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Objectives: To describe practice patterns of an integrated complex family planning-pediatric hematology oncology clinic for patients with blood disorders STUDY DESIGN: We retrospectively evaluated the outcomes of patients who had an initial consultation for blood disorders impacting menstrual bleeding in an integrated complex family planning-pediatric hematology oncology clinic from October 2015 to September 2020. We reviewed all charts to extract medical and gynecologic history, blood disorder diagnosis, hormonal treatment prior to and following initial consultation, subsequent visits to the integrated clinic, and hormonal treatment up to 24 months after initial consultation.Results: We saw 47 patients; their most common blood disorder diagnosis was protein defect (14 of 47, 30%). Most patients (30 of 47, 64%) were not using any hormonal treatment prior to their initial consultation. After the initial consultation, 26 (55%) elected to start, change, or discontinue hormonal treatment for abnormal menstrual bleeding, the most common treatment being combined hormonal contraception (CHC, 22 of 47, 47%), alone or as dual therapy. Over the study duration, 36 patients (77%) initiated, changed, or discontinued their hormone treatment, 22 (61%) of whom changed their treatment plan more than once. CHC usage decreased from 19 of 47 (40%) to 8 of 37 (22%) and hormonal device usage, particularly the implant, increased from 9 of 47 (19%) to 11 of 37 (30%) over the 24 months from initial consultation.Conclusion: Most patients in an integrated complex family planning-pediatric hematology oncology clinic will change their menstrual bleeding hormone treatment with initial consultation, although management may require multiple changes. The most common treatment 24 months following the initial consultation was hormonal devices.Implications: Patients with blood disorders affecting menstrual bleeding have complex needs that could be addressed by an integrated complex family planning-pediatric hematology oncology clinic. Most patients require multiple changes in treatment to achieve adequate control of their bleeding, and patients were more likely to choose hormonal devices for management over time. [ABSTRACT FROM AUTHOR]

Long-acting reversible contraception (LARC) is the collective name for intrauterine contraception (copper intrauterine devices and levonorgestrel intrauterine systems) and the subdermal contraceptive implant. LARC methods are highly effective, require minimal user effort and do not require regular healthcare appointments; however the insertion and removal procedures can only be undertaken by clinicians trained to do so. The progestogen-only subdermal implant is the most effective method of reversible contraception in the United Kingdom and is licensed for 3 years. The copper intrauterine device is the most effective non-hormonal method of contraception. These devices are licensed for five or 10 years and can also be used as emergency contraception. The levonorgestrel intrauterine systems (LNG-IUS) are licensed for 3, 5, or 6 years. The Mirena LNG-IUS is also licensed for use in treating heavy menstrual bleeding and for endometrial protection as part of hormone replacement therapy. [ABSTRACT FROM AUTHOR]

Heavy Menstrual Bleeding (HMB) is a common gynaecological presentation, which can affect girls and women throughout their reproductive years and cause significant health issues. This review discusses the most recent evidence-based management of HMB and strategies for providing safe and effective care during the Covid 19 pandemic. Thus protocols and recommendations for HMB, developed to tackle the Covid 19, could become the 'new normal' for both primary and secondary care. There is a need for administrative changes, improved technology and effective communication to adapt these new recommendations. [ABSTRACT FROM AUTHOR]

Study Objective On this study we sought to determine the relationship of bleeding disorders to iron deficiency anemia. Additionally, this study was undertaken to examine all current treatment modalities used in a menorrhagia clinic with respect to heavy menstrual bleeding management to identify the most effective options for menstrual management in the setting of an underlying bleeding disorder. Design, Setting, Participants, Interventions, and Main Outcome Measures We performed a retrospective chart review of adolescents younger than 21 years with heavy menstrual bleeding attending a multidisciplinary hematology-adolescent gynecology clinic. Information including demographic characteristics, bleeding diathesis, hematologic parameters, treatment, and the diagnosis was extracted from each chart. Subjects were grouped into 2 categories on the basis of the diagnosis of a bleeding disorder. Hemoglobin level, iron deficiency anemia, and need for transfusion were compared between a bleeding disorder and no bleeding disorder group. Subjects were grouped into categories depending on hormonal modality and treatment success of the groups were compared. Results Seventy-three subjects were tested for a bleeding disorder. Of the subjects who completed testing, 34 (46%) were diagnosed with a bleeding disorder. Thirty-nine subjects (54%) had heavy menstrual bleeding because of other causes. There was no significant difference in hemoglobin between those with and without a bleeding disorder. Iron deficiency anemia was significantly higher in subjects without a bleeding disorder. In a comparison of hormone therapy success, the levonorgestrel intrauterine device (89%, 8 out of 9 subjects) had the highest rate of menstrual suppression followed by norethindrone acetate 5-10 mg/d (83%, 5 out of 6 subjects), and the transdermal patch (80%, 4 out of 5 subjects). All subjects using tranexamic acid as well as hormonal therapy had 100% achievement of menstrual suppression. Conclusion A high frequency of bleeding disorders was found in those tested. Subjects with a bleeding disorder were less likely to present with severe anemia requiring blood transfusion and less likely to have iron deficiency anemia. Although combined oral contraceptives were commonly used clinically for menstrual suppression, they were not found to be the most effective option. [ABSTRACT FROM AUTHOR]

This review studies women's preferences for shared decision-making about heavy menstrual bleeding treatment and evaluates interventions that support shared decision-making and their effectiveness. PubMed, Cochrane, Embase, Medline and ClinicalTrials.gov were searched. Three research questions were predefined: 1) What is the range of perspectives gathered in studies that examine women facing a decision related to heavy menstrual bleeding management?; 2) What types of interventions have been developed to support shared decision-making for women experiencing heavy menstrual bleeding?; and 3) In what way might women benefit from interventions that support shared decision-making? All original studies were included if the study population consisted of women experiencing heavy menstrual bleeding. We used the TIDieR (Template for Intervention: Description and Replication) checklist to assess the quality of description and the reproducibility of interventions. Interventions were categorized using Grande et al. guidelines and collated and summarized outcomes measures into three categories: 1) patient-reported outcomes; 2) observer-reported outcomes; and 3) doctor-reported outcomes. Fifteen studies were included. Overall, patients preferred to decide together with their doctor (74%). Women's previsit preference was the strongest predictor for treatment choice in two studies. Information packages did not have a statistically significant effect on treatment choice or satisfaction. However, adding a structured interview or decision aid to increase patient involvement did show a positive effect on treatment choice and results, patient satisfaction and shared decision-making related outcomes. In conclusion shared decision-making is becoming more important in the care of women with heavy menstrual bleeding. Structured interviews or well-designed (computerized) tools such as decision aids seem to facilitate this process, but there is room for improvement. A shared treatment choice is only possible after careful provision of information, elicitation of patients' preferences and integrating those preferences. Interventions should be designed accordingly. [ABSTRACT FROM AUTHOR]

