Prevalence of heavy menstrual bleeding and experiences of affected women in a European patient survey

Standardizing the evaluation and management of iron deficiency anemia secondary to heavy menstrual bleeding in the emergency department

BACKGROUND

Comprehensive guidelines for the management of iron deficiency anemia (IDA) in adolescents with heavy menstrual bleeding (HMB) presenting to the emergency department (ED) are lacking, leading to variability in care. We aimed to standardize the evaluation and management of these patients through the development and implementation of an evidence-based algorithm using quality improvement methodology.

METHODS

Baseline data of the target population identified variability across four key measures of clinical management: therapy choice and administration, laboratory evaluation, hematology service consultation, and patient disposition. Literature review and consensus from pediatric hematology and gynecology providers informed a draft algorithm that was refined in an iterative multidisciplinary process. From December 2022 to July 2023, we aimed to achieve a 25% relative increase in patients to receive optimal management per the algorithm, while using sequential Plan-Do-Study-Act (PDSA) cycles. Process measures focusing on provider documentation and balancing measures, such as ED length of stay, were assessed concurrently.

RESULTS

Forty-nine patients were evaluated during four PDSA cycles. Improvement of ≥40% above baseline regarding recommended therapy administration was achieved across four PDSA cycles. Adherence to recommended therapy choice improved from 57% (baseline) to 100%, minimal laboratory evaluation from 14% to 83%, hematology consultation from 36% to 100%, and appropriate disposition from 71% to 100%. ED length of stay remained stable.

CONCLUSION

Implementation of a standardized algorithm for management of IDA secondary to HMB in adolescents in the ED increased adherence to evidence-based patient care.

Patients' motives and considerations on treatment decision-making for heavy menstrual bleeding: a qualitative study

BACKGROUND

Several treatment modalities for heavy menstrual bleeding are available. However, many women report being unsatisfied in their search for an appropriate and effective treatment. The aim of this study is to gain insights in the experienced impact of heavy menstrual bleeding and the motives and considerations of women during the decision-making process for treating heavy menstrual bleeding.

METHODS

An interpretative qualitative study was performed, using in-depth interviews. In total, 14 semi-structured interviews were conducted with patients who consulted a physician for treatment of heavy menstrual bleeding. Participants were recruited via the Netherlands Patients Federation (N = 10) or via the outpatient clinic in the Máxima Medical Center (N = 4). The interviews were conducted by phone or online between February 2020 and March 2021. In the interviews three topics were addressed: (1) participant's experience with heavy menstrual bleeding, (2) experience with patient journey of treatment decision-making and (3) elaborating on alternative treatments for heavy menstrual bleeding. A thematic analysis was conducted.

RESULTS

Fourteen participants aged between 30 and 59 years old were interviewed. Three main themes emerged; "Considerations in taking the (next) step to seek help", "Various sources of information can contribute, confuse or frighten decision-making process" and "A physician's understanding and a relationship of trust are needed to guide the decision-making process".

CONCLUSION

Our results show that women's considerations and decision making strongly depend on the obtained information and experience, the relationship with the physician, the influence of the social environment, the pre-visit expectations/desires, the fear of treatment complications and uncertainty of the effect of the treatment. It is a physicians role to create a trusting and open atmosphere during consultation. Patient-centered communication is helpful to share knowledge, and gain insights into a patient's hopes, fears and worries.

Menstrual blood loss is an independent determinant of hemoglobin and ferritin levels in premenopausal blood donors

INTRODUCTION

To prevent blood donors from developing iron deficiency (ferritin <15 μg/L) and subsequent anemia (hemoglobin <120 g/L), blood services rely on information about known risk factors, including the donor's sex and age. For example, while Finnish women are able to donate whole blood with a minimum donation interval of 91 days, women in the 18 to 25-year-old age group are recommended to donate no more than once per year. Menstrual blood loss is not accounted for in blood donation interval recommendations, despite being a known risk factor of iron deficiency. We aim to investigate to what extent menstrual bleeding is associated with ferritin and hemoglobin levels in female blood donors, and quantify the association of other menstruation-related variables not currently accounted for by blood services (i.e., use of hormonal contraception, heavy menstrual bleeding) with iron deficiency or anemia.

MATERIAL AND METHODS

The study population consisted of 473 premenopausal and 491 postmenopausal Dutch whole blood donors. Exclusion criteria were current pregnancy, BMI ≥50, ferritin ≥200, pictorial blood assessment chart (PBAC) ≥400, and age <18 or ≥70 years. Menstrual blood loss was quantified using a PBAC, a semiquantitative method to evaluate the number of used menstrual products and the degree of staining. We identified predictors of log(ferritin)/hemoglobin and iron deficiency/anemia using Bayesian linear and logistic regression models and quantified the average percentage of variance in log(ferritin) and hemoglobin explained by the covariates.

RESULTS

Menstrual blood loss accounted for most of the explained variance in hemoglobin (8%) and second only to the number of days since last donation for ferritin (8%). Heavy menstrual bleeding (PBAC ≥150, OR = 3.56 [1.45-8.85], prevalence 13%) was associated with anemia, and use of levonorgestrel-releasing intrauterine device was negatively associated with iron deficiency (OR = 0.06 [0.01-0.44]). After statistical control for menstrual blood loss, age was not associated with iron status.

CONCLUSIONS

Menstrual blood loss and blood donation were the most important determinants of iron status in premenopausal women. Thus, results suggest that accounting for menstrual blood loss in donation interval guidelines may benefit blood donors.

Self-Reported Menstrual Health, Symptomatology, and Perceived Effects of the Menstrual Cycle for Elite Junior and Senior Football Players

PURPOSE

To describe the self-reported menstrual health, symptomatology, and perceived effects of the menstrual cycle on athletic performance for national and international Australian football (soccer) players.

METHODS

Players from national and domestic teams were invited to complete an online questionnaire regarding menstrual health, use of hormonal contraceptives (HCs), negative symptomatology, and perceived disruption of the menstrual cycle to performance. Descriptive statistics and binomial regressions with odds ratios (OR) were used to report the relationship of menstrual-related variables with perceived performance disruption.

RESULTS

A total of 199 players (20.9 [5.1] y) completed the questionnaire, with 18% of players reporting using HCs. One primary amenorrhea case was detected, and 26% of players reported menarche at age ≥15 years. For non-HC users, the prevalence of secondary amenorrhea was 2%, oligomenorrhea was 19%, and heavy menstrual bleeding was 11%. Ninety-seven percent of players reported experiencing physical or affective menstrual symptoms (5 [1.3] per player), and 40% of all players reported that menstrual symptoms impacted their ability to work, study, train, or compete. Furthermore, 40% of players perceived their training or performance to be disrupted by the menstrual cycle. Increasing number of menstrual symptoms (OR = 1.43; 95% CI, 1.28-1.62; P < .001), heavy menstrual bleeding (OR = 12.73; 95% CI, 3.4-82.8; P < .001), and pelvic pain (OR = 3.40; 95% CI, 1.7-7.2; P < .001) increased the likelihood of perceiving the menstrual cycle to disrupt performance.

CONCLUSION

Heavy menstrual bleeding and HC use were low among this cohort of national and international footballers, whereas amenorrhea and oligomenorrhoea were comparable with other football populations. Nearly all players reported menstrual symptoms, and increased symptomatology was associated with greater perceived effects on performance.

Review of interventions and effectiveness for heavy menstrual bleeding in women with moderate and severe von Willebrand disease

INTRODUCTION

Women with VWD have an increased risk of gynaecological complications due to haemostatic challenges of menstruation.

AIM

Review gynecological bleeding symptoms and their management in women with moderate-severe VWD.

MATERIALS AND METHODS

Retrospective cohort analysis of prospectively collected data for women with moderate and severe VWD attending a joint multidisciplinary clinic between January 2010 and December 2020. Data was collected from electronic patient records on response to treatment options using PBAC, quality of life (QoL) assessment using SF-36 scores, haemoglobin and ferritin in comparison to pre-treatment values.

RESULTS

Of the 67 women managed in the clinic; all reported heavy menstrual bleeding (HMB). Combination therapy with concurrent hormonal agents and tranexamic acid was required in 80% of women. There was an overall 64% improvement in PBAC scores in the first year, reflecting on QoL with 35% improvement in SF-36 score and correction of anaemia in 21% of cases. The cumulative effect of continued treatment culminated in greater reduction of blood loss, with an overall 71% improvement in PBAC scores by 5 years. One in 10 women required surgical treatment for a gynaecological pathology. Non-compliance was the cause of excessive unscheduled bleeding in 50% of adolescents. After 3 years, one in five women experienced a relapse of symptom, of whom 46% became perimenopausal and 54% discontinued hormonal treatments due to concerns about fertility, hair loss and weight gain.

CONCLUSION

Management of HMB requires careful monitoring and follow-up by MDT with close collaboration between the gynaecology team and HTC. Control of HMB often requires a combination therapy.

The impact of hematology electronic consultations on the management of iron deficiency

OBJECTIVES

Delays in the evaluation and treatment of iron deficiency can lead to increased disease-related morbidity and mortality. Electronic consultation (e-consult) is a referral modality that allows providers quicker access to recommendations from a specialist based on electronic chart review. While the use of e-consult is expanding in classical hematology, gaps exist in the understanding of patient outcomes related to its use for iron deficiency.

METHODS

We randomly selected 200 e-consults and 200 traditional referrals from 3,336 hematology referrals for iron deficiency at a single center. The primary outcomes of the retrospective analysis were: time to completion of the referral, and time to treatment with intravenous iron. Secondary outcomes included recurrence of iron deficiency, need for repeat e-consult, conversion to in-person evaluation, and assessment of whether the etiology of iron deficiency was addressed.

RESULTS

E-consults significantly reduced the time from referral to intravenous iron repletion (e-consult, 33 days; traditional referral, 68 days; p < .05). Assessment of the underlying etiology occurred in 70.7% of the e-consult encounters compared to 92.5% of traditional referrals (p < .05).

