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Miller JD, Lenhart GM, Bonafede MM, Lukes AS, Laughlin-Tommaso SK. Cost-Effectiveness of Global Endometrial Ablation vs. Hysterectomy for Treatment of Abnormal Uterine Bleeding: US Commercial and Medicaid Payer Perspectives. Popul Health Manag 2015; 18:373-82. [PMID: 25714906 PMCID: PMC4675184 DOI: 10.1089/pop.2014.0148] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Cost-effectiveness modeling studies of global endometrial ablation (GEA) for treatment of abnormal uterine bleeding (AUB) from a US perspective are lacking. The objective of this study was to model the cost-effectiveness of GEA vs. hysterectomy for treatment of AUB in the United States from both commercial and Medicaid payer perspectives. The study team developed a 1-, 3-, and 5-year semi-Markov decision-analytic model to simulate 2 hypothetical patient cohorts of women with AUB-1 treated with GEA and the other with hysterectomy. Clinical and economic data (including treatment patterns, health care resource utilization, direct costs, and productivity costs) came from analyses of commercial and Medicaid claims databases. Analysis results show that cost savings with simultaneous reduction in treatment complications and fewer days lost from work are achieved with GEA versus hysterectomy over almost all time horizons and under both the commercial payer and Medicaid perspectives. Cost-effectiveness metrics also favor GEA over hysterectomy from both the commercial payer and Medicaid payer perspectives-evidence strongly supporting the clinical-economic value about GEA versus hysterectomy. Results will interest clinicians, health care payers, and self-insured employers striving for cost-effective AUB treatments.
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Affiliation(s)
| | | | | | - Andrea S. Lukes
- Carolina Women's Research and Wellness Center, Durham, North Carolina
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Bahamondes L, Ali M. Recent advances in managing and understanding menstrual disorders. F1000PRIME REPORTS 2015; 7:33. [PMID: 25926984 PMCID: PMC4371378 DOI: 10.12703/p7-33] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Menstrual disorders are a major reason for gynaecological consultations worldwide and, unfortunately there are many different definitions and classifications of this condition. Clear definitions and terminology are necessary for scientific literature, particularly for clinicians, and for clinical trials comparing two treatments. The International Federation of Gynaecology and Obstetrics (FIGO) Menstrual Disorders Working Group has proposed abandoning the use of one common term, dysfunctional uterine bleeding (DUB), while continuing to use the terms abnormal uterine bleeding (AUB) and heavy menstrual bleeding (HMB). Furthermore, the group issued the PALM-COEIN classification system for menstrual disorders, which has quickly been adopted around the world. The PALM-COEIN system allows clinicians and researchers to identify and classify women with both AUB and HMB in a systematic manner, provides reliable information for research purposes and for epidemiological and prevalence studies in different settings, and supports accurate diagnoses and treatment. Additionally, this classification system is useful for selecting treatments appropriate for different stages of women's reproductive years and for different patterns of menstrual bleeding. Among the proposed treatments are the use of combined oral contraceptives, the levonorgestrel-releasing intrauterine system, tranexamic acid, mefenamic acid, and other nonsteroidal anti-inflammatory drugs (NSAIDs).
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Affiliation(s)
- Luis Bahamondes
- Human Reproduction Unit, Department of Obstetrics and Gynaecology, Faculty of Medicine, University of CampinasCaixa Postal 6181; 13084-971, CampinasBrazil
| | - Moazzam Ali
- Reproductive Health and Research, World Health OrganizationAvenue Appia CH-1211 Geneva 27Switzerland
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Ultrasound features of polycystic ovaries relate to degree of reproductive and metabolic disturbance in polycystic ovary syndrome. Fertil Steril 2015; 103:787-94. [DOI: 10.1016/j.fertnstert.2014.12.094] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Revised: 11/12/2014] [Accepted: 12/03/2014] [Indexed: 11/17/2022]
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Miller JD, Lenhart GM, Bonafede MM, Basinski CM, Lukes AS, Troeger KA. Cost effectiveness of endometrial ablation with the NovaSure(®) system versus other global ablation modalities and hysterectomy for treatment of abnormal uterine bleeding: US commercial and Medicaid payer perspectives. Int J Womens Health 2015; 7:59-73. [PMID: 25610002 PMCID: PMC4294654 DOI: 10.2147/ijwh.s75030] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES Abnormal uterine bleeding (AUB) interferes with physical, emotional, and social well-being, impacting the quality of life of more than 10 million women in the USA. Hysterectomy, the most common surgical treatment of AUB, has significant morbidity, low mortality, long recovery, and high associated health care costs. Global endometrial ablation (GEA) provides a surgical alternative with reduced morbidity, cost, and recovery time. The NovaSure(®) system utilizes unique radiofrequency impedance-based GEA technology. This study evaluated cost effectiveness of AUB treatment with NovaSure ablation versus other GEA modalities and versus hysterectomy from the US commercial and Medicaid payer perspectives. METHODS A health state transition (semi-Markov) model was developed using epidemiologic, clinical, and economic data from commercial and Medicaid claims database analyses, supplemented by published literature. Three hypothetical cohorts of women receiving AUB interventions were simulated over 1-, 3-, and 5-year horizons to evaluate clinical and economic outcomes for NovaSure, other GEA modalities, and hysterectomy. RESULTS Model analyses show lower costs for NovaSure-treated patients than for those treated with other GEA modalities or hysterectomy over all time frames under commercial payer and Medicaid perspectives. By Year 3, cost savings versus other GEA were $930 (commercial) and $3,000 (Medicaid); cost savings versus hysterectomy were $6,500 (commercial) and $8,900 (Medicaid). Coinciding with a 43%-71% reduction in need for re-ablation, there were 69%-88% fewer intervention/reintervention complications for NovaSure-treated patients versus other GEA modalities, and 82%-91% fewer versus hysterectomy. Furthermore, NovaSure-treated patients had fewer days of work absence and short-term disability. Cost-effectiveness metrics showed NovaSure treatment as economically dominant over other GEA modalities in all circumstances. With few exceptions, similar results were shown for NovaSure treatment versus hysterectomy. CONCLUSION Model results demonstrate strong financial favorability for NovaSure ablation versus other GEA modalities and hysterectomy from commercial and Medicaid payer perspectives. Results will interest clinicians, health care payers, and self-insured employers striving for cost-effective AUB treatments.
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Affiliation(s)
| | | | | | | | - Andrea S Lukes
- Carolina Women’s Research and Wellness Center, Durham, NC, USA
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Calaf J, Lete I, Canals I, Crespo C, Espinós B, Cristóbal I. Cost-effectiveness analysis in the treatment of heavy menstrual bleeding in Spain. Eur J Obstet Gynecol Reprod Biol 2015; 184:24-31. [DOI: 10.1016/j.ejogrb.2014.10.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Revised: 10/08/2014] [Accepted: 10/22/2014] [Indexed: 11/25/2022]
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Síndrome de ovario poliquístico: diagnóstico en la adolescencia. REVISTA MÉDICA CLÍNICA LAS CONDES 2015. [DOI: 10.1016/j.rmclc.2015.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Adams Hillard PJ. Menstruation in adolescents: what do we know? And what do we do with the information? J Pediatr Adolesc Gynecol 2014; 27:309-19. [PMID: 25438706 DOI: 10.1016/j.jpag.2013.12.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Accepted: 12/02/2013] [Indexed: 11/24/2022]
Abstract
The menstrual cycle has been recognized as a vital sign that gives information about the overall health of an adolescent or young adult female. Significant deviations from monthly cycles can signal disease or dysfunction. This review highlights the evidence based parameters for normal puberty, menarche, cyclicity, and amount of bleeding. The review addresses sources of information available online, noting inaccuracies that appear in web sites, even and especially those targeting adolescents. The review includes a call to action to provide accurate information about the menstrual cycle as a VITAL SIGN.
