Monitored Anesthesia Care in Uterine Artery Embolization for Leiomyomas and Adenomyosis

Background: Patients undergoing an interventional radiology procedure report some degree of anxiety. Therefore, procedure-related anxiety needs to be managed. The aim of our study was to investigate patient satisfaction with monitored anesthesia care (MAC) for uterine artery embolization (UAE)-related procedural anxiety in symptomatic uterine fibroids or adenomyosis. Method(s): Between May 2021 and June 2022, 36 patients with symptomatic fibroids or adenomyosis underwent UAE with MAC. Follow-up evaluations consisted of clinical symptoms, degree of satisfaction with MAC in UAE, and complications. Result(s): MAC in UAE was successfully performed in all patients. UAE significantly reduced patients' complaints such as bleeding and pain: the scores for bleeding and pain were significantly reduced after 3 months of UAE compared with those before UAE, indicating the effectiveness of UAE. The mean score of satisfaction with MAC in UAE was 4.3 points, meaning that 94.4% of women were satisfied or very satisfied. No major complications were observed. Conclusion(s): MAC in UAE for symptomatic uterine fibroids or adenomyosis can be emotionally effective and safe for patients who are anxious about the procedure.Copyright © 2023 The Author(s).

An outpatient service evaluation in a UK tertiary referral centre for paediatric and adolescent gynaecology

Background: Pressure on waiting lists prompted this service evaluation in a tertiary referral centre for paediatric and adolescent gynaecology (PAG). The service is located in Bristol in England. The centre is one of 11 commissioned by NHS England to provide care for patients with congenital gynaecological anomalies, as well as seeing patients with other PAG presentations from aged 2 upwards. Alongside general PAG clinics, there is a quarterly multi-disciplinary transition clinic for children with differences in sex development and a monthly joint adult endocrinology / gynaecology clinic where patients with Turner Syndrome are seen annually. Aim(s): To collect and analyse data pertaining to the pre-Covid PAG outpatient service, to inform1 anticipated service developments aimed at reducing waiting list times for new patients and streamlining of services for certain patient groups Methods: This service evaluation was registered with the local clinical audit team (GYNAE/SE/2020-21-11). We performed a retrospective review of the electronic notes of every PAG appointment from 1st March 2019 - 29th February 2020 (pre-Covid-19 UK restrictions). A database of PAG clinics was created and then the team manually went through each appointment's notes / letters and extracted the relevant data which was entered into a Microsoft Excel spreadsheet. Result(s): There were 385 appointments during this time period. There was data available for 376 appointments and 338 of these were filled by PAG patients. 72 appointments were (21%) for primary ovarian insufficiency (POI) of late effects of childhood cancer, 53 (16%) were for patients with Turner syndrome and 48 (14%) for heavy menstrual bleeding, of which 23 (48%) were new referrals, with this being the most common reason for referral to the team. The remaining appointments were for a variety of conditions. Conclusions and Actions: Our services would benefit from streamlining to maximise capacity and reduce waiting times. To this end: - A second endocrinologist has been recruited to double capacity for the Turner Syndrome clinic2. - An adolescent heavy menstrual bleeding clinic3,4 has been set up to streamline care for these patients. This is a one-stop face-to-face clinic offering a transabdominal pelvic ultrasound scan and a telephone follow-up 3 or 6 months later - To consider a POI / late effects of childhood cancer service to run alongside the menopause and reproductive medicine clinics with psychology support5 PAG constitutes a wide range of diagnoses, and a regular assessment is helpful to ensure care can be offered as efficiently as possible.Copyright © 2023

Prevalence and Course of Covid-19 in Patients with Congenital Bleeding Disorders in Russia