Objective: To compare the efficacy, acceptability and compliance of combined hormonal vaginal ring (CVR), with combined hormonal pills (CHP) in patients with heavy menstrual bleeding (HMB).Study Design: This prospective study was conducted in 50 women with HMB in age group of 25-40 years. Patients were divided in two groups of 25 each and followed for six treatment cycles. In each group, cycle comprised of three weeks of CVR (releases 15μg of EE and 120μg of the etonogestrel per day) or CHP (containing 30μgm of EE and 150μgm of LNG) use, followed by one ring or pill free week. After each cycle, patients were evaluated about the amount of blood loss and duration of bleeding by the pictoral blood assessment chart (PBAC), early bleeding (EWB), continued bleeding (CWB), intermenstrual bleeding, intended bleeding, compliance, and user acceptability. The collected data were analyzed using the Chi square test, t-test and ANOVA test.Result: Reduction in PBAC score for CVR (70.73%) and CHP group (70.02%), duration of bleeding and incidence of EWB was comparable among the two groups. The incidence of intermenstrual bleeding was lower in CVR than in CHP group in cycle 3 and 4 with significant p value. The incidence of CWB was significantly lower and the incidence of intended bleeding pattern in CVR group was significantly higher in cycle 3, 4, 5 and 6, signifying better cycle control. Compliance was also higher in CVR (88%) than CHC (75.33% of all cycles).Conclusion: This trial suggests that both the CVR and CHP are very effective short-term treatments for HMB in reproductive age group. However, women had better cycle control and compliance with CVR. This may be an attractive option among the wide variety of medications used to treat HMB. [ABSTRACT FROM AUTHOR]

Heavy menstrual bleeding is defined as excessive menstrual blood loss which interferes with the woman's physical, emotional, social and material quality of life, and which can occur alone or in combination with other symptoms. In the majority of cases, an accurate history may indicate the cause of the bleeding. Common investigations include haematological blood tests, ultrasound scan and endometrial biopsy. Management may be medical or surgical, depending on the patient's age, pathology identified and fertility wishes. All interventions should aim to improve quality of life rather than focussing on menstrual blood loss alone. This review considers the intricacies involved when managing women with heavy menstrual bleeding. [ABSTRACT FROM AUTHOR]

Abstract: Ethnopharmacological relevance: In Dominica, women offer dysmenorrhea, delayed menses, and menorrhagia as prevalent menstrual troubles. Dominican humoral theory considers menstruation to be “hot” such that menstrual problems are caused by the introduction of too much “cold” in the body. These conditions can be painful and may require herbal medicine. Our method finds the most culturally salient plants for these conditions—those which are of common knowledge across the population. We hypothesize that cultural agreement on ethnobotanical treatments (1) reflects their perceived ethnophysiological efficacy, and that (2) salient plants contain bioactive compounds appropriate for the menstrual conditions for which Dominicans employ the plants. Materials and Methods: Qualitative data on local explanatory models and treatment of menstrual conditions were collected using participant-observation, focus groups, and informal key informant interviews. Quantitative ethnobotanical data come from freelist (or “free-list”) tasks, conducted with 54 adults. Results: Mean salience values calculated from freelisted data reveal that the same four plants, Cinnamomum verum (synonym Cinnamomum zeylanicum) (Lauraceae), Mentha suaveolens (Lamiaceae), Pimenta racemosa (Myrtaceae) and Sphagneticola trilobata (synonym Wedelia trilobata) (Asteraceae) are used to treat dysmenorrhea and delayed menses. The only remedy reported for menorrhagia, Sphagneticola trilobata (Asteraceae), is also a treatment for dysmenorrhea and delayed menses. The Dominican humoral system views menstruation as a "hot" condition, yet these "bush medicines" are also "hot." Dominicans do not view menstruation as a problem, rather, they reckon that excess "cold" in a woman׳s menstruating body impedes menstrual function to cause problems thus requiring "hot" plants to alleviate their symptoms. A literature review revealed that all four plants contain analgesic, anti-nociceptive, and anti-inflammatory properties. Additionally, Mentha suaveolens is muscle-relaxing and anti-spasmodic, Cinnamomum verum has a mild anti-coagulant, and Sphagneticola trilobata has wound healing, anti-stress, and sedative properties. Conclusions: In Dominican menstrual problems there is correspondence between cultural consensus, bioactivity, and humoral theory. Examining the ethnophysiology of menstruation and its complications provides evidence for the expectations of actions and effectiveness of locally culturally salient medicinal plants. [Copyright &y& Elsevier]

Abstract: Objective: To assess whether, among other prognostic factors, a history of Cesarean section is associated with endometrial ablation failure in the treatment of menorrhagia. Study design We compared women who had failed ablation to women who had successful ablation for menorrhagia in a case–control study. Failed ablation was defined as the need for hysterectomy due to persistent heavy menstrual bleeding after ablation. Successful ablation was defined as an ablation for menorrhagia not needing hysterectomy and the woman being satisfied with the result. Both cases and controls were identified from the surgery registration in the Máxima Medical Center between January 1999 and January 2009. Cases were women that had an endometrial ablation and a hysterectomy, whereas controls only had an endometrial ablation. From the medical files we collected for each patient clinical history, including the presence of a previous Cesarean section, baseline characteristics at the moment of initial ablation, data of the ablation technique and follow-up status. We used univariable and multivariable logistic regression to estimate the risk of failure of endometrial ablation. Results: We compared 76 cases to 76 controls. Among the cases, 12 women had had a previous Cesarean section versus 15 in the control group (15.8% versus 19.7%; odds ratio (OR) 0.76; 95% CI 0.3–1.8). Factors predictive for failure of ablation were dysmenorrhea (OR 3.0; 95% CI 1.5–6.1), having a submucous myoma (OR 3.2; 95% CI 1.5–6.8) and uterine depth (per cm OR 1.3; 95% CI 1.0–1.6). Presence of intermenstrual bleeding, sterilization and age were not associated with failure of ablation. Conclusion: A previous Cesarean delivery is not associated with an increased risk of failure of endometrial ablation, but dysmenorrhea, a submucous myoma and longer uterine depth are. This should be incorporated in the counseling of women considering endometrial ablation. [Copyright &y& Elsevier]

Objective: To describe the clinical management of menorrhagia in a woman with hyperparathyroidism–jaw tumor syndrome (HPT-JT). Design: Case report. Setting: Large translation research hospital. Patient(s): A 26-year-old nulligravid woman with familial HPT-JT presented with life-long menorrhagia resistant to progesterone intrauterine device (IUD) therapy and a desire for fertility. Intervention(s): Aromatase inhibitor therapy. Main Outcome Measure(s): Clinical response to therapy and pregnancy. Result(s): Imaging demonstrated an enlarged endometrial lining and thickening of the junctional zone. At operative hysteroscopy, multiple atypical endometrial polyp-like lesions filled the entire uterine cavity and were removed. Histologic evaluation demonstrated the lesions to be adenomyomas with an abundance of aromatase expression. Postoperative treatment included an aromatase inhibitor. The patient''s menorrhagia, which had previously been resistant to progesterone IUD therapy, resolved with the aromatase inhibitor. After 10 months of this treatment, the aromatase inhibitor was discontinued and a repeated hysteroscopy revealed a markedly improved uterine cavity. The patient subsequently became pregnant on her first natural cycle and delivered a healthy term infant. Conclusion(s): Aromatase inhibitors may represent a novel treatment for benign uterine pathology in HPT-JT. [Copyright &y& Elsevier]