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Affiliation(s)
- Paula J Adams Hillard
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA
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De Sanctis V, Soliman AT, Fiscina B, Elsedfy H, Elalaily R, Yassin M, Skordis N, Di Maio S, Piacentini G, Kholy ME. Endocrine check-up in adolescents and indications for referral: A guide for health care providers. Indian J Endocrinol Metab 2014; 18:S26-38. [PMID: 25538875 PMCID: PMC4266866 DOI: 10.4103/2230-8210.145055] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The American Academy of Pediatrics recommends that young people between the ages of 11 and 21 years should be seen annually by their pediatricians, since annual checkups can be an important opportunity for health evaluation and anticipatory guidance. Parents of infants and young children are accustomed to regularly visiting a pediatrician for their child's checkups. Unfortunately, when children reach the teen years, these annual checkups may decrease in frequency. In routine check-ups and medical office visits, particular attention should be paid to the possibility of a developmental or endocrine disorder. Early diagnosis and treatment may prevent medical complications in adulthood and foster age-appropriate development. Our purpose is to acquaint readers with the concept, based on current scientific understanding, that some endocrine disorders may be associated with a wide range of deleterious health consequences including an increased risk of hypertension and hyperlipidemia, increased risk of coronary artery disease, type 2 diabetes, significant anxiety and lack of self-esteem. Understanding the milestones and developmental stages of adolescence is essential for pediatricians and all other health providers who care for adolescents. Treating adolescents involves knowledge of a variety of medical, social and legal information; in addition, close working relationships must be established within the adolescent's network to create an effective care system. In summary, we underline the importance of a periodic endocrine checkup in adolescents in order to identify endocrine problems early and develop an approach to treatment for those patients who need help during this time. Indications for endocrine referral for professional and other healthcare providers are also included. These lists are clearly not intended to be comprehensive, but will hopefully serve as a guide for specific clinical circumstances.
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Affiliation(s)
- Vincenzo De Sanctis
- Quisisana Hospital, Pediatric and Adolescent Outpatient Clinic, Ferrara, Italy
| | - Ashraf T Soliman
- Department of Pediatrics, Division of Endocrinology, Alexandria University Children's Hospital, Alexandria, USA
| | | | - Heba Elsedfy
- Department of Pediatrics, Ain Shams University, Cairo, Egypt
| | - Rania Elalaily
- Department of Primary Health Care, AbuNakhla Hospital, Doha, Qatar
| | - Mohamed Yassin
- Department of Hematology, Alamal Hospital, Hamad Medical Center, Doha, Qatar
| | - Nicos Skordis
- Division of Pediatric and Adolescent Endocrinology, Paedi Center for Specialized Pediatrics, St George's University Medical School at the University of Nicosia, Cyprus, Italy
| | - Salvatore Di Maio
- Emeritus Consultant in Pediatrics, Santobono-Pausilipon Hospital, Naples, Italy
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De Sanctis V, Bernasconi S, Bianchin L, Bona G, Bozzola M, Buzi F, De Sanctis C, Rigon F, Tatò L, Tonini G, Perissinotto E. Onset of menstrual cycle and menses features among secondary school girls in Italy: A questionnaire study on 3,783 students. Indian J Endocrinol Metab 2014; 18:S84-S92. [PMID: 25538883 PMCID: PMC4266874 DOI: 10.4103/2230-8210.140251] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
PREMISE Healthcare professionals need updated information about what is the range of "normal" variation of menstrual cycle features to support young girls and their parents in managing reproductive health, and to detect diseases early. MATERIALS AND METHODS This cross-sectional study aimed to provide an updated picture of age at menarche and main menstrual cycle characteristics and complaints in an Italian population-based sample of 3,783 adolescents attending secondary school. Girls filled in a self-administered anonymous questionnaire including questions about demography, anthropometry, smoking and drinking habits, use of contraceptive, socioeconomic status, age at menarche, menstrual pattern, and physical/psychological menstrual complaints. Mean age at menarche and prevalence of polymenorrhea (cycle length < 21 days), oligomenorrhea (cycle length > 35 days), irregularity, dysmenorrhea, and of physical/psychological complaints were computed. Factors associated with age at menarche and menstrual disturbances were explored by using multiple logistic models. RESULTS The girls' mean age was 17.1 years (SD 1.4 years) and the mean age at menarche was 12.4 years (SD 1.3 years); menarche occurred with two monthly peaks of frequency in July-September and in December-January (P < 0.0001). Age at menarche was significantly associated with geographic genetics (as expressed by parents' birth area), mother's menarcheal age, BMI, family size, and age at data collection. The prevalence of polymenorrhea was about 2.5%, oligomenorrhea was declared by 3.7%, irregular length by 8.3%, while long bleeding (>6 days) was shown in 19.6% of girls. Gynecological age was significantly associated with cycle length (P < 0.0001) with long cycles becoming more regular within the fourth year after menarche, while frequency of polymenorrhea stabilized after the second gynecological year. Oligomenorrhea and irregularity were both significantly associated with long menstrual bleeding (adjusted OR = 2.36; 95% CI = 1.55-3.60, and adjusted OR = 2.59; 95% CI = 1.95-3.44, respectively). CONCLUSIONS The findings of the study support the levelling-off of secular trend in menarche anticipation in Italy and confirm the timing in menstrual cycle regularization. The study provides updated epidemiological data on frequency of menstrual abnormalities to help reproductive health professionals in managing adolescent gynecology.
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Affiliation(s)
- Vincenzo De Sanctis
- Private Accredited Hospital Quisisana, Paediatric and Adolescent Outpatients Clinic, Ferrara, Italy
| | | | - Luigi Bianchin
- Rehabilitation Centre, Associazione La Nostra Famiglia, Padua, Italy
| | - Gianni Bona
- Department of Mother and Child Health, Division of Pediatrics, Azienda Ospedaliero-Universitaria Maggiore della Carità, Novara, Italy
| | - Mauro Bozzola
- Internal Medicine and Therapeutics, Section of Childhood and Adolescence, University of Pavia, Foundation IRCCS San Matteo, Pavia, Italy
| | - Fabio Buzi
- Department of Pediatrics, “Carlo Poma” Hospital, Mantova, Italy
| | - Carlo De Sanctis
- Department of Pediatric and Endocrinology, Ospedale Infantile Regina Margherita, Turin, Italy
| | - Franco Rigon
- Department of Pediatrics, University of Padua, Padova, Italy
| | - Luciano Tatò
- Department of Pediatrics, University of Verona, Verona, Italy
| | - Giorgio Tonini
- Centre of Pediatric Diabetology, Burlo Garofolo Hospital, Trieste, Italy
| | - Egle Perissinotto
- Department of Cardiac, Thoracic, Vascular Sciences, Unit of Biostatistics, Epidemiology and Public Health, University of Padua, Padova, Italy
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60
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Alvisi S, Baldassarre M, Lambertini M, Martelli V, Berra M, Moscatiello S, Marchesini G, Venturoli S, Meriggiola MC. Sexuality and psychopathological aspects in premenopausal women with metabolic syndrome. J Sex Med 2014; 11:2020-8. [PMID: 24848980 DOI: 10.1111/jsm.12585] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Metabolic syndrome (MetS) is a cluster of cardiovascular risk factors that have been suggested to impact female sexual function. AIMS This study aims to assess the prevalence of female sexual dysfunction (FSD) in premenopausal women with MetS compared with healthy controls (HC). Psychopathological aspects and the relationship to FSD were also evaluated in both groups. METHODS Two hundred four premenopausal women, of whom 98 had diagnosis of MetS, were asked to complete the Female Sexual Function Index (FSFI), the Female Sexual Distress Scale (FSDS), and the Middlesex Hospital Questionnaire (MHQ). Routine laboratory tests and anthropometric measurements were routinely performed. MAIN OUTCOME MEASURES FSFI and FSDS questionnaires, prevalence of FSD, and MHQ scores. RESULTS In the MetS group compared with the HC group, we found: a lower global FSFI score (P=0.005), higher prevalence of pathological scores compared with HC group, and lower scores in the desire, arousal, lubrication, and orgasm domains. An inverse correlation between the FSFI score and the number of risk factors for MetS was detected. MetS women reported significantly higher total scores in the somatization and depression domains when compared with the HC group. The logistic regression showed that high triglycerides (odds ratio [OR] 3.097; 95% confidence interval [CI] 1.272-7.542; P=0.026) and somatization (OR 7.068; CI 95% 2.291-21.812; P=0.001) are independently associated with FSD in premenopausal women. CONCLUSIONS Our results indicate a higher prevalence of sexual dysfunction in MetS women. A number of risk factors for MetS are positively associated with FSD and higher triglycerides seem to be the strongest predictors of sexual dysfunction. Psychopathological dimensions such as somatization are strongly associated with sexual dysfunction.