Introduction: Published data on the course of COVID-19 in patients with congenital bleeding disorders (CBDs) is limited. There are questions about howCOVID-19 affects the course of CBDs and, conversely, how CBDs affect the course of coronavirus infection? Some authors suggest that patients with CBDs to be less severely affected by COVID-19. The aim of the study: analysis of the prevalence and course of COVID-19 in patients with CBDs in Russia. Method(s): A web-based questionnaire was developed to collect data. The survey was conducted in the period from 25.06.2022 to 31.07.2022. A cluster of 187 patients from different regions and cities of Russia were interviewed. Result(s): The average age of patients was 37 years. The survey group consisted of 144 patients with hemophilia A, 16 with hemophilia B, 24 with vonWillebrand's disease and 1 patient with factor VII deficiency. COVID-19 affected 115 (61.5%) of 187 surveyed patients and 22 (19%) patients suffered from coronavirus infection twice. Hospitalisation was required for 14 (12.3%) patients. At the beginning of the disease, 82 (71%) patients were on prophylactic treatment with the factor concentrates;11 (10%) received therapy with emicizumab, 20 (17%) received therapy with the factor concentrates on demand and 2 (1.7%) received bypass agents. During COVID-19 different types of bleeding were observed in 9 (7.8%) patients: hemarthrosis, ecchymosis, hematomas, epistaxis, menorrhagia, haemorrhoid bleeding. Due to COVID-19 the blood coagulation parameters were monitored for 15 (13%) of 115 patients who had been ill. The haemostatic therapy regimen was changed in 19 (16.5%) patients. Anticoagulant therapy was received by 8 (7%) patients. There were no thrombotic cases. A change in the course of the underlying disease after COVID-19 was noted by 21 (18%) patients, of which 11 noted an increase in joint pain and 9 reported the appearance of pain in previously intact joints. Discussion/Conclusion: The absence of thrombotic complications in patients with CBDs and COVID-19 suggests that hypocoagulability state may be protective against COVID-19 hypercoagulability-related adverse effects. However, the aggravating condition is an increase in joint pain and the involvement of new joints possible due to both hemostatic disorders and autoimmune reaction.

Studying the Predictive Effects of Bacterial Carotenoids in the Treatment of Endometriosis Using Virtual Screening Methods

Background: Endometriosis is a chronic inflammatory disease defined as the presence of endometrial tissue outside the uterus, which causes pelvic pain and infertility. Cytokines appear to play vital roles in the development and progression of endometriosis and associated infertility. Tumor necrosis factoralpha (TNF-alpha) is a multifunctional pro-inflammatory cytokine, responsible for autoimmune and inflammatory disorders. TNF- alpha plays an important role in endometrial physiology as well as during early implantation. In addition, this cytokine has a considerable pathophysiological function in diseases such as menorrhagia, endometriosis, or infertility due to its regulatory impact on proliferation, differentiation, and angiogenesis in the human endometrium. In women with endometriosis, TNF-alpha levels increases in peritoneal fluid and serum significantly. In the present study, we focused on finding novel small molecules that can directly block TNFalpha- hTNFR1 (human TNF receptor 1) interaction. Method(s): In this regard, TNF-alpha inhibiting capacity of natural carotenoids was investigated in terms of blocking TNF-alpha-hTNFR1 interaction with the help of a combination of in silico approaches, based on virtual screening, molecular docking, and molecular dynamics (MD) simulation. Result(s): A total of 125 carotenoids were selected out of 1204 natural molecules, based on their pharmacokinetics properties, and they all met Lipinski's rule of five. Among them, sorgomol, strigol, and orobanchol had the most favorable DELTAG with the best pharmacokinetics properties and were selected for MD simulation studies, which explored the complex stability and the impact of ligands on protein conformation. It was shown that sorgomol formed the most hydrogen bonds, resulting in the highest binding energy with the lowest RMSD and RMSF. Conclusion(s): Our results showed that sorgomol was the most appropriate candidate as a TNF-alpha inhibitor. In conclusion, the present study could serve to expand possibilities to develop new therapeutic small molecules against TNF-alpha which plays an important role in the inflammation of endometriosis.

A Case Report of Non-puerperal Uterine Inversion

Objective: Non-puerperal uterine inversion is a rare occurrence. The common etiology for this condition is uterine sarcoma, endometrial carcinoma, and myoma. Case Presentation: This case is a 44-year-old woman with a protruding malodorous vaginal mass, abdominal pain, and urinary retention. Total hysterectomy with bilateral salpingectomy was per-formed. Conclusion: Diagnosis of uterine inversion might be difficult and requires a high index of suspicion. © 2023 Bentham Science Publishers.

