Métodos de estudio de pacientes con sangrado uterino posmenopáusico: recomendaciones prácticas / Study methods of patients with postmenopausal uterine bleeding: practical recommendations

Resumen El sangrado uterino posmenopáusico se define como aquel sangrado que ocurre después del cese definitivo de la menstruación en la etapa reproductiva de la mujer como consecuencia de la claudicación biológica de los ovarios, o como un sangrado no esperado en mujeres con terapia de reposición hormonal sistémica de la menopausia. Representa el 5% de las consultas ginecológicas y, si bien su origen suele ser por causas benignas, puede requerir una evaluación minuciosa para descartar patologías malignas del endometrio. El objetivo de este trabajo es establecer un flujograma diagnóstico basado en la evidencia para la evaluación de las pacientes con sangrado uterino posmenopáusico.

Abstract Postmenopausal uterine bleeding is defined as the bleeding that occurs after the last menstruation due to loss of ovarian function, or a non-scheduled bleeding in patients with hormonal therapy. It represents 5% of the gynecologic visits, and even though its origin is often benign, it requires a thorough evaluation to discard malignant diseases. The objective of these review is to propose a diagnostic algorithm based on the available evidence for the evaluation of patients with postmenopausal uterine bleeding.

El papel de la enfermedad de von Willebrand en la hemorragia uterina anormal / Von Willebrand Disease in Abnormal Uterine Bleeding

RESUMEN La hemorragia uterina anormal es un término empleado para las alteraciones en la regularidad, duración y/o volumen de sangrado menstrual y es considerada una causa común de consulta médica y en ocasiones supone un reto diagnóstico para el médico tratante. Dentro del abordaje de la etiología de dicha patología, las coagulopatías afectan alrededor del 13 por ciento de las mujeres, y la más común es la enfermedad de von Willebrand. El objetivo de este trabajo fue realizar una revisión de la literatura científica actual sobre el papel que cumple la enfermedad de von Willebrand en la hemorragia uterina anormal. Esta es una patología hereditaria derivada de una deficiencia del factor von Willebrand encargado de la adhesión plaquetaria. La prevalencia de esta enfermedad puede ser baja, sin embargo, cuando se estudia la población de mujeres con menorragia, la frecuencia puede ir de 5 a 20 por ciento. Se han descrito diferentes problemas ginecológicos asociados a la enfermedad de von Willebrand, tales como menorragia, dismenorrea y una importante deficiencia de hierro asociada a esta, además de una mayor incidencia de quistes ováricos, endometriosis, hiperplasia endometrial y pólipos endometriales. La literatura actual sugiere que se realice tamizaje a aquellas mujeres con cuadro clínico sugestivo. Con respecto al tratamiento la literatura reporta el uso de ácido tranexámico y anticonceptivos orales, pero el que mayor utilidad ha demostrado es la desmopresina(AU)

ABSTRACT Abnormal uterine bleeding is a term used for alterations in the regularity, duration and / or volume of menstrual bleeding and it is considered a common cause of medical consultation; sometimes it is a diagnostic challenge for the treating physician. Within the aetiology approach of said pathology, coagulopathies affect around 13 percent of women, and the most common is von Willebrand disease. The objective is to review the current scientific literature on the influence of von Willebrand disease in abnormal uterine bleeding. This is an inherited pathology derived from a deficiency of the von Willebrand factor responsible for platelet adhesion. The prevalence of this disease may be low, however, when studying the population of women with menorrhagia, the frequency can range from 5 to 20 percent. Different gynecological problems associated with von Willebrand disease have been described, such as menorrhagia, dysmenorrhea and a significant iron deficiency associated with it, in addition to a higher incidence of ovarian cysts, endometriosis, endometrial hyperplasia and endometrial polyps. The current literature suggests that those women with suggestive clinical symptoms should be screened. Regarding treatment, the literature reports the use of tranexamic acid and oral contraceptives, nonetheless desmopressin has proven to be most useful(AU)

