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Re-definition and re-classification of menstrual disorders
Abstract
Historically, the terminology used for abnormal uterine bleeding has been inconsistent and confusing. The Fédération Internationale de Gynécologie et d'Obstétrique (FIGO) has recently approved new definitions and a standardized classification system for menstrual disorders and other contributors to the problem of abnormal uterine bleeding. This article describes the need for these changes and aims to encourage their use in routine clinical practice, medical education and scientific research, with the hope that they will lead to improved reproductive healthcare for women.
... Abnormal uterine bleeding (AUB) is one of the common presenting complaints encountered by a gynaecologist [1]. It has negative impact on women's health and well-being including anaemia, impacting their life by impairing sexuality, and leads to absenteeism and social embarrassment. ...
Background: Abnormal uterine bleeding (AUB) is defined as any bleeding that does not correspond with the frequency, duration or amount of blood flow of a normal menstrual cycle. It is a common reason for women of all ages to visit gynaecologist resulting in unrequired hysterectomy in developing countries. The aim of the present study was to determine the clinical spectrum and pathologies of endometrium by endometrial biopsy of patients with AUB in study population.. It was done on women presenting with abnormal uterine bleeding. This study was a prospective study done on 124 patients presenting with AUB who underwent endometrial biopsy. The histopathological patterns of endometrium studied and data analysed. Results: The commonest presenting complaint in AUB patients was heavy menstrual bleeding seen in 81(65.3%) followed by irregular menstrual bleeding in 25(20.2%) cases. The predominant endometrial histopathological finding was secretory endometrium 39cases (31.45%), proliferative endometrium in 25cases (20.16%) and simple hyperplasia without atypia 29 cases (23.38%). Malignant lesions were more common in patients more than 50yrs of age and comprised of 2 cases (1.61%) of all cases. Conclusion: Histopathological examination of the endometrium showed a wide spectrum of pathological changes from normal endometrium to malignancy. It is important to confirm the underlying disorder in all cases of AUB evaluation especially in peri-and post-menopausal women. Accurate analysis of endometrial sampling is the key to choose ideal treatment modality for obtaining desired optimal outcome.
... Menstrual problems are also associated with loss of productivity. It has been estimated that women with HMB lose 3.6 more working weeks per year than women with normal bleeding (Maybin et al., 2013). Menstrual problems also incur increased healthcare expenses, given that laboratory costs of diagnosis and pharmaceutical costs of treatment can be expensive (Marsh et al., 2014). ...
STUDY QUESTION
Are physical activity (PA) and body mass index (BMI) associated with irregular periods and heavy menstrual bleeding (HMB) in Australian women?
SUMMARY ANSWER
Overweight and obese women have higher odds of both irregular periods and HMB than underweight/normal-weight women, but high levels of PA reduce the odds of HMB.
WHAT IS KNOWN ALREADY
Most studies on relationships between PA and menstrual problems have focused on female athletes, but there have been few population-based studies.
STUDY DESIGN, SIZE, DURATION
Prospective cohort study, 10618 participants in the Australian Longitudinal Study of Women’s Health (ALSWH) who completed mailed surveys in 1996, with follow-ups in 2000, 2003, 2006, 2009, 2012, and 2015.
PARTICIPANTS/MATERIALS, SETTING, METHODS
Participants were aged 22 to 27 in 2000. They were asked to report their PA levels and the frequency of irregular periods and HMB in each survey. BMI was calculated at every survey from self-reported weight and height. Generalised estimating equation population-averaged model analyses were conducted to calculate odds ratios (OR) and 95% confidence intervals (95% CIs).
MAIN RESULTS AND THE ROLE OF CHANCE
At age 22 to 27 years, the prevalence of irregular periods was 19.4%. This remained stable over 15 years. There were no associations between PA and irregular periods. Overweight and obese women had higher odds of irregular periods [overweight: OR 1.08, (95% CI 1.00–1.17); obese: OR 1.29, (95%CI 1.18–1.41)] than women who were underweight/normal weight.