Abstract: Background: This study compared the efficacy of the contraceptive vaginal ring (CVR; NuvaRing; N.V. Organon, Oss, the Netherlands) and norethisterone for treatment of idiopathic heavy menstrual bleeding (HMB) during the fertile age. Study Design: Ninety-five women with idiopathic HMB were selected in this randomized controlled trial. They were treated with either the CVR (n=48) or norethisterone (n=47) for three cycles. Each cycle consisted of 3 weeks of CVR use and then a 1-week ring-free period or norethisterone tablets, 5 mg three times daily from Cycle Days 5 to 26. Outcome measures were as follows: menstrual blood loss assessed by pictorial blood loss assessment chart (PBAC), duration of menses, hemoglobin, serum ferritin, quality of life (QoL) questionnaire, side effects and overall satisfaction with treatment. Result: Significant improvements in PBAC score, the duration of menses, hemoglobin, serum ferritin and QoL were observed at the end of the study in each group. No statistically significant differences were found regarding the mean PBAC score (90.2±24.4 vs. 92.3±26.7) and its percent reduction (68.6% vs. 69.5%), duration of menses (5.3±1.2 vs. 5.5±1.1 days), hemoglobin and serum ferritin at the end of the study between the CVR and the norethisterone groups, respectively. Significantly more ring users were satisfied and elected to continue with treatment. Conclusion: Both the CVR and oral norethisterone are effective treatments for idiopathic HMB. The CVR may be an attractive option especially for those requesting contraception as well. [Copyright &y& Elsevier]

Abstract: Objective: Unexplained menorrhagia can be caused by underlying bleeding disorders. The aim of this study was to investigate the current work-up of menorrhagia in routine gynaecological practice, with a special interest in haemostatic evaluation. Secondly, we investigated the outcome of individualized treatment in our centre. Study design: Retrospective medical chart review of 112 consecutive patients referred with menorrhagia to a general gynaecology clinic of a university teaching hospital in the Netherlands between January 2006 and January 2007. In April 2008 we performed a structured telephone interview evaluating the effectiveness of their therapy. Results: We included 112 patients, whose median age was 42 years. Twenty-nine percent were anaemic (hemoglobin <12.0g/dL). Seventy-one (63%) had unexplained menorrhagia. Only two patients had haemostatic evaluation and neither had von Willebrand''s disease. Forty percent (29/71) needed two or more different therapies, 17% (12/71) needed three different therapies and two patients needed a total of seven different therapies. Eight patients underwent hysterectomy, six of them after endometrial ablation. Most patients (80%) were successfully treated medically or surgically and were satisfied with their therapy during follow-up. Eleven patients declined therapy and accepted their heavy periods. Conclusion: Haemostatic evaluation in women with unexplained menorrhagia is uncommon in gynaecological practice in our centre. Although most of the patients were satisfied with their treatment, a significant number required hysterectomy and another important proportion had to accept their menorrhagia. We hypothesize that the identification of haemostatic disorders might improve care for these women. [Copyright &y& Elsevier]

Abstract: Study Objectives: We reviewed the management and treatment outcomes of menorrhagia in adolescents with inherited bleeding disorders and assessed the impact of menorrhagia on their quality of life. Design: Retrospective review of case notes and a questionnaire study. Setting: Comprehensive-care hemophilia treatment center. Participants: Adolescents with inherited bleeding disorders who had registered at the center and were attending the multidisciplinary hemophilia and gynecology clinic for management of menorrhagia. Interventions: Review of medical records and assessment of menstrual blood loss using the pictorial blood assessment chart and quality of life measurements during menstruation using a questionnaire. Main Outcome Measures: Scores on pictorial blood assessment charts and quality of life measurements before and after treatment. Results: Of 153 girls aged 12 to 19 years who had registered at the center and had an inherited bleeding disorder, 42 (27%) attended the multidisciplinary clinic for management of menorrhagia. The majority (38/42; 90%) had experienced menorrhagia since menarche. Of the group, 5 (12%) required hospital admission for acute menorrhagia and severe anemia. Treatment options for menorrhagia included tranexamic acid, desmopressin, combined oral contraceptive pills, clotting factor concentrate, and the levonorgestrel intrauterine system. These treatment modalities, alone or in combination, were associated with a reduction in menstrual blood loss (median pre- and posttreatment pictorial blood assessment chart scores were 215 and 88, respectively) and improvement in quality of life scores (median pre- and posttreatment were 26 and 44, respectively). Conclusions: Menorrhagia is a common symptom in adolescents with inherited bleeding disorders. It can present acutely, and it adversely affects quality of life. Treatment options include hemostatic and/or hormonal therapies and can improve the quality of life of affected girls. [Copyright &y& Elsevier]

Objective: To determine the effects of new conservative surgical management for diffuse uterine adenomyosis. Design: Retrospective clinical study. Setting: Gynecology department in a general hospital. Patient(s): A total of 44 women with diffuse adenomyosis. Intervention(s): Conservative surgical management. Main Outcome Measure(s): Mean visual analog scale score of dysmenorrhea and menorrhagia after a 3-month follow-up. Result(s): After this surgery, the mean visual analog scale score of dysmenorrhea decreased from 9.4 to 0.8, and anemia due to menorrhagia improved in all women. Two patients became pregnant, with one interstitial pregnancy and one normal pregnancy that is continuing. No major complications or sequelae were observed. Conclusion(s): This procedure should be considered as a therapeutic option in women with symptoms of diffuse uterine adenomyosis who wish to avoid hysterectomy. [Copyright &y& Elsevier]

Abstract: Menorrhagia is a significant health problem for many women. It increases with age and peaks during the perimenopause. Although historically, hysterectomy as been the mainstay for treatment there are many effective medical and surgical alternatives to hysterectomy that may be eminently suitable for perimenopausal women as menopause will intervene in due course. The incidence, aetiology, initial management and effective treatment options are discussed in this review article. [Copyright &y& Elsevier]

Intrauterine progestins, progesterone receptor modulators, and antagonists have many important current and potential gynecologic applications. This article will describe the evidence for use of intrauterine progestin for common gynecologic conditions beyond its important role in contraception. We will review the evidence for use of intrauterine progestin delivery for menorrhagia, endometriosis management, adenomyosis treatment, uterine fibroids, endometrial hyperplasia, and its concurrent use in women on hormone replacement therapy or tamoxifen. [Copyright &y& Elsevier]