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Affiliation(s)
- Stefania Alvisi
- Gynecology and Physiopathology of Human Reproduction, University of Bologna and S.Orsola-Malpighi Hospital, Bologna, Italy
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61
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Madhra M, Fraser IS, Munro MG, Critchley HOD. Abnormal uterine bleeding: advantages of formal classification to patients, clinicians and researchers. Acta Obstet Gynecol Scand 2014; 93:619-25. [DOI: 10.1111/aogs.12390] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Accepted: 04/02/2014] [Indexed: 12/30/2022]
Affiliation(s)
- Mayank Madhra
- MRC Centre for Reproductive Health; University of Edinburgh; Queen's Medical Research Institute; Edinburgh UK
| | - Ian S. Fraser
- Department of Obstetrics and Gynaecology; Queen Elizabeth II Research Institute for Mothers and Infants; University of Sydney; Sydney New South Wales Australia
| | - Malcolm G. Munro
- Department of Obstetrics and Gynecology; David Geffen School of Medicine; University of California; Los Angeles California USA
- Gynecologic Services; Kaiser Permanente Los Angeles Medical Center; Los Angeles California USA
| | - Hilary O. D. Critchley
- MRC Centre for Reproductive Health; University of Edinburgh; Queen's Medical Research Institute; Edinburgh UK
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62
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MacEachern K, Kaur H, Toukh M, Mumal I, Hamilton A, Scovil S, James P, Elbatarny HS, Othman M. Comprehensive Evaluation of Hemostasis in Normal Women. Clin Appl Thromb Hemost 2014; 21:72-81. [DOI: 10.1177/1076029614527495] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Women with mild bleeding disorders (MBDs) pose a diagnostic challenge and menorrhagia, the most common presenting symptom that remains underreported. We tested the hypothesis that screening apparently normal females using general and gynecological bleeding assessment tools and a global hemostatic assay together with platelet aggregation can help predict MBDs. We assessed 47 women using electronic bleeding assessment tools; e-bleeding questionnaire; and e-Pictorial Bleeding Assessment Chart (e-PBAC) based on previously validated methods, thrombelastography (TEG), and platelet aggregation together with basic coagulation testing. Three women had elevated bleeding score with von Willebrand disease diagnosis confirmed in one case and eleven cases had elevated e-PBAC. We report normal ranges for TEG and platelet aggregation in women during the first half of the menstrual cycle and show 23.4% of apparently normal women may have general or heavy menstrual bleeding. This is a prelude to a larger study to determine the validity of bleeding assessment tools in screening for MBDs in women.
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Affiliation(s)
- Kimberly MacEachern
- Health Science Department, St Lawrence College, Kingston, Ontario, Canada
- Saint Elizabeth Health Care, Kingston, Ontario, Canada
| | - Harmanpreet Kaur
- Department of Biomedical and Molecular Sciences, Queen’s University, Kingston, Ontario, Canada
| | - Mazen Toukh
- Health Science Department, St Lawrence College, Kingston, Ontario, Canada
- Department of Biomedical and Molecular Sciences, Queen’s University, Kingston, Ontario, Canada
| | - Iqra Mumal
- Department of Biomedical and Molecular Sciences, Queen’s University, Kingston, Ontario, Canada
| | - Alexander Hamilton
- Health Science Department, St Lawrence College, Kingston, Ontario, Canada
- Department of anesthesiology and preoperative medicine, Queen’s University, Kingston, Ontario, Canada
| | | | - Paula James
- Department of Medicine, Queen’s University, Kingston, Ontario, Canada
| | - Hisham S. Elbatarny
- Health Science Department, St Lawrence College, Kingston, Ontario, Canada
- Department of Biomedical and Molecular Sciences, Queen’s University, Kingston, Ontario, Canada
| | - Maha Othman
- Health Science Department, St Lawrence College, Kingston, Ontario, Canada
- Department of Biomedical and Molecular Sciences, Queen’s University, Kingston, Ontario, Canada
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63
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Clark NM, Podolski AJ, Brooks ED, Chizen DR, Pierson RA, Lehotay DC, Lujan ME. Prevalence of Polycystic Ovary Syndrome Phenotypes Using Updated Criteria for Polycystic Ovarian Morphology: An Assessment of Over 100 Consecutive Women Self-reporting Features of Polycystic Ovary Syndrome. Reprod Sci 2014; 21:1034-1043. [PMID: 24520081 DOI: 10.1177/1933719114522525] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The prevalence of polycystic ovary syndrome (PCOS) and its distinct clinical phenotypes were assessed using 3 sets of international diagnostic criteria in women self-reporting concerns over outward features of PCOS. Revised ultrasonographic criteria for polycystic ovaries (PCO) based on modern ultrasound technology were used. Of the participants, 53%, 62%, and 70% were diagnosed with PCOS using National Institutes of Health, Androgen Excess and PCOS Society, and Rotterdam criteria, respectively. Prevalence of Frank, Ovulatory, Normoandrogenic, and Non-PCO PCOS were 66%, 13%, 11%, and 9%, respectively. Frank PCOS was associated with the severest metabolic disturbances whereas metabolic profiles in Normoandrogenic PCOS did not differ from controls, supporting reduced health risks in women without androgen excess. Metabolic disturbances and hyperandrogenism were linked to excess adiposity across all the groups. Using updated criteria for PCO, the prevalence of Non-PCO PCOS and PCO alone in healthy women recruited from the general population was reduced compared to the previous reports.