CONCLUSIONS

These findings highlight advantages of e-consults in improving care delivery in iron deficiency, and identifying gaps that can be improved through practice standardization to ensure equitable, high-value care.

Association Between Intrauterine System Hormone Dosage and Depression Risk

OBJECTIVE

The authors compared the associated risk of incident depression between first-time users of low-, medium-, and high-dose levonorgestrel-releasing intrauterine systems (LNG-IUSs).

METHODS

This national cohort study was based on Danish register data on first-time users of LNG-IUSs, 15-44 years of age, between 2000 and 2022. Cox regression and a G-formula estimator were used to report 1-year average absolute risks, risk differences, and risk ratios of incident depression, defined as initiation of an antidepressant or receipt of a depression diagnosis, standardized for calendar year, age, education level, parental history of mental disorders, endometriosis, menorrhagia, polycystic ovary syndrome, dysmenorrhea, leiomyoma, and postpartum initiation.

RESULTS

In total, 149,200 women started using an LNG-IUS, among whom 22,029 started a low-dose one (mean age, 22.9 years [SD=4.5]), 47,712 a medium-dose one (mean age, 25.2 years [SD=6.2]), and 79,459 a high-dose one (mean age, 30.2 years [SD=5.6]). The associated subsequent 1-year adjusted absolute risks of incident depression were 1.21% (95% CI=1.06-1.36), 1.46% (95% CI=1.33-1.59), and 1.84% (95% CI=1.72-1.96), respectively. For the users of high-dose LNG-IUSs, the risk ratios were 1.52 (95% CI=1.30-1.74) and 1.26 (95% CI=1.10-1.41) compared with users of the low- and medium-dose LNG-IUSs, respectively. For users of medium-dose LNG-IUSs, the risk ratio was 1.21 (95% CI=1.03-1.39) compared with users of low-dose LNG-IUSs.

CONCLUSIONS

First-time use of an LNG-IUS was positively associated with incident depression in an LNG-dose-dependent manner across low-, medium-, and high-dose LNG-IUSs. Although the observational design of the study does not permit causal inference, the dose-response relationship contributes to the body of evidence suggesting a relationship between levonorgestrel exposure and risk of depression.

The relationship between menorrhagia, iron deficiency, and anaemia in recreationally active females: An exploratory population based screening study

OBJECTIVES

Iron deficiency, anaemia, and menorrhagia - or heavy menstrual bleeding - are interrelated conditions that are highly prevalent and commonly underrecognised in exercising females of reproductive age. This study utilised a screening tool to identify risk factors and symptoms associated with heavy menstrual bleeding, iron deficiency, and anaemia in this population.

DESIGN

An observational, cross sectional survey study was employed.

METHODS

1042 active females (aged 18-65) completed a comprehensive screening questionnaire and 887 (85 % compliance) provided a fingerprick blood sample for haemoglobin (Hb) concentration measurement. Women that presented as anaemic (defined as a [Hb] < 120 g/L) or deemed to be at risk of iron deficiency (120 < [Hb] < 130 g/L) were asked to complete follow-up blood tests to screen for iron studies.

RESULTS

Average [Hb] was 134.2 ± 12.1 g/L, with 94 individuals considered anaemic (10.6 %). Of the sample, 104 underwent follow-up blood tests; 51 (~49 %) presented with iron deficiency (defined as ferritin <30 μg/L). Based on survey responses, 274 (30.9 %) participants were determined to have heavy menstrual bleeding. Those presenting with heavy menstrual bleeding were younger, exercised fewer hours per week, and were more likely to have a history of iron deficiency or anaemia (all p < 0.05). Participants reporting a history of anaemia or iron deficiency were more likely to have heavy menstrual bleeding (anaemia: 39.7 %; iron deficiency; 36.9 %; both p < 0.05).

CONCLUSIONS

In this cohort of exercising females of reproductive age, the prevalence of anaemia was 10.6 %. There is a strong association between heavy menstrual bleeding and a self-reported history of iron deficiency and anaemia. Greater awareness of heavy menstrual bleeding and its relationship with iron deficiency and anaemia is needed in this population. Non-invasive screening should be conducted to raise awareness and further understand the associated risk factors and symptomatology.

A quick method to customize pictorial blood assessment tools towards better measurement: Method development and validation

OBJECTIVE

Identification of heavy menstrual bleeding (HMB) cases in primary care settings is often done by using pictorial blood assessment charts (PBAC). The study aims to highlight the challenge of assessing blood loss, to develop a standardized method to efficiently customize a patient-reported pictorial chart, to validate the tool produced with our proposed method, and to demonstrate the feasibility of using PBACs in settings where resources are scarce.

MATERIALS AND METHODS

Using blood samples and feedback from 21 women aged 30-51 years, we followed guidelines suggested in the literature, developed a method to produce PBACs for regular, long and night sizes, and had 9 participants testuse them. Linear regression analysis was performed to determine the correlation between participants' scores and menstrual blood weight.

RESULTS

The study demonstrated the feasibility of customizing product-sensitive and size-specific pictorial charts by adopting essential steps including collecting menstrual blood with menstrual cups, employing fluid application techniques, and using sanitary pads as icons for easy identification. Linear regression analyses of score versus blood weight showed that the recorded blood weight was around 95% of the scored values (R2 = 0.9428, 0.947, and 0.9508, respectively; p < 0.001).

CONCLUSION

Valid patient-reported PBACs created by the proposed method provides an innovative women's healthcare solution to assist HMB identification and reduce health expenditure by preventing risks for HMB related complications in varying economic and technological contexts. Women's participation in tracking menstrual abnormalities may improve health literacy.

Recommendations for diagnosis, treatment, and prevention of iron deficiency and iron deficiency anemia

Iron is an essential nutrient and a constituent of ferroproteins and enzymes crucial for human life. Generally, nonmenstruating individuals preserve iron very efficiently, losing less than 0.1% of their body iron content each day, an amount that is replaced through dietary iron absorption. Most of the iron is in the hemoglobin (Hb) of red blood cells (RBCs); thus, blood loss is the most common cause of acute iron depletion and anemia worldwide, and reduced hemoglobin synthesis and anemia are the most common consequences of low plasma iron concentrations. The term iron deficiency (ID) refers to the reduction of total body iron stores due to impaired nutrition, reduced absorption secondary to gastrointestinal conditions, increased blood loss, and increased needs as in pregnancy. Iron deficiency anemia (IDA) is defined as low Hb or hematocrit associated with microcytic and hypochromic erythrocytes and low RBC count due to iron deficiency. IDA most commonly affects women of reproductive age, the developing fetus, children, patients with chronic and inflammatory diseases, and the elderly. IDA is the most frequent hematological disorder in children, with an incidence in industrialized countries of 20.1% between 0 and 4 years of age and 5.9% between 5 and 14 years (39% and 48.1% in developing countries). The diagnosis, management, and treatment of patients with ID and IDA change depending on age and gender and during pregnancy. We herein summarize what is known about the diagnosis, treatment, and prevention of ID and IDA and formulate a specific set of recommendations on this topic.

Abnormal uterine bleeding: The well-known and the hidden face

Abnormal uterine bleeding (AUB) is a bleeding from the uterine corpus that is abnormal in regularity, volume, frequency or duration. It encompasses heavy menstrual bleeding, irregular menstrual bleeding and intermenstrual bleeding, which are common symptoms among women of reproductive age, impacting their overall well-being. Menstruation involves interactions between endometrial epithelial and stromal cells, immune cell influx, and changes in endometrial vasculature. These events resemble an inflammatory response with increased vessel permeability, tissue breakdown, and the arrival of innate immune cells. However, the mechanisms of menstrual cessation are poorly understood. AUB can be related to structural causes (polyp, adenomyosis, leiomyoma, malignancy/hyperplasia) and nonstructural conditions (coagulopathy, ovulatory dysfunction, endometrial, iatrogenic). While transvaginal ultrasound is the primary method for the screening of intracavitary lesions, saline infusion sonohysterography is more accurate to detect endometrial polyps and submucous leiomyomas, while hysteroscopy with biopsy remains the reference method for a definitive diagnosis. The main goals in managing AUB are addressing and correcting the underlying primary cause, if possible, and establishing a regular bleeding pattern or amenorrhea, which can be done with antifibrinolytic agents, progestins, gonadotropin-releasing hormone agonists and antagonists, or surgical interventions, each one with specific indications and limitations. Further research is necessary to assess the effectiveness and the long-term effects of various medical and surgical treatments. Meanwhile, the availability of diagnostic methods such as transvaginal ultrasound and hysteroscopy and the universal distribution of medical treatments for AUB should be prioritized by policymakers to minimize the diagnostic and treatment delay and thus reduce the risk of AUB-related anemia and the need of hysterectomy.

A 52-mg levonorgestrel-releasing intrauterine system vs bipolar radiofrequency nonresectoscopic endometrial ablation in women with heavy menstrual bleeding: long-term follow-up of a multicenter randomized controlled trial

BACKGROUND

The symptom of heavy menstrual bleeding has a substantial impact on professional, physical, and social functioning. In 2021, results from a randomized controlled trial comparing a 52-mg levonorgestrel-releasing intrauterine system and radiofrequency nonresectoscopic endometrial ablation as treatments for women with heavy menstrual bleeding were published. Both treatment strategies were equally effective in treating heavy menstrual bleeding during 2-year follow-up. However, long-term results are also relevant for both patients and healthcare providers.

OBJECTIVE

This study aimed to assess long-term differences in reintervention risk and menstrual blood loss in women with the symptom of heavy menstrual bleeding treated according to a strategy starting with a 52-mg levonorgestrel-releasing intrauterine system or radiofrequency nonresectoscopic endometrial ablation.