Severe Hypertriglyceridemia as a Cause of Arterial Thrombosis with Peripheral Embolic Complications

Lead Author's Financial Disclosures: Nothing to disclose. Study Funding: None. Background/Synopsis: Extensive evidence exists in support of a causal association of elevated triglyceride-rich lipoprotein (TRL) levels with the risk of atherosclerosis progression. Hypertriglyceridemia has been established as a risk factor for venous thrombosis, including a 2- fold increase in the risk of venous thrombosis in postmenopausal women. However, there is limited data on the role of hypertriglyceridemia in the arterial thrombosis. Objective/Purpose: Not Applicable. Methods: Case description: A 51-year-old white female with hypertension and type 2 diabetes (hemoglobin A1C, 7.4%) was transferred for further management of newly diagnosed bilateral renal and splenic infarcts. No risky habits were elicited except for the use of combined hormonal contraceptives over the past two years to control menorrhagia. Family history was significant for hypertriglyceridemia. Her physical exam was unremarkable. Testing for COVID-19 was negative. An extensive hypercoagulable and autoimmune work-up was unremarkable. Fasting lipid profile was significant for elevated levels of triglycerides, 1,274 mg/dL (replicated on two separate occasions), very low-density lipoprotein-cholesterol, 255 mg/dL, and non-high-density lipoprotein-cholesterol, 214 mg/dL, directly measured low-density lipoprotein cholesterol, 39 mg/dL and lipoprotein(a), 6 mg/dL. There was no structural pathology on the echocardiogram, including no interatrial shunt or intracardiac thrombus. Her whole-body computed tomography angiography revealed a focal calcified protruding thrombus in the distal thoracic aorta. No significant plaque was seen elsewhere in the aorta. Results: Decision-making. The posterior thrombus in the distal thoracic and proximal abdominal aorta was determined as a culprit for the visceral organ infarcts. Over the course of the hospital stay her abdominal pain gradually resolved. Treatment with low dose aspirin and therapeutic dose of low-molecular weight heparin was initiated followed by apixaban and aspirin on discharge. She was started on atorvastatin 40 mg, fenofibrate 145 mg, icosapent ethyl 4 g, resulting in a 70% reduction in the triglycerides levels (306 mg/dL). In 3 months, her repeat CT angiography showed significant resolution of the aortic atherothrombosis with no signs of aortic wall inflammation. At the 6-month follow-up visit she was switched to dual antiplatelet therapy with a plan to repeat imaging in 6 months. Conclusions: This case illustrates challenges in managing patients with arterial thrombosis in the setting of familial hypertriglyceridemia. Apart from severely elevated triglycerides no other etiology was evident. We propose further investigation of the prothrombotic properties of TRL and the role of targeted triglyceride-lowering therapies on atherothrombotic outcomes.

Menstrual Cycle Changes after COVID-19 Infection: Does Coronavirus-induced Stress Lead to Hormonal Change?

Background: Pieces of clinical evidence suggest that coronavirus disease-2019 (COVID-19) viral infection results in hormonal imbalance leading to changes in menstrual cycles of women. This study has been conducted with the aim to determine the effect of COVID-19 infection and its vaccine on menstrual cycle patterns. Materials and methods: This was a cross-sectional study to observe any changes in menstrual cycle after COVID-19 infection or after its vaccination. A Web Link collector generated the survey‘s universal resource locator (URL) and was sent via social media messages to females in the general population as well as healthcare workers. Results: Menstrual cycles remained unaltered in 154/228 (67.5%) of women post-COVID-19 infection irrespective of its severity. Out of 228, one-third of women, i.e., 74/228 (33%), reported changes in their menstrual patterns, with respect to either cycle length, duration of flow, number of pads used, pain during menses, or premenstrual symptoms (PMSs). Menstrual blood loss was decreased by 14% (32/228) and 18%;42 women complained of increased flow during menses. Twenty percent of women who had severe infections had menorrhagia. Out of the 590 women who completed the questionnaire, 436 (73.8%) were vaccinated against COVID-19 and 154 (26%) were unvaccinated. After vaccination, 290/436 around one-third of women (66.5%) had normal menstrual cycle, 21 women (4.8%) had decreased menstrual blood flow, and 18 women (4.1%) reported increased menstrual flow. Conclusion: COVID-19 infection affected the menstrual cycle of only one-third of women and this effect was temporary. This effect might be due to stress and anxiety affecting the hypothalamic-pituitary axis (HPA). More studies are needed to support this effect.

