Evaluation of the efficacy of levonorgestrel intrauterine system in the management of heavy menstrual bleeding: An analytical observational study

Background: Heavy menstrual bleeding (HMB) poses threat to the quality of life among women. To prevent HMB, the levonorgestrel-releasing intrauterine system (LNG-IUS) is a well-known nonsurgical, long-performing, and alternative method. Objectives: The objective of this study was to determine the efficacy of LNG-IUS in women with HMB through an analytical observational study. Materials and Methods: This study was performed among 60 patients who visited the gynecology and obstetrics outpatient department (OPD) at the Institute of Post-Graduate Medical Education and Research and Seth Sukhlal Karnani Memorial Hospital (IPGMER and SSKMH), Kolkata, West Bengal, India from May 2019 to April 2020 due to HMB. The mean demographic and clinical profiles were evaluated, and comparative analysis was performed for hemoglobin (Hb), spotting, pain, and endometrial thickness on day 0 and follow-up 3 months, 6 months, and 12 months. Results: The mean age of patients was 37.77 ± 4.58 years was obtained. The Hb level was significantly (P < .001) increased, whereas pictorial blood loss assessment chart (PBAC) score, endometrial thickness, spotting, and pain were significantly (P < .01 and P < .001) reduced. The majority of patients had pallor, but the rates of spontaneous expulsion and hysterectomy were observed lower after using LNG-IUS among studied patients. Conclusion: the usage of LNG-IUS is potential in the treatment of HMB in women, which may lead to a better quality of life. This can be the alternative to hysterectomy and oral pills for long-term use. It is suggested in a future study with larger sample size and multicentric approach to minimize hospital biasness.

Endometrial hyperplasia treatment with the levonorgestrel-impregnated intrauterine system or oral progestogens / Шинэ санаа Шинэ нээлт

Background@#To investigate relapse rates after the successful treatment of patients with non-atypical endometrial hyperplasia (EH) either a levonorgestrel impregnated intrauterine system (LNG-IUS; MIRENA®) or two regimens of oral dydrogesterone (DGS) after primary histological response. Currently, the incidence of EH is indistinctly reported to be around 200,000 new EH cases per year in Western countries.@*Methods@#Patients were at their choice assigned to one of the following three treatment arms: LNG-IUS; 10 mg of oral DGS administered for 10 days per cycle for 6 months; or 10 mg of oral DGS administered daily for 6 months. The women were followed for 6 months after ending therapy. [Figure2] Women aged 25-55 years with low or medium risk endometrial hyperplasia met the inclusion criteria, and 35 completed the therapy. @*Results@#Histological relapse was observed in 55/ (41%) women who had an initial complete treatment response. The relapse rates were similar in the three therapy groups (P = 0.66). In our study involved 25-55 (mean 42.2±1.61) aged 35 women. Among them had reproductive aged 31.43% (n= 11) premenopausal women 42.86 % (n= 15) postmenopausal women 25.71% (n= 9). Their mean body mass index had 28.8±1.15 kg/m², and normal weight 34.29% (n=12), overweight 34.29% (n=12), obese 17.14% (n=6), extremely obese 14.29 % (n=5). [Figure3] Types of obesity had normal 37.14% (n=13), android 25.71% (n=9), gynecoid 37.14% (n=13). Mean parity had 1.8±0.19 to nulliparous 14.29% (n=5), primiparous 60% (n=21), multiparous 25.71% (n=9). Smoke 17.14% (n=6). Non combined disease had 65.7% (n=23), diabetes mellitus 17.14% (n=6), PCOS 14.29% (n=5), cardiovascular disease had 2.86% (n=1). [Table1] Mean endometrial thickness of TVUS had ( 16.0±0.91mm). Smoke (p=0.0391), types of obesity (p=0.0436) and myoma of the uterus (p=0.0187) seen affected the endometrial thickness. LNG-IUD group had after treatment’s menstrual period 11.11% heavy 80ml (n=1), 88.89% light 5ml (n=8). DGS (5-25 day) group had after treatment’s menstrual period 9.09% heavy =80ml (n=1), 90.91% light5ml (n=10), DGS (16-25 day) group after treatment menstrual period 40% heavy 80ml (n=6), 46.67% normal 5-80ml (n=7), 13.33% light 5ml (n=2) байв. Therefore between the three treatment groups had no differences. But treatment’s before and after result had statistics probability differences (P= 0.4064). [Figure4] @*Conclusions@#Finally, given the long natural history of menorrhagia, study outcomes need to be assessed over a period that is longer than 2 years. In conclusion, our study showed that both the LNG-IUD, oral progestin treatment reduced the adverse effect of menorrhagia on women’s lives over the course of two years. LNG-IUD was the more effective first choice, as assessed impact of bleeding on the women’s quality of life.