The prevalence of HMB at age 22–27 years was 15.9%; this doubled over 15 years. Women who were highly active had 10% lower odds of HMB than women who reported no PA [OR 0.90, (95%CI 0.82–0.98)]. Overweight and obese women had higher odds of HMB [overweight: OR 1.15, (95%CI 1.07–1.23); obese: OR 1.37, (95%CI 1.26–1.49)] than women who were underweight/normal weight. Among obese women, high levels of PA were associated with 19% [OR 0.81, (95%CI 0.68–0.97)] reduction in the odds of HMB.
LIMITATIONS, REASONS FOR CAUTION
Data collected in the ALSWH are self-reported, which may be subject to recall bias. Reverse causation, due to menstrual problems impacting PA, is possible although sensitivity analyses suggest this is unlikely to have affected the results. Other conditions, e.g., polycystic ovary syndrome, for which no or incomplete data were available, could have affected the results.
WIDER IMPLICATIONS OF THE FINDINGS
Intervention studies are needed to assess the effect of increasing PA in women with HMB, but these preliminary findings suggest that promoting PA could be an affordable and feasible strategy for reducing HMB in young adult women.
STUDY FUNDING/COMPETING INTEREST(S)
The ALSWH is funded by the Australian Government. Funding for these analyses was provided by a University of Queensland (UQ) International Postgraduate Research Scholarship and a UQ International Development Fellowship. The authors declare no conflicts of interest.
TRIAL REGISTRATION NUMBER
N/A
There is general inconsistency in the nomenclature used to describe abnormal uterine bleeding (AUB), in addition to a plethora of potential causes-several of which may coexist in a given individual. It seems clear that the development of consistent and universally accepted nomenclature is a step toward rectifying this unsatisfactory circumstance. Another requirement is the development of a classification system, on several levels, for the causes of AUB, which can be used by clinicians, investigators, and even patients to facilitate communication, clinical care, and research. This manuscript describes an ongoing process designed to achieve these goals, and presents for consideration the PALM-COEIN (polyp; adenomyosis; leiomyoma; malignancy and hyperplasia; coagulopathy; ovulatory dysfunction; endometrial; iatrogenic; and not yet classified) classification system for AUB, which has been approved by the International Federation of Gynecology and Obstetrics (FIGO) Executive Board as a FIGO classification system.
The menopausal transition is characterized by irregular menstrual cycles and unpredictable hormone levels, including dramatic swings in estradiol (E2). An increasing number of studies have found variable high E2 and low luteal phase progesterone occur with progression of Stages of Reproductive Aging Workshop (STRAW)stage, but the cause remains unclear. To explore the causes of the erratic changes in E2, individual within-cycle secretion patterns of E2, progesterone, follicle-stimulating hormone, luteinizing hormone, inhibin A, and inhibin B were explored in detail.
Blood samples taken three times per week over 1 1/3 menstrual cycles from 77 women aged 21 to 55 classified as mid-reproductive age (STRAW stages 5 and 4; n = 21), late-reproductive age (STRAW stages 4 and 3; n = 16), early menopausal transition (STRAW stage 2; n = 17), and late menopausal transition (STRAW stage 1; n = 23) were analyzed.
Eleven of the 29 (37%) early and late menstrual transition ovulatory cycles exhibited a specific pattern of E2 secretion that was characterized by a second increase in E2 during the mid- and late luteal phases and that continued to a peak during the subsequent menstrual phase. This second rise and fall in E2 was typical in appearance of a normal follicular phase, except that it was superimposed on an existing ovulatory cycle(specifically during the luteal and menstrual phases). The pattern was therefore referred to as a luteal out-of-phase(LOOP) follicular event. In four of these LOOP cycles, a luteinizing hormone peak and ovulatory episode followed the second E2 peak early in the subsequent cycle. Compared with the typical ovulatory cycles, the cycles with LOOP events exhibited lower luteal phase progesterone, higher early cycle follicle-stimulating hormone, and lower early cycle inhibin B. They were also associated with abnormally short (<21 d) or long (>40 d) cycle length.
Many of the marked increases in ovulatory cycle E2 and cycle irregularities during the menopausal transition may be due to LOOP events and appear to be triggered by prolonged high follicular phase follicle-stimulating hormone levels.