Menstrual abnormalities after COVID-19 vaccines: A systematic review.

The objective of this systematic review is to give a comprehensive interpretation of menstrual cycle changes after the COVID-19 vaccination. Additionally, it is imperative to assess reports of menstrual changes following vaccination to dispel concerns that COVID-19 vaccines hinder the likelihood of pregnancy in the long run. A literature review was conducted using digital databases to systematically identify the studies reporting any menstrual abnormalities after the COVID-19 vaccine. Detailed patient-level study characteristics including the type of study, sample size, administered vaccines, and menstrual abnormalities were abstracted. A total of 78 138 vaccinated females were included in this review from 14 studies. Of these, 39 759 (52.05%) had some form of a menstrual problem after vaccination. Due to the lack of published research articles, preprints were also included in this review. Menorrhagia, metrorrhagia, and polymenorrhea were the most commonly observed problems and the overall study-level rate of menstrual abnormality ranged from 0.83% to 90.9%. Age, history of pregnancy, systemic side-effects of COVID-19, smoking, and second dose of COVID-19 vaccine were predictors of menstrual problems after vaccination.

Alteraciones menstruales tras la vacunación contra la COVID-19: revisión sistemática Resumen El objetivo de esta revisión sistemática es aportar una interpretación amplia sobre los cambios de los ciclos menstruales tras la vacunación contra la COVID-19. Además, es imperativo evaluar los informes sobre los cambios menstruales tras la vacunación, para disipar preocupaciones en cuanto a que las vacunas contra la COVID-19 dificultan la probabilidad de embarazo a largo plazo. Se realizó una revisión de la literatura utilizando bases de datos digitales para identificar sistemáticamente los estudios que reportan cualquier alteración menstrual tras la vacuna contra la COVID-19. Se resumieron las características detalladas del estudio al nivel del paciente, incluyendo tipo de estudio, tamaño de la muestra, vacunas administradas, y alteraciones menstruales. Se incluyó en la revisión a un total de 78 138 mujeres vacunadas, procedentes de 14 estudios. De ellas, 39 759 (52,05%) tuvieron algún tipo de problema menstrual tras la vacunación. Debido a la falta de artículos de investigación publicados, también se incluyeron preimpresos en esta revisión. Menorragia, metrorragia, y polimenorrea fueron los problemas más comúnmente observados, oscilando la tasa global de alteraciones menstruales a nivel de estudios entre el 0,83 y el 90,9%. La edad, los antecedentes de embarazos, los efectos secundarios sistémicos de la COVID-19, el tabaquismo y la segunda dosis de la vacuna contra la COVID-19 fueron factores predictivos de problemas menstruales tras la vacunación.

SEVERE IRON DEFICIENCY ANAEMIA SECONDARY TO UTERINE FIBROIDS CAUSING CEREBRAL VENOUS SINUS THROMBOSIS

Background and aims: Cerebral venous sinus thrombosis (CVST) is a rare cause of stroke, contributing to less than 1%. We report an unusual case of severe iron deficiency anaemia (IDA) causing CVST in a young woman with menorrhagia. Methods: Case report: A 40-year-old female with underlying anaemia presented with headache, right leg numbness and expressive dysphasia. She experienced massive menstrual bleeding prior to the symptoms onset on background of uterine fibroids. There was no history of contraceptive pills consumption, massive blood transfusion, COVID-19 infection or vaccination. Systemic review was unremarkable. Results: Blood investigations revealed haemoglobin of 4.5g/dl, MCV 52.3fL, platelet 657x1////////09/L and low ferritin level. Coagulation profile, connective tissue disease, thrombophilia screening, serum homocysteine and HIV test were normal. Computed tomography (CT) of the head showed left temporoparietal lobe infarct and left dural venous sinus thrombosis. CT venography revealed CVST within the distal left transverse sinus and the vein of Labbe. Pelvic ultrasound showed multiple uterine fibroids. She was warfarinised and had iron and red cell transfusion. She agreed to take progesterone-only pill and interval hysterectomy after gynaecological review. Discussion: CVST in association with IDA is rare in adults and is more prevalent in men. In IDA, hypercoagulability and venous stasis play a vital role in thrombus formation. One study found that IDA in women caused arachidonic acid-induced platelet dysfunction causing menorrhagia which is reversible with iron repletion. Conclusion: IDA is a rare cause of CVST but should be considered in the context of relevant history and blood tests.

