Analysis of management efficacy in patients with heavy menstrual bleeding associated with antithrombotic therapy / 中华妇产科杂志

Objective: To evaluate different methods' efficacy of controlling acute bleeding and managing long-term menstruation in patients with heavy menstrual bleeding (HMB) associated with antithrombotic therapy. Methods: The clinical data of 22 cases with HMB associated with antithrombotic therapy admitted to Peking University People's Hospital from January 2010 to August 2022 were analyzed, aged 39 years old (26-46 years). Changes in menstrual volume, hemoglobin (Hb), and quality of life were collected after control of acute bleeding and long-term menstrual management. Menstrual volume was assessed by pictorial blood assessment chart (PBAC), and quality of life was assessed by menorrhagia multi-attribute scale (MMAS). Results: (1) Treatment of acute bleeding: of the 22 cases with HMB associated with antithrombotic therapy, 16 cases were treated in our hospital and 6 in other hospital for emergency bleeding; of the 16 cases treated in our hospital, 3 underwent emergency intrauterine Foley catheter balloon compression due to severe bleeding (Hb decreased by 20 to 40 g/L within 12 hours). Of the 22 cases with antithrombotic therapy-related HMB, 15 (including 2 cases with severe bleeding) underwent emergency aspiration or endometrial resection, and intraoperative placement of levonorgestrel-releasing intrauterine system (LNG-IUS) followed by a significant reduction in bleeding volume; 3 cases had controlled acute bleeding after rivaroxaban dose reduction and continued observation; 2 cases were given gonadotropin-releasing hormone agonists to control acute bleeding in other hospital, of which 1 case was temporarily treated with periodic blood transfusion, and the other one patient underwent total hysterectomy; and 2 cases had temporary amenorrhea with oral mifepristone after intrauterine balloon compression or oral norethindrone. (2) Long-term menstrual management: of the 22 cases with antithrombotic therapy-related HMB, 15 had LNG-IUS placement and 12 had LNG-IUS placement for 6 months, and menstrual volume was significantly reduced [PBAC scores were 365.0 (272.5-460.0) vs 25.0 (12.5-37.5), respectively; Z=4.593, P<0.001], Hb was significantly increased [91.5 g/L (71.8-108.2 g/L) vs 128.5 g/L (121.2-142.5 g/L); Z=4.695, P<0.001], and quality of life was significantly improved [MMAS scores were 415.0 (327.5-472.5) vs 580.0 (570.0-580.0), respectively; Z=-3.062, P=0.002] before placement compared with 6 months after placement. Three rivaroxaban dose reduction patients' PBAC scores decreased by 20 to 35 but remained >100, and perceived quality of life did not change significantly. Two cases with temporary amenorrhea treated with oral mifepristone felt significantly improved quality of life, and the MMAS scores increased by 220 and 180, respectively. Conclusion: Intrauterine Foley catheter balloon compression, aspiration or endometrial ablation could be used to control acute bleeding in patients with antithrombotic therapy-related HMB, and LNG-IUS for long-term management could reduce menstrual volume, increase hemoglobin, and improve the quality of life of patients.

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.

Controvérsias acerca do dispositivo intrauterino: uma revisão / Controversies about the intrauterine device: a review

O dispositivo intrauterino (DIU) é atualmente o método contraceptivoreversível mais usado no mundo, sobretudo nos países em desenvolvimento, com maior número de usuáriasna Ásia oriental. Entretanto, ainda há controvérsias envolvendo o seu uso. Por esse motivo, consultamos sitescom bancos de dados eletrônicos como Medline, Lilacs, Wholis e Biblioteca Cochrane, sem restrição linguística,à procura de artigos que abordassem controvérsias sobre o DIU e selecionamos 32, os quais foram incluídos napresente revisão. O mecanismo de ação se deve à reação inflamatória, citotóxica, comprometendo a qualidade,viabilidade e a migração do esperma pela ação do DIU com cobre sobre o muco cervical. A inserção imediatamenteapós uma gestação apresenta várias vantagens, como prevenção de gravidez indesejada, porém não há consensose é tão segura e eficaz quando comparada à inserção fora desse período. O uso profilático de antibióticos nãodiminui o risco de infecções do trato genital, podendo ser indicada para mulheres que vivem em regiões comalta prevalência de doenças sexualmente transmissíveis (DST). Menorragia e dismenorreia são os efeitos colateraismais frequentes referidos pelas usuárias de DIU e as principais causas de sua remoção. O uso de anti-inflamatóriosnão hormonais para tratá-los é motivo de controvérsias na literatura. Sobre o uso de DIU em nulíparas, existemrelativamente poucos estudos na literatura e as conclusões não são seguras. Apesar dos dados sobre adolescentesquanto à segurança, eficácia e aceitação, serem escassos, há pressa no que diz respeito ao uso nesse grupo,tendo em vista a prevenção de gravidez indesejada, tão comum entre elas. As contraindicações são limitadas àgravidez, neoplasias malignas uterinas e efeitos adversos aos componentes do DIU. Apesar de o DIU ser usadohá muitos anos, existe ainda questionamentos de como a fertilidade subsequente é afetada...