Non-descent vaginal hysterectomy in previous cesarean section: a retrospective study

Background: Non-descent vaginal hysterectomy (NDVH) is removal of uterus through vagina in non-prolapsed uterus. As there is an increase in caesarean section, hysterectomy in women with previous caesarean section is also increasing. The objective of this study is to assess the feasibility and safety of non-descent vaginal hysterectomy in patients with previous caesarean section.Methods: This is a retrospective study conducted in the department of obstetrics and gynecology, Government Medical College, Thrissur from January 2017 to December 2018. Non-descent vaginal hysterectomy in 24women with previous caesarean section was studied. Details regarding age, parity, number of caesarean sections, indication of surgery, intraoperative and postoperative complications were evaluated.Results: All 24 women underwent non-descent vaginal hysterectomy successfully. 10 women (41.7%) were between 46-49 years. Commonest indication of hysterectomy was fibroid uterus (41.7%) and most common complaint was heavy menstrual bleeding (79%). There was bladder injury in one woman with history of previous 2 caesarean section. 3 women developed UTI in postoperative period.Conclusions: Vaginal hysterectomy is associated with lower complications and more rapid recovery. A successful NDVH in previous caesarean section depends on the expertise and experience of the surgeon. NDVH in previous caesarean is safe in expert hands.

Role of selective progesterone receptor modulators in the treatment of symptomatic uterine fibroids

Background: Uterine leiomyomas are benign tumours of smooth muscle cells and fibrous tissue that develop within the wall of the uterus. Objective of this study was to compare efficacy and safety of Mifepristone and Ulipristal acetate in the treatment of symptomatic uterine fibroids.Methods: The present randomized comparative prospective study was conducted among 120 non-pregnant and non-lactating females of age 25-50 years with symptomatic fibroids reported in the department of obstetrics and gynecology, Chhatrapati Shivaji Subharti Hospital, Meerut, Uttar Pradesh for a duration of 2 years from September 2017 to July 2019.The selected subjects were divided into two treatment arms i.e. Group 1: ulipristal acetate: 5 mg OD for 3 months and Group 2: mifepristone: 25 mg OD for 3 months. Detailed history of the patient, general physical examination and systemic examination was done followed by per abdomen examination, per speculum and per vaginal examination. A blood examination, USG (pelvis), Pap smear and endometrial biopsy was done. Subjects visited the hospital at visit 1, visit 2, visit 3, visit 4, visit 5 and visit 6 for 6 months.Results: In both the groups, maximum subjects were in the age group of 36-40 years, followed by 41-50 years. When mean PBAC score at first, second, third, fourth and fifth visit was compared statistically among ulipristal acetate and mifepristone group, it was found to be statistically significant. Uterine pain was reduced more in mifepristone group as compared to ulipristal acetate group at all the different intervals. Size was reduced more in mifepristone group as compared to ulipristal acetate group at all the different intervals.Conclusions: Authors conclude from this study that mifepristone should be preferred over ulipristal acetate for treatment of symptomatic fibroids.

Trastornos hereditarios de la coagulación en adolescentes con sangrado menstrual excesivo, ¿debemos evaluar la vía fibrinolítica? / Inherited bleeding disorders in adolescents with excessive menstrual bleeding: should we evaluate the fibrinolytic pathway?