Sangramento uterino anormal / Bleeding abnormal uterine

O sangramento uterino anormal (SUA) é um distúrbio em que um ou mais dos parâmetros do sangramento uterino normal está alterado: quantidade, duração ou frequência.(1) É também definido como perda menstrual excessiva, com repercussões físicas, emocionais, sociais e materiais na qualidade de vida da mulher, que podem ocorrer isoladamente ou em combinação com outros sintomas.(2) O SUA é uma condição comum que afeta até 40% das mulheres no mundo, impacta negativamente a qualidade de vida das mulheres, sendo a vida social e os relacionamentos prejudicados em quase dois terços dos casos.(AU)

Correlación clínica, imagenológica e histológica en patología endometrial: experiencia en el hospital Dr. Francisco Antonio Rísquez (2006-2016) / Clinical, imaging and histological correlation in endometrial pathology: experience in the hospital Dr. Francisco Antonio Rísquez (2006-2016)

Para el estudio y diagnóstico de la patología endometrial se cuenta con el ultrasonido transvaginal y la biopsia de endometrio. Objetivo: Determinar la correlación clínica, ultrasonográfica e histológica en patología endometrial, en pacientes tratadas en el Servicio de Cirugía del Hospital Dr. Francisco Antonio Rísquez, entre 2006 y 2016. Métodos: Estudio retrospectivo, transversal. Se incluyeron las pacientes intervenidas quirúrgicamente por patologías uterinas, que contaron con información completa en la historia clínica. Se utilizó estadística descriptiva, sensibilidad, especificidad y coeficiente de correlación. Resultados: El grupo etario más afectado fue el de 41 a 50 años, con 62,73 %, el motivo de consulta más frecuente fue sangrado genital con 52 casos (47,3 %), 52 pacientes (47,3 %) presentaron sangrado menstrual abundante y 40 (36,4 %) refirieron sangrado abundante y prolongado. Ecográficamente, el diagnóstico más frecuente fue leiomiomatosis uterina (87 casos, 79,1 %). La línea endometrial estuvo entre 1,3 y 11,3 mm en 80,9 %; en 54 casos (49,1 %) la biopsia de endometrio reportó secretor sin atipia. No se observó correlación estadística entre la clínica y la biopsia de endometrio (p=0,478 Kappa=0,00). La correlación estadística entre el ultrasonido y la biopsia de endometrio fue casi perfecta (p=0,000 Kappa=0,947) y entre la biopsia preoperatoria y la definitiva fue moderada (p=0,000 Kappa 0,542). La sensibilidad del ultrasonido es de 100 % y especificidad de 90,91 %. Conclusiones: La sensibilidad y especificidad del ultrasonido respecto a la biopsia de endometrio fue elevada. La frecuencia de patología endometrial en la biopsia endometrial fue baja(AU)

For the study and diagnosis of endometrial pathology it has with transvaginal ultrasound and endometrial biopsy. Objective: To determine the correlation of clinical, ultrasound and histological endometrial pathology in patients treated in the service of surgery of the Hospital Dr. Francisco Antonio Rísquez, between 2006 and 2016. Methods: Retrospective, cross-sectional study. Included patients surgically treated by uterine pathologies, which counted with complete information in the medical record. We used descriptive statistics, sensitivity, specificity, and correlation coefficient. Results: The most affected age group was that of 41 to 50 years, in 62,73%, the reason for more frequent consultation was bleeding genital with 52 cases (47.3%), 52 patients (47.3%) they had heavy menstrual bleeding and 40 (36.4%) abundant and prolonged bleeding was referred. Ecograficamente, the most frequent diagnosis was uterine leiomyomatosis (87 cases, 794.1%). The endometrial line was between 1.3 and 11.3 mm 80.9%; in 54 cases (49.1%) the endometrial biopsy reported secretory without atypia. No statistical correlation between the clinic and the endometrial biopsy was observed (p = 0, 478 Kappa = 0, 00). The statistical correlation between ultrasound and endometrial biopsy was almost perfect (p = 0, 000 Kappa = 0, 947) and between preoperative biopsy and the final was moderate (p = 0, 0000,542 Kappa). The sensitivity of ultrasound is 100% and specificity of 90.91%. Conclusions: The sensitivity and specificity of ultrasound for endometrial biopsy was high. The frequency of endometrial pathology in endometrial biopsy was low(AU)