Objective: To compare the value of SF36v2 versus multi-attribute utility score (MAS) for predicting treatment outcome in heavy menstrual bleeding (HMB).Study Design: Longitudinal observational study, in an outpatient service of a large UK teaching hospital. 193 women took part. Women were asked to complete SF36v2 and a multi-attribute utility score (MAS) for menorrhagia before the first consultation. Patient management was determined through an evidence based guideline and blind to their response to the questionnaire. Treatment outcome at 8 months was examined in relation to the physical (PCS) and mental (MCS) health summary scales of SF36v2 and to MAS.Results: At study entry equal numbers of patients, 179 (93%), returned usable responses for SF36v2 and the multi-attribute scale; 178 (92%) returned both. Baseline SF36v2 scores for role physical, bodily pain, social functioning and mental health were significantly lower (p<0.05) for the group of women who finally required surgery, but the difference in PCS or MCS was not statistically significant. The mean MAS score for those who did not need surgery was 50.7, and for those who needed surgery following failed medical treatment was 35.06. The difference was statistically significant (p<0.001, 95% CI 7.47-23.82). Using logistic regression analysis there was a statistically significant association between baseline MAS but not MCS or PCS and the need for surgery. However, there was considerable overlap between treatment groups.Conclusions: MAS may be a better predictor of management outcome compared to SF36v2 for HMB; but its utility for the individual patient is limited. [ABSTRACT FROM AUTHOR]

Abstract: Background: This study was conducted to evaluate the effect of levonorgestrel-releasing intrauterine devices (LNG-IUDs) on menorrhagia in patients receiving anticoagulant therapy after cardiac valve replacement. Study Design: Forty women with menorrhagia who underwent cardiac valve replacement and were taking anticoagulant medication were enrolled in the study. The women were randomly divided into two groups: LNG-IUDs were inserted into 20 women in Group 1 over the first 3 days of menstrual bleeding, while the women in Group 2 were followed without any intervention. The activated partial thromboplastin time, prothrombin time, international normalized ratio, hematocrit level, hemoglobin level, ferritin level and pictorial bleeding assessments for the quantity of menstrual bleeding were recorded. Results: Three months after insertion of LNG-IUDs, the women in Group 1 had a significant decrease in blood loss and higher hemoglobin, hematocrit and ferritin values. No difference was detected for these parameters in the control group at the third and sixth months of the study. Coagulation parameters did not differ between the two groups. Conclusion: LNG-IUDs can be considered as an effective non-surgical treatment for menorrhagia in women receiving anticoagulant therapy after cardiac valve replacement. [Copyright &y& Elsevier]

Objective: To compare three types of equipment during hysteroscopic resection. Design: A randomized study. Setting: Women''s clinic at Ullevaal University Hospital, Oslo, Norway. Patient(s): Two hundred premenopausal women with menorrhagia caused by dysfunctional bleedings, fibroids, or polyps. Intervention(s): Hysteroscopic resection was performed either with monopolar electrodes using glycine 1.5% as irrigant or with two different types of bipolar electrodes (TCRis; Olympus, Hamburg, Germany and Versapoint; Gynecare, Menlo Park, CA) using saline as irrigant. Main Outcome Measure(s): Change in serum sodium as a result of irrigant consumption, operating time, and amount of tissue removed. Result(s): A statistically significant reduction in mean serum sodium from 138.7 mmol/L to 133.8 mmol/L was seen in the monopolar group, compared with the case of the saline groups with no reduction. The amount of resected tissue in the monopolar and TCRis group was approximately 1.00 g/min, compared with 0.65 g/min in the Versapoint group. Loss of fluid during the procedure was significantly higher in the two bipolar groups. Conclusion(s): Bipolar electrodes appear to have a safer profile compared with monopolar electrodes because of the unchanged serum sodium. Irrigant consumption was significantly higher in the two bipolar groups, without any side effects during or after the procedure. Furthermore, the TCRis loop appears to be superior to the Versapoint loop, as regards operating time and amount of tissue removed. [Copyright &y& Elsevier]

Abstract: One in 20 women of reproductive age consults their general practitioner each year in the UK because of heavy menstrual bleeding. The impact on their social, professional and sexual life can be significant and, more than half will be referred to secondary care without any investigation or treatment being instituted. There are many causes for menorrhagia but, of those who undergo hysterectomy, more than half will be found to have a completely normal uterus. Hysterectomy has been a popular treatment for heavy periods, with one in five women in the UK having their uterus removed before the age of 60 years. New effective treatments – such as the Mirena intrauterine system and second generation endometrial ablation – should see rates of hysterectomy for the treatment of dysfunctional uterine bleeding fall. [Copyright &y& Elsevier]

Abstract: Background: Menorrhagia is a common problem in women of reproductive age. Its aetiology in the absence of organic pathology, hormonal or haematological disorders remains largely unknown. Traditional medical therapy may not be beneficial in the long run. Hysterectomy for this condition is an invasive over treatment. First generation endometrium ablation techniques aimed at destroying the endometrium, were associated with life threatening complications. The second generation endometrial ablation techniques like uterine thermal balloon therapy have reduced these problems. Methods: Fifty patients were selected for the procedure between 2002 and 2005. The patients qualified for the procedure if they had completed their family, had normal pelvic ultrasound findings, benign endometrial histology, normal PAP smear and clinically a normal size or bulky uterus. Results: 50% patients were in the age group of 35–45 years. 28(56%) procedures were done under local anaesthesia and 22(44%) under general anaesthesia. The patients were followed up for a period of 3 to 29 months (median 16 months). Seven(14%) had amenorrhoea and 40(80%) had normal periods or hypomenorrhoea. Three(6%) patients continued to have menorrhagia and were considered failures. 94% patients were satisfied with the procedure and there were no complications in this series. Conclusions: Uterine balloon therapy is a simple, safe and effective method for the treatment of menorrhagia in selected patients. [Copyright &y& Elsevier]

: ObjectiveTo evaluate the change in intrauterine pressure during thermal balloon endometrial ablation and to identify risk factors associated with treatment failure.: DesignProspective observational study.: SettingUniversity-affiliated teaching hospital.: Patient(s)Seventy two consecutive patients with idiopathic menorrhagia refractory to medical treatment.: Intervention(s)Thermal balloon endometrial ablation under patient-controlled sedation.: Main outcome measure(s)Change in intrauterine pressure during the treatment cycle and risk factors associated with treatment failure.: Result(s)A spontaneous decrease in intrauterine pressure occurred in most patients (93%). The mean (±SD) decrease was 34.1 ± 14.9 mm Hg, or 19.5% ± 9.1%. The treatment failed in 10 patients (13.9%), and the mean end pressure was significantly lower in this group (131.1 ± 14.1 mm Hg vs. 145.1 ± 18.0 mm Hg; P=.02). The chance of success of treatment was significantly lower when the end pressure was <140 mm Hg (odds ratio, 0.42 [95% CI, 0.27 to 0.68]; P=.01), the intrauterine volume was >10 mL (odds ratio, 0.43 [95% CI, 0.22 to 0.83]; P=.058) and the uterus was retroverted (odds ratio, 0.36 [95% CI, 0.20 to 0.65]; P=.008).: Conclusion(s)Maintaining high intrauterine pressure during the treatment cycle and correction of the retroversion may help to improve treatment success in thermal balloon endometrial ablation. [Copyright &y& Elsevier]