Resumen: Introducción: El Sangrado Menstrual Excesivo (SME) es un problema frecuente en la adolescencia. La prevalencia de trastornos hereditarios de la coagulación (THC) como causa del SME no está bien establecida y la participación de defectos de la vía fibrinolítica ha sido poco explorada. Objetivo: Determinar la prevalencia de THC y defectos de la fibrinólisis en adolescentes con SME. Pacientes y Método: Se incluyeron 93 adolescentes, edad 11 a 18 años. Los antecedentes personales y familiares de sangra do se obtuvieron con un cuestionario estandarizado. Se controló exámenes: tiempo de protrom- bina (TP), tiempo de tromboplastina parcial activada (TTPa), estudio del factor Von Willebrand, recuento y función plaquetaria. Los pacientes que no fueron diagnosticados como THC, se evaluaron adicionalmente con el tiempo de lisis del coágulo. Resultados: 41 pacientes (44%) fueron diagnos ticados como THC: Enfermedad de Von Willebrand n = 28, defectos de la función plaquetaria n = 8, hemofilia leve n = 5. Se confirmó disminución del tiempo de lisis del coágulo en 31 pacientes. El 54% de pacientes diagnosticado como THC, tuvo SME como la primera manifestación hemorrágica. Conclusión: Estos resultados apoyan la necesidad de evaluación de la coagulación, incluyendo la vía fibrinolítica, en el estudio de adolescentes con SME.

Abstract: Introduction: Heavy Menstrual Bleeding (EMB) is a frequent problem in adolescence. The prevalence of inherited bleeding disorders (IBD) as a cause of EMB is not well established and the involvement of fibri nolytic pathway defects has been poorly explored. Objective: To determine the prevalence of IBD and fibrinolysis defects in adolescents with EMBs. Patients and Method: 93 adolescents (11 to 18 years old) were included. Personal and family history of bleeding were obtained through a standard ized questionnaire. The following lab tests were performed: prothrombin time (PT), activated partial thromboplastin time (aPTT), von Willebrand factor quantification, and platelet count and function. Those patients who were not diagnosed with IBD were further evaluated with clot lysis time assay. Results: 41 patients (44%) were diagnosed as IBD (Von Willebrand disease n = 28, platelet func tion defects n=8, mild hemophilia n = 5. Decreased clot lysis time was found in 31 patients. 54% of patients diagnosed with IBD had EMB as the first hemorrhagic manifestation. Conclusion: These results support the need to evaluate the coagulation process, including the fibrinolytic pathway in the study of adolescents with EMB.

Comparison of safety and efficacy of Ormeloxifene and Norethisterone acetate in the treatment of heavy menstrual bleeding

Background: Menorrhagia (menstrual blood loss more than 80% per cycle) affects 10-33% of women at some stage of their lives. Medical management is the first line of therapy for menorrhagia (heavy menstrual bleeding: HMB). Progestins have been found to be very effective in the management of heavy menstrual bleeding especially during acute episodes, norethisterone acetate being widely used for the same. Ormeloxifene is a new drug with promising results in managing HMB. The study was undertaken to compare the efficacy, safety and acceptability of Ormeloxifene /Norethisterone acetate in the medical management of heavy menstrual bleeding.Methods: This was a retrospective study conducted from January 2016 till December 2018 in which 98 women of reproductive age group presented with abnormal uterine bleeding without any organic, systematic and iatrogenic causes. The patients were divided into 2 groups. Those wanting contraception along with control of HMB were assigned to Group O and given Ormeloxifene and others were given norethisterone (Group N). The primary outcomes measured were menstrual blood loss assessed subjectively by patients and ultrasonography for endometrial thickness. The secondary outcomes measured were acceptability and side effects of Ormeloxifene and norethisterone.Results: There is a significant reduction in menstrual blood loss as evidenced by the history of patients recorded on follow up and there was a significant reduction in the endometrial thickness as evidenced on follow up scan at the end of 3-4 months. no major side effects were observed with both the drugs.Conclusions: Ormeloxifene in comparison to norethisterone acetate with its effectiveness, significant results, convenient dosages schedule and no major side effects is an effective and safe alternative medical management of HMB.