TeleCondutas: sangramento uterino anormal / TeleGuides: abnormal uterine bleeding

Sangramento uterino anormal (SUA) é caracterizado por diferentes padrões de sangramento menstrual que variam de alteração no volume, irregularidades na duração e no ciclo menstrual. A condição costuma impactar na qualidade de vida das mulheres, sendo um problema de saúde frequente no atendimento da Atenção Primária à Saúde, acometendo cerca de 10% das mulheres em idade reprodutiva. As principais causas do sangramento uterino anormal são disfunções ovulatórias, gravidez, anormalidades estruturais, distúrbios de coagulação e causas iatrogênicas. Esta guia apresenta informação que orienta a conduta para casos de sangramento uterino anormal no contexto da Atenção Primária à Saúde, incluindo: classificação, etiologias de SUA por faixa etária, avaliação diagnóstica, tratamento, encaminhamento para serviço especializado.

Metaplasia ósea endometrial / Endometrial osseous metaplasia

La metaplasia ósea endometrial es una patología que se presenta con poca frecuencia y causa una gran variedad de síntomas como: sangrado uterino, dolor pélvico e infertilidad. Esta última, generalmente es secundaria y junto con el antecedente previo de aborto, constituyen una pieza clave en la sospecha diagnóstica. En el estudio de esta enfermedad, es necesario el uso de ecografía transvaginal y radiografía simple abdominal. El tratamiento definitivo se realiza mediante la extracción histeroscópica del material óseo, el cual es enviado a patología para corroborar el diagnóstico. La infertilidad revierte con la extracción del tejido óseo y no se han demostrado complicaciones en gestaciones futuras. Presentamos el caso de una paciente con metaplasia ósea endometrial por su rareza e importancia en el diagnóstico diferencial de sangrado uterino(AU)

Endometrial osseous metaplasia is a rare pathology that causes a variety of symptoms such as uterine hemorrhage, pelvic pain and infertility. This last consequence is generally secondary, and along with a history of abortions, represents a key element in suspected diagnosis. It is necessary to use transvaginal ultrasound and simple abdominal radiography for the study of the disease. The final treatment is performed by hysteroscopic removal of the bone material, which is sent to the pathology laboratory to confirm diagnosis. The infertility may be eliminated with the removal of the bone material and no further complications in future pregnancies have been observed. This is the case of a patient with endometrial osseous metaplasia, which is reported because of its infrequency and importance in the differential diagnosis of uterine bleeding(AU)

Sangramento uterino anormal: proposta de abordagem do Grupo Heavy Menstrual Bleeding: Evidence-Based Learning for Best Practice (HELP) / Heavy menstrual bleeding: management proposal of the Heavy Menstrual Bleeding: Evidence-Based Learning for Best Practice Group (HELP)

O Sangramento Uterino Anormal (SUA) representa um problema de saúde pública complexo que pode acometer 1/3 das mulheres em todo o mundo. Apresenta um impacto negativo importante na qualidade de vida de mulheres e associa-se a elevados custos econômicos diretos e indiretos. Trata-se de uma condição desafiadora tanto para as mulheres afetadas quanto para os profissionais de saúde. A nomenclatura atribuída ao SUA é confusa e faltam ainda recomendações diagnósticas e terapêuticas padronizadas. Foi criado o grupo Heavy Menstrual Bleeding: Evidence-based Learning for Best Practice (HELP) com proposta abordar os aspectos inconclusivos do SUA. Foram avaliados 134 documentos, incluindo 121 artigos científicos e 14 revisões de medicamentos, para desenvolvimento dos protocolos HELP. Foram elaborados protocolos simplificados referentes ao diagnóstico e tratamento do SUA, visando contribuir de forma mais eficaz com os médicos em seus diferentes cenários de atuação. O roteiro diagnóstico sugerido, compreendendo perguntas chaves e ações específicas, sinaliza para indicação de métodos propedêuticos adicionais. O tratamento proposto visa reduzir a perda do sangue menstrual e melhorar de a qualidade de vida das pacientes.(AU)