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Affiliation(s)
- Nina M Clark
- Division of Nutritional Sciences, Human Metabolic Research Unit, Cornell University, Ithaca, NY, USA
| | - Amanda J Podolski
- Division of Nutritional Sciences, Human Metabolic Research Unit, Cornell University, Ithaca, NY, USA
| | - Eric D Brooks
- Division of Nutritional Sciences, Human Metabolic Research Unit, Cornell University, Ithaca, NY, USA
| | - Donna R Chizen
- Department of Obstetrics, Gynecology & Reproductive Sciences, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Roger A Pierson
- Department of Obstetrics, Gynecology & Reproductive Sciences, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Denis C Lehotay
- Department of Pathology, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Marla E Lujan
- Division of Nutritional Sciences, Human Metabolic Research Unit, Cornell University, Ithaca, NY, USA
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Fraser IS, Langham S, Uhl-Hochgraeber K. Health-related quality of life and economic burden of abnormal uterine bleeding. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/17474108.4.2.179] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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65
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Pai M, Chan A, Barr R. How I manage heavy menstrual bleeding. Br J Haematol 2013; 162:721-9. [DOI: 10.1111/bjh.12447] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Accepted: 05/17/2013] [Indexed: 12/12/2022]
Affiliation(s)
| | - Anthony Chan
- Department of Pediatrics; McMaster University; Hamilton; Canada
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66
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Fraser IS, Zeun S, Parke S, Wilke B, Junge W, Serrani M. Improving the Objective Quality of Large-Scale Clinical Trials for Women With Heavy Menstrual Bleeding. Reprod Sci 2013; 20:745-54. [DOI: 10.1177/1933719113477492] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ian S. Fraser
- University of Sydney and Sydney Centre for Reproductive Health Research, Family Planning NSW, Sydney, New South Wales, Australia
| | | | | | - Baerbel Wilke
- Laboratorium für Klinische Forschung, Schwentinental, Germany
| | - Wolfgang Junge
- Laboratorium für Klinische Forschung, Schwentinental, Germany
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67
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Abstract
There exists a spectrum of potential causes of abnormal uterine bleeding (AUB) in nonpregnant reproductive-aged women. In some instances the abnormal bleeding may emanate from definable pathologic entities in the endometrial cavity such as polyps or submucous leiomyomas (fibroids), while in others, it may occur secondary to coagulopathies or disorders of local or systemic hemostasis. If the patient is subjected to a rigorous evaluation more than one potential contributor may be identified, a circumstance that challenges the clinician since entities such as polyps, leiomyomas, and adenomyosis may frequently be asymptomatic, even in women with AUB. The bench or clinical investigator may also be influenced by the existence of the multiplicity of potential causes that could confound the results of research. This paper describes FIGO's (Fédération Internationale de Gynécologie et d'Obstétrique) new PALM-COEIN classification of causes of AUB in the reproductive years (Polyp, Adenomyosis, Leiomyoma, Malignancy and hyperplasia-Coagulopathy, Ovulatory disorder, Endometrial, Iatrogenic, Not yet classified). This system is designed to assist clinicians in the evaluation of patients, investigators in the design and interpretation of research and faculty in the education of medical students and residents/trainees. Additionally, given the longstanding existence of a confusing array of conflicting definitions, the manuscript describes the FIGO standardized terminology for both normal menstruation and AUB symptoms.
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Affiliation(s)
- Malcolm G Munro
- Department of Obstetrics & Gynecology, David Geffen School of Medicine at UCLA, Kaiser Permanente, Southern California, Los Angeles, CA 90027, USA.
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68
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Abu Hashim H. Medical treatment of idiopathic heavy menstrual bleeding. What is new? An evidence based approach. Arch Gynecol Obstet 2012; 287:251-60. [PMID: 23117248 DOI: 10.1007/s00404-012-2605-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2012] [Accepted: 10/18/2012] [Indexed: 12/29/2022]
Abstract
BACKGROUND Heavy menstrual bleeding (HMB) is an important health problem affecting up to 30 % of reproductive age women, interfering with their quality of life. Medical therapy, with the avoidance of unnecessary surgery, is an attractive option. PURPOSE To provide a comprehensive review of the current medical treatments available for idiopathic HMB and to focus on the newly introduced modalities. Furthermore, to provide a practical algorithm based on the best available evidence. METHODS A PubMed search was conducted looking for the different trials, reviews and various guidelines relating to medical treatment of idiopathic HMB. RESULTS The most effective medical treatment for idiopathic HMB is the levonorgestrel-releasing intrauterine system. It provides a reliable long-term effect. Importantly, there is a growing scientific evidence for new modalities entailing; modified-release formulation of tranexamic acid, the new four-phasic estradiol valerate/dienogest contraceptive pills and combined contraceptive vaginal ring. Also, vaginal danazol has been tried. CONCLUSION Maintenance of status quo, i.e., keeping first-line treatment of idiopathic HMB as medical treatment is an essential issue. Modified-release formulation of tranexamic acid, the new four-phasic contraceptive pills and contraceptive vaginal ring are recently added to the medical armamentarium for treatment of idiopathic HMB increasing its efficacy.
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Affiliation(s)
- Hatem Abu Hashim
- Department of Obstetrics and Gynecology, Mansoura Faculty of Medicine, Mansoura University, Mansoura, Egypt.
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69
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Cirilli AR, Cipot SJ. Emergency Evaluation and Management of Vaginal Bleeding in the Nonpregnant Patient. Emerg Med Clin North Am 2012; 30:991-1006. [DOI: 10.1016/j.emc.2012.08.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Munro MG, Critchley HOD, Fraser IS. The FIGO systems for nomenclature and classification of causes of abnormal uterine bleeding in the reproductive years: who needs them? Am J Obstet Gynecol 2012; 207:259-65. [PMID: 22386064 DOI: 10.1016/j.ajog.2012.01.046] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Revised: 01/13/2012] [Accepted: 01/31/2012] [Indexed: 11/15/2022]
Abstract
In November 2010, the International Federation of Gynecology and Obstetrics formally accepted a new classification system for causes of abnormal uterine bleeding in the reproductive years. The system, based on the acronym PALM-COEIN (polyps, adenomyosis, leiomyoma, malignancy and hyperplasia-coagulopathy, ovulatory disorders, endometrial causes, iatrogenic, not classified) was developed in response to concerns about the design and interpretation of basic science and clinical investigation that relates to the problem of abnormal uterine bleeding. A system of nomenclature for the description of normal uterine bleeding and the various symptoms that comprise abnormal bleeding has also been included. This article describes the rationale, the structured methods that involved stakeholders worldwide, and the suggested use of the International Federation of Gynecology and Obstetrics system for research, education, and clinical care. Investigators in the field are encouraged to use the system in the design of their abnormal uterine bleeding-related research because it is an approach that should improve our understanding and management of this often perplexing clinical condition.
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Affiliation(s)
- Malcolm G Munro
- Department of Obstetrics & Gynecology, David Geffen School of Medicine at UCLA, Kaiser Permanente, Southern California, Los Angeles, CA, USA
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71
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Tinelli A, Hurst BS, Mettler L, Tsin DA, Pellegrino M, Nicolardi G, Dell'Edera D, Malvasi A. Ultrasound evaluation of uterine healing after laparoscopic intracapsular myomectomy: an observational study. Hum Reprod 2012; 27:2664-2670. [DOI: 10.1093/humrep/des212] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Rigon F, De Sanctis V, Bernasconi S, Bianchin L, Bona G, Bozzola M, Buzi F, Radetti G, Tatò L, Tonini G, De Sanctis C, Perissinotto E. Menstrual pattern and menstrual disorders among adolescents: an update of the Italian data. Ital J Pediatr 2012; 38:38. [PMID: 22892329 PMCID: PMC3462713 DOI: 10.1186/1824-7288-38-38] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Accepted: 07/31/2012] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The most striking event in the whole process of female puberty is the onset of menstruation. To our knowledge, no large population-based studies have been performed on the topic of menstrual health among Italian adolescents in recent years. The aims of this study were to produce up-to-date information on the menstrual pattern of Italian girls attending secondary school, and to estimate the prevalence of menstrual cycle abnormalities in this population. METHODS This was a cross-sectional study on a population-based sample of Italian adolescents aged 13-21 years attending secondary school. Only girls who had already started menstruating were requested to participate. Information was collected by means of a questionnaire that included items on the girls' demographic details, anthropometrics, smoking and drinking habits, use of contraceptive pills, and socioeconomic status. The questions on the girls' menstrual pattern concerned their age at menarche, duration of the most recent menstruation intervals (<21, 21-35, >35 days, variable), average days of bleeding (<4, 4-6, >6 days), and any menstrual problems and their frequency. RESULTS A total of 6,924 questionnaires were administered and 4,992 (71%) were returned. One hundred girls failed to report their date of birth, so 4,892 subjects were analyzed. The girls' mean age was 17.1 years (SD ±1.4); their mean age at menarche was 12.4 (±1.3) years, median 12.4 years (95%CI 12.3-12.5). In our sample population, 3.0% (95%CI 2.5%-3.4%) of the girls had menstruation intervals of less than 21 days, while it was more than 35 days in 3.4% (95%CI 2.9%-3.9%). About 9% of the girls (95%CI 7.7%-9.4%) said the length of their menstruation interval was currently irregular. Short bleeding periods (<4 days) were reported in 3.2% of the sample population (95%CI 2.7%-3.7%), long periods (>6 days) in 19% (95%CI 17.9%-20.1%). Menstruation-related abdominal pain was reported by about 56% of our sample. About 6.2% of the girls (95%CI 5.4%-7.0%) were suffering from dysmenorrhea. CONCLUSIONS In conclusion, to the best of our knowledge, this is one of the largest studies on menstrual patterns and menstrual disorders among Italian adolescent girls. Adolescent girls referring persistent oligomenorrhoea, in first two years from menarche, had a higher risk for developing a persistent menstrual irregularity. They had longer bleeding periods (>6 days) and this has practical implications because it makes these adolescents potentially more susceptible to iron deficiency anemia. Clinicians need to identify menstrual abnormalities as early as possible in order to minimize their possible consequences and sequelae, and to promote proper health information.We recommend that adolescents should be encouraged to chart their menstrual frequency and regularity prospectively from the menarche onwards.