The aim of this prospective study was to investigate factors predicting choice of treatment for excessive menstrual bleeding, with special emphasis on women''s pre-treatment preference. A cohort of women with heavy menstruation and their treatment process in gynaecology outpatient clinics were followed-up for 1 yr. A total of 383 35–54-yr-old women attending 14 Finnish hospitals participated. They completed a questionnaire before their first outpatient clinic visit, and postal follow-ups were conducted 3 and 12 months later. Information on treatment(s) during the follow-up was taken from medical records and questionnaires. The choice between hysterectomy and conservative treatments, and fulfillment of pre-treatment preference were the main outcome measures. During the 1-yr follow-up, 51% (n=196) of the women underwent hysterectomy and nine were still awaiting it, 12% (n=44) had a minor surgical procedure, 11% (n=41) had oral medication, 9% (n=33) used a hormonal intrauterine system, and nine women changed preventive method. Forty-two women (11%) reported having had no treatment. Data on previous treatments suggested that conservative treatment modalities were under-used. Most of the treatment decisions were made within the first 3-month period. Women''s pre-treatment preference was the strongest predictor of chosen treatment. Unemployment, irregular periods and anxiety decreased the probability of a decision for hysterectomy, while pelvic pain and inconvenience due to bleeding increased it. The treatment plan accorded with pre-treatment preference in 72% of the women preferring hysterectomy and in 74% of those preferring a conservative option. [Copyright &y& Elsevier]

: ObjectiveTo determine baseline characteristics of women undergoing uterine artery embolization (UAE) for symptomatic fibroids.: DesignMulticenter, prospective, single-arm clinical treatment trial.: SettingEight Ontario university and community hospitals.: Patient(s)Five hundred fifty-five women undergoing UAE for fibroids.: Intervention(s)Baseline questionnaires completed before UAE.: Main outcome measure(s)Questionnaires were analyzed for demographic, medical, and gynecologic histories. Fibroid symptoms, impact of symptoms, previous consultations, and treatments were also analyzed.: Result(s)The Ontario cohort (66% white, 23% black, 11% other races) had an average age of 43. Thirty-one percent were under age 40. Most women were university educated (68%) and working outside the home (85%). Women reported heavy menstrual bleeding (80%), urinary urgency/frequency (73%), pain during intercourse (41%), and work absences (40%). They experienced fibroid-related symptoms for an average of 5 years and consulted with on average of three gynecologists before UAE. High fibroid life-impact scores were reported by 58%. Black women were significantly younger (40.7 vs. 44.0 years), more likely to experience symptoms longer (7 vs. 5 years), and more likely to undergo myomectomy before UAE (24% vs. 9%) than white women.: Conclusion(s)Our study illustrates that large numbers of women with highly symptomatic fibroid disease are averse to surgery despite their burden of suffering and are actively seeking alternatives to hysterectomy. [Copyright &y& Elsevier]

: ObjectiveTo evaluate fibroid uterine volume reduction, symptom relief, and patient satisfaction with uterine artery embolization (UAE) for symptomatic fibroids.: DesignMulticenter, prospective, single-arm clinical treatment trial.: SettingEight Ontario university and community hospitals.: Patient(s)Five hundred thirty-eight patients undergoing bilateral UAE.: Intervention(s)Bilateral UAE performed with polyvinyl alcohol particles sized 355–500 μm.: Main outcome measure(s)Three-month follow-up evaluations including fibroid uterine volume reductions, patient reported symptom improvement (7-point scale), symptom life-impact (10-point scale) reduction, and treatment satisfaction (6-point scale).: Result(s)Median uterine and dominant fibroid volume reductions were 35% and 42%, respectively. Significant improvements were reported for menorrhagia (83%), dysmenorrhea (77%), and urinary frequency/urgency (86%). Mean menstrual duration was significantly reduced after UAE (7.6 to 5.4 days). Improvements in menorrhagia were unrelated to pre-UAE uterine size or post-UAE uterine volume reduction. Amenorrhea occurring after the procedure was highly age dependent, ranging from 3% (1%–7%) in women under age 40 to 41% (26%–58%) in women age 50 or older. Median fibroid life-impact scores were significantly reduced after UAE (8.0 to 3.0). The majority (91%) expressed satisfaction with UAE treatment.: Conclusion(s)UAE reduced fibroid uterine volume and provided significant relief of menorrhagia that was unrelated to initial fibroid uterine size or volume reduction. Patient satisfaction with short-term UAE treatment outcomes was high. [Copyright &y& Elsevier]

: ObjectiveTo evaluate the effectiveness of uterine artery embolization in women with uterine myomas in terms of the clinical results for the relief of related symptoms.: DesignA pilot study on 26 women affected by uterine single myoma.: SettingTertiary level care in an university hospital.: Patient(s)Twenty-six patients, aged 32 to 54 years, suffering of menorrhagia, pelvic pain, and abdominal mass for single myoma, intramural localization.: Intervention(s)Selective uterine artery embolization performed under peridural anesthesia.: Main outcome measure(s)We measured the x-ray dose to which patients were exposed. Color power Doppler ultrasound examinations were performed during the follow-up evaluations at 1 to 6 months and 1 year after the procedure.: Result(s)Uterine artery embolization was successfully performed in 100% of cases. The mean fluoroscopy time was of 20 minutes during the procedure. The mean dose of x-ray absorbed by the ovary was estimated at 18.7 cGy and the mean dose of x-ray absorbed by the skin was 126.7 cGy. A reduction of myoma volume of 55% was found at 6 months’ ultrasound examination and 75% at the 1-year examination.: Conclusion(s)Patients are well satisfied and have short recovery times with this procedure. Uterine artery embolization may be a valid alternative to traditional surgery. [Copyright &y& Elsevier]

Objective: The purpose of this study was to compare the satisfaction rate and the effectiveness of transcervical hysteroscopic endometrial resection and thermal destruction of the endometrium in the treatment of menorrhagia.Study Design: A prospective randomized trial with 2 years of follow-up was carried out in the Department of Gynecology of the University of Naples. Eighty-two patients who were affected by menorrhagia that was unresponsive to medical treatment were respectively randomized to transcervical hysteroscopic endometrial resection or to thermal destruction of the endometrium. Satisfaction rate, operative time, discharge time, complication rate, reintervention rate, and resumption of normal activity were evaluated in each group.Results: The satisfaction rate was significantly higher in the thermal destruction group. Operative time was significantly shorter in the thermal destruction group (24 +/- 4 minutes vs 37 +/- 6 minutes). Intraoperative blood loss was significantly lower in the thermal destruction group (7.2 +/- 2.8 mL vs 89 +/- 38 mL). Reintervention rates were higher in the transcervical hysteroscopic endometrial resection group, although postoperative pain was not significantly different between the two groups. Discharge time, complication rate, and resumption of normal activity were not significantly different between the two groups.Conclusion: Thermal destruction of the endometrium for the treatment of menorrhagia should be considered an effective therapeutic option because of its acceptability among patients, shorter operative time, and lower blood loss. [ABSTRACT FROM AUTHOR]