The nomenclature relating to AUB has been thoroughly discussed in Chapter 3. To reiterate, clinicians and investigators use a variety of terms to describe disorders of menstrual bleeding, often commingling a variety of descriptive and diagnostic terms and phrases. The fact that similar terms are used in different ways in different countries and even by different gynecologists within a single practice setting has confounded both the design and interpretation of clinical investigation in this arena. 1 As a result, the simplified nomenclature discussed previously will be used to facilitate discussion about the definitions and symptoms of AUB. These definitions generally use the 5th and 95th centiles to discriminate between normal and abnormal menstrual function.
Women today may reasonably anticipate in the order of some 400 menstrual cycles over their reproductive lifespan. The endometrium is thus subject to repeat cycles of shedding and repair and notably healing of the endometrium post menses is "scarless". The local molecular and cellular mechanisms involved in post menstrual resolution of the inflammatory events associated with menstruation and endometrial repair remain to be fully determined. Menstrual complaints are common. It is highly likely that unrestrained local inflammatory events and/ or deficient repair processes within the endometrium contribute to the women's experience of heavy menstrual bleeding (HMB). The management of women with HMB may need to utilize therapeutic approaches that optimize endometrial repair processes, post menses. These approaches may be necessary in addition to current therapies that hitherto have focused on limiting the local inflammation associated with menstruation. Research endeavors thus need to focus upon the molecular and cellular causes of problematic uterine bleeding. Herein the events associated with pre-menstrual progesterone withdrawal, limitation of blood loss, the expression of vasoactive mediators and factors that may modulate vascular morphology are described. Such lines of enquiry and knowledge will be essential if novel targets for treatment of menstrual bleeding complaints, such as HMB, are to be identified.
Adenomyosis is a common condition that causes substantial morbidity. Until recently, the reference standard for a definitive diagnosis was histology of hysterectomy specimens. Ultrasound and magnetic resonance imaging (MRI) may allow accurate non-invasive diagnosis.
To compare the diagnostic accuracy of these techniques.
Systematic review with meta-analysis.
Women who had ultrasound and/or MRI, and whose results were compared with a reference standard.
Electronic searches were conducted in literature databases from database inception to 2010. The reference lists of known relevant articles were searched for further articles. Selected studies reported data on ultrasound and/or MRI with histological confirmation of diagnosis. Two reviewers independently selected articles without language restrictions, and extracted data in the form of 2 × 2 tables. We computed sensitivity and specificity for individual studies and pooled these results in a meta-analysis. We also performed meta-regression to examine how the index tests compared on diagnostic accuracy.
Twenty-three articles (involving 2,312 women) satisfied the inclusion criteria. Transvaginal ultrasound had a pooled sensitivity of 72% (95% CI 65-79%), specificity of 81% (95% CI 77-85%), positive likelihood ratio of 3.7 (95% CI 2.1-6.4) and negative likelihood ratio of 0.3 (95% CI 0.1-0.5). MRI had a pooled sensitivity of 77% (95% CI 67-85%), specificity of 89% (95% CI 84-92%), positive likelihood ratio of 6.5 (95% CI 4.5-9.3), and negative likelihood ratio of 0.2 (95% CI 0.1-0.4). The results show that a correct diagnosis was obtained more often with MRI.
Transvaginal ultrasound and MRI show high levels of accuracy for the non-invasive diagnosis of adenomyosis.
In this study, we sought to 1) describe elements of the financial and quality-of-life burden of dysfunctional uterine bleeding (DUB) from the perspective of women who agreed to obtain surgical treatment; 2) explore associations between DUB symptom characteristics and the financial and quality-of-life burden; 3) estimate the annual dollar value of the financial burden; and 4) estimate the most that could be spent on surgery to eliminate DUB symptoms for which medical treatment has been unsuccessful that would result in a $50,000/quality-adjusted life-year incremental cost-effectiveness ratio.
We collected baseline data on DUB symptoms and aspects of the financial and quality-of-life burden for 237 women agreeing to surgery for DUB in a randomized trial comparing hysterectomy with endometrial ablation. Measures included out-of-pocket pharmaceutical expenditures, excess expenditures on pads or tampons, the value of time missed from paid work and home management activities, and health utility. We used chi2 and t tests to assess the statistical significance of associations between DUB characteristics and the financial and quality-of-life burden. The annual financial burden was estimated.