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Affiliation(s)
- Franco Rigon
- Department of Paediatrics, University of Padua, Padua, Italy
| | - Vincenzo De Sanctis
- Private Accredited Hospital Quisisana, Paediatric and Adolescent Outpatients Clinic, Ferrara, Italy
| | - Sergio Bernasconi
- Department of Clinical and Experimental Medicine, University of Parma, Parma, Italy
| | - Luigi Bianchin
- Child and Adolescent Psychiatry Unit, ULSS 16, Padua, Italy
| | - Gianni Bona
- Division of Paediatrics, Department of Mother and Child Health, Azienda Ospedaliero-Universitaria Maggiore della Carità, Novara, Italy
| | - Mauro Bozzola
- Internal Medicine and Therapeutics, Section of Childhood and Adolescence, University of Pavia, Foundation IRCCS San Matteo, Pavia, Italy
| | - Fabio Buzi
- Department of Paediatrics, "Carlo Poma" Hospital, Mantova, Italy
| | - Giorgio Radetti
- Department of Paediatrics, Regional Hospital of Bolzano, Bolzano, Italy
| | - Luciano Tatò
- Department of Paediatrics, University of Verona, Verona, Italy
| | - Giorgio Tonini
- Department of Paediatrics, Institute for Maternal and Child Health, IRCCS "Burlo Garofolo" and University of Trieste, Trieste, Italy
| | - Carlo De Sanctis
- Paediatric Department of Paediatrics, Koelliker Hospital, Turin, Italy
| | - Egle Perissinotto
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
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Merino PM, Codner E, Cassorla F. A rational approach to the diagnosis of polycystic ovarian syndrome during adolescence. ACTA ACUST UNITED AC 2012; 55:590-8. [PMID: 22218441 DOI: 10.1590/s0004-27302011000800013] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2011] [Accepted: 10/19/2011] [Indexed: 11/21/2022]
Abstract
Polycystic ovarian syndrome (PCOS) is a lifelong disorder characterized by hyperandrogenism and ovulatory dysfunction, with a wide spectrum of clinical symptoms and signs. Three different sets of diagnostic criteria have been established in order to define this disease in adult women, but there is controversy regarding the use of these criteria in adolescence. During puberty, the adult criteria for ovulatory dysfunction does not seem applicable, because an irregular menstrual pattern and a decreased ovulatory rate is a physiologic event during this period of life. Also, a higher prevalence of polycystic ovarian morphology (PCOM) may be observed during this period, so PCOM is not a useful criterion to define PCOS in young women. These findings suggest that a key factor to diagnose to PCOS during adolescence is hyperandrogenism. In addition, since PCOM is not clearly associated with hyperandrogenism during this period of life, the term "polycystic ovarian syndrome" during adolescence creates confusion and may be misleading.
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Affiliation(s)
- Paulina M Merino
- Institute of Maternal and Child Research, School of Medicine, University of Chile, Chile.
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74
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Kaunitz AM, Inki P. The levonorgestrel-releasing intrauterine system in heavy menstrual bleeding: a benefit-risk review. Drugs 2012; 72:193-215. [PMID: 22268392 DOI: 10.2165/11598960-000000000-00000] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Heavy menstrual bleeding (HMB) is a common problem in women of reproductive age and can cause irritation, inconvenience, self-consciousness and fear of social embarrassment. Our objective was to review and appraise literature identified from the MEDLINE and EMBASE databases to evaluate the clinical evidence and provide an update on the risks and benefits of using the levonorgestrel-releasing intrauterine system (LNG-IUS) in the treatment of HMB. The LNG-IUS consistently reduces menstrual blood loss (MBL) in women with HMB, including those with underlying uterine pathology or bleeding disorders. The available data suggest that it reduces MBL to a greater extent than other medical therapies, including combined oral contraceptives, oral progestogens (both short- or long-cycle regimens), tranexamic acid and oral mefenamic acid. In addition, the LNG-IUS and endometrial ablation appear to reduce MBL to a similar extent. The adverse effects reported with the LNG-IUS in women with HMB are similar to those typically observed in women using the system for contraception. Uterine perforations were not reported in any of the studies reviewed, but expulsion rates may be higher than in the general population of LNG-IUS users. Overall, the LNG-IUS has a positive effect on most quality-of-life domains, at least comparable to those achieved with hysterectomy or endometrial ablation, and is consistently a cost-effective option across a variety of countries and settings. In conclusion, the LNG-IUS is an effective treatment option for women with HMB, including those with underlying organic pathology or bleeding disorders.
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Affiliation(s)
- Andrew M Kaunitz
- Department of Obstetrics and Gynecology, University of Florida College of Medicine-Jacksonville, FL 32209, USA.
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75
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Tinelli A, Hurst BS, Hudelist G, Tsin DA, Stark M, Mettler L, Guido M, Malvasi A. Laparoscopic myomectomy focusing on the myoma pseudocapsule: technical and outcome reports. Hum Reprod 2012; 27:427-435. [DOI: 10.1093/humrep/der369] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Tehrani FR, Simbar M, Abedini M. Reproductive morbidity among Iranian women; issues often inappropriately addressed in health seeking behaviors. BMC Public Health 2011; 11:863. [PMID: 22078752 PMCID: PMC3247136 DOI: 10.1186/1471-2458-11-863] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Accepted: 11/14/2011] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Reproductive morbidity has a huge impact on the health and quality of life of women. We aimed to determine the prevalence of reproductive morbidities and the health seeking behavior of a nationally representative sample of Iranian urban women. METHODS A sample of 1252 women, aged 18-45 years, was selected using the multi stage, stratified probability sampling procedure. Data were collected through interviews and physical, gynecological and ultrasonographic examinations. RESULTS Reproductive tract infection (RTIs), pelvic organ prolapse (POP) and menstrual dysfunction were the three main groups of morbidities with a prevalence of 37.6%, 41.4% and 30.1%., respectively. Our study demonstrated that 35.1, 34.5 and 9.6 percent of women experienced one, two or these reproductive organ disorders mentioned, respectively, while 20.6 percent of participants had none of these disorders. Findings also showed that the majority of women who suffered from reproductive morbidities (on average two out of three) had not sought appropriate care for these except for infertility. CONCLUSIONS Reproductive health morbidities impose a large burden among Iranian women and have negative impact on their reproductive health and wellbeing.