STUDY DESIGN

This study was a long-term follow-up study of a multicenter randomized controlled trial (MIRA trial), in which women were allocated to either a 52-mg levonorgestrel-releasing intrauterine device (n=132) or radiofrequency nonresectoscopic endometrial ablation (n=138). Women from the original trial were contacted to fill out 6 questionnaires. The primary outcome was the reintervention rate after allocated treatment. Secondary outcomes included surgical reintervention rate, menstrual bleeding measured by the Pictorial Blood Loss Assessment Chart, (disease-specific) quality of life, sexual function, and patient satisfaction.

RESULTS

From the 270 women who were randomized in the original trial, 196 (52-mg levonorgestrel-releasing intrauterine system group: n=94; radiofrequency nonresectoscopic endometrial ablation group: n=102) participated in this long-term follow-up study. Mean follow-up duration was 7.4 years (range, 6-9 years). The cumulative reintervention rate (including both medical and surgical reinterventions) was 40.0% (34/85) in the 52-mg levonorgestrel-releasing intrauterine system group and 28.7% (27/94) in the radiofrequency nonresectoscopic endometrial ablation group (relative risk, 1.39; 95% confidence interval, 0.92-2.10). The cumulative rate of surgical reinterventions only was significantly higher among patients with a treatment strategy starting with a 52-mg levonorgestrel-releasing intrauterine system compared with radiofrequency nonresectoscopic endometrial ablation (35.3% [30/85] vs 19.1% [18/94]; relative risk, 1.84; 95% confidence interval, 1.11-3.10). However, the hysterectomy rate was similar (11.8% [10/94] in the 52-mg levonorgestrel-releasing intrauterine system group and 18.1% [17/102] in the radiofrequency nonresectoscopic endometrial ablation group; relative risk, 0.65; 95% confidence interval, 0.32-1.34). Most reinterventions occurred during the first 24 months of follow-up. A total of 171 Pictorial Blood Loss Assessment Chart scores showed a median bleeding score of 0.0. No clinically relevant differences were found regarding quality of life, sexual function, and patient satisfaction.

CONCLUSION

The overall risk of reintervention after long-term follow-up was not different between women treated according to a treatment strategy starting with a 52-mg levonorgestrel-releasing intrauterine system and those treated using a strategy starting with radiofrequency nonresectoscopic endometrial ablation. However, women allocated to a treatment strategy starting with a 52-mg levonorgestrel-releasing intrauterine system had a higher risk of surgical reintervention, which was driven by an increase in subsequent endometrial ablation. Both treatment strategies were effective in lowering menstrual blood loss over the long term. The results of this long-term follow-up study can support physicians in optimizing the counseling of women with heavy menstrual bleeding, thus promoting informed decision-making regarding choice of treatment.

Risk of abnormal uterine bleeding associated with high-affinity compared with low-affinity serotonin and norepinephrine reuptake inhibitors

BACKGROUND

Concerns have been raised about the potential association between selective serotonin reuptake inhibitors (SSRIs)/serotonin-norepinephrine reuptake inhibitors (SNRIs) and the risk of abnormal uterine bleeding (AUB), which may be influenced by the affinity of SSRIs/SNRIs for serotonin transporter. Thus, we assessed whether SSRIs/SNRIs with high-affinity for serotonin transporter are associated with AUB compared to SSRIs/SNRIs with low-affinity in non-pregnant women.

METHODS

Using the UK Clinical Practice Research Datalink, we identified a cohort of women aged 15-24 years, newly prescribed a high- or low-affinity SSRI/SNRI between 1990 and 2019. Confounding was addressed using standardized morbidity ratio weighting. We used weighted Cox proportional hazards models to estimate the hazard ratio (HR) and 95 % confidence interval (CI) of AUB associated with high-affinity compared with low-affinity SSRIs/SNRIs. We assessed the risk of anemia as a secondary outcome.

RESULTS

The cohort included 156,307 users of high-affinity SSRIs/SNRIs and 102,631 users of low-affinity SSRIs/SNRIs. High-affinity SSRIs/SNRIs were not associated with an increased risk of AUB compared with low-affinity SSRIs/SNRIs (incidence rates: 46.3 versus 42.4 per 1000 person-years, respectively; HR 1.01, 95 % CI 0.93-1.09). Duration of use, age, and comorbidities did not modify the risk. However, high-affinity SSRIs/SNRIs were associated with an increased risk of anemia (HR 1.29, 95 % CI 1.04-1.61) compared with low-affinity SSRIs/SNRIs.

LIMITATIONS

Residual confounding may still be present.

CONCLUSIONS

The risk of AUB did not differ between high- and low-affinity SSRIs/SNRIs. However, the potential risk of anemia suggests the need for monitoring and further investigation of the risk of AUB with these medications.

Iron deficiency anemia among women: An issue of health equity

Iron deficiency is the most common and widespread nutritional deficiency in the world. For women, the risk of iron deficiency and iron deficiency anemia increases due to iron demands during pregnancy and regular iron losses due to menstruation during reproductive years. These interrelated conditions are of public health concern as they are highly prevalent, and the negative consequences such as chronic fatigue, cognitive impairment and poor quality of life are broad and multifaceted. People of low socioeconomic status are at higher risk of iron deficiency due to low intake of expensive iron-rich foods, and decreased access to healthcare. In this review, we applied a health equity lens to describe the current state of care for women with iron deficiency with or without anemia. We have highlighted several structural challenges that span from the laboratory diagnosis, inconsistent screening guidelines, and stigma associated with heavy menstrual bleeding, to treatment barriers.

Parity, mode of birth, and long-term gynecological health: A follow-up study of parous and nonparous women in the Australian Longitudinal Study on Women's Health cohort

BACKGROUND

Although gynecological health issues are common and cause considerable distress, little is known about their causes. We examined how birth history is associated with urinary incontinence (UI), severe period pain, heavy periods, and endometriosis.

METHODS

We studied 7700 women in the Australian Longitudinal Study on Women's Health with an average follow-up of 10.9 years after their last birth. Surveys every third year provided information about birth history and gynecological health. Logistic regression was used to estimate how parity, mode of birth, and vaginal tears were associated with gynecological health issues. Presented results are adjusted odds ratios (OR) with 95% confidence intervals.

RESULTS

UI was reported by 16%, heavy periods by 31%, severe period pain by 28%, and endometriosis by 4%. Compared with women with two children, nonparous women had less UI (OR 0.35 [0.26-0.47]) but tended to have more endometriosis (OR 1.70 [0.97-2.96]). Also, women with only one child had less UI (OR 0.77 [0.61-0.98]), but more severe period pain (OR 1.24 [1.01-1.51]). Women with 4+ children had more heavy periods (OR 1.42 [1.07-1.88]). Compared with women with vaginal birth(s) only, women with only cesarean sections or vaginal birth after cesarean section had less UI (ORs 0.44 [0.34-0.58] and 0.55 [0.40-0.76]), but more endometriosis (ORs 1.91 [1.16-3.16] and 2.31 [1.25-4.28]) and heavy periods (ORs 1.21 [1.00-1.46] and 1.35 [1.06-1.72]). Vaginal tear(s) did not increase UI after accounting for parity and birth mode.

CONCLUSION

While women with vaginal childbirth(s) reported more urinary incontinence, they had less menstrual complaints and endometriosis.

COVID-19 and abnormal uterine bleeding: potential associations and mechanisms

The impact of COVID-19 on menstruation has received a high level of public and media interest. Despite this, uncertainty exists about the advice that women and people who menstruate should receive in relation to the expected impact of SARS-CoV-2 infection, long COVID or COVID-19 vaccination on menstruation. Furthermore, the mechanisms leading to these reported menstrual changes are poorly understood. This review evaluates the published literature on COVID-19 and its impact on menstrual bleeding, discussing the strengths and limitations of these studies. We present evidence consistent with SARS-CoV-2 infection and long COVID having an association with changes in menstrual bleeding parameters and that the impact of COVID vaccination on menstruation appears less significant. An overview of menstrual physiology and known causes of abnormal uterine bleeding (AUB) is provided before discussing potential mechanisms which may underpin the menstrual disturbance reported with COVID-19, highlighting areas for future scientific study. Finally, consideration is given to the effect that menstruation may have on COVID-19, including the impact of the ovarian sex hormones on acute COVID-19 severity and susceptibility and reported variation in long COVID symptoms across the menstrual cycle. Understanding the current evidence and addressing gaps in our knowledge in this area are essential to inform public health policy, direct the treatment of menstrual disturbance and facilitate development of new therapies, which may reduce the severity of COVID-19 and improve quality of life for those experiencing long COVID.

Bleeding assessment in a large cohort of patients with Osteogenesis Imperfecta

BACKGROUND

Osteogenesis Imperfecta (OI) is characterised by bone fragility. Among several features, easy bruising and multiple case reports on haemorrhagic events have been reported. This paper describes the diverse manifestations of bleeding and bruising in a large cohort of 328 OI patients. The aim of this study is to provide insight in the diverse aspects and therapeutic considerations of bleedings in OI.

METHODS

This descriptive cohort study was conducted at the National Expert Center for adults with OI in the Netherlands. Bleeding was assessed by the validated self-bleeding assessment tool (Self-BAT) The tool was distributed among 328 adults with different clinically confirmed types of OI.

RESULTS

195 of 328 invited patients (completion rate 60%) with OI type 1 (n = 144), OI type 3 (n = 17) and OI type 4 (n = 34), aged between 18 and 82 years, completed the tool. Self-BAT scores were above the normal range in 42% of all patients. For males Self-BAT scores were increased in 37% with a mean score of 3.7, ranged between 0 and 18. For females the Self-BAT scores were increased in 44% with a mean of 5.4 and a range of 0-24. No statistical differences in OI subtypes were found.

CONCLUSIONS

Bleeding tendency appears to be a relevant complication in OI patients as this study confirms the presumption of bleeding tendency. There are specific recommendations to clinicians who treat OI patients to consider an assessment of bleeding tendency and use potential interventions to reduce haemorrhagic complications and improve quality of life.

