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.

Amenorrea hipotalámica: consideraciones etiológicas y clínicas a raíz de una paciente / Hypothalamic amenorrhea: report of one case

Hypothalamic amenorrhea is secondary to the dysfunction of the hypothalamic pacemaker that regulates the pulsatile secretion of gonadotropin releasing hormone (GnRH). We report a 21 years old female with an isolated and persistent hypogonadotropic hypogonadism probably of congenital origin. The patient had a good olfactory function, did not have anatomical alterations and two GnRH stimulation tests showed a pre puberal pattern. Hormone replacement therapy allowed her to complete her puberal development.

Treatment outcome of hyperprolactinaemic infertility with carbegoline in sub saharan Africa

Hyperprolactinaemia is a known cause of infertility. We explored the efficacy of carbegoline, the long acting dopamine agonist that was recently introduced into our medical practice. Seventy six patients with infertility secondary to hyperprolactinaemia were studied over a period of 20 weeks each. All the patients had carbegoline twice weekly for eight weeks. Two dosage regimen were used based on the pretreatment prolactin level; less than 50ng/ml had 0.25mg twice weekly [n=58] and 50ng/ml and above 0.5mg twice weekly [n=18]. Normalization of prolactin level was achieved in 75 [98.7%] patients. At the end of the study period, there was resumption of menstrual flow in 10 [76.9%] of the 13 patients that were amenorrhoiec and all the 39 [100%] patients that were oligomenorrhoeic had their normal menstrual cycle restored. Resumption of ovulatory cycles occurred in 87.7% of those with anovulatory cycles. Of the 76 patients, 69 [90.8%] got pregnant during the 20 weeks study. However, out of the 69 that got pregnant, 13 [18.8%] got pregnant while on carbegoline therapy. There was no case of carbegoline resistance or discontinuation recorded in this study. Carbegoline is a cost effective first line therapy in the management of infertile women with hyperprolactinaemia

Comparison of the effects of cabergoline and bromocriptine in women with hyperprolactinemic amenorrhea

Dopamine agonists are the preferred treatment for most patients with hyperprolactinemic disorders, these agents are extremely effective in lowering serum prolactin levels, eliminating galactorrhea, restoring regular menses and decreasing tumor size. Dopamine agonists, including bromocriptine, quinagolide and cabergoline are differ in their efficacy and tolerability. However, there are relatively few reports in the world comparing the beneficial and adverse effects of bromocriptine and cabergoline in the treatment of hyperprolactinemic patients and there is also lack of such studies in Iraq. Therefore, this study sets out to compare the efficacy and safety of cabergoline with those of bromocriptine in women with hyperprolactinemic amenorrhea in Mosul city. One hundred and thirty women with hyperprolactinemic amenorrhea were treated with either cabergoline [0.5 mg weekly] or bromocriptine [2.5 mg twice daily] administerd randomly for 8 weeks. Clinical and biochemical status was assessed at baseline and at the end of trial. Amenorrhea persisted in 9 women of the cabergoline-treated women and 20 of the bromocriptine-treated women. Galactorrhea disappeared in the cabergoline group and persisted in 12 of the bromocriptine group. Normoprolactinemia was achieved in 87.7% women treated with cabergoline and in 67.7% of women treated with bromocriptine. The reduction of prolactin level is statistically higher in the cabergoline group compared with the bromocriptine group. cabergoline and bromocriptine are effective in the treatment of hyperprolactinemic amenorrhea .Cabergoline has the advantage over bromocriptine in terms of both efficacy and tolerability and therefore it is preferred in the treatment of hyperprolactinemic amenorrhea

Predictors of successful conception in a clinical trial of 30 patients with primary amenorrheic hypogonadotrophic hypogonadism treated by ovulation induction

A clinical trial was designed to assess the association between the treatment of infertile females with Hypogonadotrophic Hypogonadism and their fertility state considering conception as the desired outcome. Serum hormones, LH, FSH and estradiol, endometrial thickness and count of active ovarian follicles were assessed by U/S to evaluat their role in anticipating a successful conception. Standard protocols of ovulation induction were used in a clinical trial [historical cohort design] of 30 patients with primary hypogonadotrophic hypogonadism. For ethical reasons no attempt was made to fix the number of induction courses given to the female patient [such a variability is suspected to confound the result to a limited extent], so a female was followed up with several courses of ovulation induction [according to the advice of the physician in charge] for a median duration of I year with conception as the final outcome of interest. Four serum hormonal markers [FSH, LH, Prolaction and estradiol] were assessed before and 12-14 days after initiating therapy. Transvaginal U/S was done to measure endometrial thickness and the number of dominant follicles in both ovaries after 12-14 days of treatment. Serum estradiol concentration, endometrial thickness and number of dominant follicles were significant predictors of successful conception. Using endometrial thickness as a decision rule to predict successful conception at a cutoff value of 7 mm, considering the rule as positive if equal or greater than 7 mm, resulted in a positive predictive value [PPV] of 50% [Relative risk of having conception was 4.3 times]. The confidence in a positive rule was increased to 71.4% [PPV =11.4%] when the cutoff value was set higher at 8 mm endometrial thickness. Using the number of dominant follicles as a decision rule at a cutoff value of 4 resulted in a PPV of 60%. This PPV was further increased to 72.7%] when the cutoff value was set higher at 5. An U/S finding of 5 or more dominant follicles increased the.probability of having conception by 12.6 times. A serum estradiol concentration at day 12 of 114 pgm/ml and higher predicted successful conception with a PPV of 50% [relative risk of having conception was 7], increasing this cutoff value of serum estradiol to a maximum of 498.5 pgm/ml increased the PPV to 66.7%. a clinician can predict successful conception after the first 2 weeks of initiating therapy with a moderate degree of confidence depending on serum estradiol, endometrial thickness and number of dominant follicles in the ovary. Other factors however need to be considered to increase the confidence of prediction, such as the type of insemination technique, sperm count of husband. A larger sample size and a survival analysis design is needed to assess the exact risk of having conception after each course of treatment