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Affiliation(s)
- Fahimeh Ramezani Tehrani
- Associate professor, Reproductive Endocrinology Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Science, Tehran, Iran
| | - Masoumeh Simbar
- Associate professor, Department of Reproductive Health, Faculty of Nursing and Midwifery, Shahid Beheshti University of Medical Science, Tehran, Iran
- Faculty of Nursing and Midwifery of Shahid Beheshti Medical Science University (3th floor, Deputy of research), Vali-Asr Avenue, Cross of Vali-Asr and Neiaiesh Highway, Opposite to Rajaee Heart Hospital, Tehran, Iran
| | - Mehrandokht Abedini
- Director for Department of Geriatric Health care Department, Deputy of Health, Ministry of Health and Medical Education Tehran, Iran
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Munro MG, Critchley HOD, Broder MS, Fraser IS. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet 2011; 113:3-13. [PMID: 21345435 DOI: 10.1016/j.ijgo.2010.11.011] [Citation(s) in RCA: 719] [Impact Index Per Article: 55.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2010] [Accepted: 01/07/2011] [Indexed: 02/07/2023]
Abstract
There is general inconsistency in the nomenclature used to describe abnormal uterine bleeding (AUB), in addition to a plethora of potential causes-several of which may coexist in a given individual. It seems clear that the development of consistent and universally accepted nomenclature is a step toward rectifying this unsatisfactory circumstance. Another requirement is the development of a classification system, on several levels, for the causes of AUB, which can be used by clinicians, investigators, and even patients to facilitate communication, clinical care, and research. This manuscript describes an ongoing process designed to achieve these goals, and presents for consideration the PALM-COEIN (polyp; adenomyosis; leiomyoma; malignancy and hyperplasia; coagulopathy; ovulatory dysfunction; endometrial; iatrogenic; and not yet classified) classification system for AUB, which has been approved by the International Federation of Gynecology and Obstetrics (FIGO) Executive Board as a FIGO classification system.
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Affiliation(s)
- Malcolm G Munro
- Department of Obstetrics and Gynecology, University of California, Los Angeles, USA.
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Munro MG, Critchley HOD, Fraser IS. The FIGO classification of causes of abnormal uterine bleeding: Malcolm G. Munro, Hilary O.D. Crithcley, Ian S. Fraser, for the FIGO Working Group on Menstrual Disorders. Int J Gynaecol Obstet 2011; 113:1-2. [PMID: 21316671 DOI: 10.1016/j.ijgo.2011.01.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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79
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Non-contraceptive health benefits of intrauterine hormonal systems. Contraception 2011; 82:396-403. [PMID: 20933112 DOI: 10.1016/j.contraception.2010.05.005] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2010] [Accepted: 05/04/2010] [Indexed: 11/21/2022]
Abstract
Non-contraceptive health benefits are now recognized as an important aspect of the overall impact of all hormonal contraceptives. The levonorgestrel-releasing intrauterine systems (LNG IUS) are particularly effective at producing a number of health benefits for women using the LNG IUS as a contraceptive (reduced menstrual bleeding; reduced dysmenorrhea and the potential for prevention of a number of gynecological conditions in the longer term, such as iron-deficiency anemia, endometrial hyperplasia, uterine fibroids, acute episodes of pelvic inflammatory disease, endometriosis and perhaps others). The LNG IUS also has the potential to specifically treat a range of pre-existing gynecological conditions such as heavy menstrual bleeding due to a wide range of underlying causes, endometrial hyperplasia, uterine fibroids, adenomyosis, and endometriosis. These health benefits should be recognized as a key component in the decision-making process for individual women in choosing a specific type of hormonal or other contraceptive. Investment in research into the very substantial health benefits of hormonal contraceptives, such as the LNG IUS, has generally been ignored in comparison with the massive investment into understanding the often subtle or rare complications of hormonal contraceptive use. Both are important, but there is a real need to define more accurately those women who will benefit most from these health benefits.
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80
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Lujan ME, Podolski AJ, Chizen DR, Lehotay DC, Pierson RA. Digit ratios by computer-assisted analysis confirm lack of anatomical evidence of prenatal androgen exposure in clinical phenotypes of polycystic ovary syndrome. Reprod Biol Endocrinol 2010; 8:156. [PMID: 21189149 PMCID: PMC3022844 DOI: 10.1186/1477-7827-8-156] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2010] [Accepted: 12/29/2010] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND We recently showed that women with four clinical phenotypes of polycystic ovary syndrome (PCOS) do not demonstrate anatomical evidence of elevated prenatal androgen exposure as judged by a lower ratio of the index (2D) to ring (4D) finger. However, those findings conflicted with a previous study where women with PCOS had lower right hand 2D:4D compared to healthy female controls. Both these studies used Vernier calipers to measure finger lengths--a method recently shown to be less reliable at obtaining finger length measurements than computer-assisted analysis. METHODS Ninety-six women diagnosed with PCOS according to the 2003 Rotterdam criteria had their finger lengths measured with computer-assisted analysis. Participants were categorized into four recognized phenotypes of PCOS and their 2D:4D compared to healthy female controls (n = 48) and men (n = 50). RESULTS Digit ratios assessed by computer-assisted analysis in women with PCOS did not differ from female controls, but were significantly lower in men. When subjects were stratified by PCOS phenotype, 2D:4D did not differ among phenotypes or when compared to female controls. CONCLUSION Computer-assisted measurements validated that digit ratios of women with PCOS do not show anatomical evidence of increased prenatal androgen exposure.
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Affiliation(s)
- Marla E Lujan
- Division of Nutritional Sciences, College of Agriculture of Life Sciences, Ithaca, NY 14853, USA
| | - Amanda J Podolski
- Division of Nutritional Sciences, College of Agriculture of Life Sciences, Ithaca, NY 14853, USA
| | - Donna R Chizen
- Obstetrics, Gynecology & Reproductive Sciences, College of Medicine, University of Saskatchewan, Saskatoon, SK S7N0W8, Canada
| | - Denis C Lehotay
- Pathology, College of Medicine, University of Saskatchewan, Saskatoon, SK S7N0W8, Canada
| | - Roger A Pierson
- Obstetrics, Gynecology & Reproductive Sciences, College of Medicine, University of Saskatchewan, Saskatoon, SK S7N0W8, Canada
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81
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Druckmann R. Dysfunctional uterine bleeding: from adolescence to menopause. Horm Mol Biol Clin Investig 2010; 3:461-7. [PMID: 25961220 DOI: 10.1515/hmbci.2010.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2010] [Accepted: 09/02/2010] [Indexed: 12/19/2022]
Abstract
Dysfunctional uterine bleeding (DUB) is defined as excessive or prolonged uterine bleeding in premenopausal women that is not caused by pelvic pathology, medications, systemic disease or pregnancy. It is a common condition that can lead not only to physical symptoms such as iron deficiency, anaemia, cramps and fatigue, but also has significant psychological and social effects that impair a woman's quality of life. Progesterone is highly important in the regulation of menstrual bleeding and a progesterone-deficient anovulatory state is a common cause of DUB. There are a wide range of treatment options available including hormonal therapies (oral cyclical progestogens, depot progestogens, progestogen-releasing intrauterine devices, combined oral contraceptives, danazol, gonadotrophin-releasing hormone analogues and hormone replacement therapy), non-hormonal therapies (non-steroidal anti-inflammatory drugs and antifibrinolytic drugs) and surgery (hysterectomy and endometrial ablation). The choice of appropriate therapy should be based on factors such as the mechanism behind the DUB, which symptoms are most problematic, and the woman's need for fertility or contraception. However, there is currently a lack of clinical evidence to help support these decisions.