[Prevalence of menorrhagia among women in Reunion Island]

OBJECTIVES

To estimate the prevalence of menorrhagia in women in Reunion Island using the Higham score, to evaluate self-reporting as an alternative diagnostic method, and to study women's level of knowledge about menorrhagia and its impact on their quality of life.

METHODS

This was a descriptive, cross-sectional observational study involving 185 adult women with menstrual periods living in Reunion Island. Women volunteered to answer an online self-questionnaire proposed by healthcare professionals from January to May 2023 in Reunion Island. They completed a general information questionnaire, the Higham score, a menorrhagia knowledge questionnaire and a menstrual quality of life questionnaire.

RESULTS

The prevalence of menorrhagia in the sample was 48.1% using the Higham score and 46.5% using self-report. Women's level of knowledge about menorrhagia is still insufficient, given the significant impact on quality of life during menstruation among those suffering from this symptom.

CONCLUSION

The prevalence of menorrhagia in our sample of women on Reunion Island is high. Measures need to be taken to break the taboos surrounding menstruation, promote menstrual education and foster a better understanding by women of menstrual pathologies, particularly menorrhagia. Early detection of this symptom would enable faster treatment and avoid complications and adverse effects on quality of life.

Menstrual characteristics and associations with sociodemographic factors and self-rated health in Spain: a cross-sectional study

BACKGROUND

Evidence on how menstrual characteristics may differ based on socioeconomic factors and self-rated health is significantly scarce. The main aim of this study was to investigate the associations between menstrual characteristics, sociodemographic factors and self-rated health among women and people who menstruate (PWM) aged 18-55 in Spain.

METHODS

This cross-sectional study includes data from an online survey collected in March-July 2021 across Spain. Descriptive statistical analyses and multivariate logistic regression models were performed.

RESULTS

The analyses included a total of 19,358 women and PWM. Mean age at menarche was 12.4 (SD = 1.5). While 20.3% of our participants experienced a menstrual abundance over 80 ml, 64.1% reported having menstrual blood clots; 6.4% menstruated for longer than 7 days. 17.0% had menstrual cycles that were shorter than 21 days or longer than 35 days. Reports of moderate (46.3%) and high (22.7%) intensity menstrual pain were common. 68.2% of our participants experienced premenstrual symptoms in all or most cycles. The odds for lighter menstrual flow, shorter bleeding days and menstrual cycles were higher as age increased, and amongst participants with less educational attainment. Caregivers presented higher odds for abundant menstrual flow and longer menstruations. Reporting financial constraints and a poorer self-rated health were risk factors for abundant menstrual flow, menstrual blood clots, shorter/longer menstruations and menstrual cycles, premenstrual symptoms, moderate and intense menstrual pain.

CONCLUSIONS

This study suggests that age, educational attainment, caregiving, experiencing financial hardship and a poorer self-rated health may shape or mediate menstrual characteristics. It thus highlights the need to investigate and address social inequities of health in menstrual research.

Can storytelling of women's lived experience enhance empathy in medical students? A pilot intervention study

PURPOSE

This pilot study aimed to investigate the acceptability and efficacy of a patient storytelling intervention (live and recorded) on empathy levels of medical students.

MATERIALS AND METHODS

Medical students participated in a storytelling intervention that had three components: listening to live or recorded stories from women with abnormal uterine bleeding, reflective writing, and a debriefing session. Empathy scores of students pre- and post-intervention were measured using the Jefferson Scale of Empathy-student version (JSE-S). Students also completed a feedback survey. Descriptive and inferential statistics were used to analyse quantitative data and content analysis was used for text comments.

RESULTS

Both live and recorded storytelling interventions had positive effects on student's empathy scores post intervention. Overall, students were satisfied with the intervention and reported that it improved their understanding of life experiences of women. Suggestions were made for an in-person storytelling session and interactive discussion after listening to each story.

CONCLUSION

A storytelling intervention has the potential to improve medical students' empathy and understanding of lived experience of women with health conditions. This could be valuable when student-patient interactions are limited in healthcare settings, or to enable stories of small numbers of patient volunteers to reach students.

Adenomyosis in women undergoing hysterectomy for abnormal uterine bleeding associated with uterine leiomyomas

BACKGROUND

Uterine leiomyomas and adenomyosis are both common and often associated with abnormal uterine bleeding (AUB), including the symptom of heavy menstrual bleeding (HMB). Understanding the prevalence of adenomyosis in women with uterine leiomyomas could inform clinicians and patients in a way that may improve therapeutic approaches.

OBJECTIVE

To explore the prevalence of adenomyosis in a group of women who underwent hysterectomy for AUB-L, to determine the prevalence of submucous leiomyomas, and to examine the utility of preoperative ultrasound to detect the presence of adenomyosis.

METHODS

The Kaiser Permanente Hysterectomy Database (KPHD) was searched for women aged 18-52 undergoing hysterectomy for leiomyoma-associated chronic AUB (AUB-L) in 2018 and 2019. A target sample of 400 comprised those with at least 3 years in the Health System. Radiologists evaluated preoperative pelvic ultrasound images to determine leiomyoma size and level 2 FIGO type (submucous or other), and the linked electronic medical record abstracted for clinical features, including histopathological evidence of adenomyosis.

RESULTS

Of the 370 subjects that met the study criteria, adenomyosis was identified via histopathology in 170 (45.9%). There was no difference in the adenomyosis prevalence with (47.1%) and without (43.0%) at least one submucous leiomyoma. Subgroup analysis of ultrasound images by an expert radiologist for the presence of adenomyosis demonstrated a positive predictive value of 54.0% and a negative predictive value of 43.4%.

CONCLUSIONS

Adenomyosis was present in almost half of this AUB-L cohort undergoing hysterectomy and was equally prevalent in those with and without submucous leiomyomas as determined by sonographic evaluation. The imaging findings are in accord with prior investigators and demonstrate that 2-D ultrasound is insensitive to the presence of adenomyosis when the uterus is affected by leiomyomas. Further research is necessary to determine the impact of various adenomyosis phenotypes on the presence and severity of the symptom of HMB.

Menstrual cycle abnormalities in women: characteristics, perceptions, and health-seeking behaviours

OBJECTIVES

To evaluate menstruation characteristics, perceptions, and health-seeking behaviours in women.

METHODS

We conducted this cross-sectional study with 394 women between February 2021 and October 2021. According to the self-perception of women, menstruation characteristics were divided into two groups, including 'normal' and 'abnormal'. The data were collected using the Personal Information Form, Assessment Form of the Menstrual Cycle Characteristics, and Health-Seeking Behaviour Scale.

RESULTS

Among all women, 49.7% perceived their menstruation characteristics as 'normal', and 50.3% perceived them as 'abnormal'. The menstruation characteristics negatively affected the daily life of 57.6% of women in the normal group and 68.7% of women in the abnormal group. Online health-seeking behaviour was the most common behaviour of seeking remedy; however, professional health-seeking behaviour was inadequate. Among women who perceived their menstruation characteristics as 'normal', excessive menstrual bleeding, extreme pain, and adverse effects on daily life increased health-seeking behaviour. Among women who perceived their menstruation characteristics as 'abnormal', irregular cycles, frequent bleeding, low levels of bleeding, the use of too many pads, extreme pain, and adverse effects on daily life increased health-seeking behaviour.

CONCLUSION

The participants in this study exhibited insufficient health-seeking behaviour for abnormal menstruation characteristics. Women should be directed by health professionals to reliable online sources to seek help, and they should be encouraged to display professional health-seeking behaviour.

Evaluation of Radiofrequency Endometrial Ablation: A 17-year Canadian Experience

STUDY OBJECTIVE

The purpose of this study was to better elucidate radiofrequency endometrial ablation (REA) durability by assessing the probability of failure as defined by need for postablation hysterectomy. Age at index REA, duration from REA until hysterectomy, and REA failure (REAF) risk factors were analyzed.

DESIGN

A retrospective cohort study was conducted using patient data between April 1, 2002, and March 31, 2019. REAF cases were identified using operative procedure codes. Cox proportional hazard regression assessed the effect of age at index REA on time to postablation hysterectomy. Kaplan-Meier survival curve evaluated timing of postablation hysterectomy, stratified by age at index REA.

SETTING

This study was conducted at Regina General Hospital in Regina, Saskatchewan, Canada.

PATIENTS

Patient population included those who were 21 years of age or older, were premenopausal, and had a history of heavy menstrual bleeding at the time of REA.

INTERVENTIONS

The intervention under investigation was REA.

MEASUREMENTS AND MAIN RESULTS

The overall probability of postablation hysterectomy was 22.6%. The probabilities of postablation hysterectomy were 36.1% for women younger than 30 years (n = 128), 28% for women 30 to 34.9 years old (n = 528), 29.6% for women 35 to 39.9 years old (n = 1152), and 17.6% for women 40 years and older (n = 2221). Characteristics associated with REAF included tubal occlusion, cesarean section, dysmenorrhea, and chronic pelvic pain (p <.01) among women younger than 40 years. Leiomyomas accounted for higher failure rates in women 40 years and older (p <.01).

CONCLUSION

Postablation hysterectomy is more likely to occur in women younger than 40 years. REA can be considered in women aged 30 to 39.9 years old, who have no known REAF risk factors. Women younger than 40 years with REAF risk factors will experience higher rates of hysterectomy. Thus, the decision to proceed with REA should be individualized with careful consideration for the underlying causes of abnormal uterine bleeding, while respecting patient autonomy.

Prevalence of heavy menstrual bleeding and associations with physical health and wellbeing in low-income and middle-income countries: a multinational cross-sectional study

BACKGROUND

Data on the prevalence of heavy menstrual bleeding in low-income and middle-income countries (LMICs) are scarce. We aimed to assess the validity of a scale to measure heavy menstrual bleeding and calculate its prevalence in southern Asia and sub-Saharan Africa, and to examine associations between heavy menstrual bleeding and health outcomes.