The intrauterine device (IUD) is nowadays the most widely used reversiblecontraceptive method in the world, particularly in developing countries, with the highest use in Eastern Asia.Nevertheless, there are still controversies involving its use. For this reason, we searched Medline, Lilacs, Wholisand Cochrane Collaboration databases for articles in any language, addressing controversies about the IUD, selecting 32 for inclusion in this review. The mechanism of action is due to cytotoxic and inflammatory reaction,compromising the quality, viability and sperm migration, by the action of the IUD with cupper on the cervicalmucus. Insertion immediately after a pregnancy ends has several potential advantages, like preventing an unwantedpregnancy. However, there is no consensus if the insertion in this period is as safe and effective as the intervalinsertion. The prophylactic use of antibiotics has not decreased the risk of upper genital tract infection, but itmay be justified for women living in regions with high prevalence for sexually transmitted diseases (STD). Themost frequent side effects reported by users of IUD are menorrhagia and dysmenorrhea, considered the mostcommon reasons for its removal. Non-steroidal anti-inflammatory drugs used for these associated symptoms arecause for controversy in the literature. Concerning the utilization of IUDs in nuliparous women, there are relativelyfew studies in the medical literature and the conclusions are no definitive. There are little data regarding safety,efficacy, and acceptability of IUDs in teenagers. However, this should be countered with the pressing need toprevent unintended pregnancy in this group of women. Contraindications are restricted to pregnancy, malignantuterine neoplasms and adverse effects of the IUD components in the user...

Effects of IUD on Iron status in IUD users in Gorgan, Iran

CuT380A intra uterine device Intra Uterine Device [IUD] is used in the health system of Iran. The most important and frequent side effects of the lUDs are hypermenorrhea and polymenorrhea. In Iran, iron supplement are not prescribed for the IUD users and there are no documents indicating their iron reservation status. This study was performed to determine the iron status in Gorganian IUD users. This historical cohort study was performed on 100 IUD users [exposed group] and 100 non-IUD users [non-exposed group] in the Golestan province in north east of Iran in 2008. To evaluate the iron status hemoglobin and ferritin levels were measured. Data was analyzed by SPSS 13 by using Chi square and Independent T-test. A p-value less than 0.05 were considered as statistically significant. Hgb less than 10.5 was seen in 5% and 6% of IUD users and non-IUD users respectively which was not statistically significant [OR: 1.43, 95% CI: 0.39-5.25]. Low Ferretin Level [less than 15] was seen in 53% of IUD users and in 35% of non-IUD users which was statistically significant [OR: 2.35, 95% CI: 1.28-4.29] Duration of menstrual period in the two groups was statistically significant [7.5 +/- 2.4 vs. 6.4 +/- 1.8, p= 0.005] but interval of menstruation [days] was not statistically significant [26.7 +/- 4.7 vs. 28 +/- 11.2, p> 0.05]. On the basis of the results obtained we suggest either routine iron supplementation following application of IUD, or use of the hormone releasing IUD as an alternative for copper lUDs

Quebec platelet disorder

A case of Quebec platelet disorder is hereby reported. A 33 years old woman presented with history of epistaxis and gum bleeding since childhood and menorrhagia and bleeding per vaginum after puberty, also had history of excessive blood loss after birth of child. Her coagulation profile was normal but platelet function testing by platelet aggregation assay showed abnormal aggregation of platelet with epinephrine. This type of response is seen in "Quebec platelet disorder" which is a rare autosomal dominant disorder of platelet function characterized by increased bleeding after any injury or trauma