A randomized controlled trial to study the efficacy of intravaginal hormonal ring for control of heavy menstrual bleeding as compared to combined oral contraceptive pills

Background: Heavy menstrual bleeding (HMB) is one of the commonest presenting complaints in reproductive age group. Although combined oral contraceptives (COCs) are commonly used in such patients, combined hormones by intravaginal route has been found acceptable and effective. Aim of the study is to compare the efficacy and side effects of combined intravaginal hormonal ring (IHR) with COCs in control of HMB in these patients.Methods: Hundred women with HMB fulfilling inclusion criteria were randomized into two equal groups and treated with either IHR or COCs for three cycles. Each cycle consisted of three weeks of IHR/COC use followed by 1-week ring-free/non-hormonal pills period. Outcome measures were change in PBAC score (pictorial blood loss assessment chart), hemoglobin rise, side effects and overall patient satisfaction.Results: The percentage reduction in PBAC score, the duration of menses and increase in hemoglobin levels were statistically significant at the end of study in each group. The PBAC score reduction was 87.37% vs 61.52%, menses duration was 4.24±0.74 versus 5.16±1.67, and hemoglobin increase was 3.16 (95% CI:0.142-1.412) and 1.24 (95% CI:1.048-1.640) in the IHR versus COC group. However, the intergroup reduction of mean PBAC score was not statistically significant. Significantly more ring users were satisfied and elected to continue with treatment.Conclusions: Both the IHR and COCs are effective treatments for HMB in reproductive age group. IHR may be an attractive option for HMB due to better compliance and lesser systemic side-effects.

Success of uterine artery embolization in the management of postabortal arteriovenous malformations

Background: Uterine artery arteriovenous malformations are an abnormal and non-functional connection between the uterine arteries and veins. It may be congenital or acquired. AVM can cause heavy menstrual bleeding and may have an impact on infertility. Uterine artery embolization is an alternate method to hysterectomy preserving the menstrual and reproductive function. Objectives of this study was to diagnose Arterio-venous malformations after abortions in patients with heavy menstrual bleeding and treating these patients with UAE.Methods: The retrospective study of patients with postabortal arteriovenous malformations managed at Dayanand Medical College and Hospital, during January 2012 to December 2018 was done. Inclusion criteria for this study post abortal heavy menstrual bleeding patients in reproductive age group diagnosed to be having AV malformations on CT angiography. Exclusion criteria for this study were H/O AUB prior to abortion, patients with fibroids, PID, endometriosis, adenomyosis, genital tract malignancies. Patients who do not have AV malformations on CT angiography.Results: This is a retrospective seven years study between January 2012 to December 2018 during which we received 23 patients who developed arterio-venous fistula following an abortion. The patients had heavy menstrual bleeding. All the patients had taken some hormonal treatment before reporting to us. All these patients underwent CT angiography. After that they all were subjected to UAE. All these patients were followed up to 6 months where they showed improvement in the symptoms.Conclusions: Acquired AVM is rare disorder following an abortion or a caesarean section. Heavy menstrual bleeding is a common symptom often requiring hysterectomy but with the advent of uterine artery embolization by blocking the uterine artery we can conserve the uterus where a lady can have normal menstrual and reproductive functions.

Management of single submucosal fibroid in unmarried females with uterine artery embolization

