such as endometrial or colorectal cancer. 2 When it comes to the risk of endometrial cancer and the need for endometrial biopsy, the evidence base remains unclear. ...
... 2 When it comes to the risk of endometrial cancer and the need for endometrial biopsy, the evidence base remains unclear. 14,15 Current guidelines recommend an age cutoff, at either 40 13,15 or 45 years, 12,15 above which patients should perform a biopsy. In general, all of these guidelines recognize IMB as an indicator for biopsy, while others combine this with the clinical history or co-morbidity of the patient, such as obesity and polycystic ovary syndrome (PCOS). ...
Abnormal uterine bleeding (AUB) is defined as abnormal volume, duration, or frequency of menstrual period and is a common symptom in women of all ages (premenopausal, perimenopausal, and postmenopausal). The acronym PALM‐COEIN, introduced by the International Federation of Gynecology and Obstetrics (FIGO), facilitates the evaluation and differential diagnosis of AUB, mostly in premenopausal women with AUB. Endometrial evaluation (including ultrasound or hysteroscopic imaging and tissue sampling) for subtle pathology is proposed in patients who are at high risk for endometrial cancer and in patients at low risk who present with AUB and who present poor correspondence in medical treatment. Many new diagnostic modalities are available in clinicians in order to help the assessment of women presenting with abnormalities in their menstrual pattern. The present study reviews the optimal management of women presenting with AUB, taking into consideration the actual need for invasive management in these women, who of them require it, and who can be diagnosed without histological verification. The importance of endometrial tissue sampling in women who present with AUB as well as the best timing for a clinician to conduct a biopsy are two axons analyzed below, according to the latest worldwide guidelines and major publications about this subject.
... Because of these changes, the removal rate within the first year after IUCD insertion was 4-15% [5]. It is still unknown how the copper IUCD affects uterine hemodynamics, which has significance for the pathophysiology of the illness, generated an abnormally heavy menstrual flow [6]. Using three-dimensional (3D) doppler analysis, researchers discovered that women with IUCD-induced heavy menstrual bleeding had increased subendometrial vascularization. ...
... 20 The hysteroscopic "see-andtreat" approach allows exploration of the uterine cavity, targeted endometrial and endocervical biopsies, and if indicated immediate treatment of endocervical, endometrial, or submucosal pathologies polyps and myomas. [21][22][23][24][25][26] As has been suggested the use of blind endometrial sampling to evaluate the uterine cavity, is an inaccurate technique for diagnosing pathologies commonly associated with AUB, such as endometrial polyps, submucous myomas, and focal endometrial abnormalities including adenocarcinoma and its precursors. 16 The use of hysteroscopy with directed biopsy ensures the recognition of these lesions. ...
Background: Hysteroscopy is the gold standard for uterine cavity evaluation because it allows direct visualization of the uterine cavity, mitigate characteristics of lesions such as nature, size, shape, location and vascular pattern. Methods: This was a prospective observational study conducted in department of obstetrics and gynecology at Chirayu Medical College and Hospital, Bhopal (MP). Patients presenting to general gyne OPD with abnormal uterine bleeding at Chirayu Medical College and Hospital between January 2021 to May 2022 were studied. All patients selected for study had a thorough evaluation with detailed history, clinical examination, lab tests and sonography followed by hysteroscopy and endometrial biopsy. Results: Mean age of patients in our study was 44 years with majority of patients in 41-50 years age group. Predominant complaint reported was heavy menstrual bleeding (HMB) (47.50%) followed by HMB with frequent cycle (11.25%). Hysteroscopy detected intrauterine abnormality in 42.50% cases. Most common finding on hysteroscopy in our study was hyperplastic endometrium in 17.50% patients followed by endometrial polyp in 15% of patients. Atrophic endometrium was seen in 2.5% and 2.5% had submucous fibroid. Conclusions: Hysteroscopy allows diagnosis or exclusion of intracavitary pathologies, which are underdiagnosed on routine pelvic sonography. It also enables treatment in the same sitting with accurate tissue biopsy from the representative areas and facilitates planning of further management. When combined with endometrial biopsy and pelvic ultrasonography, it can establish an accurate diagnosis in a majority of patients thereby reducing the burden of hysterectomy.
... The effect of the copper IUCD on uterine hemodynamics and its relationship with the pathophysiology of IUCDinduced heavy menstrual bleeding is still not well clarified [4]. By using three-dimensional (3D) Doppler analysis, only few studies have demonstrated an increase in subendometrial vascularization in women with IUCD-induced heavy menstrual bleeding [5]. ...