METHODS

Between Aug 2, 2021 and June 14, 2022, we surveyed 6626 women across ten cities (Meherpur and Saidpur, Bangladesh; Warangal, Narsapur, and Tiruchirappalli, India; Kathmandu, Nepal; Dakar, Senegal; Nairobi, Kenya; Kampala, Uganda; and Lusaka, Zambia), including questions on demographics, health, and the SAMANTA scale, a six-item measure of heavy menstrual bleeding. We conducted confirmatory factor analysis to assess construct validity of the SAMANTA scale, calculated the prevalence of heavy menstrual bleeding, and used regression analyses to examine associations of heavy menstrual bleeding with health outcomes.

FINDINGS

4828 women were included in the final analytic sample. Factor analysis indicated a one-factor model representing heavy menstrual bleeding. In the pooled analytic sample, 2344 (48·6%) of 4828 women were classified as experiencing heavy menstrual bleeding, and the prevalence was lowest in Dakar (126 [38·3%] of 329 women) and Kampala (158 [38·4%] of 411 women) and highest in Kathmandu (326 [77·6%] of 420 women). Experiencing heavy menstrual bleeding was significantly associated with feeling tired or short of breath during the menstrual period (risk ratio 4·12 (95% CI 3·45 to 4·94) and reporting worse self-rated physical health (adjusted odds ratio 1·27, 95% CI 1·08 to 1·51), but was not associated with subjective wellbeing (β -3·34, 95% CI -7·04 to 0·37).

INTERPRETATION

Heavy menstrual bleeding is highly prevalent and adversely impacts quality of life in women across LMIC settings. Further attention is urgently needed to understand determinants and identify and implement solutions to this problem.

FUNDING

Bill & Melinda Gates Foundation, United States Agency for International Development, National Institutes of Health.

Efficacy and safety of vilaprisan in women with uterine fibroids: data from the ASTEROID 3 randomized controlled trial

OBJECTIVE

Vilaprisan is a highly potent selective progesterone receptor modulator shown to reduce heavy menstrual bleeding, induce amenorrhea, and diminish uterine fibroid volume in phase 2 studies. The objective of ASTEROID 3 was to demonstrate the superiority of vilaprisan compared with placebo in the treatment of heavy menstrual bleeding in women with uterine fibroids.

DESIGN

Randomized, double-blind, placebo-controlled, multicenter phase 3 study.

SETTING

Hospitals and medical centers.

PATIENT(S)

Women with ≥1 uterine fibroid of ≥3 cm and heavy menstrual bleeding of >80 mL/cycle.

INTERVENTION(S)

Women were randomly assigned to 1 of 4 treatment arms, which were planned to comprise 2 treatment periods of 12 weeks, each with vilaprisan (2 mg/d) or placebo that were continuous or separated by a break of one bleed.

MAIN OUTCOME MEASURE(S)

Amenorrhea (primary end point; <2 mL in the last 28 days of treatment) and heavy menstrual bleeding response (key secondary end point; <80 mL/cycle and >50% reduction in bleeding from baseline) were measured with the alkaline hematin method. Change in volume of the 3 largest fibroids from baseline to end of treatment was assessed by ultrasound. Safety was monitored throughout the study.

RESULT(S)

Overall, 75 women completed the first 12 weeks of treatment. Statistically significant and clinically meaningful differences were observed between the vilaprisan- and placebo-treated groups in both the full analysis and per-protocol sets. In the per-protocol set (n = 36 and n = 12 for the vilaprisan and placebo groups, respectively), amenorrhea was observed more frequently in women treated with vilaprisan than in those who received placebo (83.3% vs. 0%, P<.0001), with a median time to onset of 3 days in the vilaprisan group. Similarly, more vilaprisan- than placebo-treated women achieved a response in heavy menstrual bleeding (91.7% vs. 25.0%, P<.0001). Serious adverse events were reported for 22 (27.8%) of 79 women and were evenly distributed among the 4 groups receiving vilaprisan and/or placebo. None of these events led to study discontinuation or were related to the liver, and no new safety findings were identified compared with the earlier phase 2 ASTEROID studies.

CONCLUSION(S)

Vilaprisan is efficacious and well tolerated over 12 weeks in the treatment of heavy menstrual bleeding associated with uterine fibroids. Further investigations of the long-term efficacy and safety of vilaprisan are warranted.

CLINICAL TRIAL REGISTRATION NUMBER

NCT03400943 (ClinicalTrials.gov).

Dysmenorrhea, Workability, and Absenteeism in Australian Women

Background: This study determined the prevalence of bothersome menstrual symptoms and their association with workability in naturally menstruating women not using hormonal contraception. Materials and Methods: A representative sample of community-dwelling Australian women aged 18-39 years selected from two large national electronic databases responded to a survey on general health. This study focuses on self-reported dysmenorrhea and menstrual bleeding and their association with workability and absenteeism in working women, assessed by the Workability Index. Results: Of 3,555 women, 1,573 (44.2% [95% CI: 42.6%-45.9%]) reported moderate to severe dysmenorrhea and 774 (21.8% [95% CI: 20.4%-23.2%]) reported heavy to very heavy bleeding. Women with dysmenorrhea were 50% more likely to report poorer work performance and twice as likely to report more days of sick leave in the past year (absenteeism) than other women. Conclusions: Despite the availability of safe and effective management options, Australian working women aged 18-39 years continue to experience bothersome dysmenorrhea and menstrual bleeding. Dysmenorrhea is associated with increased absenteeism and poorer workability. Therefore, awareness needs to be raised among women and health care providers of ways to manage dysmenorrhea and heavy bleeding and the unmet need for intervention in the community, respectively.

Rates of medical or surgical treatment for women with heavy menstrual bleeding: the ECLIPSE trial 10-year observational follow-up study

Background

Heavy menstrual bleeding is a common problem that can significantly affect women's lives until menopause. There is a lack of evidence on longer-term outcomes after seeking health care and treatment for heavy menstrual bleeding.

Objectives

To assess the continuation rates of medical treatments and the rates of ablative and surgical interventions among women who had participated in the ECLIPSE trial (ISRCTN86566246) 10 years after initial management for heavy menstrual bleeding in primary care. To explore experiences of heavy menstrual bleeding and influences on treatment for women.

Design

This was a prospective observational cohort study, with a parallel qualitative study.

Setting

Primary care.

Participants

A total of 206 women with heavy menstrual bleeding who had participated in the ECLIPSE trial consented to providing outcome data via a questionnaire approximately 10 years after original randomisation. Their mean age at follow-up was 54 years (standard deviation 5 years). A purposeful sample of 36 women also participated in semistructured qualitative interviews.

Interventions

The ECLIPSE trial randomised participants to either the levonorgestrel-releasing intrauterine system (52 mg) or the usual medical treatment (oral tranexamic acid, mefenamic acid, combined oestrogen-progestogen or progesterone alone, chosen as clinically appropriate by general practitioners and women). Women could subsequently swap or cease their allocated treatment.

Main outcome measures

The main outcome measures were rates of ablative and surgical treatments; the rate of continuation of medical treatments; and quality of life using the Short Form questionnaire-36 items and EuroQol-5 Dimensions; women's experiences of heavy menstrual bleeding; and the influences on their decisions around treatment.

Results

Over the 10-year follow-up period, 60 out of 206 (29%) women had received a surgical intervention [hysterectomy, n = 34 (17%); endometrial ablation, n = 26 (13%)]. Between 5 and 10 years post trial intervention, 89 women (43%) had ceased all medical treatments and 88 (43%) were using the levonorgestrel-releasing intrauterine system alone or in combination with other oral treatments. More women in the usual medical treatment group had also used the levonorgestrel-releasing intrauterine system than women in the levonorgestrel-releasing intrauterine system group. Fifty-six women (28%) used the levonorgestrel-releasing intrauterine system at 10 years. There was no statistically significant difference in generic quality-of-life scores between the two original trial groups, although small improvements in the majority of domains were seen in both groups across time. Women reported wide-ranging impacts on their quality of life and normalisation of their heavy menstrual bleeding experience as a result of the taboo around menstruation. Women's treatment decisions and experiences were influenced by the perceived quality of health-care interactions with clinicians and their climacteric status.

Limitations

Fewer than half of the original 571 participants participated; however, the cohort was clinically and demographically representative of the original trial population.

Conclusions

Medical treatments for women with heavy menstrual bleeding can be initiated in primary care, with low rates of surgical intervention and improvement in quality of life observed 10 years later. Clinicians should be aware of the considerable challenges that women with heavy menstrual bleeding experience at presentation and subsequently over time, and the importance and value to women of patient-centred communication in this context.

Future work

Any further evaluation of treatments for heavy menstrual bleeding should include long-term evaluation of outcomes and adherence.

Trial registration

The original ECLIPSE trial was registered as ISRCTN86566246.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 17. See the NIHR Journals Library website for further project information.

Heavy menstrual bleeding in adolescents: incidence, diagnostics, and management practices in primary care

BACKGROUND

Heavy menstrual bleeding (HMB), self-reported by 37% of adolescents, can be the first sign of a bleeding disorder (BD) during adolescence. The Dutch general practitioner (GP) guideline demands laboratory diagnostics and referral for patients at risk for a BD. How often adolescents consult the GP for HMB and which diagnostic and management strategies are used are unknown.

OBJECTIVES

This study aims to estimate the incidence of HMB in adolescents in primary care and to identify diagnostic and management practices for HMB, considering the HMB GP guideline.

METHODS

Retrospective analyses of a GP network database containing over 200 Dutch GPs were performed. Adolescents aged 10 to 21 years, with a new diagnosis of HMB between 2010 and 2020, and a 6-month follow-up were eligible. The incidence rate and diagnostic and therapeutic strategy data were extracted.