Background: Uterine fibroids (leiomyomas) are the most common benign neoplasm of the female pelvis. The location of fibroids, whether submucosal, subserosal, pedunculated subserosal, intramural, or endocavitary, is important because signs and symptoms may be determined by location. Uterine artery embolization (UAE) for many patients is an effective alternative treatment to surgical therapy for fibroid tumors. It is a minimally invasive procedure, which allows for rapid recovery and return to normal activities. Objective of this study was to know the efficacy of minimally invasive technique UAE for reducing symptoms in sub-mucous uterine leiomyoma in unmarried females.Methods: This retrospective analysis was performed on 9 unmarried females with symptomatic single submucosal fibroid diagnosed on MRI with size range of 3.5 cms to 6.5 cms. They presented at Dayanand Medical College and Hospital, Ludhiana, Punjab in a period of 3 years from January 2016-December 2019. Inclusion criteria were unmarried females, single submucosal fibroid diagnosed on USG/MRI. Exclusion criteria was active infection, more than one fibroid in uterus, prior GnRH analogues treatment during the previous 3 months.Results: All patients presented with heavy menstrual bleeding (HMB) and dysmenorrhea, lower abdomen pain was encountered in 3 patients and 2 patients had inter-menstrual bleeding. Recurrent, UTI was there in 1 patient and 1 patient had vaginal discharge. All fibroids belonged to stage 1 FIGO classification. UAE was done and patients were followed for 6 months. Symptomatic success was seen in 100% patients and 77.77% patients expelled the fibroid per vaginally.Conclusions: UAE is alternative method of treatment for submucosal fibroids in unmarried females who do not want to undergo surgery. Proper case selection can give us good results and symptomatic relief.

Levonorgesterel releasing intra uterine system in the control of heavy menstrual bleeding. Is it an alternative to hysterectomy?

Background: Heavy menstrual bleeding (HMB) affects 10 to 35% of women. Studies indicate LNG-IUS which releases controlled amounts of levonorgestrel (LNG) is effective in non- surgical treatment for HMB and has fewer side effects when compared to the conventional pharmacological agents. It also improves the quality of life. Levonorgesterel releasing intra uterine system can be an alternative to hysterectomy in the control of HMB.Methods: Retrospective study of 2 years in a tertiary care centre, Kochi. 170 women with abnormal uterine bleeding were enrolled in the study. Clinical examination, routine investigations and imaging was done.  Endometrial sampling done and followed with HPE reports in indicated cases.Results: Mean age was 41 years. 30.6% had menorrhagia. Adenomyosis in 44% and endometrial hyperplasia in 19. 4%. Lost follow up in 12.9% cases and expulsion in 3.6%. 4.1% were unsatisfied and had hysterectomy. The uterine width in adenomyosis was significantly reduced p <0.012. The mean ET in endometrial hyperplasia cases also significantly reduced with p <0.01. Satisfaction rate was 97%.Conclusions: LNG-IUS is having a high success rate in controlling menstrual symptoms, thereby improving the quality of life and avoiding hysterectomy in women with abnormal uterine bleeding. It is highly efficient in symptomatic relief of adenomyosis and reduction in the uterine volume (width). Endometrial hyperplasia showed complete regression with LNG-IUS.

Role Of Ormeloxifene In Management Of Symptomatic Uterine Leiomyoma In Reproductive Age Group

Introduction : Abnormal uterine bleeding due to leiomyoma is commomn problem in the reproductive age group and was found to be third most common cause of hysterectomies in teaching hospital of India1. The search for ideal drug for medical management of fioid is still on so that we can avoid operative interventions in symptomatic women of reproductive age group. Ormeloxifene is Selective Estrogen Receptor Modulator developed at CDRI, Luckhnow. It has proven to be an important drug in treatment of AUB, but its utility in fioid is yet to be defined. Through this study, we have explored its role in AUB due to leiomyoma. Aim and objective: To assess decrease in menstrual blood loss (MBL) by pictorial blood loss assessment chart to assess increase in hemoglobin level, to assess change in endometrial thickness, to assess change in fioid size in patients of AUB with leiomyoma treated with Ormiloxifene. Materials and Methods: Subjects were given tablet ormeloxifene 60 mg biweekly for 3 months, followed by 60mg weekly for next 3 months. Subjects were assessed after 3 months and 6 months for MBL, endometrial thickness, fioid volume and hemoglobin level. Observation: There was statistically significant decrease in MBL, endometrial thickness, (p=0.0334 and p=0.0096) , increase in hemoglobin(p=0.0001) and no change in fioid volume. after 3 months and 6 months respectivelyConclusion: SERM such as ormeloxifene in standard biweekly dosage is effective in providing symptomatic relief in a patient of AUB-L when prescribed for a short period of 6 months