Immune thrombocytopenia secondary to COVID-19 vaccine: a rare case

Background: SARS-CoV-2 associated COVID-19 was declared as pandemic in March'20.It led to accelerated scientific development leading to production of several vaccines.In India,first vaccine used was ChAdOx1 nCoV-19.Reports of pro-thrombotic and hemorrhagic complications with it are there but isolated immune thrombocytopenia is rare.We are reporting secondary immune thrombocytopenia (ITP) possibly attributed to COVID-19 vaccine. Aims: A 21-years female came to General Medicine with complaints of weakness,rashes all over body,bleeding from gums, menorrhagia and reddish discoloration of urine.She had history of COVID-19 vaccination 2 days back.On examination, she was mildly febrile, showed multiple pin-point petechial haemorrhages over face,abdomen,both limbs and sub-conjunctival haemorrhage with no complaints of headache/visual disturbances/pain abdomen/respiratory distress.Systemic examination showed no significant findings.She had no previous history of bleeding/drug intake/no family history of bleeding or any other significant conditions. Methods: Lab investigations showed Hb:8.6gm%,TLC:14,400/cmm, platelet counts:10,000/cmm.Peripheral blood smear showed normocytic normochromic RBC with leucocytosis and marked thrombocytopenia with absent hemoparasites.Urine examination showed numerous RBCs with no pus cells.S. electrolytes were normal, SGOT/ SGPT were mildly increased, total proteins were normal.S. bilirubin,urea,creatinine were normal.HIV,HCV,HBsAg,CMV IgM were negative.To rule out connective tissue disorders,ANA and dsDNA were performed which came negative.Her USG abdomen and CTchest were normal.COVID-19 RT-PCR was negative.ITP secondary to COVID-19 vaccination was suspected. Results: She was started with i.v. methylprednisolone pulse therapy for 3 days and IVIG for 2 days and also received trenexamic acid for menorrhagia.She received 6 units of random donor platelets which improved platelet count.After haematology consultation,oral prednisolone for 7 days with alternate day platelet count monitoring was started.She improved symptomatically with no new bleeding.She was discharged after 10 days with an advice to follow up. Summary/Conclusions: ITP is autoimmune disorder with autoantibodies against platelets,more common in females.It is usually idiopathic,but occasionally secondary to viral infections/vaccinations. Incidence of vaccine associated ITP is <1%.Previously reported with various vaccines like influenza,measles,mumps,rubella,etc.Vaccine induced thrombotic thrombocytopenia (VITT) with COVID-19 vaccine has been well documented,but ITP is rare.VITT is usually characterized by major thrombotic episodes at unusual locations like sagittal sinus,splanchnic circulation,etc. with visual, neurological and abdominal features.No such findings seen in our case.Although she had low platelet count,yet mild symptoms which improved with conservative management with steroid and IVIG.Although we could not establish a temporal link;yet based on findings,ITP secondary to COVID-19 vaccine could not be ruled out.It is important to be aware of this complication as although rare,it could lead to significant morbidity and fatal bleed if not managed promptly. Steroids and IVIG is highly effective in ITP irrespective of cause.However,more investigations need to be done to establish a temporal relationship with COVID-19 vaccine. Nevertheless,occurrence of ITP should not be a deterrent in vaccination,though caution should be exerted in history of thrombocytopenia.