Background
Previous studies reported changes in the local vasoactive substance production within the endometrium with a subsequent increase in vascularity as a possible mechanism of intrauterine contraceptive device (IUCD)-induced heavy menstrual bleeding. This research investigates the role of power Doppler velocimetries of the uterine arteries, endometrium, and sub-endometrium vascularization as a predictor of IUCD-induced heavy menstrual bleeding.
Results
Endometrium flow index (FI) and vascularization flow index (VFI) significantly increased in both groups: women with heavy menstrual bleeding (group A) and women without heavy menstrual bleeding (group B), with significantly higher increase in group A. Endometrium VFI ≥ 0.18 had the highest significant diagnostic characteristics in the prediction of heavy menstrual bleeding, followed by sub-endometrium VI ≥ 3.75.
Conclusion
The results of this study suggest an increase in uterine blood flow in women with IUCD-induced menorrhagia. Endometrial and sub-endometrial Doppler vascular indices can be used for the prediction of IUCD-induced heavy menstrual bleeding.
... Kör endometrial örnekleme yöntemlerinin doku örneklemesi için birinci basamak yöntem olmakla birlikte, bu testlerin yalancı negatiflik oranının da yüksek olduğu göz önünde bulundurulmalıdır (6). Yabancı kaynaklarda PUK'un etiyolojisinde de birçok faktör suçlanmaktadır. ...
Postmenopozal Uterin Kanama: Ultasonografi Bulguları ve Patoloji Sonuçlarının Analizi Öz Amaç: Postmenopozal uterin kanama (PUK) ile başvuran hastalarda ultrasonografik bulguların ve patoloji sonuçlarının değerlendirlmesi. Materyal ve Metot: Bu tanımlayıcı retrospektif çalışma, Ekim 2008- Mayıs 2015 arası, Zekai Tahir Burak Kadın Sağlığı Eğitim ve Araştırma Hastanesine PUK nedeniyle başvuran toplam 979 kadının sosyodemografik ve klinik bilgileri, medikal kayıtlardan elde edilerek yapılmıştır. Hastaların yaş, gravida, parite, endometrial kalınlıkları ve endometriumun histopatoloji sonuçları incelenmiştir. Bulgular: PUK nedeniyle başvuran hastaların yaşlarının ortanca değeri 55 (42-88) idi. Gravida ve parite ortanca değerleri sırasıyla 5 (0-22), 3 (0-15) idi. Transvajinal ultrasonografide saptanan ortalama endometrial kalınlık ise 7.3 ± 6.5 mm idi. PUK patoloji sonuçları sırası ile atrofi ve yetersiz endometrium %33.5; yüzeyel epitel, proliferatif veya sekretuar endometrium % 28.2 ve endometrial polip %26.6 oranda izlemekteydi. Hastaların % 4.3 ‘ünde endometrium kanseri tespit edildi, servikal patolojiler ise % 2.8 oranında gözlendi. Sonuç: PUK çoğunlukla benign endometrial patolojiler ile birliktelik göstermektedir, ancak PUK nedeniyle başvuran her 20-25 kadından 1’inde endometrium kanseri tespit edilmektedir.
... ABNORMAL Uterine Bleeding (AUB) is a common problem gynecological practice, accounting for 15% of office visits & 25% of gynecological operation [1] . AUB has been defined by FIGO as bleeding from the uterine corpus that is abnormal in volume, regularity, and/or timing, and has been present for the majority of the past 6 months [2] . Dysfunctional Uterine Bleeding (DUB) is defined as abnormal bleeding from uterus in absence of organic disease of the genital tract and its management can be complex [3] . ...
BACKGROUND
The International Endometrial Tumor Analysis (IETA) group developed a catalog of standardized terms to describe findings that may be associated with uterine pathology. However, there is a lack of reliability studies for these descriptors in the literature.
OBJECTIVE
The objective of this study was to estimate interobserver and intraobserver reliability with regard to the IETA group descriptors for endometrial vascular characteristics in women with abnormal uterine bleeding.
MATERIALS AND METHODS
Five nonexpert and five expert raters assessed stored still images of transvaginal ultrasound examinations obtained from 68 women with abnormal uterine bleeding and endometrial thickening. Endometrial vascularity was evaluated using the IETA group descriptors for color flow and vascular pattern. Interobserver agreement was estimated by comparing the assessments of the nonexpert and expert raters. Intraobserver agreement was estimated by repeating the raters’ assessment after 4 weeks. Interrater agreement to the subjective assessment of an expert investigator was also computed.