RESULTS

We identified 1879 new diagnoses of HMB in adolescents. The average incidence rate was 7.91 per 1000 person-years. No diagnostic studies were performed in 67%. Laboratory studies were mainly restricted to hemoglobin levels (31%). Full coagulation screening occurred in 1.3%, and ferritin levels in 10%. Medication was prescribed in 65%; mostly hormonal treatment (56%) and/or nonsteroidal antiinflammatory drugs (NSAIDs) (18%). The referral rate was higher after >2 follow-up visits (6.7%) vs after 1 GP visit for HMB (1.6%; Odds ratio: 8.8; 95% CI: 5.1-15), mostly to gynecologists (>85%).

CONCLUSION

According to this GP database study, few adolescents visit their GP with HMB despite its high self-reported incidence. Most adolescents were prescribed hormonal contraception without further diagnostics. Referral was rare and mostly occurred after multiple follow-up visits.

Menstrual abnormalities after COVID-19 vaccination in the Netherlands: A description of spontaneous and longitudinal patient-reported data

AIMS

During the COVID-19 vaccination campaigns, the number of reports of menstrual abnormalities increased rapidly. Here, we describe the nature and potential risk factors associated with menstrual abnormalities based on spontaneously reporting data as well as data from a prospective cohort event monitoring (CEM) study as these are poorly studied.

METHODS

Reports of menstrual abnormalities received by the Netherlands Pharmacovigilance Centre Lareb in the spontaneous reporting system between February 2021 and April 2022 were summarized. In addition, logistic regression analysis was performed on the reported menstrual abnormalities in the CEM study to assess the association between person characteristics, prior SARS-CoV-2 infection and use of hormonal contraceptives and the occurrence of menstrual abnormalities after vaccination.

RESULTS

We analysed over 24 000 spontaneous reports of menstrual abnormalities and over 500 episodes (among 16 929 included women) of menstrual abnormalities in the CEM study. The CEM study showed an incidence of 41.4 per 1000 women aged ≤54 years. Amenorrhoea/oligomenorrhoea and heavy menstrual bleeding collectively accounted for about half of all abnormalities reported. Significant associations were observed for the age group 25-34 years (odds ratio 2.18; 95% confidence interval 1.45-3.41) and the Pfizer vaccine (odds ratio 3.04; 95% confidence interval 2.36-3.93). No association was observed for body mass index and presence of most comorbidities assessed.

CONCLUSION

The cohort study showed a high incidence of menstrual disorders among women aged ≤54 years, and this observation was supported by the analysis of spontaneous reports. This suggests that a relation between COVID-19 vaccination and menstrual abnormalities is plausible and should be further investigated.

Iron deficiency and sexual dysfunction in women

INTRODUCTION

Sexual dysfunction negatively affects approximately 40% to 50% of adult women across various stages of life. Common risk factors include sexual traumas, relationship problems, chronic conditions, medication side effects, and poor physical health, including iron deficiency.

OBJECTIVES

This review summarizes a presentation from a symposium that discussed the types and causes of sexual dysfunction at key times in women's lives, focusing on the relationship between iron deficiency and sexual dysfunction.

METHODS

The symposium was held at the XV Annual European Urogynaecological Association Congress, Antibes, France, in October 2022. Symposium content was identified through literature searches of PubMed. Original research, review articles, and Cochrane analyses discussing sexual dysfunction in association with iron deficiency/anemia were included.

RESULTS

Iron deficiency in women is commonly caused by abnormal uterine bleeding, but women may develop iron deficiency anemia (IDA) because of increased iron needs or reduced iron intake/absorption. Treatment with oral iron supplementation has been shown to improve sexual function in women with IDA. Ferrous sulphate is considered as a standard of care for oral iron treatment; prolonged-release iron formulations have improved tolerability, enabling lower doses and better tolerability.

CONCLUSION

IDA and sexual dysfunction are related, so the identification of sexual dysfunction or iron deficiency in a woman should prompt an investigation of the other condition. Testing for iron deficiency is an inexpensive and simple step that can be routinely included in the workup of women with sexual dysfunction. Once identified, IDA and sexual dysfunction in women should be treated and followed to optimize quality of life.

The Perceived Impact of Iron Deficiency and Iron Therapy Preference in Exercising Females of Reproductive Age: A Cross-Sectional Survey Study

Background

Patient perceptions of iron deficiency and efficacy of iron therapy may differ from the interpretations of doctors. Qualitative investigation at an individual level related may help define patient expectations and therapeutic targets. Therefore, we aimed to explore this concept in exercising females of reproductive age.

Methods

Exercising females (n = 403) who either (a) were currently experiencing iron deficiency, or (b) have experienced iron deficiency in the past were included. A survey comprising open-ended text response questions explored three 'domains': (1) the impact of iron deficiency, (2) the impact of iron tablet supplementation (where applicable), and (3) the impact of iron infusion treatment (where applicable). Questions were asked about training, performance, and recovery from exercise. Survey responses were coded according to their content, and sentiment analysis was conducted to assess responses as positive, negative, or neutral.

Results

Exercising females showed negative sentiment toward iron deficiency symptoms (mean range = -0.94 to -0.81), with perception that fatigue significantly impacts performance and recovery. Iron therapies were perceived to improve energy, performance, and recovery time. Participants displayed a strong positive sentiment (mean range = 0.74 to 0.79) toward iron infusion compared to a moderately positive sentiment toward oral iron supplementation (mean range = 0.44 to 0.47), with many participants perceiving that oral iron supplementation had no effect.

Conclusion

In Australia, women prefer an iron infusion in treatment of iron deficiency compared to oral iron.

Contemporary evaluation of women and girls with abnormal uterine bleeding: FIGO Systems 1 and 2

Abnormal uterine bleeding (AUB) is common, often debilitating, and may affect over 50% of reproductive-aged women and girls. Whereas AUB is a collection of symptoms that include intermenstrual bleeding and abnormalities in period duration, cycle length, and regularity, it is heavy menstrual bleeding (HMB) that is most contributory to iron deficiency and related anemia. It is apparent that AUB, in general, and HMB, in particular, remain underrecognized and underreported. FIGO created two systems for assessing and classifying AUB. FIGO System 1 defines the bleeding pattern using four primary descriptors: frequency, duration, regularity, and flow volume. FIGO System 2 provides a structured classification system of possible causes of AUB, using the acronym PALM-COEIN. "PALM" refers to structural causes of AUB (Polyp, Adenomyosis, Leiomyoma, Malignancy), and "COEI" refers to nonstructural causes (Coagulopathy, Ovulatory dysfunction, Endometrial, and Iatrogenic). The "N" is reserved for those entities that are currently not otherwise classified. Using FIGO System 1 as a gateway to FIGO System 2 streamlines the investigation of reproductive-aged women and girls with AUB. Understanding the pathogenesis of the FIGO System 2 "PALM-COEIN" causes helps interpret investigations and the onward management of AUB. Numerous evidence gaps exist concerning AUB; however, if researchers and trialists universally adopt FIGO Systems 1 and 2 for the assessment and diagnosis of AUB, clear translatable research findings can be applied globally.

Our path from abnormal uterine bleeding and iron deficiency to impaired fetal development: A long and winding road

Abnormal uterine bleeding adversely impacts the lives of reproductive‐aged girls and women; furthermore, the resulting periconceptual iron deficiency risks enduring neurological sequelae in the child.

Qualitative study exploring which research outcomes best reflect women's experiences of heavy menstrual bleeding: stakeholder involvement in development of a core outcome set

OBJECTIVE

This work contributed to the development of a core outcome set (COS) for heavy menstrual bleeding (HMB). The objective was to determine which research outcomes best reflect how HMB affects women's lives and to identify additional research outcomes, not previously reported. It was important to explore and record participants' reasoning for prioritising outcomes and use this information to reinforce the patients' voice during later phases of the COS development.

DESIGN

Patient workshop discussions and telephone interviews.

SETTING

East London teaching hospital.

PARTICIPANTS

Inclusion criteria were that participants must be over 18 years old, that either they or their partner had a history of HMB and that they had a good understanding of written and spoken English.

RESULTS

41 participants were recruited for the study. 8 women and 1 man completed the study. The eight female participants were representative of the different underlying causes and treatments for HMB. Participants ranged in age from their early 20s to their 60s and represented a range of ethnic groups. The five main themes that were identified as being important to patients were: 'restriction', 'relationships and isolation', 'emotions and self-perception', 'pain' and 'perceptions of treatment'. We identified eight coding nodes that did not correspond with our list of previously reported outcomes in studies of HMB. These nodes were consolidated and became five new outcomes for potential inclusion in the COS.

CONCLUSIONS

HMB stops women living their lives as they would wish. It affects their relationships, education, careers, reproductive wishes, social life and mental health. This is a condition of girls and women in the prime of their lives, but for many, the constant threat of a heavy period starting means that they sacrifice that freedom. The societal and economic costs of women being incapacitated every month has an effect on everyone.

TRIAL REGISTRATION

The COS study is registered with the COMET (Core Outcome Measures in Effectiveness Trials) Initiative-project reference number 789.

Impact of iron supplementation on patient outcomes for women with abnormal uterine bleeding: a protocol for a systematic review and meta-analysis

BACKGROUND

Abnormal uterine bleeding (AUB), which includes heavy menstrual bleeding (HMB), is a common condition placing women at increased risk for developing iron deficiency and iron deficiency anemia (IDA). Depletion of iron stores has negative implications on physical, social, and emotional health, as well as quality of life. Iron supplements are safe, effective, and readily available, while red blood cell (RBC) transfusions have inherent risks including infectious and immune reactions. Despite high prevalence of IDA among women with AUB, there are limited studies on the impact of iron therapies on patient outcomes. This systematic review and meta-analysis will evaluate the impact of iron supplementation on patient outcomes for women with AUB, when compared to combination therapy, no intervention, placebo, or standard of care.