Abnormal uterine bleeding (AUB) is a complex public health problem that can affect one third of women worldwide. It has a significant negative impact on quality of life of women and is associated with high direct and indirect economic costs. It is a challenging condition for both the women affected and for the health professionals. The nomenclature assigned to the AUB is confusing and still miss diagnostic and therapeutic recommendations standardized. The Heavy Menstrual Bleeding: Evidence-based Learning for Best Practice Group (HELP) was created with the proposal to address the inconclusive aspects of AUB. The group evaluated 134 documents, including 121 scientific articles and 14 reviews of drugs for the development of protocols HELP. Simplified protocols were drawn up relating to the diagnosis and treatment of AUB, to contribute more effectively with doctors at different scenarios of operation. The script diagnostic suggested, comprising keys questions and specific actions, can indicate additional diagnostic methods. The proposed treatment aims to reduce the loss of menstrual blood and improve the quality of life of patients.(AU)

Genitorragia en una paciente prepuberal: reporte de un caso y su diagnóstico diferencial / Vaginal bleeding in the prepubescent child: clinical case and differential diagnosis

la genitorragia en pacientes prepuberales es siempre anormal, por lo que requiere estudio. Objetivo: presentar el caso clínico de una paciente prepuberal con genitorragia y revisar en la literatura los diagnósticos diferenciales. Caso clínico: paciente de 10 años con historia de 3 meses de genitorragia sin otros síntomas. Al examen físico mamas Tanner I, vello púbico Tanner II. Genitales externos sin lesiones, himen anular, rojo y delgado. Se descartó pubertad precoz. Se insertó una tórula húmeda en la vagina que dio salida a un trozo de papel higiénico y vello púbico. Después del procedimiento no ha presentado nuevos episodios de sangrado. Conclusión: la genitorragia es un signo alarmante, pero la mayoría de las veces las causas son benignas. En este caso la causa del sangrado fue un cuerpo extraño. Se recomienda derivar a ginecólogo infanto juvenil para evaluación exhaustiva...

Vaginal bleeding in prepubescent girls is always abnormal and needs evaluation. Objective: to present a clinical case and discuss differential diagnosis. Case report: A 10 years old girl with 3 months of vaginal bleeding and no other symptoms. Her breast exam is Tanner stage 1. Her pubic hair is Tanner stage 2, external genitalia were normal; her hymen was red, thin and annular. Precocious puberty was ruled out. By inserting a small sterile catheter into the vagina a piece of pubic hair and toilet paper were easily removed, after that all symptoms resolved. Conclusion: Vaginal bleeding in prepubertal children is an alarming symptom. Our patient vaginal bleeding was due to a vaginal foreign body one of the most common causes. It is recommended that all patients must be referred to a pediatric gynecologist in order to be exhaustively evaluated...