Objective: We sought to establish the lowest dose of 3-keto-desogestrel, when added to a copper-releasing intrauterine contraceptive device, that is needed to reduce menstrual blood loss to a very low level and to treat (essential) menorrhagia successfully.Study Design: A double-blind group comparative study was designed in which 203 healthy women with or without menorrhagia were enrolled and randomized to four different Multiload Cu250 intrauterine contraceptive devices, releasing 0 (control), 1.5, 3, or 6 microg of 3-keto-desogestrel daily. Menstrual blood loss, hemoglobin, and serum ferritin levels were determined before and during treatment.Results: All 3-keto-desogestrel-copper intrauterine contraceptive devices reduced menstrual blood loss significantly, causing a reduction of up to 30 to 40 mL after 12 months of use. All women with essential menorrhagia were considered to have been successfully treated after 6 months of use. Serum ferritin levels rose with all three 3-keto-desogestrel-loaded devices.Conclusion: A Multiload Cu250 intrauterine contraceptive device releasing 1.5 microg of 3-keto-desogestrel daily is able to reduce menstrual blood loss to a very low level and to replete body iron stores in women with or without menorrhagia. Higher doses have no superior effect. [ABSTRACT FROM AUTHOR]

Background: Heavy menstrual bleeding affects the physical functioning and social well-being of many women. The levonorgestrel-releasing intrauterine system and endometrial ablation are 2 frequently applied treatments in women with heavy menstrual bleeding.Objective: This study aimed to compare the effectiveness of the levonorgestrel-releasing intrauterine system with endometrial ablation in women with heavy menstrual bleeding.Study Design: This multicenter, randomized controlled, noninferiority trial was performed in 26 hospitals and in a network of general practices in the Netherlands. Women with heavy menstrual bleeding, aged 34 years and older, without a pregnancy wish or intracavitary pathology were randomly allocated to treatment with either the levonorgestrel-releasing intrauterine system (Mirena) or endometrial ablation, performed with a bipolar radiofrequency device (NovaSure). The primary outcome was blood loss at 24 months, measured with a Pictorial Blood Loss Assessment Chart score. Secondary outcomes included reintervention rates, patient satisfaction, quality of life, and sexual function.Results: We registered 645 women as eligible, of whom 270 women provided informed consent. Of these, 132 women were allocated to the levonorgestrel-releasing intrauterine system (baseline Pictorial Blood Loss Assessment Chart score, 616) and 138 women to endometrial ablation (baseline Pictorial Blood Loss Assessment Chart score, 630). At 24 months, mean Pictorial Blood Loss Assessment Chart scores were 64.8 in the levonorgestrel-releasing intrauterine system group and 14.2 in the endometrial ablation group (difference, 50.5 points; 95% confidence interval, 4.3-96.7; noninferiority, P=.87 [25 Pictorial Blood Loss Assessment Chart point margin]). Compared with 14 women (10%) in the endometrial ablation group, 34 women (27%) underwent a surgical reintervention in the levonorgestrel-releasing intrauterine system group (relative risk, 2.64; 95% confidence interval, 1.49-4.68). There was no significant difference in patient satisfaction and quality of life between the groups.Conclusion: Both the levonorgestrel-releasing intrauterine system and endometrial ablation strategies lead to a large decrease in menstrual blood loss in women with heavy menstrual bleeding, with comparable quality of life scores after treatment. Nevertheless, there was a significant difference in menstrual blood loss in favor of endometrial ablation, and we could not demonstrate noninferiority of starting with the levonorgestrel-releasing intrauterine system. Women who start with the levonorgestrel-releasing intrauterine system, a reversible and less invasive treatment, are at an increased risk of needing additional treatment compared with women who start with endometrial ablation. The results of this study will enable physicians to provide women with heavy menstrual bleeding with the evidence to make a well-informed decision between the 2 treatments. [ABSTRACT FROM AUTHOR]

Abstract: One in twenty women of reproductive age seek advice from their general practitioner each year because of heavy menstrual bleeding. It is the fourth most common condition that requires referral to a gynaecologist for investigations and treatment. There are many causes for menorrhagia but of those who undergo hysterectomy as treatment, more than half will be found to have a completely normal uterus. Hysterectomy used to be the treatment for menorrhagia for women under the age of 60 years. Now effective treatment such as Mirena intrauterine system and second generation endometrial ablation has seen the rate of hysterectomy for dysfunctional uterine bleeding fall. [Copyright &y& Elsevier]

Objectives: To compare the effectiveness of endometrial thermal ablation and the levonorgestrel intrauterine system (LNG-IUS) in the management of menorrhagia. Study design: Fifty women attending a gynaecology clinic at a District General Hospital in south-west England were randomised to either surgical treatment using thermal ablation (Thermochoice, Gynecare) or medical treatment using a LNG-IUS (Mirena, Schering Healthcare). A pictorial menstrual chart was completed pre-insertion/operatively and again at 6 months post-insertion/operatively. Non-parametric tests (Mann–Whitney) were used for statistical analysis. Results: Follow-up analysis was possible in 23 women in the Thermochoice group and 21 women in the Mirena group. The menstrual scores were slightly higher in the Thermochoice group (median 101) than the Mirena group (median 75) (P=0.025) pre-insertion/operatively but this difference was lost post-insertion/operatively (P=0.689) with median menstrual scores of 27 for the Thermochoice group and 19 for the Mirena group, respectively. Conclusion: Both Thermochoice endometrial ablation and a Mirena LNG-IUS are equally effective in the management of menorrhagia. The choice of treatment should be tailored to the woman’s needs and preferences. [Copyright &y& Elsevier]

Objective: The aim of this study was to determine which factors in the perioperative period influence the success of endometrial ablation in alleviating menorrhagia.Study Design: We performed a retrospective chart review of 120 women aged 27 to 49 years who underwent endometrial ablation after 2 months of preoperative treatment with danazol (Danocrine, 800 mg/d orally) or leuprolide (Lupron, 3.75 mg in one intramuscular injection each month). Patients who required medical management or additional operations to control the vaginal bleeding during follow-up (median follow-up, 37 weeks) were considered to have ablation failures.Results: Sixty-three percent of patients (76/120) had a successful procedure. The chance of success was greater if a cavity of normal appearance was found (odds ratio, 2.3; P =.04). The finding of an intramural fibroid before the procedure resulted in a reduced trend toward success (odds ratio, 0.4; P =.06). The use of danazol pretreatment improved the rate of success overall (odds ratio, 2.2; P =.05) and especially among women <40 years old (P =.01)Conclusion: Perioperative findings may provide useful information in counseling patients regarding endometrial ablation. Success is greater among patients with a normal intrauterine cavity and after preoperative treatment with danazol. [ABSTRACT FROM AUTHOR]