METHODS

We will conduct a systematic review and meta-analysis of randomized controlled trials and observational studies evaluating the impact of iron interventions on patient outcomes for women with AUB. Systematic literature searches will be conducted in major databases including MEDLINE, EMBASE, CENTRAL, CINAHL, and Web of Science. Studies assessing the impact of iron interventions on patient outcomes in women experiencing AUB, in comparison to combination therapy, no intervention, placebo, or standard of care, will be included in the review. Independent reviewers will screen for eligibility, assess risk of bias, and abstract data. Overall certainty of evidence for each outcome will be assessed using the GRADE approach. We will meta-analyze outcomes which are sufficiently homogeneous to summarize intervention effects and narratively synthesize nonhomogeneous outcomes. The main outcomes of interest are hemoglobin levels immediately prior to surgery and post-operatively, number of RBC transfusions, and adverse effects. Secondary outcomes will include length of hospital stay, intraoperative blood loss, adverse and side effects, quality of life, and iron indices.

DISCUSSION

This review will evaluate the impact of iron interventions on patient outcomes in women with IDA secondary to AUB with focus on changes in hematological and iron indices, red blood cell utilization, quality of life, cost of treatment, and adverse events. The results will inform evidence-based clinical practice for the management of iron deficiency and IDA secondary to AUB.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019137282.

The relationship between heavy menstrual bleeding, iron deficiency, and iron deficiency anemia

For reproductive-aged women, the symptom of heavy menstrual bleeding is highly prevalent and a major contributor to iron deficiency and its most severe manifestation, iron deficiency anemia. It is recognized that these 2 clinical entities are not only highly prevalent, but their interrelationship is poorly appreciated and frequently normalized by society, healthcare providers, and affected girls and women themselves. Both heavy menstrual bleeding and iron deficiency, with or without anemia, adversely impact quality of life-heavy menstrual bleeding during the episodes of bleeding and iron deficiency on a daily basis. These combined issues adversely affect the lives of reproductive-aged girls and women of all ages, from menarche to menopause, and their often-insidious nature frequently leads to normalization. The effects on cognitive function and the related work and school absenteeism and presenteeism can undermine the efforts and function of women in all walks of life, be they students, educators, employers, or employees. There is also an increasing body of evidence that suggests that iron deficiency, even in early pregnancy, may adversely impact fetal neurodevelopment with enduring effects on a spectrum of cognitive and psychological disorders, critically important evidence that begs the normalization of iron stores in reproductive-aged women. The authors seek to raise individual, societal, and professional awareness of this underappreciated situation in a fashion that leads to meaningful and evidence-based changes in clinical guidance and healthcare policy directed at preventing, screening, diagnosing, and appropriately managing both disorders. This manuscript provides evidence supporting the need for action and describes the elements necessary to address this pervasive set of conditions that not only affect reproductive-aged girls and women but also the lives of children everywhere.

Risk of Hysterectomy After Endometrial Ablation: A Systematic Review and Meta-analysis

OBJECTIVE

To assess the risk of hysterectomy after nonresectoscopic endometrial ablation in patients with heavy menstrual bleeding.

DATA SOURCES

The EMBASE, MEDLINE, ClinicalTrials.gov and Cochrane databases were searched for eligible articles from inception until June 13, 2022. We used combinations of search terms for endometrial ablation and hysterectomy.

METHODS OF STUDY SELECTION

Articles included in the review described the incidence of hysterectomy at a specific point in time after ablation with a minimum follow-up duration of 12 months.

TABULATION, INTEGRATION, AND RESULTS

The literature search yielded a total of 3,022 hits. A total of 53 studies met our inclusion and exclusion criteria, including six retrospective studies, 24 randomized controlled trials, and 23 prospective studies. A total of 48,071 patients underwent endometrial ablation between 1992 and 2017. Follow-up duration varied between 12 and 120 months. Analyses per follow-up moment showed 4.3% hysterectomy rate at 12 months of follow-up (n=29 studies), 11.1% at 18 months (n=1 study), 8.0% at 24 months (n=11 studies), 10.2% at 36 months (n=12 studies), 7.6% at 48 months (n=2 studies), and 12.4% at 60 months (n=6 studies). Two studies reported a mean hysterectomy rate at 10 years after ablation of 21.3%. Minimal clinically relevant differences in hysterectomy rates were observed among the different study designs. Furthermore, we found no significant differences in hysterectomy rate among the different nonresectoscopic endometrial ablation devices.

CONCLUSION

The risk of hysterectomy after endometrial ablation seems to increase from 4.3% after 1 year to 12.4% after 5 years. Clinicians can use the results of this review to counsel patients about the 12% risk of hysterectomy 5 years after endometrial ablation.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42020156281.

Hypophosphataemia risk associated with ferric carboxymaltose in heart failure: A pooled analysis of clinical trials

AIMS

Iron deficiency is a common finding among patients with heart failure (HF) and is associated with adverse outcomes, including decreased quality of life, increased risk of hospitalization, and decreased survival. Intravenous ferric carboxymaltose (FCM) has been shown to improve outcomes among patients with HF and concomitant iron deficiency, but FCM is associated with an increased risk of hypophosphataemia. We aimed to better characterize this risk among HF populations.

METHODS AND RESULTS

This pooled analysis examined data from 41 studies of adults with iron deficiency across disease states and therapeutic areas. Among the 7931 patients treated with FCM available for analysis, 14% made up the HF subgroup. Additional subgroups included women's health (36%), non-dialysis-dependent chronic kidney disease (NDD-CKD; 27%), haemodialysis-dependent chronic kidney disease (HD-CKD; 1%), gastrointestinal (10%), neurology (3%), and other (10%). The incidence of post-baseline moderate or severe hypophosphataemia (i.e. serum phosphate [PO4 3- ] level <2.0 mg/dL) varied across the therapeutic areas, with the lowest incidences observed in the HD-CKD (0%), HF (8.1%), and NDD-CKD (12.8%) subgroups. The prevalence of moderate or severe hypophosphataemia among the women's health, other, gastrointestinal, and neurology subgroups was 30.1%, 40.6%, 51.0%, and 55.6%, respectively. In the HF subgroup, one patient (<0.1%) had a serum PO4 3- of <1.0 mg/dL recorded, compared with 4.8% and 4.0% of the subjects in the neurology and gastrointestinal groups, respectively. With the exception of the HD-CKD subgroup, mean serum PO4 3- levels decreased through weeks 2 to 4, and then returned toward baseline and plateaued by week 8. The strongest predictor of hypophosphataemia was preserved kidney function (estimated glomerular filtration rate: >60 mL/min/1.73 m2 vs. <30 mL/min/1.73 m2 ; odds ratio: 12.2). Among patients in the HF subgroup, the incidence of treatment-emergent adverse events potentially related to hypophosphataemia (e.g. cardiac failure, ventricular tachyarrhythmias, fatigue, muscle weakness, bone pain, neurological symptoms, and muscle pain) was lower among FCM-treated patients than among those receiving placebo, and lower among patients with a post-baseline PO4 3- <2 mg/dL vs. those not meeting such criteria.

CONCLUSIONS

The risk of laboratory-assessed hypophosphataemia in HF patients treated with FCM was lower than that seen in patients in other therapeutic areas treated with FCM, and clinical events associated with hypophosphataemia are uncommon with FCM therapy in this population. Appropriate monitoring, particularly soon after administration in the unlikely event of repeated dosing in HF patients, will allow for further refinement of management strategies. [Correction added on 24 February 2023, after first online publication: In the preceding sentence, "…administration, will allow…" has been corrected to "…administration in the unlikely event of repeated dosing in HF patients, will allow…" in this version.].

Women's experiences of heavy menstrual bleeding and medical treatment: a qualitative study in primary care

BACKGROUND

Heavy menstrual bleeding (HMB) is common and can affect women's lives. Evidence on women's experiences and their treatment of this problem after seeking primary care is lacking.

AIM

To explore women's experiences of HMB and their medical treatment up to 10 years after initial management in general practice.

DESIGN AND SETTING

This was a qualitative study in UK primary care.

METHOD

Semistructured interviews with a purposeful sample of 36 women who had participated in the ECLIPSE trial of medical treatments for HMB in primary care (levonorgestrel-releasing intrauterine system or other usual medical treatments - oral tranexamic acid, mefenamic acid, combined oestrogen-progestogen; or progesterone alone). Data were analysed thematically and a process of respondent validation was undertaken.

RESULTS

Women reported the wide-ranging and debilitating impact of HMB on their lives. They had often normalised their experience underlining persisting societal taboos about menstruation and reflecting low general awareness of HMB as treatable. Women commonly delayed seeking help for several years. They could then be frustrated by lack of a medical explanation for HMB. Women who had pathology identified felt able to make better sense of their HMB. Experiences of medical treatments varied considerably but were strongly influenced by the perceived quality of healthcare interactions with clinicians. Other influences on women's treatment included considerations for their fertility, health concerns, family and peers, and views when approaching menopause.

CONCLUSION

Clinicians should be aware of the considerable challenges faced by women with HMB; widely differing experiences of, and influences on, their treatment; and the value of patient-centred communication in this context.

Quality of information regarding abnormal uterine bleeding available online

INTRODUCTION

The Internet and electronic devices with Internet access allow for a greater fluidity of information and speed of communication, especially in the field of health. Abnormal uterine bleeding (AUB) affects approximately 3-30% of women and can negatively impact their health and quality of life. Information regarding AUB that is available on the Internet may not be clear or accurate, rendering it difficult to understand and likely to result in delayed medical evaluation, which subsequently leads to worsening of the AUB.

OBJECTIVE

To evaluate the quality of the information regarding AUB currently available on the Internet, including information regarding treatments.

METHODS

The Google Trends website was searched for the most widely used English terms related to AUB. The identified descriptors were searched individually on the Google, Yahoo!, and Bing search engines. The first 10 results of each search were pre-selected and evaluated for inclusion in this study. Selected websites were categorically divided into two groups (news/magazine and academic) and individually analyzed by three experts using the DISCERN quality criteria (reliability, general quality, and quality of information) and the presence or absence of the Health on the Net Foundation Code of Conduct (HONcode®) seal.