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82
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Wilkinson JP, Kadir RA. Management of abnormal uterine bleeding in adolescents. J Pediatr Adolesc Gynecol 2010; 23:S22-30. [PMID: 20869283 DOI: 10.1016/j.jpag.2010.08.007] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2010] [Accepted: 08/11/2010] [Indexed: 11/16/2022]
Affiliation(s)
- Jeffrey P Wilkinson
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina, USA.
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83
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Lujan ME, Kepley AL, Chizen DR, Lehotay DC, Pierson RA. Development of morphologically dominant follicles is associated with fewer metabolic disturbances in amenorrheic women with polycystic ovary syndrome: a pilot study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2010; 36:759-766. [PMID: 20645396 DOI: 10.1002/uog.7751] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/07/2010] [Indexed: 05/29/2023]
Abstract
OBJECTIVES To determine if amenorrheic women with polycystic ovary syndrome (PCOS) demonstrate ultrasonographically detectable changes in follicle population. METHODS Sixteen women with PCOS reporting the absence of menses for more than 3 months were enrolled in the study. Subjects had a physical examination, fasting blood tests and two transvaginal ultrasound scans spaced 1 month apart. In cases where evidence of a morphologically dominant follicle (≥ 10 mm in diameter) occurred, subsequent ultrasound scans were performed to determine the fate of the dominant follicle. Differences in total follicle population, maximum follicle diameter and clinical, hormonal and metabolic features were determined. RESULTS Forty-four percent of subjects showed changes in follicle population of 6-10 follicles and 37% showed changes in follicle population of > 10. Maximum follicle diameters ranged between 5.4 and 33.0 mm. Four subjects demonstrated follicle diameters ≥ 10 mm. Of those who developed dominant follicles, two subjects ovulated, one subject developed a persistent anovulatory follicle and the dominant follicle regressed in the remaining subject. Diagnostic criteria for PCOS were similar among women that did or did not develop dominant follicles (menstrual cycle length, P = 0.880; hirsutism score, P = 0.809; free androgen index, P = 0.991; total follicle count, P = 0.199). However, lower glycosylated hemoglobin (P = 0.047) and insulin levels (P = 0.049) and better insulin sensitivity (P = 0.048) were noted in women who attained dominant follicles. CONCLUSION Amenorrheic women with PCOS demonstrate changes in follicle population that are consistent with active follicle growth and regression despite prolonged periods of anovulation. Morphologic selection occurs in amenorrheic women and attainment of dominant follicles is associated with improved metabolic status.
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Affiliation(s)
- M E Lujan
- Department of Nutritional Sciences, Cornell University, College of Agriculture and Life Sciences, Ithaca, NY 14853, USA.
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84
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Systematic review highlights difficulty interpreting diverse clinical outcomes in abnormal uterine bleeding trials. J Clin Epidemiol 2010; 64:293-300. [PMID: 20705427 DOI: 10.1016/j.jclinepi.2010.03.017] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2009] [Revised: 03/07/2010] [Accepted: 03/13/2010] [Indexed: 11/24/2022]
Abstract
OBJECTIVES (1) To systematically collect and organize into clinical categories all outcomes reported in trials for abnormal uterine bleeding (AUB); (2) to rank the importance of outcomes for patient decision making; and (3) to improve future comparisons of effects in trials of AUB interventions. STUDY DESIGN AND SETTING Systematic review of English-language randomized controlled trials of AUB treatments in MEDLINE from 1950 to June 2008. All outcomes and definitions were extracted and organized into major outcome categories by an expert group. Each outcome was ranked "critically important," "important," or "not important" for informing patients' choices. RESULTS One hundred thirteen articles from 79 trials met the criteria. One hundred fourteen different outcomes were identified, only 15 (13%) of which were ranked as critically important and 29 (25%) as important. Outcomes were grouped into eight categories: (1) bleeding; (2) quality of life; (3) pain; (4) sexual health; (5) patient satisfaction; (6) bulk-related complaints; (7) need for subsequent surgical treatment; and (8) adverse events. CONCLUSION To improve the quality, consistency, and utility of future AUB trials, we recommend assessing a limited number of clinical outcomes for bleeding, disease-specific quality of life, pain, sexual health, and bulk-related symptoms both before and after treatment and reporting satisfaction and adverse events. Further development of validated patient-based outcome measures and the standardization of outcome reporting are needed.
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Uterine artery embolization vs hysterectomy in the treatment of symptomatic uterine fibroids: 5-year outcome from the randomized EMMY trial. Am J Obstet Gynecol 2010; 203:105.e1-13. [PMID: 20579960 DOI: 10.1016/j.ajog.2010.01.049] [Citation(s) in RCA: 114] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2009] [Revised: 10/22/2009] [Accepted: 01/19/2010] [Indexed: 01/22/2023]
Abstract
OBJECTIVE The purpose of this study was to compare clinical outcome and health related quality of life (HRQOL) 5 years after uterine artery embolization (UAE) or hysterectomy in the treatment of menorrhagia caused by uterine fibroids. STUDY DESIGN Patients with symptomatic uterine fibroids who were eligible for hysterectomy were assigned randomly 1:1 to hysterectomy or UAE. Endpoints after 5 years were reintervention rates, menorrhagia, and HRQOL measures that were assessed by validated questionnaires. RESULTS Patients were assigned randomly to UAE (n = 88) or hysterectomy (n = 89). Five years after treatment 23 of 81 UAE patients (28.4%) had undergone a hysterectomy because of insufficient improvement of complaints (24.7% after successful UAE). HRQOL measures improved significantly and remained stable until the 5-year follow-up evaluation, with no differences between the groups. UAE had a positive effect both on urinary and defecation function. CONCLUSION UAE is a well-established alternative to hysterectomy about which patients should be counseled.
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86
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Lujan ME, Brooks ED, Kepley AL, Chizen DR, Pierson RA, Peppin AK. Grid analysis improves reliability in follicle counts made by ultrasonography in women with polycystic ovary syndrome. ULTRASOUND IN MEDICINE & BIOLOGY 2010; 36:712-718. [PMID: 20381953 PMCID: PMC2893214 DOI: 10.1016/j.ultrasmedbio.2010.02.008] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2009] [Revised: 01/19/2010] [Accepted: 02/22/2010] [Indexed: 05/29/2023]
Abstract
Poor reliability has been reported when counting the total number of follicles in polycystic ovaries using conventional two-dimensional (2-D) ultrasound viewing methods. In the current study, we report good reliability in follicle counts when observers imposed a programmable grid system over the viewing window. Four observers estimated total follicle counts in 45 ovarian ultrasound scans by compartmentalizing the ovary into 9 to 12 grid sections and performing focused follicle counts per section. The mean number of follicles counted per ovary was 44.6 +/- 2.3. The level of inter-observer agreement when making follicle counts was 0.82 and total follicle counts did not differ among observers. The level of intra-observer agreement was 0.93 which further corroborated the utility of this method for making dependable follicle counts. In summary, the ability to obtain reproducible follicle counts will help to establish reliable diagnostic criteria for polycystic ovarian morphology.
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Affiliation(s)
- Marla E Lujan
- Division of Nutritional Sciences, College of Agriculture and Life Sciences, Cornell University, Ithaca, New York 14853, USA.