El sangrado menstrual excesivo afecta la calidad de vida en adolescentes / Heavy menstrual bleeding affects quality of life in adolescents

Resumen Introducción: El sangrado menstrual excesivo (SME) se presenta aproximadamente en 37% de las adolescentes y afecta en distinto grado su calidad de vida. Objetivo: Medir la magnitud del impacto del SME en la calidad de vida en adolescentes. Pacientes y Método: Se entrevistó a adolescentes con diagnóstico de SME entre 10 y 18 años y a uno de sus tutores. Se aplicó el cuestionario de calidad de vida PedsQL 4.0 escala genérica, su versión Proxy PedsQL 4.0 al tutor, más 3 preguntas sobre limitación de actividades diarias. La concordancia entre la percepción de calidad de vida del tutor y adolescente se evaluó con el gráfico de Bland y Altman. Resultados: 46 adolescentes y tutores fueron evaluados. El puntaje total promedio PedsQL 4.0 para las adolescentes fue 64,48 (DS 14,54), con un rango de 18,48 a 88,04 con mayor compromiso en la dimensión emocional. Un 50% de las adoles centes falta al colegio, 80,4% a educación física y 65,2% a actividades al aire libre o fiestas. No hubo concordancia entre la percepción de las adolescentes y sus tutores. Conclusiones: Se evidenció un deterioro de la calidad de vida de las adolescentes encuestadas, siendo la dimensión emocional la más afectada. El desempeño en el cuestionario fue incluso más bajo que en patologías crónicas publicadas con esta misma herramienta.

Abstract Introduction: Heavy menstrual bleeding (HMB) occurs in 37% of adolescents and compromise their quality of life. Objective: To measure the magnitude of the impact of the SME on the quality of life in adolescents. Patients and Method: We interviewed adolescents diagnosed with HMB between 10 and 18 years old and one of their guardians. PedsQL 4.0 generic core scale was applied to measure quality of life, its Proxy PedsQL 4.0 version was applied to the guardian and 3 more questions to adolescents about limitation of daily activities. The concordance between the guardian's perception of the adolescent quality of life and the adolescent's perception was evaluated with the Bland and Altman graph. Results: 46 adolescents and guardians were evaluated. The total average PedsQL 4.0 score for adolescents was 64.48 (SD 14.54), with a range of 18.48 to 88.04 with a greater involvement in the emotional dimension. 50% of adolescents missed school, 80.4% physical education and 65.2% outdoor activities or parties. There was no agreement between the perception of the girls and guar dians. Conclusions: We evidence a deterioration in the quality of life of the surveyed adolescents, being the emotional dimension most affected. The performance in the questionnaire was also lower than in samples of chronic diseases published with this same tool.

Abnormal Uterine Bleeding / Sangramento uterino anormal

Abstract Abnormal uterine bleeding is a frequent condition in Gynecology. It may impact physical, emotional sexual and professional aspects of the lives of women, impairing their quality of life. In cases of acute and severe bleeding, women may need urgent treatment with volumetric replacement and prescription of hemostatic substances. In some specific cases with more intense and prolonged bleeding, surgical treatment may be necessary. The objective of this chapter is to describe the main evidence on the treatment of women with abnormaluterinebleeding, both acuteand chronic.Didactically,thetreatmentoptions were based on the current International Federation of Gynecology and Obstetrics (FIGO) classification system (PALM-COEIN). The etiologies of PALM-COEIN are: uterine Polyp (P), Adenomyosis (A), Leiomyoma (L), precursor and Malignant lesions of the uterine body (M), Coagulopathies (C), Ovulatory dysfunction (O), Endometrial dysfunction (E), Iatrogenic (I), and Not yet classified (N). The articles were selected according to the recommendation grades of the PubMed, Cochrane and Embase databases, and those in which the main objective was the reduction of uterine menstrual bleeding were included. Only studies written in English were included. All editorial or complete papers that were not consistent with abnormal uterine bleeding, or studies in animal models, were excluded. The main objective of the treatment is the reduction of menstrual flow and morbidity and the improvement of quality of life. It is important to emphasize that the treatment in the acute phase aims to hemodynamically stabilize the patient and stop excessive bleeding, while the treatment in the chronic phase is based on correcting menstrual dysfunction according to its etiology and clinical manifestations. The treatment may be surgical or pharmacological, and thelatterisbasedmainlyonhormonaltherapy,anti-inflammatorydrugsandantifibrinolytics.