Background: Heavy menstrual bleeding affects up to one third of women in the United States, resulting in a reduced quality of life and significant cost to the health care system. Multiple treatment options exist, offering different potential for symptom control at highly variable initial costs, but the relative value of these treatment options is unknown.Objective: The objective of the study was to evaluate the relative cost-effectiveness of 4 treatment options for heavy menstrual bleeding: hysterectomy, resectoscopic endometrial ablation, nonresectoscopic endometrial ablation, and the levonorgestrel-releasing intrauterine system.Study Design: We formulated a decision tree evaluating private payer costs and quality-adjusted life years over a 5 year time horizon for premenopausal women with heavy menstrual bleeding and no suspected malignancy. For each treatment option, we used probabilities derived from literature review to estimate frequencies of minor complications, major complications, and treatment failure resulting in the need for additional treatments. Treatments were compared in terms of total average costs, quality-adjusted life years, and incremental cost-effectiveness ratios. Probabilistic sensitivity analysis was conducted to understand the range of possible outcomes if model inputs were varied.Results: The levonorgestrel-releasing intrauterine system had superior quality-of-life outcomes to hysterectomy with lower costs. In a probabilistic sensitivity analysis, levonorgestrel-releasing intrauterine system was cost-effective compared with hysterectomy in the majority of scenarios (90%). Both resectoscopic and nonresectoscopic endometrial ablation were associated with reduced costs compared with hysterectomy but resulted in a lower average quality of life. According to standard willingness-to-pay thresholds, resectoscopic endometrial ablation was considered cost effective compared with hysterectomy in 44% of scenarios, and nonresectoscopic endometrial ablation was considered cost effective compared with hysterectomy in 53% of scenarios.Conclusion: Comparing all trade-offs associated with 4 possible treatments of heavy menstrual bleeding, the levonorgestrel-releasing intrauterine system was superior to both hysterectomy and endometrial ablation in terms of cost and quality of life. Hysterectomy is associated with a superior quality of life and fewer complications than either type of ablation but at a higher cost. For women who are unwilling or unable to choose the levonorgestrel-releasing intrauterine system as a first-course treatment for heavy menstrual bleeding, consideration of cost, procedure-specific complications, and patient preferences can guide the decision between hysterectomy and ablation. [ABSTRACT FROM AUTHOR]

Background: Since 1995 uterine artery embolization has been described as an alternative for hysterectomy in patients with symptomatic fibroids. Many studies including several randomized controlled trials established uterine artery embolization as a valuable treatment. These randomized controlled trials reported outcomes in terms of health-related quality of life, clinical outcomes, efficacy, and cost-effectiveness after 1, 2, and 5 years of follow-up.Objective: The purpose of this study was to compare clinical outcome and health-related quality of life 10 years after uterine artery embolization or hysterectomy in the treatment of heavy menstrual bleeding caused by uterine fibroids in a randomized controlled trial.Study Design: In all, 28 Dutch hospitals recruited patients with symptomatic uterine fibroids who were eligible for hysterectomy. Patients were 1:1 randomly assigned to uterine artery embolization or hysterectomy. The outcomes assessed at 10 years postintervention were reintervention rates, health-related quality of life, and patient satisfaction, which were obtained through validated questionnaires. Study outcomes were analyzed according to original treatment assignment (intention to treat).Results: A total of 177 patients were randomized from 2002 through 2004. Eventually 81 uterine artery embolization and 75 hysterectomy patients underwent the allocated treatment shortly after randomization. The remaining patients withdrew from the trial. The 10-year questionnaire was mailed when the last included patient had been treated 10 years earlier. The mean duration of follow-up was 133 months (SD 8.58) accompanied by a mean age of 57 years (SD 4.53). Questionnaires were received from 131 of 156 patients (84%). Ten years after treatment, 5 patients underwent secondary hysterectomy resulting in a total of 28 of 81 (35%) (24/77 [31%] after successful uterine artery embolization). Secondary hysterectomies were performed for persisting symptoms in all cases but 1 (for prolapse). After the initial treatment health-related quality of life improved significantly. After 10 years, generic health-related quality of life remained stable, without differences between both groups. The urogenital distress inventory and the defecation distress inventory showed a decrease in both groups, probably related to increasing age, without significant differences between study arms. Satisfaction in both groups remained comparable. The majority of patients declared being (very) satisfied about the received treatment: 78% of the uterine artery embolization group vs 87% in the hysterectomy group.Conclusion: In about two thirds of uterine artery embolization-treated patients with symptomatic uterine fibroids a hysterectomy can be avoided. Health-related quality of life 10 years after uterine artery embolization or hysterectomy remained comparably stable. Uterine artery embolization is a well-documented and less invasive alternative to hysterectomy for symptomatic uterine fibroids on which eligible patients should be counseled. [ABSTRACT FROM AUTHOR]

Abstract: Our objective was to report on the use of the levonorgestrel-releasing intrauterine system (LNG-IUS, Mirena®) in renal transplant recipients. A retrospective case review was done to identify renal transplant recipients for whom a LNG-IUS had been inserted. All of the women had been seen in the Gynecology Department, Beaumont Hospital, during the period 2000 to 2010. Parameters including age, year of transplantation, indication for insertion, duration of use, discontinuation and complications were documented. The main outcome measure was discontinuation of the LNG-IUS due to pelvic infection. Eleven women were identified who had undergone renal transplantation and were using the LNG-IUS. The mean duration of use was 38 (range 1–84) months. Four women were using the LNG-IUS for contraception and seven were using it for the treatment of menorrhagia, either alone or in conjunction with endometrial ablative procedures. One woman discontinued use in order to conceive. There were no unplanned pregnancies. There were no documented cases of pelvic infection in women using the device. Renal transplant recipients have a critical need for safe and effective contraception. The use of the LNG-IUS has been avoided in the patients due to the theoretical risk of intrauterine device-related pelvic infection in immune-suppressed patients. However, on the basis of our results, we believe that it is acceptable to use the LNG-IUS in renal transplant recipients for both contraception and for the treatment of menorrhagia as the theoretical risk of infection in these immune-suppressed patients does not appear to be increased. [Copyright &y& Elsevier]

Background The objective of the study was to describe a novel Xp13.2 chromosome microduplication in a child with some features of Turner syndrome but with menorrhagia after normal menarche. We used clinical evaluation and high resolution chromosome (microarray) analysis. Case A 15-year-old girl with typical (short stature, pulmonic stenosis, widely-spaced nipples) and atypical (Madelung deformity, menorrhagia) manifestations of Turner syndrome had a novel chromosome constitution with extra material (microduplication) at band Xq13.2 that contained the X-inactive-specific-transcript locus. She also had connective tissue laxity, suggestive of vessel fragility as a contributor to her menorrhagia as well as her diagnosis of von Willebrand disease. This first case of selective X-inactive-specific-transcript locus duplication suggests a role for gene repression in Turner syndrome and other disorders that affect ovarian function. Conclusion High-resolution chromosome (microarray) analysis, now a standard of care, will provide new insights into adolescents with abnormal growth and reproductive tract symptoms, especially when accompanied by congenital anomalies. [ABSTRACT FROM AUTHOR]

Background Factor V deficiency is a rare coagulation disorder. Excessive uterine bleeding is common in affected women. We describe a case of 2 siblings with Factor V deficiency and menorrhagia who achieved control of bleeding with differing treatments. Cases Patient 1 is a 16-year-old female with Factor V deficiency and menorrhagia which was previously controlled with oral contraceptives (OC). She developed heavy bleeding treated with fresh frozen plasma, anti-inhibitor coagulant complex (AICC), and OC taper. A levonorgestrel IUD was placed with good control of her menorrhagia. Patient 2 is the 12-year-old sister of Patient 1. She was treated with AICC, aminocaproic acid, and her menorrhagia was ultimately controlled with continuous OCs. Summary and Conclusion Factor V deficiency is a rare cause of menorrhagia. Various treatment modalities are available. In these adolescent sisters desiring future fertility, menorrhagia was managed with OCs and an IUD. [ABSTRACT FROM AUTHOR]