Outcome of abdominal myomectomy

To find out the results of in abdominal myomectomy in terms of complications and fertility. Study design. Place and Duration of study Jinnah Medical and Dental college and Hospital, Baqai Medical University and other private hospitals where author practiced from January 2003 to January 2009. The study included all women who underwent abdominal myomectomy. Indications for surgery were menorrhagia, abdominal mass, dyspareunia, infertility, repeated abortions and chronic pelvic pain. Patients who had endometriosis, adenomyosis, ovarian cyst and those whose spouse had abnormal semen analysis, patient not desirous for further pregnancies and malignancies were excluded. All patients had routine pelvic ultrasound and hysterosalpingogram before and after surgery. Morbidity such as intra operative blood loss, injury to adjacent viscera, trauma to the tubes, febrile morbidity, wound haematoma, infection, fertility, recurrence of myoma, adhesion formation were noted. All patients were followed at 3, 6 and 12 monthly interval. The analysis was performed by using SPSS version 10. Frequency and percentages were computed for presentation of all categorical variables. A total of 50 abdominal myomectomies were performed during the study period. Mean age of the patients was 36 years with parity of 0 -2. Duration of operation ranged between 60 - 90 minutes. Blood loss varied between 1800ml - 2500ml. Hospital stay was between 5-7 days. Fibroid size ranged between 5 - 7cm. Uterine cavity got opened in 5[10%] cases. In 10[20%] patients myomas had distorted the tubes bilaterally and trauma resulted during surgery. Febrile morbidity was noted in 7[14%] cases, vaginal discharge in 2[4%] and lower abdominal pain in 5[10%]. Uterine cavity of reduced size in 7[14%] patients and bilateral tubal blockage in 10[20%] cases were noted on hysterosalpingogram. At follow up two patients conceived at 12 months and one patient at 24 months. Abdominal myomectomy is a preferred treatment for women who want to become pregnant in future and is associated with fewer complications

Case report leech infestation presenting as metromenorrhagia

This case s presented to show that leech infestation is still not uncommon in Iraq especially of the genital tract. Leech infestation, could cause menorrhagia in women. A 45 years old multiparous woman from Sinjar's rural areas in Mosul province, attending the out patient department with severe vaginal bleeding, and a history of moderate, continuous vaginal bleeding for four months. She underwent diagnostic curettage three months before, which revealed normal secretory endometrium. The infected woman was pale and hypotensive with features of chronic iron deficiency anemia. Speculum and gynecological examinations demonstrated no abnormalities. Total abdominal hysterectomy as an emergency was done with preservation of both ovaries; bleeding persisted postoperatively; re-assessment by speculum pelvic examination revealed leech infestation of the vagina. The Leech belongs to Phyllum Annelida, class Hirudinea, and order Rhychobdellida. An infestation with leeches should be considered in patients who present with menorrhagia and history of immersion in fresh water lakes or streams in tropical infested areas. Leech infestation is not common in gynecological practice, and is rare nowadays as water supplied to all cities and villages is passing through filtration and disinfection process. Leech infestation should be remembered, as a cause of menorrhagea, in areas where using river water and sitting at riverside is habitual for women in infested rural areas

Menorrhagia; outcome of hysterectomies after 40 years of age

This was a prospective study on out come of hysterectomies performed for menorrhagia after 40 years of age. Objective To determine the symptom profile, indications, route of surgery, intra and post operative complications, histopathological results and satisfaction rate of women who underwent hysterectomy for menorrhagia. A prospective observational study, CMH Peshawar. Period: From June 2002 to May 2003. Hundred women with menorrhagia undergoing hysterectomy after 40 years of age were selected for this study. Inclusion criteria were determined and patients were regularly followed starting from their inclusion in the study till six weeks after surgery. A questionnaire was designed to record the relevant information. DUB was the main cause of menorrahgia in 68% of patients followed by leiomyoma uterus in 25%. These results were confirmed by histopathology reports. Ninety eight percent of our patients were satisfied with the surgery. Their symptom profile and quality of health was much improved after hysterectomy. Hysterectomy is the most common major gynaecological operation. Intra and post operative complications rate was less in our patients when compared with other international studies. This was due to proper selection of the patients and experience of the surgeons, as 100% hysterectomies were done either by consultant or senior registrars

Subclinical hyperthyroidism as a potential factor for dysfunctional uterine bleeding