Hysteroscopic findings in patients with post-menstrual spotting with prior cesarean section / Achados histeroscópicos em pacientes com sangramento pós-menstrual tipo escape com cesárea anterior

Objective: To identify uterine hysteroscopic findings among patients with prior cesarean section and whom had post-menstrual bleeding spotting type. Methods: We conducted a descriptive and prospective study between June 2008 and December 2009 involving women admitted to our clinic in Ji-Paraná (RO), Brazil, and who complained of prolonged genital bleeding after menstrual period. A total of 20 women with the simultaneous following characteristics were selected: at least one prior cesarean section, aged between 18 and 45 years, no use of hormonal contraceptives, and no history of uterine surgery that could change the cavity anatomy. All participants underwent a hysteroscopic examination. Results: During hysteroscopy, in 90% of the patients, the presence of a cesarean section scar was observed in the last third of the cervix. This scarring causes an anomaly in the uterine cavity anatomy, characterized by the viewing of an enlargement followed by a retraction of the anterior wall, which affords the presence of a pseudocavity with depth and lumen narrowing in variable degrees. Two patients did not present the pseudocavity. Conclusion: Pseudocavities in cesarean section scar are usually found in hysteroscopic examination of patients with prior cesarean section and abnormal uterine spotting.

Objetivo: Identificar os achados histeroscópicos uterino em grupo de pacientes com operação cesariana anterior e sangramento pós-menstrual tipo escape. Métodos: Foi realizado um estudo descritivo e prospectivo, com mulheres que compareceram em consultório em Ji-Paraná (RO), entre junho de 2008 e dezembro de 2009, com queixa de sangramento genital prolongado tipo escape após período menstrual. Destas, foram selecionadas 20 mulheres que apresentavam, simultaneamente, as seguintes características: ao menos uma cesárea prévia; idade entre 18 e 45 anos; sem uso de método anticoncepcional hormonal; e ausência de qualquer outra cirurgia uterina capaz de alterar a anatomia da cavidade. As pacientes selecionadas foram submetidas a exame histeroscópico. Resultados: À histeroscopia, em 90% das pacientes, observou-se, no terço final do colo, a presença da cicatriz de cesárea. Essa cicatriz causa, no interior da cavidade uterina, uma anomalia em sua anatomia, caracterizada pela visualização, na parede anterior, de uma dilatação seguida de retração, que proporciona a presença de pseudocavidade com profundidade e oclusão da luz em graus variáveis. Já em duas pacientes, não foi detectada a pseudocavidade. Conclusão: A pseudocavidade na cicatriz da cesariana é o achado mais freqüente à observação histeroscópica em pacientes com cesárea prévia e sangramento uterino anormal pós-menstrual tipo escape.

Sangramento vaginal em mulheres de 45 - 55 anos: diagnóstico e tratamento / Vaginal bleeding in women 45-55 years: diagnosis and treatment

É de grande preocupação às mulheres margeando a idade de 45 a 55 anos o quadro de perda de sangue via vaginal de início repentino e/ou aumento abrupto. Sendo a assim a principal causa de procura pelos serviços de pronto atendimento de Ginecologia dos diversos hospitais gerais e maternidades. De causa mais comum pelos pólipos endometriais, miomas e mais raramente por carcinoma endometrial. Devido ao fato, de muito interesse dos especialistas e médicos de atendimentos primários a definição de uma sequência lógica e prática para diagnóstico e tratamento de tal afecção. Na atualidade dá-se importância a história clínica, duração do quadro e antecedentes ginecológicos. Parte-se para a avaliação clínica via exame especular para fins de quantificação do sangramento, toque vaginal para possível aumento de volume uterino. Diagnóstico por imagem através de Ultrassonografia endovaginal e histerossonografia. Diagnóstico armado através da histeroscopia diagnóstica,a fins de obstenção de biópsias para diagnóstico histopatológico e estadiamento em casos de carcinoma endometrial. O tratamento clínico vale-se do uso da hormonioterapia, anti-inflamatórios não esteróides e antagonistas do GnRH; passando para o cirúrgico através da histeroscopia cirúrgica, histerectomia e Wertein-Meygs + RtQt.