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Lujan ME, Bloski TG, Chizen DR, Lehotay DC, Pierson RA. Digit ratios do not serve as anatomical evidence of prenatal androgen exposure in clinical phenotypes of polycystic ovary syndrome. Hum Reprod 2009; 25:204-11. [PMID: 19855107 DOI: 10.1093/humrep/dep363] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Polycystic ovary syndrome (PCOS) is heterogeneous in its clinical presentation and four major phenotypes have been identified. The precise etiology of PCOS is unknown; however, variable exposure to prenatal androgens may be responsible for the spectrum of endocrine and metabolic disturbances characteristic of this syndrome. Since prenatal testosterone exposure is known to decrease the ratio of the second to fourth finger lengths (2D:4D), we characterized the left and right hand 2D:4D in women with clinical variants of PCOS. We hypothesized that if prenatal androgens were involved in the development of the phenotypic spectrum of PCOS, then lower 2D:4D would be differentially expressed among clinical variants of the syndrome. METHODS Digit ratios were determined in 98 women diagnosed with PCOS by the 2003 international consensus guidelines and in 51 women with regular menstrual cycles, no clinical or biochemical signs of hyperandrogenism and normal ovarian morphology. Women with PCOS were categorized into four clinical phenotypes (i.e. Frank, Non-PCO, Ovulatory and Mild) and 2D:4D among groups were compared by Tukey-Kramer multiple comparisons tests. RESULTS Left (P = 0.77) and right (P = 0.68) hand 2D:4D were similar among the four clinical phenotypes and no phenotype of PCOS demonstrated a 2D:4D that differed from controls (Left Hand, P = 0.44 and Right Hand, P = 0.75). CONCLUSIONS Women with PCOS do not demonstrate finger length patterns that are consistent with increased prenatal androgen exposure. These findings do not preclude a role for prenatal androgens in the development of PCOS; however, low 2D:4D are not a characteristic of PCOS.
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Affiliation(s)
- Marla E Lujan
- Division of Nutritional Sciences, Cornell University, 216 Savage Hall, Ithaca, NY 14853, USA.
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Lujan ME, Chizen DR, Peppin AK, Dhir A, Pierson RA. Assessment of ultrasonographic features of polycystic ovaries is associated with modest levels of inter-observer agreement. J Ovarian Res 2009; 2:6. [PMID: 19515259 PMCID: PMC2700106 DOI: 10.1186/1757-2215-2-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2009] [Accepted: 06/10/2009] [Indexed: 11/17/2022] Open
Abstract
Background There is growing acceptance that polycystic ovaries are an important marker of polycystic ovary syndrome (PCOS) despite significant variability when making the ultrasound diagnosis. To better understand the nature of this variability, we proposed to evaluate the level of inter-observer agreement when identifying and quantifying individual ultrasonographic features of polycystic ovaries. Methods Digital recordings of transvaginal ultrasound scans performed in thirty women with PCOS were assessed by four observers with training in Radiology or Reproductive Endocrinology. Observers evaluated the scans for: 1) number of follicles ≥ 2 mm per ovary, 2) largest follicle diameter, 3) ovarian volume, 4) follicle distribution pattern and 5) presence of a corpus luteum (CL). Lin's concordance correlation coefficients and kappa statistics for multiple raters were used to assess inter-observer agreement. Results Agreement between observers ranged from 0.08 to 0.63 for follicle counts, 0.27 to 0.88 for largest follicle diameter, 0.63 to 0.86 for ovarian volume, 0.51 to 0.76 for follicle distribution pattern and 0.76 to 0.90 for presence of a CL. Overall, reproductive endocrinologists demonstrated better agreement when evaluating ultrasonographic features of polycystic ovaries compared to radiologists (0.71 versus 0.53; p = 0.04). Conclusion Inter-observer agreement for assessing ultrasonographic features of polycystic ovaries was moderate to poor. These findings support the need for standardized training modules to characterize polycystic ovarian morphology on ultrasonography.
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Affiliation(s)
- Marla E Lujan
- Division of Nutritional Sciences, Cornell University, Ithaca, USA.
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Evaluation and treatment of menorrhagia in an adolescent population. J Minim Invasive Gynecol 2009; 15:682-8. [PMID: 18971130 DOI: 10.1016/j.jmig.2008.08.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2008] [Revised: 08/18/2008] [Accepted: 08/23/2008] [Indexed: 11/21/2022]
Abstract
Bleeding in adolescence is a common but, potentially, difficult condition to manage. Adolescents present with unique issues related to their age, involvement of family members, different differential diagnosis when compared to an older populations, and challenges associated with their evaluation and treatment.
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Gonadotropin-releasing hormone analog combined with a low-dose oral contraceptive to treat heavy menstrual bleeding. Int J Gynaecol Obstet 2008; 104:236-9. [PMID: 19062012 DOI: 10.1016/j.ijgo.2008.10.032] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2008] [Revised: 09/29/2008] [Accepted: 10/08/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To compare the effects of low-dose oral contraceptives used alone and in combination with a gonadotropin-releasing hormone (GnRH) analog to treat heavy menstrual bleeding. METHODS Fifty-eight patients with heavy menstrual bleeding were prospectively randomized into two treatment groups to receive either a low-dose oral contraceptive alone (group 1), or combined with a GnRH analog (group 2) for 6 months. The patients' hormonal profiles, and hemoglobin and hematocrit levels were measured at the beginning and at the end of the treatment period. RESULTS Hemoglobin and hematocrit levels significantly improved in both groups after 6 months of treatment (P<0.05 and P<0.01, respectively). Even in the first month of the study, the number of pads used and the duration of menstruation were significantly decreased in both groups and markedly lower in group 2 (P<0.01). CONCLUSION The addition of a GnRH analog to low-dose oral contraceptive treatment for heavy menstrual bleeding resulted in better control of vaginal bleeding, even in the first month of therapy.
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Abstract
The conventional wisdom about menstruation in adolescents, perpetuated in textbooks, requires updating. Recently published national surveys and reviews of large historical databases provide information about menstruation in adolescents, including the following: (1) Girls are experiencing earlier pubertal development than previously noted, suggesting that guidelines for the evaluation of potentially pathologic precocious puberty be reassessed. (2) There are racial differences in pubertal development, with African American girls experiencing earlier signs than Caucasian girls, and Mexican American girls intermediate in pace. (3) The absence of pubertal development by age 14 is associated with a high probability of conditions with impaired reproductive potential. (4) Absence of menarche by age 15 is statistically uncommon and should be evaluated. (5) Parameters for normal menstrual cyclicity indicate that most menstrual cycles for adolescents are between approximately 20 and 45 days. (6) Because menstrual cycles outside of this range are statistically uncommon, consideration should be give to evaluating adolescents with bleeding that is either too frequent or too infrequent. (7) A number of conditions with the potential for significant sequelae in adulthood can present as abnormal menses in adolescence, and thus merit early diagnosis and management.
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Affiliation(s)
- Paula J Adams Hillard
- Division of Gynecologic Specialties, Stanford University, Department of Obstetrics and Gynecology, 300 Pasteur Drive, Room HH333, MC: 5317, Stanford, CA, USA 94305, USA.
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Abstract
PURPOSE OF REVIEW The aim of this article is to review the current evidence for optimal management of the adolescent who presents with heavy periods. RECENT FINDINGS A recent survey of clinicians involved in adolescent gynaecology revealed a lack of consistency in the management of acute adolescent heavy menses. Very few randomized trials have been undertaken for acute heavy menses in women of any age, although one recent trial compared the oral contraceptive pill with oral medroxy progesterone acetate in adult women and showed them to be equally effective. The applicability of this trial to adolescents is unclear. Furthermore, although guidelines have been produced for menorrhagia management in adults, there is again only limited clinical research specific to adolescents and thus room for concern that the approaches for adult women may not always be appropriate for teenagers. One small study on the successful use of the levonorgestrel intrauterine system in teenagers does mean that this management option can now be considered. SUMMARY There is a need for careful assessment of the menstrual problem for, although anovulatory bleeds are the most common cause, bleeding disorders also need to be considered. Pelvic pathology is uncommon. Adolescents can also present with acute ongoing heavy bleeding. Whilst a range of approaches is reported, there are no studies to guide optimal management.
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Affiliation(s)
- Sonia Grover
- Department of Paediatric and Adolescent Gynaecology, Royal Children's Hospital, University of Melbourne, Melbourne, Australia.
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