Objective: To review systematically the literature on uterus-sparing surgical treatment options for adenomyosis. Design: Systematic literature review. Setting: Tertiary academic center. Patient(s): Women with histologically proven adenomyosis treated with uterus-sparing surgical techniques. Intervention(s): Conservative uterine-sparing surgery for adenomyosis classified as (1) complete excision of adenomyosis, (2) cytoreductive surgery or incomplete removal of the lesion, or (3) nonexcisional techniques, with studies selected if women with adenomyosis were treated surgically without performing hysterectomy. Main Outcome Measure(s): The cure rate after interventional strategies, the rate of symptom (dysmenorrhea and menorrhagia) control, and pregnancy rate in each group of intervention. Result(s): A quality assessment tool was used to assess the scientific value of each study. In total, 64 studies dealing with 1,049 patients were identified. After complete excision, the dysmenorrhea reduction, menorrhagia control, and pregnancy rate were 82.0%, 68.8%, and 60.5%, respectively. After partial excision, the dysmenorrhea reduction, menorrhagia control, and pregnancy rate were 81.8%, 50.0%, and 46.9%, respectively. Conclusion(s): Uterine-sparing operative treatment of adenomyosis and its variants appear to be feasible and efficacious. Well-designed, comparative studies are urgently needed to answer the multiple questions arising from this intriguing intervention. [Copyright &y& Elsevier]

Objective: Menorrhagia is a common problem impairing the quality of life (QOL) of many women. Both levonorgestrel-releasing intrauterine system (LNG-IUS) and hysterectomy are effective treatment modalities but no long-term comparative studies of QOL and costs exist. The objective of this study was to compare QOL and costs of LNG-IUS or hysterectomy in the treatment of menorrhagia during 10-year follow-up. Study design: A total of 236 women, aged 35-49 years, referred for menorrhagia to 5 university hospitals in Finland were randomly assigned to treatment with LNG-IUS (n = 119) or hysterectomy (n = 117) and were monitored for 10 years. The main outcome measures were health-related QOL (HRQOL), psychosocial well-being, and cost-effectiveness. Results: A total of 221 (94%) women were followed for 10 years. Although 55 (46%) women assigned to the LNG-IUS subsequently underwent hysterectomy, the overall costs in the LNG-IUS group ($3423) were substantially lower than in the hysterectomy group ($4937). Overall, levels of HRQOL and psychosocial well-being improved during first 5 years but diminished between 5 years and 10 years and the improved HRQOL returned close to the baseline level. There were no significant differences between LNG-IUS and hysterectomy groups. Conclusion: Both LNG-IUS and hysterectomy improved HRQOL. The improvement was most striking during the first 5 years. Although many women eventually had hysterectomy, LNG-IUS remained cost-effective. [Copyright &y& Elsevier]

Abstract: Recent studies have suggested a unifying pathophysiological concept to explain the underlying defects of von Willebrand factor (VWF) causing von Willebrand disease (VWD) and have highlighted the relevance of simple VWF related activities in producing a useful diagnosis. A standardized bleeding history condensed into a final bleeding score and few widely available laboratory tests, such as VWF ristocetin cofactor activity, VWF antigen and factor VIII (FVIII), in the index case and in his/her relatives are of critical importance. Ristocetininduced platelet aggregation (RIPA) should also be tested. Trial with desmopressin should be carried out in patients, except those with virtual absence of VWF or with increased RIPA. Desmopressin should be used in all responsive patients as first choice. Substitutive treatment with VWF/FVIII containing products should be used in unresponsive patients, in those with heightened response to desmopressin or in those undergoing interventions requiring good hemostasis for more than 3–5 days. Special consideration should be deserved to the treatment of menorrhagia and parturition. [Copyright &y& Elsevier]

Objective: We sought to assess the efficacy and safety of 2 dosing regimens of a novel, oral tranexamic acid formulation (Lysteda; Ferring Pharmaceuticals Inc, Parsippany, NJ) in women with cyclic heavy menstrual bleeding. Study Design: This was a multicenter, double-blind, placebo-controlled, randomized, parallel-group trial for 3 menstrual cycles (n = 304). Women with mean menstrual blood loss (MBL) of ≥80 mL/cycle were randomized to receive either 1.95 g/d or 3.9 g/d of tranexamic acid or placebo for up to 5 days of menstrual bleeding. Primary efficacy endpoints were mean MBL reduction from baseline, mean MBL reductions that were considered “meaningful” by subjects, and mean MBL reductions from baseline >50 mL/cycle. Adverse events (AEs) were also assessed. Results: Only the 3.9 g/d group met all 3 primary efficacy endpoints. AEs did not significantly differ among the 3 groups. There were no serious study-related AEs. Conclusion: The 3.9-g/d dose met all 3 primary efficacy endpoints, whereas the 1.95 g/d dose met 2 primary efficacy endpoints. Both doses were well tolerated. [ABSTRACT FROM AUTHOR]

Abstract: Heavy menstrual bleeding is associated with increased local fibrinolysis. Antifibrinolytic agents have been used in women with menorrhagia with and without bleeding disorders, and have been demonstrated to decrease menstrual blood flow approximately 50% and improve quality of life. Most studies have been done with the antifibrinolytic agent tranexamic acid, a synthetic lysine derivative. Studies have been performed comparing tranexamic acid with placebo, non-steroidal anti-inflammatory agents, and progesterone in women with menorrhagia and have predominantly demonstrated a greater reduction in menstrual blood flow with tranexamic acid. In women with menorrhagia and an underlying bleeding disorder, tranexamic acid was compared to intranasal desmopressin and also demonstrated a greater reduction in menstrual blood flow. In aggregate the studies demonstrate that antifibrinolytic agents are effective medical management for women with menorrhagia with or without bleeding disorders, reducing menstrual blood flow and improving quality of life. [ABSTRACT FROM AUTHOR]

Objective: To describe four cases of hepatic adenoma in adolescents and women with severe inherited bleeding disorders treated with norethisterone. Design: Case reports. Setting: Necker-Enfants Malades University Hospital, Paris, Department of Pediatric Endocrinology, Gynecology and Diabetes. Patient(s): Two adolescents and two young women with inherited platelet disorders, treated with high-dose norethisterone (10 to 20 mg/day) to induce amenorrhea. Intervention(s): Immediate cessation of norethisterone. Main Outcome Measure(s): Spontaneous regression of hepatic adenoma. Result(s): In four patients with inherited platelet disorders, hepatic adenoma developed at 14, 18, 22, and 24 years of age, respectively, during continuous norethisterone therapy started at 1.5, 2.5, 10.0, and 13.0 years of age, respectively. Life-threatening bleeding occurred in two patients. Immediate norethisterone discontinuation was followed by complete or nearly complete tumor regression within a few months. Conclusion(s): Our four cases strongly support a causal link between norethisterone treatment and hepatic adenoma. Continuous high-dose (10 to 20 mg/day) continuous norethisterone to treat menorrhagia in adolescents and young women with bleeding disorders is inadvisable. If other nortestosterone derivatives are needed, the patient should be closely monitored for the development of hepatic adenoma. [ABSTRACT FROM AUTHOR]