A review on ethnomedicinal and phytopharmacological potential of traditionally wild and endemic plant Berberis tinctoria Lesch

Introduction: Berberis tinctoria an evergreen shrub, endemic and predominantly found at a higher altitude of the Nilgiri Biosphere Reserve, India. This leaf and fruit are edible, which are also used in homeopathic remedies for countless illnesses. Objectives: B. tinctoria with diverse ethnomedicinal uses was focused in the prevailing study to detailed the phytochemical and pharmacological properties for further imminent research in this species. Materials and methods: Published data in this review were all gathered from the online bibliographical databases: PubMed, Elsevier, Scopus, Google Scholar, Web of Science, and local ethnic community peoples of Kurumba and Toda. Results: B. tinctoria was used as a Ayurvedic and homeopathy medicine by the tribal communities. The previous findings of B. tinctoria were used for skin diseases, wound healing, inflammatory, menorrhagia, diarrhea, jaundice, and a snakebites. The phytochemical studies revealed that secondary metabolites, antioxidants, and antimicrobial activity as a result of major alkaloid isoforms of berberine, berbamine, jatrorrhizine, etc. Conclusion: B. tinctoria is an important plant due to the presence of bioactive phytochemicals, especially berberine protoberberine group of benzylisoquinoline. As a result of its diverse ethnopharmacological importance, as well as numerous commercial products and novel bioactive compounds yet to be discovered for future drug discovery and development.

A retrospective review of the role of platelet aggregometry in the diagnosis of platelet disorders in a single Comprehensive care centre

Basingstoke and North Hampshire hospital is part of the Southern Haemophilia Network (SHN) and is the Comprehensive Care Centre for the network. It spans a wide area and also receives regional referrals for further investigations of suspected platelet disorders. Platelet aggregation is a second-line test to investigate patients with possible bleeding disorders. It is usually performed after clotting factors are established to be normal and there is still concern about an underlying bleeding disorder. The aim of this study was to assess whether platelet aggregation studies led to a formal diagnosis of a platelet disorder. Further outcomes were to assess how many bleeding assessment tool (BAT) scores were documented and whether these corresponded with diagnostic rates. Patient records were retrospectively analysed over 13 months (from 20 June to 21 July). Seventy-two patients were identified who underwent platelet aggregation studies. These included regional and local referrals. Patients identified had their electronic records analysed for the appropriate information. Of note, platelet aggregation studies were stopped at the beginning of the COVID pandemic and only restarted in summer 2020. Therefore, these numbers may not be fully representative of a normal year due to a waiting list which developed during the suspension of this test. The 72 patients were made up of 78% females ( n = 56) and 22% males ( n = 16). Out of the 72 patients reviewed, 63% ( n = 45) were regional referrals and 37% were local referrals ( n = 27). The average age of this group was 31.89 years. Median age was 31 years (range 74). The youngest patient was 2 years old and the oldest was 76. BSH guidelines recommend using the BAT as a standardised tool for assessing bleeding history. However, it is not sensitive in determining which patients require further testing including platelet aggregometry. Only one patient had a documented BAT score out of the 72 referrals (1.39%). Platelet aggregometry did not go on and lead to a diagnosis in this patient. All the samples for platelet aggregometry were taken on site in keeping with national guidance. Three of the four cases of thrombocytopenia, (75%) had a blood film reviewed locally. Platelet aggregometry led to a diagnosis in 17% of patients ( n = 12) with a higher number of diagnoses in males than females. Forty-four per cent ( n = 7) of males seen were diagnosed with a platelet disorder compared to 9% ( n = 5) of females. Other diagnoses included connective tissue disease at 8% ( n = 6), drug induced/acquired defect 5% ( n = 4), thrombocytopenia 5% ( n = 4) and other bleeding disorders (such as VWF or Factor XI deficiency) at 4% ( n = 3). Out of the 12 diagnoses of bleeding disorders, 100% ( n = 12) were registered with the national database. In total 67% ( n = 48) of patients were discharged followed their platelet aggregations studies. In this study, platelet aggregometry had a low rate of diagnostic yield. There was a higher rate of diagnosis in the male population which likely reflects the that women are more heavily investigated due to menorrhagia . Despite the low diagnostic rates, platelet aggregation studies lead to a high number of discharges and reassurance to a number of patients that there is no underlying bleeding disorder. Therefore, they continue to have important role in the diagnosis and exclusion of underlying bleeding disorders.