Resumo O sangramento uterino anormal é uma afecção frequente que pode afetar negativamente aspectos físicos, emocionais, sexuais e profissionais, piorando a qualidade de vida das mulheres. Nos casos de sangramento intenso e agudo, as mulheres podem necessitar de tratamento de urgência, com reposição volumétrica e substâncias hemostáticas. Há situações que necessitam de tratamento prolongado, e ainda situações em que o tratamento cirúrgico pode ser necessário. O objetivo deste estudo é descrever as principais evidências sobre o tratamento das mulheres com sangramento uterino anormal, tanto na fase aguda quanto na crônica. A apresentação do tratamento foi baseada no sistema de classificação (PALM-COEIN, na sigla em inglês) da Federação Internacional de Ginecologia e Obstetrícia (FIGO). As etiologias do PALMCOEIN são: Pólipo uterino (P), Adenomiose (A), Leiomiomia (L), lesões precursoras e Malignas do corpo uterino (M), Coagulopatias (C), distúrbios da Ovulação (O), disfunção Endometrial (E), Iatrogênicas (I), e não classificadas nos itens anteriores (N). Os artigos foram selecionados conforme os graus de recomendação das bases de dados PubMed, Cochrane e Embase que tivessem como objetivo o tratamento do sangramento uterino anormal em mulheres. Somente artigos escritos em inglês foram incluídos. Todos os editoriais ou papers completos que não tratassem de sangramento uterino anormal, ou estudos baseados em modelos animais, foram excluídos. O tratamento tem como objetivo a redução do fluxo menstrual, reduzindo morbidade e melhorando a qualidade de vida. O tratamento na fase aguda visa estabilizar hemodinamicamente a paciente e estancar o sangramento excessivo, enquanto a terapia da fase crônica é baseada na correção da disfunção menstrual, conforme sua etiologia ou conforme a manifestação clínica. O tratamento pode ser cirúrgico ou medicamentoso, sendo o segundo baseado principalmente em fármacos hormonais, anti-inflamatórios ou antifibrinolíticos.

A Rare Case of Intra-Endometrial Leiomyoma of Uterus Simulating Degenerated Submucosal Leiomyoma Accompanied by a Large Sertoli-Leydig Cell Tumor

A 50-year-old peri-menopausal woman presented with hard palpable mass on her lower abdomen and anemia from heavy menstrual bleeding. Ultrasonography showed a 13x12 cm sized hypoechoic solid mass in pelvis and a 2.5x2 cm hypoechoic cystic mass in uterine endometrium. Abdomino-pelvic computed tomography revealed a hypodense pelvic mass without enhancement, suggesting a leiomyoma of intraligamentary type or sex cord tumor of right ovary with submucosal myoma of uterus. Laparoscopy revealed a large Sertoli-Leydig cell tumor of right ovary with a very rare entity of intra-endometrial uterine leiomyoma accompanied by adenomyosis. The final diagnosis of ovarian sex-cord tumor (Sertoli-Leydig cell), stage Ia with intra-endometrial leiomyoma with adenomyosis, was made. Considering the large size of the tumor and poorly differentiated nature, 6 cycles of chemotherapy with Taxol and Carboplatin regimen were administered. There is neither evidence of major complications nor recurrence during 20 months' follow-up.