RESULTS AND CONCLUSION
The reproducibility of assigning IETA color score is good regardless of the degree of expertise of the rater, although the experts displayed better interobserver reliability (κ = 0.74 vs. 0.57) and intraobserver reliability (κ = 0.84 vs. 0.63). However, the reproducibility of describing IETA vascular patterns is significantly worse for both expert and nonexpert raters in both interobserver reliability (experts κ = 0.49 vs. 0.34) and intraobserver reliability (experts κ = 0.65 vs. 0.42). Both expert and nonexpert raters exhibited acceptable agreement with the reference standard, with experts performing better for both color score (κ = 0.79 vs. 0.70) and vascular pattern (κ = 0.63 vs. 0.44).
Abnormal uterine bleeding (AUB) is a frequent symptom in perimenopausal women. It is defined as uterine bleeding in which the duration, frequency, or amount of bleeding is considered excessive and negatively affects the woman’s quality of life (QoL) and psychological well-being. In cases of structural uterine pathology, hysterectomy (usually performed via a minimally invasive approach) offers definitive symptom relief and is associated with long-lasting improvement of QoL and sexuality. However, over the past 30 years, uterus-preserving treatments have been introduced as alternatives to hysterectomy. Hysteroscopic polypectomy, myomectomy, or endometrial resection/endometrial ablation are minimally invasive techniques that can be used as an alternative to hysterectomy to treat AUB due to benign conditions. Although associated with high patient satisfaction and short-term improvement in their QoL, hysteroscopic treatments do not eliminate the risk of AUB recurrence or the need for further intervention. Therefore, considering the impact of different treatment options on QoL and sexuality during preoperative shared decision making could help identify the most appropriate and personalized treatment options for perimenopausal women suffering from AUB.
To compare magnetic resonance and ultrasound imaging for uterine fibroid measurement.
Eighteen women undergoing hysterectomy for symptomatic fibroids underwent preoperative pelvic ultrasound and magnetic resonance imaging. Resected fibroids were correlated with the images. Weighted kappa agreement statistics and Spearman correlations for patient characteristics were calculated.
Magnetic resonance imaging identified 121 of 151 pathologically confirmed fibroids, yielding 91% positive predictive value (95% confidence interval [CI], 85-95) and 80% sensitivity (95% CI, 73-86). Positive predictive value and sensitivity for ultrasound were 97% (95% CI, 89-100) and 40% (95% CI, 32-48), respectively. Mean diameter-equivalent discrepancies between imaging and pathologic measurements were 0.51 +/- 0.68 cm for magnetic resonance imaging and 0.76 +/- 0.88 cm for ultrasound. kappa statistics comparing imaging to pathology showed better agreement for magnetic resonance than ultrasound (kappa = 0.60 vs 0.36). The number of fibroids detected by magnetic resonance imaging predicted measurement errors (r = 0.76; P = .0002).
Superior sensitivity and minimal measurement discrepancies suggest magnetic resonance imaging may be preferentially used for fibroid assessment in clinical research.
Background
The aim of the study was to compare the accuracy of hydrosonography with that of transvaginal ultrasonography in detection of intracavitary pathologies in patients with history of abnormal uterine bleeding.
Study design
Prospective, randomized, and unblinded study.
Material and methods
A total of 197 women ( n = 130 premenopausal and n = 67 postmenopausal) aged between 23 and 71 years (mean age 45.7 ± 8.9) presenting with a history of abnormal uterine bleeding were included into the study. Hydrosonography was carried out by experienced gynecologists, on the same setting in an outpatient clinic immediately after the performance of transvaginal sonography. The finally obtained surgical-pathologic findings were compared with the results obtained from transvaginal sonography and hydrosonography. Sensitivity, specificity, positive, and negative predictive values were calculated for each procedure.