The Development of Immune Thrombocytopenia Due to COVID-19 Presenting as Menorrhagia.

Immune thrombocytopenia (ITP), also known as immune thrombocytopenic purpura, is a hematological disorder characterized by a decreased platelet count, predisposing patients to bleeding. Coronavirus disease 2019 (COVID-19) has been linked to multiple cases of newly diagnosed ITP and is usually found in moderate-to-severe infections, peaking in children and elderly adults. Menorrhagia is the medical term for menstrual periods with abnormally heavy or prolonged bleeding occurring at regular intervals or prolonged uterine bleeding lasting more than seven days. Here, we report the case of a 23-year-old African American female who presented with the chief complaint of menorrhagia and was subsequently diagnosed as having ITP induced by an asymptomatic COVID-19 infection.

The Impact of the COVID-19 Pandemic on Women's Reproductive Health.

Background: The COVID-19 pandemic has profoundly affected the lives of the global population. It is known that periods of stress and psychological distress can affect women's menstrual cycles. We therefore performed an observational study of women's reproductive health over the course of the pandemic thus far. Materials and Methods: An anonymous digital survey was shared by the authors via social media in September 2020. All women of reproductive age were invited to complete the survey. Results: 1031 women completed the survey. Mean age was 36.7 ± 6.6 years (range, 15-54). 693/70% reported recording their cycles using an app or diary. 233/23% were using hormonal contraception. 441/46% reported a change in their menstrual cycle since the beginning of the pandemic. 483/53% reported worsening premenstrual symptoms, 100/18% reported new menorrhagia (p = 0.003) and 173/30% new dysmenorrhea (p < 0.0001) compared to before the pandemic. 72/9% reported missed periods who not previously missed periods (p = 0.003) and the median number of missed periods was 2 (1-3). 17/21% of those who "occasionally" missed periods pre-pandemic missed periods "often" during pandemic. 467/45% reported a reduced libido. There was no change in the median cycle length (28 days) or days of bleeding (5) but there was a wider variability of cycle length (p = 0.01) and a 1 day median decrease in the minimum (p < 0.0001) and maximum (p = 0.009) cycle length. Women reported a median 2 kg increase in self-reported weight and a 30-min increase in median weekly exercise. 517/50% of women stated that their diet was worse and 232/23% that it was better than before the pandemic. 407/40% reported working more and 169/16% were working less. Women related a significant increase in low mood (p < 0.0001), poor appetite (p < 0.0001), binge eating (p < 0.0001), poor concentration (p < 0.0001), anxiety (p < 0.0001), poor sleep (p < 0.0001), loneliness (p < 0.0001) and excess alcohol use (p < 0.0001). Specific stressors reported included work stress (499/48%), difficulty accessing healthcare (254/25%), change in financial (201/19%) situation, difficulties with home schooling (191/19%) or childcare (99/10%), family or partner conflict (170/16%), family illness or bereavement (156/15%). Conclusions: The COVID-19 pandemic has significantly impacted the reproductive health of women. The long term health implications of this are yet to be determined and future studies should address this.

Immune Thrombocytopenic Purpura in a Patient With SARS-CoV-2 and Epstein-Barr Virus.

A 35-year-old female was admitted to the hospital for menorrhagia and fatigue. Initial labs revealed that the patient had severe thrombocytopenia and also tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The main objective in this case is to describe the investigation that eventually led to a diagnosis of idiopathic thrombocytopenic purpura (ITP) in the setting of a SARS-CoV-2 coronavirus disease 2019 (COVID-19) infection and co-infection with Epstein-Barr virus (EBV). The majority of ITP cases are idiopathic and most are diagnosed and managed without hospital admission. Admission and careful management were warranted in this particular case. Interestingly, however, the patient did not have any respiratory complications associated with COVID-19. She was given 1 unit of platelets and subsequently received intravenous corticosteroids. Platelet counts improved and the patient was discharged with a course of oral prednisone. This case highlights the importance of understanding the differences between primary and secondary ITP.