Sangramento vaginal em mulheres de 45 - 55 anos: diagnóstico e tratamento

É de grande preocupação às mulheres margeando a idade de 45 a 55 anos o quadro de perda de sangue via vaginal de início repentino e/ou aumento abrupto. Sendo a assim a principal causa de procura pelos serviços de pronto atendimento de Ginecologia dos diversos hospitais gerais e maternidades. De causa mais comum pelos pólipos endometriais, miomas e mais raramente por carcinoma endometrial. Devido ao fato, de muito interesse dos especialistas e médicos de atendimentos primários a definição de uma sequência lógica e prática para diagnóstico e tratamento de tal afecção. Na atualidade dá-se importância a história clínica, duração do quadro e antecedentes ginecológicos. Parte-se para a avaliação clínica via exame especular para fins de quantificação do sangramento, toque vaginal para possível aumento de volume uterino. Diagnóstico por imagem através de Ultrassonografia endovaginal e histerossonografia. Diagnóstico armado através da histeroscopia diagnóstica,a fins de obstenção de biópsias para diagnóstico histopatológico e estadiamento em casos de carcinoma endometrial. O tratamento clínico vale-se do uso da hormonioterapia, anti-inflamatórios não esteróides e antagonistas do GnRH; passando para o cirúrgico através da histeroscopia cirúrgica, histerectomia e Wertein-Meygs + RtQt.

[Diagnostic hysteroscopy]

It is an essential and necessary tool in the management of intrauterine pathologies. Indeed, it allows a better diagnosis and better distribution of therapeutics, more precisely targeted. It is a quick, minimally invasive, reproducible and reliable. Retrospective study on a series of 174 cases of diagnostic hysteroscopy performed between January 2004 and December 2006. The mean age was 42,6 years; abnormal uterine bleeding is the main symptom in 110 patients [63%], followed by infertility in 30 patients [17.2%], the abortive disease [7.5%], removal of the intrauterine device [6.9%], and others [5.1%]. Nine patients [5%] had a normal examination; intrauterine abnormalities found were: polyps [31.6%], endometrial hypertrophy [32%], submucous adenomyomas [13.8%], synechiae [12%], endometrial atrophy [9.7%], the intrauterine device [6.9%], uterine septum [6.3%], trophoblast retention [3.5%], intraluminal neoplasms [1.7%], and adenomyosis [1.7%]. The hysteroscopy is accurate, safe, with a low failure rate in the diagnosis of intrauterine abnormalities. It has better sensitivity and specificity compared with sonography and hysterosalpingography. It involves certain risks, but generally remains rare. This examination is currently the gold standard as a diagnostic technique for intracavitary uterine lesions

Anormalidades do primeiro trimestre da gravidez: ensaio iconográfico / First trimester pregnancy abnormalities: iconographic essay

As anormalidades do primeiro trimestre da gravidez são detectadas pela ultrassonografia transvaginal em exame de rotina ou em caso de sangramento vaginal anormal. A ameaça de abortamento é uma afecção comum no primeiro trimestre da gestação, ocorrendo em mais de um terço dos casos. O advento de sondas vaginais de alta resolução vem revolucionando nossa compreensão da fisiopatologia e o manejo da gestação inicial. Trata-se de ferramenta essencial para determinar a viabilidade da gestação nos casos de ameaça de abortamento. Uma conduta expectante no abortamento poderia reduzir significativamente o número de esvaziamentos desnecessários de produtos retidos, dependendo dos critérios utilizados.

First trimester pregnancy abnormalities may be detected by transvaginal ultrasonography at routine examinations or in cases where abnormal vaginal bleeding is present. Threatened miscarriage is frequently observed in the first trimester, occurring in more than one-third of pregnancies. The advent of high-resolution transvaginal ultrasonography has revolutionized the understanding of the pathophysiology and the management of early pregnancy. This method represents an essential tool for determining the pregnancy viability in cases of threatened miscarriage. An expectant approach in the management of miscarriage could significantly reduce the number of unnecessary evacuations of retained products of conception, depending on the adopted criteria.