Results
The surgical-pathologic examination confirmed normal physiologic endometrium in 50 (48%) of 104 women who were said to have normal endometrium on transvaginal sonography. Seventy (75%) of 93 women diagnosed of intracavitary pathologies on transvaginal sonography were confirmed by surgical-pathologic findings. The sensitivity, specificity, positive predictive value, and negative predictive value of transvaginal sonography in the detection of intracavitary pathology were 56, 68, 75, and 48%, respectively. Surgical-pathologic results revealed intracavitary pathologies in 23 (30%) of 76 women who were said to have normal endometrium on hydrosonography. Among 121 women diagnosed of intracavitary pathologies on hydrosonography, 101 (81%) women were confirmed after histological evaluation of the surgical specimens. The sensitivity, specificity, positive predictive value, and negative predictive value of hydrosonography in the detection of intracavitary pathology were 81, 73, 83, and 70%, respectively. Sensitivity and negative predictive value were significantly higher with hydrosonography. There were five cases of endometrial malignancy in which one of the case of malignancy was on polyp and two cases of endometrial hyperplasia with atypia which were not stated on sonographic results.
Conclusion
Hydrosonography is more accurate than transvaginal ultrasography in the detection of intracavitary pathologies in women with abnormal uterine bleeding.
Von Willebrand disease (VWD) is the most common inherited bleeding disorder and may affect as many as one in 100 women. The condition results from a deficiency, dysfunction, or absence of von Willebrand factor (VWF). In women, the most common symptom of VWD is menorrhagia. Of women with menorrhagia, 5-20% have been found to have previously undiagnosed VWD. Besides menorrhagia, women with VWD are more likely to experience other conditions that manifest with abnormal reproductive tract bleeding. The patient with a suspected bleeding disorder should be referred to a hemophilia treatment center or hematologist with expertise in bleeding disorders for definitive diagnosis. After diagnosis, the first choice of therapy for the management of menorrhagia in adolescents or adult females who do not desire child bearing is still hormonal contraceptives. Women who fail hormonal contraceptives, yet desire future child bearing, and women who desire pregnancy are candidates for hemostatic therapy, which is generally reserved for patients with VWF levels less than 50 international units/dL. During pregnancy, VWF levels rise, frequently obviating the need for hemostatic therapy at the time of delivery. Minor procedures can be managed with 1-desamino-8-D-arginine vasopressin, antifibrinolytic medication, or both, but major surgery or childbirth requires replacement with VWF and should be conducted in a center with available hematologists, anesthesiologists, pharmacists, and laboratory support experienced in the management of bleeding disorders. (Obstet Gynecol 2009;114:674-8)
Objective To compare the diagnostic accuracy of transvaginal sonography (TVS) and saline infusion sonography ISIS) for detecting intracavitary abnormalities in premenopausal women with abnormal uterine bleeding. Method Consecutive premenopausal women who underwent hysterectomy for abnormal uterine bleeding were included. All women underwent TVS and SIS before their hysterectomy The findings at TVS and SIS were compared with the findings of the hysterectomy specimen. Sensitivity, specificity, and likelihood ratios were calculated. Results The results of 50 patients with abnormal uterine bleeding were evaluated. Histological examination revealed normal endometrial histology in 27 patients, submucus myomas in 13 patients and intracavitary polyps in 10 patients. The sensitivity of TVS in directly visualizing intracavitary abnormalities was 61% for a specificity of 96%. The likelihood ratio of presence of an intracavitary abnormality was 16 and the likelihood ratio of absence of such a finding was 0.41. When defining abnormality at TVS as direct visualization of an intracavitary abnormality or an increased endometrial thickness (cut-off level 5 mm), the. sensitivity of TVS was 87% for a specificity of 56%, with corresponding likelihood ratios of 2 and 0.23, respectively. The sensitivity and specificity of SIS was 100% and 85% with likelihood ratios of 6 and 0.0, respectively. No intracavitary abnormality was missed by SIS. Conclusion The diagnostic accuracy of SIS is higher than the accuracy of TVS. A combined approach using endometrial thickness measurement by TVS and, reserving SIS for patients with increased (> 5 mm) endometrial thickness, or endometrium inadequately visualized on TVS, is the optimal method of reducing the hysteroscopy rate.
Problems associated with menstruation affect 75% of adolescent females and are a leading reason for visits to physicians. This chapter begins with a review of the timing and characteristics of normal menstruation during adolescence. It then discusses the evaluation and management of adolescents with amenorrhoea, dysmenorrhoea and abnormal uterine bleeding. An approach to adolescent amenorrhoea is presented that utilizes primary versus secondary amenorrhoea, delayed versus normal pubertal development, and the presence or absence of hyperandrogenism as nodal points for decision making. The differential diagnosis of dysmenorrhoea and the management of primary dysmenorrhoea and endometriosis are reviewed. The section on abnormal uterine bleeding contrasts anovulatory dysfunctional uterine bleeding (DUB) with bleeding secondary to problems of pregnancy, uterine pathology, exogenous hormone use and systemic bleeding disorders.