Pelvic pain and cramps were associated with activity limitations and tiredness was associated with a lower health utility. Excess pharmaceutical and pad and tampon costs were $333 per patient per year (95% confidence interval [CI], $263-$403). Excess paid work and home management loss costs were $2,291 per patient per year (95% CI, $1847-$2752). Effective surgical treatment costing $40,000 would be cost-effective compared with unsuccessful medical treatment.
The financial and quality-of-life effects of DUB represent a substantial burden.
There has been increasing recent recognition of the worldwide confusion in the terminology and definitions for abnormalities of menstrual and uterine bleeding. The present review was undertaken to objectively explore some of the origins and current uses of terms for symptoms, signs, and causes of abnormal uterine bleeding and to demonstrate the international lack of uniformity.
A detailed, but not systematic, search of the huge current and historical literature across the range of menstrual terminology, definitions, and some causes, with an emphasis on "menorrhagia" and "dysfunctional uterine bleeding."
An international collaboration to study ways of reaching worldwide agreement on descriptive terms and definitions for abnormal bleeding.
A large number of synonyms and overlapping terms for heavy menstrual bleeding have been identified, as well as smaller numbers of terms for other symptoms and causes of abnormal uterine bleeding. The origins and meanings of several of these terms have been explored in detail and wide variations in meaning demonstrated.
There is great confusion in the way these terminologies are used and there is an urgent need for international agreement on consistent use of terms and definitions for symptoms, signs, and causes of abnormal uterine bleeding.
The Queen's Medical Research Institute, Edinburgh, UK. Conflicts of interest: none declared Con-flicts of interest: MM has the following disclosures: Grant-Research
- Malcolm
- Munro
- Frcs
Jacqueline A Maybin PhD MRCOG is a Clinical Lecturer in Obstetrics and Gynaecology at the MRC Centre for Reproductive Health, University of Edinburgh, The Queen's Medical Research Institute, Edinburgh, UK. Conflicts of interest: none declared. Malcolm G Munro MD FRCS FACOG is Professor, Department of Obstetrics and Gynecology at David Geffen School of Medicine at UCLA, Kaiser Permanente, Los Angeles Medical Center, Los Angeles, CA, USA. Con-flicts of interest: MM has the following disclosures: Grant-Research Support in AUB Treatment (Bayer Women's Health, EndoSee);
Depart-ment of Obstetrics, Gynaecology and Neonatology at Queen Elizabeth II Research Institute for Mothers and Infants, The University of Sydney, NSW, Australia. Conflicts of interest: ISF has received Grant/Research Support in AUB Treatment and Contraception Trials
- Ian
- Fraser
- Dsc
Ian S Fraser AO DSc MD is Professor in Reproductive Medicine, Depart-ment of Obstetrics, Gynaecology and Neonatology at Queen Elizabeth II Research Institute for Mothers and Infants, The University of Sydney, NSW, Australia. Conflicts of interest: ISF has received Grant/Research Support in AUB Treatment and Contraception Trials (Bayer Schering Pharma, Schering Plough);
The Queen's Medical Research Institute, Edinburgh, UK. Conflicts of interest: HC has received Grant/Research Support in AUB Treatment (TAP Pharmaceuticals
- Hilary Od Critchley Md Frcog Frse
- Fmedsci
Hilary OD Critchley MD FRCOG FRSE FMedSci is Professor of Reproductive Medicine at the MRC Centre for Reproductive Health, The University of Edinburgh, The Queen's Medical Research Institute, Edinburgh, UK. Conflicts of interest: HC has received Grant/Research Support in AUB Treatment (TAP Pharmaceuticals, Bayer Pharma AG); Speakers Bureau on AUB Treatment (Bayer Pharma AG, Preglem/Gedeon-Richter);
Clinical Guideline 44 Heavy menstrual bleeding Available at
NICE. Clinical Guideline 44. Heavy menstrual bleeding. 2007. Available at:
http://www.nice.org.uk/nicemedia/pdf/CG44FullGuideline.pdf.