Role of transvaginal sonography in assessment of abnormal uterine bleeding in perimenopausal age group

Abnormal uterine bleeding [AUB] is a common problem which prompts more than 20% of all visits to outpatient clinics, and may account for more than 25% of all hysterectomies. The objective of this study was to determine the role of transvaginal ultrasonography in women of perimenopausal age group presenting with abnormal uterine bleeding. This descriptive study was conducted in Department of Obstructs and Gynaecology, Railway General Hospital, Rawalpindi. One hundred and forty-one women who attended the gynaecology clinic with abnormal uterine bleeding [menorrhagia, intermenstrual bleeding, or postcoital bleeding] between 40-47 years of age from January 2006 and April 2007 were included in this study. The mean age was 44 years. Among 141 women endometrial lesions were detected in 77 cases on histopathology after Dialatation and Curettage [D and C], while 57 [40.42%] of these were confirmed on transvaginal ultrasongraphy as an endometrial pathology prior to this invasive procedure. Among the 64 remaining patients, showing normal proliferative endometrium on histopathology, 46 cases [71.87%] showed no abnormality on tranvaginal examination. Transvaginal sonography can be safely used as an initial investigation in the management of abnormal uterine bleeding as it is a noninvasive procedure for the detection of endometrial pathology. The incidence of detection of an abnormal pathology by ultrasongraphy is high when focal lesions as fibroids, polyps or foreign body is concerned. Dilatation and curettage being a blind procedure requires hospitalization and general anaesthesia which can be safely replaced by an alternate valid, safe and non-invasive technique for evaluating the endometrial pathology in women of perimenopausal age group with abnormal uterine bleeding

Validity of hysteroscopy and histopathology in patients with menstrual irregularity

Abnormalities in menstrual cycle is the most common presenting symptom in Gynaecology out-patient. Dilatation and curettage has been the diagnostic investigation of choice for decades in such cases. With the advent of new more valid and safe methods, it has been replaced by hysteroscopy as gold standard. The objective of this study was to know the sensitivity and specificity of hysteroscopy in patients presenting with menstrual irregularity. Validity study was conducted over 269 cases for a period of two years at Maternal and child health centre, Pakistan Institute of Medical Sciences, Islamabad. Inclusion criteria were age >/= 35 years and abnormal uterine bleeding. Patient with positive pregnancy test, recent cervicitis, vaginitis, endometritis, pelvic infection were excluded. Hysteroscopy and curettage was performed after taking informed consent, mostly on outpatient basis. A predesigned Performa was used for a detailed record of hysteroscopic findings, which were later compared with histopathology report. Data was analysed using MS Excel, and Cross Tabulation was done using Epi-info. Sensitivity, specificity, positive predictive value and negative predictive value of hysteroscopy was calculated against histopathology, the gold standard. Sensitivity, specificity, positive predictive value and negative predictive value of hysteroscopy was calculated against histopathology after excluding 46 [17.1%] cases of uterine fibroid that were diagnosed only at hysteroscopy. Hysteroscopy has shown highest sensitivity for retained products of conception and adenocarcinoma [100%] while a specificity of 90% and above for all hysteroscopic findings. Seventy eight percent of the procedures were performed on outpatient basis, 95% under intravenous sedation and 95% with no operative complication. Hysteroscopy should be used as an adjunct procedure to curettage as it is a better tool for diagnosis of intracavity lesions, with a high sensitivity and specificity for endometrial carcinoma

Sangramento uterino anormal / Abnormal uterine bleeding

O sangramento uterino anormal é um distúrbio frequente que pode ocorrer em qualquer idade entre a menarca e a menopausa, mas concentra-se principalmente em seus extremos, logo após a menarca e no período perimenopausa, quando ocorrem alterações no eixo hipotálamo-hipófise-ovário, que levam com muita frequência à anovulação. O sangramento uterino disfuncional, considerado diagnóstico de exclusão, pode ser ovulatório ou anovulatório. O manejo do quadro pressupõe que o sangramento agudo seja coibido e que se evite a recidiva; para tanto, é fundamental que se estabeleça o diagnóstico etiológico. Os autores fazem uma revisão objetiva sobre o assunto, dando ênfase ao diagnóstico e tratamento da doença.