PGE receptor concentrations were measured in myometrial samples collected from 10 women at hysterectomy. Five women had normal measured menstrual blood loss (35-44 ml) and the remainder had unexplained menorrhagia occurring in the absence of any uterine, pelvic or general pathology, with losses ranging from 85 to 925 ml. Median PGE receptor concentrations were significantly higher in the women with menorrhagia (1077 fmol/mg protein) than in the women with normal menstrual blood loss (625 fmol/mg protein) and correlated with menstrual blood loss (P less than 0.02). These findings suggest that unexplained menorrhagia may simply be a constitutional variant in some women and that specific and potent PGE uterine receptor antagonists would furnish effective non-surgical treatment for unexplained menorrhagia.
. A randomized trial was arranged in Yorkshire to assess whether progestogens would improve survival as part of the primary treatment of endometrial carcinoma, in conjunction with surgery and radiotherapy. A total of 429 patients was randomized on diagnosis to the progestogen or control group and treated locally according to an agreed protocol. All the patients are now more than 1 year after operation and over half are more than 5 years after operation. The projected overall 5-year survival rate is 76% but contrary to expectation there is no statistically significant difference in survival between the patients treated with progestogens and the control group even after statistical adjustment for known prognostic factors.
PurposeSaline infusion sonography (SIS) is a relatively new technique in the evaluation of abnormal uterine bleeding. We compared the diagnostic accuracy of SIS with that of transvaginal sonography (TVS) in the detection of intracavitary abnormalities in premenopausal women with abnormal uterine bleeding.Methods
In this prospective study, consecutive premenopausal women who underwent a hysteroscopy for abnormal uterine bleeding also underwent TVS and SIS. The findings at TVS and SIS were compared with the hysteroscopic and histologic findings. Sensitivity, specificity, and likelihood ratios were calculated. Receiver operating characteristic curves were constructed to assess the performance of endometrial thickness measured using TVS.ResultsSixty-two patients were included in the study. TVS demonstrated 60% sensitivity in directly visualizing intracavitary abnormalities and 93% specificity. The likelihood ratio of the presence of an intracavitary abnormality was 8, and the likelihood ratio of the absence of an intracavitary abnormality was 0.43. Defining an abnormality at TVS as direct visualization of an intracavitary abnormality or an endometrial thickness greater than 5 mm, TVS had an 85% sensitivity and a 21% specificity, with corresponding likelihood ratios of 1.1 and 0.71, respectively. For SIS, the sensitivity, specificity, and likelihood ratios of the presence and absence of intracavitary abnormalities were 88%, 95%, 10, and 0.13, respectively.ConclusionsSIS is more accurate in the diagnosis of intracavitary abnormalities in premenopausal women than is TVS. An approach using endometrial thickness measurement by TVS and reserving SIS for patients who have an endometrial thickness greater than 5 mm or an intracavitary abnormality visualized by TVS would be the most effective method to reduce the number of hysteroscopies. © 2000 John Wiley & Sons, Inc. J Clin Ultrasound 28:217–223, 2000.
Von Willebrand disease (VWD) is the most common inherited bleeding disorder and may affect as many as one in 100 women. The condition results from a deficiency, dysfunction, or absence of von Willebrand factor (VWF). In women, the most common symptom of VWD is menorrhagia. Of women with menorrhagia, 5-20% have been found to have previously undiagnosed VWD. Besides menorrhagia, women with VWD are more likely to experience other conditions that manifest with abnormal reproductive tract bleeding. The patient with a suspected bleeding disorder should be referred to a hemophilia treatment center or hematologist with expertise in bleeding disorders for definitive diagnosis. After diagnosis, the first choice of therapy for the management of menorrhagia in adolescents or adult females who do not desire child bearing is still hormonal contraceptives. Women who fail hormonal contraceptives, yet desire future child bearing, and women who desire pregnancy are candidates for hemostatic therapy, which is generally reserved for patients with VWF levels less than 50 international units/dL. During pregnancy, VWF levels rise, frequently obviating the need for hemostatic therapy at the time of delivery. Minor procedures can be managed with 1-desamino-8-D-arginine vasopressin, antifibrinolytic medication, or both, but major surgery or childbirth requires replacement with VWF and should be conducted in a center with available hematologists, anesthesiologists, pharmacists, and laboratory support experienced in the management of bleeding disorders. LEVEL OF EVIDENCE: III.