Hiperprolactinemia y embarazo: aspectos clínicos / Hyperprolactinemia and pregnancy: clinical aspects

Se hizo un estudio retrospectivo que incluyó 54 pacientes hiperprolactinémicas que lograron embarazo en el período comprendido entre enero de 1979 y diciembre de 1992, con el objetivo de describir su comportamiento clínico antes y después del embarazo. Se dividió la muestra en 2 grupos: funcional (n = 21) y tumoral (n = 33). Se comprobó que la galactorrea y la infertilidad fueron los motivos de consulta más frecuentes en la causa idiopática y la amenorrea y la galactorrea, en las tumorales. El tratamiento previo al embarazo en todas las pacientes del grupo idiopático y en el 67,5 porciento de las de causa tumoral fue con agonistas dopaminérgicos. Más de la mitad de las pacientes de ambos grupos tuvo mejoría clínica en el primer año posparto, el resto se mantuvo sin cambios, excepto una paciente del grupo funcional que empeoró clínicamente. En el segundo año posparto aumentó el número de mujeres cuyos síntomas clínicos fueron similares a los referidos previo al embarazo. En conclusión, en nuestra serie se pudo constatar mejoría de los síntomas de la hiperprolactinemia después del embarazo en la mayoría de las pacientes(AU)

Prolactinoma resistente a Bromocriptina: informe de un caso / Prolactinoma resistent to bromocriptine

El adenoma hipofisario más frecuente es el prolactinoma. Esta patología de evolución usualmente benigna, se acompaña de amenorrea, galactorrea y/o síntomas por efecto de masa. Responde en forma muy efectiva a la bromocriptina, agonista dopaminérgico, disminuyendo la prolactina sérica a valores normales con desaparición de la galactorrea y permite recuperar el ciclo mestrual normal. Además tiene otros efectos como disminuir el tamaño de la masa tumoral. En el presente artículo se analiza el caso de una paciente de 22 años que inició control en el Hospital San Juan de Dios a los 17 años por amenorrea primaria, razón por la que fue sometida a cirugía por un prolactinoma resistente a bromocriptina. Palabras claves: Prolactinoma, Ago-nista Dopaminérgico, Bromocriptina, Resistencia a Tratamiento

Experiencia en inducción de ovulación con factor liberador de gonadotrofinas (GnRH) en pacientes con amenorrea hipotalámica / Experience in ovulation induction with gonadotropin releasing factor (GnRH) in patients with hipotalamic amenorrhea

Presentamos nuestra experiencia en inducción de ovulación y fertilidad en pacientes con amenorrea hipotalámica (AH) tratadas con Hormona liberadora de gonadotrofina (GNRH) en infusión pulsátil (GnRHp). Se trataron 13 pacientes ciomifeno negativo, de las cuales 10 tenían una AH primaria y 3 una AH secundaria. Ocho del total de las pacientes estaban interesadas en fertilidad. El tratamiento se realizó en forma ambulatorio con bomba de infusión pulsátil (ZykiomatO Alemania) programada para administrar 5 Wg de GNRH cada 90 minutos por vía endovenosa. El desarrollo folicular fue monitorizado mediante ultrasonografía y determinaciones hormonales seriadas. Se indujeron un total de 19 ciclos, 14 fueron ovulatorios con folículo único (73,7 por ciento). Trece inducciones se llevaron a cabo en las 8 pacientes expuestas a embarazo, 7 de los cuales fueron concepcionales (tasa de fecundidad: 61,5 por ciento, tasa de embarazo: 85,5 por ciento). Sólo una paciente abortó espontáneamente. No se observaron complicaciones mayores. En conclusión, la inducción de ovulación con GNRH demostró ser un método de inducción de ovulación efectivo y seguro en pacientes con AH ciomifeno resistentes. Debido a que se conservan los mecanismos de retrocontrol entre ovario e hipótesis, los embarazos múltiples y el síndrome de hiperestimulación ovárica son infrecuentes, lo que permite una monitorización menos estricta de la paciente