To evaluate the functional status of thyroid gland in apparently euthyroid women with dysfunctional uterine bleeding. Forty apparently euthyroid women with menorrhagia and no pathologic lesion in the genital tract were compared to 20 women having normal menstrual cycle as control group. All women were subjected to hormonal assay: total and free T3, T4 and TSH, Serum PRL, P [progesterone], total and free testosterone. A statistically significant difference in the values of TSH, total T3, free T3 and total T4 in the menorrhagia group compared to the control group. Prolactin was decreased significantly in the menorrhagia group. Subclinical hyperthyroidism can be a potential risk factor for dysfunctional uterine bleeding. Other studies are needed to confirm our findings

Medical intervention in adolescent menorrhagia

To find out causative factors of adolescent menorrhagia and success of various treatments. Descriptive cross sectional study Lady Willingdon Hospital, Lahore from May 2004 to April 2005. Fifty unmarried patients at 12-19 years with menorrhagia selected by non-probability convenience sampling. Blood loss was determined by duration of bleeding extending beyond seven days, passage of clots and presence of anaemia. The most common cause of menorrhagia was DUB [92%] followed by bleeding and endocrinal disorder. Non-steroidal anti-inflammatory drug and antifibrinolytic agent produced 75% subjective improvement in complaints. However, combined oral contraceptive produced 66% improvement. NSAIDS and antifibrinolytic drugs were found to be effective in reducing menstrual loss and should be used as first line of treatment

Non HFE-related hemochromatosis; a case report from Iran

Hemochromatosis, especially with cardiac and liver problem, is rare in Iran. We report a young female with pulmonary hypertension and abnormal liver function tests due to non HFE- related hemochromatosis

Fisiopatologia, diagnóstico e tratamento da menorragia na adolescência / Menorrhagia in adolescence: phisiopathology, diagnosis and treatment

A menorragia é um problema ginecológico comum em adolescentes. Os dois primeiros anos pós-menarca geralmente säo anovulatórios e a maioria dos casos de sangramento excessiva resulta da imaturidade do eixo hipotálamo-hipófise-ovário. Entretanto, o diagnóstico diferencial deve incluir coagulopatias, tireoidopatias e Síndrome de Ovários Policísticos, entre outros. A fisiopatologia do sangramento excessivo ainda näo está bem definida mas acredita-se que alteraçöes hemostáticas e hormonais estejam envolvidas. Para o diagnóstico da etiologia da menorragia, a história menstrual e a idade ginecológica (tempo decorrido desde a menarca) säo fundamentais. Um hemograma e uma ecografia transvaginal podem auxiliar bastante. O tratamento pode variar desde a tranqüilizaçäo e acompanhamento da adolescente, até a terapia medicamentosa agressiva. O tratamento cirúrgico é incomum

Malformación arteriovenosa pelviana bilateral: evaluación con ecografía doppler color / Bilateral pelvic arteriovenous malformation

La malformación arteriovenosa consiste en la proliferación de canales arteriales y venosos con formación de fístulas y tejidos capilares. Presentamos los hallazgos ecográficos de un caso de malformación arteriovenosa pelviana bilateral en un paciente de 31 años, sexo femenino, analizando los casos publicados en la bibliografía destacando el uso de la Ecografía Doppler Color Transvaginal

Management of idiopathic thrombocytopenic purpura.

Idiopathic thrombocytopenic purpura is not an uncommon bleeding disorder with a prevalence of 40-80 per million children per year. Over the last six decades, the subject of ITP has attracted the attention of pediatricians and hematologists. It is one of the subjects which has many controversies because of its unpredictable course heralded by remission relapses, and chronicity with mortality in less than 1% of cases. In the present review only the controversies in the management of acute and chronic ITP have been reviewed as it interests most pediatricians. Management of intracranial hemorrhage (ICH), severe gastrointestinal hemorrhage and menorrhagia continues to still remain a challenge in spite of newer therapies.

Management of dysfunctional uterine bleeding.

DUB is a common symptom which is mainly due to disorders of ovulation and local endometrial dysfunction. The diagnosis should be made only after excluding organic pelvic disease. Anaemia and other endocrine and systemic causes of DUB must be treated promptly. Spontaneous cure is also possible. However, in patients in whom the symptoms persist, drug treatment with combined oestrogen-progestogen, anti-prostaglandin and anti-fibrinolytic agents is often effective. Hysterectomy and hysteroscopic endometrial ablation are contemplated only in persistent DUB in older and parous women and radiotherapy has no place amongst the modern modalities of management.