Abnormal uterine bleeding is a clinical problem wich may occur at any time during the reproductive years; however, it is most prevalent during perimenarche and perimenopause, when women tend to have anovularoty cycles. Disfunctional uterine bleeding is a prevalent disease that affects women from adolescence to menopause. The treatment should control the acute bleeding and avoid the recidive. The etiological diagnosis is fundamental for this purpose. The authors make an objective review about dysfunctional uterine bleeding herein, focusing on the diagnosis and treatment of the disease.

Unusual cases of cervical pregnancy and secondary abdominal pregnancy.

A 22-year-old lady, 3rd gravida presented with discomfort in the lower abdomen and bleeding per vagina following 6 months amenorrhoea. USG of abdomen showed single dead foetus of 21 weeks gestation occupying in the cervical region, endometrial cavity was empty. On laparotomy, cervical region was seen enlarged and distended and over which body of uterus lied. After bilateral internal iliac artery ligation, vertical incision was made over the body of the uterus and cervical region. During the removal of foetal parts and placenta from the cervical region, there was severe haemorrhage for which immediate total hysterectomy was necessitated. In another case, a 28-year-old primigravida was admitted to the hospital with the complaints of abdominal pain at 34 weeks of gestation and she gave history of recurrent pain abdomen throughout pregnancy. USG of abdomen showed a suspected case of secondary abdominal pregnancy. Immediate laparotomy was done and after making a transverse incision over the gestation sac, a live foetus was delivered. A bulky uterus was visible behind the gestation sac and placenta was seen situated,over a part of sigmoid colon and the greatvessels. To see the location of placenta, a part of it got separated spontaneously and severe bleeding started which could not be properly controlled. She received 9 units of blood transfusion but ultimately died. The weight of the baby was 1.9 kg and it had talipes equinovarus. Baby was discharged after 5 days in good condition.

Comparación entre el sistema intrauterino de liberación de levonorgestrel y la ablación endometrial en el tratamiento de la hemorragia uterina disfuncional / Comparison between the levonorgestrel intrauterine system and endometrial resection in the treatment of dysfunctional uterine bleeding

Objetivo: Comparación entre el sistema intrauterino de liberación de levonorgestrel (SIL-LNG) y las técnicas de ablación endometrial (AR-E) en el tratamiento de la hemorragia uterina disfuncional (HUD). Método: Estudio retrospectivo de 170 pacientes con HUD distribuidas de la siguiente forma: 51 de ellas en el grupo AR-E y 119 en el grupo SIL-LNG. Se estudió el ciclo menstrual, la hemoglobina y el hematocrito, los efectos adversos y la satisfacción de las usuarias. Resultados: En ambos grupos se observó un incremento de los niveles de hemoglobina y hematocrito. El patrón de sangrado más frecuente fue el de amenorrea, hipomenorrea y ciclos normales tras los tratamientos. El grado de satisfacción fue muy elevado en ambos grupos. Conclusión: Ambos tratamientos son efectivos para mejorar la HUD. La paciente debe conocer los beneficios y riesgos de cada uno y elegir el más conveniente.

Objective: To compare the efficacy of levonorgestrel intrauterine system and endometrial resection in the treatment of dysfunctional uterine bleeding. Methods: Retrospective study with 170 women, 51 of them in endometrial resection group and 119 in the levonorgestrel intrauterine system group. Hemoglobin levels, menstrual bleeding patterns, adverse effects and degree of satisfaction were evaluated. Results: Hemoglobin levels increased in both groups. The most frequent bleeding patterns were amenorrhea, hypomenorrhea and normal pattern. The most of the patients in both groups were satisfied with the treatment. Conclusion: Both treatments were effective in reducing dysfunctional uterine bleeding. The woman must know risks and benefits from each one.