Tratamiento de amenorreas hiperprolactinemicas con cabergolina / Treatment of hyperprolactinemic amenorrheas with cabergoline

La cabergolina (CAB) es un agonista dopaminérgico de acción prolongada. En la primera experiencia nacional con CAB -parte de un trabajo multicéntrico internacional- se evaluaron 39 mujeres adultos y adolescentes, de 16 a 44 años, con amenorreas hiperprolactinémicas (18 microadenomas y 21 idiopáticas). Se administró CAB o bromoergocriptina (BEC) durante 24 semanas: 8 semanas fueron a doble ciego y en las 16 restantes (período abierto) 18 pacientes fueron tratadas con CAB y 21 con BEC según distribución al azar. Dosis máxima: CAB = 1,5 mg en 2 ó 3 tomas semanales 0,2, 4,6,8,12,14, 20 y 24 del tratamiento y reistalada la menstruación se dosó Progesterona. En las 4 adolescentes se continuó el tratameiento con CAB durante 1 año más. La prolactina se evaluó estadísticamente según Man Whitney (población general) o Wilcoxon (adolescentes). No hubo diferenciais significativas entre las prolactinas (ng/ml) basales de las pacientes tratadas con BEC o con CAB: 173, 86 + 28,23 y 152,11 + 14,06 respectivamente (p = NS); a la 4º semana hubo menor descenso con BEC que con CAB: 36,36 + 5,71 y 14,06 + 3,60 (p < 0,05) y a las 24 semanas se igualaron las respuestas: 19,88 + 4,48 y 9,63 + 2,62 respectivamente (p = NS). En las adolescentes se observó un marcado descenso de la PRL sin diferenciais entre BEC y CAB: basales: 168,17 + 75,47 y 213 + 96,99 (p = NS); 4 semanas: 48,00 + 8,72 y 35,00 + 12,58 (p = NS); 24 semanas; 34,33 + 10,17 y 21,75 + 7,23 (p = NS) respectivamente. A las 48 semanas persistieron los valores de la semana 24: 23,25 + 11,23 (p = NS). Algunas pacientes tratadas con BEC presentaron náuseas, vómitos y epigastralgias, síntomas no observados con CAB. Todas as pacientes lograron menstruar excepto una tratada con BEC, 6 pacientes tratadas con CAB se embarazaron y las 5 que continuaron bajo nuestro control dieron a luz niños sanos. Se concluye que la CAB constituye un recurso terapéutico útil, particularmente en la dolescencia (grupo etario de difícil manejo), por su fácil administración y casi total ausencia de efectos adversos.

O uso pulsátil do hormônio liberador de gonadotrofinas: administraçäo intravenosa versus subcutânea / The use of pulsatile gonadotropin releasing hormone: intravenous versus subcutaneous administration

Procurou-se neste trabalho comparar o efeito da administraçäo de GnRH utilizando-se a via endovenosa (E.V.) e subcutânea (S.C.) em 2 pacientes com amenorréia por deficiência de GnRH. Os resultados mostram que ocorreu a ovulaçäo nas duas pacientes quando se utilizou a via E.V. e nenhuma das duas vezes quando se utilizou a via S.C.. Os resultados sugerem que doses maiores seräo necessárias quando se usa a via S.C., aumentando o custo e duraçäo do tratamento, embora esta via de administraçäo seja mais cômoda e fácil de ser usada

Functional hypothalamic amenorrhoea-isolated gonadotropin deficiency.

A 21 year old female patient with primary amenorrhoea was diagnosed to have isolated gonadotropin deficiency with probable functional hypothalamic amenorrhoea. The evaluation included buccal smear for sex chromatin, trial of medroxy-progesterone acetate, trial of oestrogen-progesterone preparation and estimation of serum prolactin, gonadotrophin and oestrogen levels. When diagnosed as isolated gonadotropin deficiency, treatment with gonadotropin is rewarding.

Inducción de ovulación mediante la administración crónica de naltrexona en paciente con amenorrea hipotalámica secundaria / Ovulation induced by chronic administration of naltrexona in a patient with secondary hypothalamic amenorrhea

Se presenta el caso de un ciclo ovulatorio en una paciente portadora de amenorrea hipotalámica secundaria, cuya inducción de ovulación se efectuó mediante la administración oral de un antagonista opiáceo específico: Naltrexona, en una dosis de 50 mg/día por 26 días. El desarrollo folicular fue monitorizado mediante ultrasonografía transabdominal y mediciones plasmáticas seriadas de hormona luteinizante (LH), folículo estimulante (FSH), estradiol (E2) y progesterona (P4). Tanto el perfil hormonal como el seguimiento ecográfico fueron compatibles con ciclo ovulatorio con folículo único. Después de la discontinuación del tratamiento, la paciente se hizo nuevamente amenorreica declinando los valores de gonadotrofinas y estradiol a los niveles observados antes del inicio del tratamiento. Estos datos demuestran que la naltrexona puede ser un agente útil en la inducción de ovulación de pacientes con amenorrea hipotalámica