RESULTS

Of the 168 websites included in this study, 60.1% were allocated to the news/magazine group and 39.9% were allocated to the academic group. Over half of the websites (54.2%) did not have the HONcode® quality seal. Websites in the academic group were more likely to include accurate information regarding AUB with greater reliability than websites in the news/magazine group. There were no statistical differences regarding the general quality of the websites. Most websites were rated as either moderate quality (70.8%) or low quality (28.6%). The HONcode® criterion was found to be a confounding factor of the analyses, as the grouping and quality results of websites without this seal were significantly associated. In addition, websites in the news/magazines group were 6.7 times more likely to provide low quality information than websites in the academic group (odds ratio: 6.7; 95% confidence interval: 2.1-21.4).

CONCLUSION

The information regarding AUB that is available on the Internet is of low to moderate quality. Academic websites present more reliable information of greater quality. The presence of the HONcode® seal is considered important to determine the quality of the content of a website, especially for news/magazine websites, and may help Internet users identify websites that contain more reliable information. Algorithms and applications that categorize the quality of information and the reliability of health content may be useful tools that can help patients clarify their symptoms for several conditions including AUB.

A need to increase von Willebrand disease awareness: vwdtest.com - A global initiative to help address this gap

Von Willebrand disease (VWD) is an inherited bleeding disorder caused by quantitative or qualitative deficiencies in von Willebrand factor (VWF). People with VWD may experience excessive, recurrent or prolonged bleeding, particularly during menstruation, childbirth, surgery or following trauma. However, many VWD patients are undiagnosed, and therefore inadequately treated. Reasons for the underdiagnosis of VWD include its relatively mild symptoms, complex diagnosis, lack of awareness among non-specialist healthcare providers and the general population, and a lack of prioritisation of disorders disproportionately affecting females. The vwdtest.com platform was launched as part of a global initiative to raise awareness and improve diagnosis of VWD. Besides providing VWD-specific educational resources, the website includes an online bleeding self-assessment tool and offers diagnostic support for individuals, and their providers, who have a score suggestive of a bleeding disorder. vwdtest.com helps to address these unmet needs, especially in regions with limited access to educational and diagnostic resources.

Interaction predictors of self-perception menstrual symptoms and influence of the menstrual cycle on physical performance of physically active women

OBJECTIVE

To analyze the physical performance, self-perception menstrual symptoms, of physically active eumenorrheic women with endogenous ovarian cycle in two phases of the menstrual cycle.

METHODS

Twenty-six women participated in the study (age 25.8 ± 3.9 years; height 1.64 ± 0.58 m; mass 64 ± 12.32 kg; menarche 11.69 ± 1.28 years). Assessments were performed in two phases of the menstrual cycle (MC), Early-Follicular Phase (FP) and Mid-Luteal Phase (LP), performance was assessed through total time to exhaustion (TTE), complete stages (CE), and final speed (FE), through a graded exercise test (GXT). Information on the participants' menstrual symptoms and their perceptions of the influence of MC on their performance were also collected. Data normality was assessed using the Shapiro-Wilk test. Paired analyses were conducted (t test or Wilcoxon) to examine the responses between the menstrual phases. The interaction analysis of symptom predictors was performed by multiple linear regression, with a significance level of p ≤ 0.05.

RESULTS

There was no significant difference in physical performance between the phases during the GXT in TTE (mean difference 8.50; 95% CI - 11.99 to 42; p = 0.36). During FP, women with heavy flow had shorter performance in the GXT (t = - 2.5; p = 0.01), demonstrating an r² = 0.32. In LP, for the women who reported not having the perception of the influence of the menstrual cycle on exercise, the total test time was longer (t = 2.55; p = 0.01), with an r² = 0.45.

CONCLUSION

There was no difference in physical performance between FP and LP. However, menstrual flow intensity and perception of cycle interference demonstrated a decrease in TTE.

Prevalence of abnormal uterine bleeding in Brazilian women: Association between self-perception and objective parameters

INTRODUCTION

Abnormal uterine bleeding (AUB) is the main cause of demand for gynecological care during the reproductive period, with negative consequences on women's lives. In Brazil, data on the prevalence of AUB is scarce and does not reflect the national reality.

OBJECTIVE

To evaluate the prevalence of AUB and associated factors in Brazil.

METHODS

Multicenter cross-sectional study, including 8 centers representing the 5 official geographic regions of Brazil. It included postmenarchal women who answered a sociodemographic questionnaire, with socioeconomic stratum and data related to uterine bleeding (self-perception of AUB and objective data).

RESULTS

1928 women were included, with 35.5±12.5 years of age, 167 postmenopausal. The 1761 women in their reproductive period, had a menstrual cycle duration of 29.2±20.6 days, with bleeding for 5.6±4.0 days. In these, the prevalence of AUB, considering self-perception by the women, was 31.4%. Only among women who considered their bleeding abnormal, the menstrual cycle lasted less than 24 days in 28.4%, bleeding lasted longer than 8 days in 21.8%, 34.1% reported intermenstrual bleeding and 12.8% reported postcoital bleeding. Also, regarding these women, 47% reported a previous diagnosis of anemia, with 6% requiring intravenous treatment (iron or blood transfusion). Half of the women mentioned that the menstrual period had a negative impact on quality of life, while this worsening occurs in about 80% of those with self-perception of AUB.

CONCLUSION

In Brazil, the prevalence of AUB is 31.4%, assessed by self-perception, in agreement with objective AUB parameters. The menstrual period has a negative impact on the quality of life of 8 out of 10 women with AUB.

From menarche to menopause, heavy menstrual bleeding is the underrated compass in reproductive health

Menstruation is defined as monthly uterine bleeding, regarded as a sign of reproductive health. When characterized by excessive bleeding (heavy menstrual bleeding [HMB]), it may act as a useful clinical marker for diagnosis of reproductive diseases. Endometrial and myometrial mechanisms underlying abnormal uterine bleeding (AUB), which includes HMB, have hormonal, cellular, and molecular aspects. Structural and nonstructural causes of AUB, presenting with HMB as the major symptom, result in iron depletion and consequent anemia. Heavy menstrual bleeding can be considered as a single entity to identify the possible underlying causes, which may be different to some extent to those of AUB, as a whole. Furthermore, the difficulties in defining HMB through objective methods do not allow the current epidemiological scenario on the prevalence of the symptom among reproductive-age women to be outlined. Moreover, the introduction of new diagnostic methods, including imaging technologies, entails a revision of the available figures on HMB in different age groups from menarche to menopause. In addition, a proper diagnostic algorithm for HMB should be implemented to adapt recommendations for clinical investigation when HMB is present.

Investigation and management of abnormal uterine bleeding in reproductive-aged women: a descriptive review of national and international recommendations

PURPOSE

To review and compare the most recently published recommendations on the investigation and management of abnormal uterine bleeding (AUB).

MATERIALS AND METHODS

A descriptive review of recommendations from the American College of Obstetricians and Gynaecologists (ACOG), the National Institute for Health and Care Excellence (NICE), the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), the Society of Obstetricians and Gynaecologists of Canada (SOGC) and the International Federation of Gynaecology and Obstetrics (FIGO) on AUB in reproductive-aged women was carried out.

RESULTS

There is a consensus that detailed personal and family history along with physical examination are essential in the investigation of menstrual, intermenstrual or postcoital AUB. All the medical societies recommend transvaginal ultrasound as the first-line imaging modality to determine the AUB cause. Moreover, they agree (except for RANZCOG) that, in women with AUB, endometrial biopsy should only be performed if additional risk factors for endometrial cancer are present. Laboratory tests may be helpful in the AUB investigation; however, there are several discrepancies among the recommendations. Regarding AUB management, NICE, ACOG and SOGC agree that the administration of hormonal or non-hormonal medications should be the first-line treatment modality in bleeding disorders and absent or minor structural pelvic pathology. Surgical management should be preferred in cases of identified polyps, large fibroids or unsuccessful pharmacological treatment.

CONCLUSIONS

Since AUB affects a significant proportion of reproductive-aged women, the main objective is to improve the quality of life of these patients without missing cases of malignancy.

Quality of Life of Japanese Dysmenorrhea/Heavy Menstrual Bleeding Patients Treated with Levonorgestrel Intrauterine Delivery System in a Real-World Setting

INTRODUCTION

The present study collected 1-year follow-up patient-reported outcome data from Japanese women with dysmenorrhea and/or heavy menstrual bleeding (HMB) who underwent insertion of the levonorgestrel-releasing intrauterine system (LNG-IUS) 52 mg. We aimed to evaluate the quality of life (QOL) of Japanese women over the course of the investigational period.

METHODS

This was a multicenter, non-interventional, prospective, single-cohort, post-marketing surveillance study (J-MIRAI). The primary outcome was the median change in the Menstrual Distress Questionnaire (MDQ) and Menorrhagia Multi-Attribute Scale (MMAS) scores from baseline to 3 and 12 months after LNG-IUS insertion, with decreasing and increasing scores, respectively, indicating improvement. The secondary outcomes were the statistical relationships between the MDQ and menstrual pain (measured by a visual analog scale, VAS), and between the MMAS and pictorial blood loss assessment chart (PBAC) scores by regression analysis.

RESULTS

In total, 593 patients were evaluated; 376, 467, and 250 patients were diagnosed with dysmenorrhea, HMB, or both, respectively. The median MDQ score decreased significantly at 3 and 12 months after LNG-IUS insertion in both the premenstrual and menstrual periods (both p < 0.001 vs baseline), and the median MMAS score showed a similar improvement during the menstrual period. Changes in median MDQ and MMAS scores were observed regardless of patient background. Correlations between MDQ and menstrual pain (VAS) and between MMAS and PBAC scores were found (estimated regression coefficients 0.29 and - 0.15, respectively).

CONCLUSION

The LNG-IUS contributed to improvements in the QOL of patients with dysmenorrhea, HMB, and both, regardless of patient background characteristics.

TRIAL REGISTRATION

Registered at ClinicalTrials.gov (NCT02475356) on 18 June 2015.