Therapy of heavy menstrual bleeding in Korea: Subanalysis and results from a multinational clinical trial in the Asian region investigating the levonorgestrel-releasing intrauterine system versus conventional therapy

OBJECTIVE: To compare real-life clinical outcomes with the levonorgestrel-releasing intrauterine system (LNG-IUS) and conventional medical therapies (CMTs), including combined oral contraceptives and oral progestins in the treatment of idiopathic heavy menstrual bleeding (HMB) in South Korea. METHODS: This prospective, observational cohort study recruited a total of 647 women aged 18 to 45 years, diagnosed with HMB from 8 countries in Asia, including 209 women from South Korea (LNG-IUS, 169; CMTs, 40), who were followed up to one year. The primary outcome was cumulative continuation rate (still treated with LNG-IUS and CMTs) at 12 months. Secondary outcomes included bleeding pattern, assessment of the treatment efficacy by treating physician and safety profile. RESULTS: The continuation rate at 12 months was significantly higher with the LNG-IUS than CMTs (85.1% vs. 48.5%, respectively; P<0.0001). The 51.5% of CMTs patients discontinued treatment and 18.8% of LNG-IUS patients discontinued treatment. The most common reasons for discontinuation for CMTs were switching to another treatment and personal reasons. When compared to CMTs, the LNG-IUS offered better reduction in subjectively assessed menstrual blood loss and the number of bleeding days, tolerability and with better efficacy in HMB, as assessed by physician's final evaluation. CONCLUSION: This study provides novel information on the real-life treatment patterns of HMB in South Korea. The efficacy of CMTs was inferior compared to the LNG-IUS in the clinical outcomes measured in this study. Due to the better compliance with LNG-IUS, the cumulative continuation rate is higher than CMTs. We conclude that the LNG-IUS should be used as the first-line treatment for HMB in Korean women, in line with international guidelines.

Comparison of the efficacy and safety of norethisterone vs. combined oral contraceptive pills for the management of puberty menorrhagia.

Background: The most common cause of puberty menorrhagia is immaturity of the hypothalamic pituitary ovarian axis. Treatment is directed towards stabilizing the endometrium and treating the hormonal alterations. The objective of this study was to compare the efficacy and safety of norethisterone and combined oral contraceptive (COC) pills for the management of puberty menorrhagia. Methods: A total of 60 young girls from age of menarche to 19 years with menorrhagia were randomized to receive either norethisterone or COC pills. The end points included change from baseline in health-related quality-of-life parameters, estimation of blood loss and effect on hemoglobin level. Health-related quality-of-life question scores at baseline and after treatment were calculated as mean for norethisterone group and COC pills group. Results: Norethisterone and COC pills treatment groups showed mean improvement in Menorrhagia Impact Questionnaire (MIQ) scores compared to baseline. However, the total mean score was higher in norethisterone group compared to COC pills group after three treatment cycles (21 Vs 17). The treatment failure was less in norethisterone group compared to COC pills group. Conclusions: Use of norethisterone was more effective and better tolerated compared to combined oral contraceptive pills for the management of puberty menorrhagia.

A comparative study of tranexamic acid and ethamsylate in menorrhagia.

Background: Menorrhagia interferes with the woman's physical, social, emotional, and/or material quality of life. Antifibrinolytic drugs are effective in decreasing excessive menstrual bleeding. The objective of this study was to compare the effects of tranexamic acid and ethamsylate on quality of life in women with menorrhagia. Methods: The 50 women with menorrhagia were randomised to receive either tranexamic acid or ethamsylate. Twenty five patients were allocated to receive tranexamic acid 500 mg six hourly, and 25 patients to receive ethamsylate 500 mg six hourly. Among the parameters measured by the MIQ were impairment in social activities, work performance, physical activities, productivity, hygienic condition, psychological condition. Health-related quality-of-life question scores (MIQ scores) at baseline and after treatment were calculated as mean for tranexamic acid group and ethamsylate group. Results: Tranexamic acid and ethamsylate treatment groups showed mean improvement in MIQ scores compared to baseline. However, the total mean score was higher in tranexamic acid group compared to ethamsylate group after three treatment cycles (21 Vs 17). Conclusions: Use of tranexamic acid and ethamsylate improved health-related quality of life in patients with menorrhagia. Tranexamic acid showed better improvement in health-related quality of life compared to ethamsylate in patients with menorrhagia.