Endometrial bleeding

A Mini-Review of Office Hysteroscopic Techniques for Endometrial Tissue Sampling in Postmenopausal Bleeding

Postmenopausal bleeding (PMB) is a common cause for a gynecological visit. Endometrial cancer risk varies from 3% to 25% in women with PMB. There is a significant concern of malignancy of the endometrium and the endocervical canal by a physician in postmenopausal women, and hence, most prefer operating room hysteroscopies with dilation and curettage (D & C) compared to in-office procedures. With increased availablility of miniaturized instruments such as mini- resectoscope and tissue removal systems, there is high likelihood of blind D & C being replaced by hysteroscopic- guided targetted biopsy or visual D & C. The cost-effectiveness of office hysteroscopy is also well demonstrated. In December 2020, an electronic search was performed of PubMed, MEDLINE, and Cochrane Library to look for articles on office hysteroscopic biopsy techniques in postmenopausal women from 2010 to 2020. Relevant studies were included where various office hysteroscopic techniques are used for endometrial sampling in PMB. Studies with 5 Fr scissors, biopsy forceps, crocodile forceps, cup forceps, bipolar electrode, in-office tissue removal system (morcellator), flexible hysteroscope, and mini-resectoscope were included. Standard reference was used as an adequate endometrial sample for histology. The objective of this review is to explore the current evidence on different office hysteroscopic techniques available for endometrial tissue sampling in PMB.

Effect of Oral Semaglutide on the Pharmacokinetics of Levonorgestrel and Ethinylestradiol in Healthy Postmenopausal Women and Furosemide and Rosuvastatin in Healthy Subjects

Background

The first oral glucagon-like peptide-1 receptor agonist (GLP-1RA) comprises semaglutide co-formulated with the absorption enhancer, sodium N-(8-[2-hydroxybenzoyl] amino) caprylate (SNAC). Oral semaglutide may alter the pharmacokinetics of co-administered drugs via effects of semaglutide or SNAC. Two separate one-sequence crossover trials investigated the effects of oral semaglutide and SNAC on the pharmacokinetics of ethinylestradiol, levonorgestrel, furosemide and rosuvastatin.

Methods

Healthy, postmenopausal women (n = 25) received once-daily combined ethinylestradiol and levonorgestrel (Trial 1) and healthy male and female subjects (n = 41) received single doses of furosemide and rosuvastatin (Trial 2), either alone, with SNAC alone or with oral semaglutide. Lack of drug–drug interaction was concluded if 90% confidence intervals (CIs) for the ratio of area under the plasma concentration–time curve (AUC) or maximum concentration (C_max), with/without oral semaglutide, were within a pre-specified interval (0.80–1.25).

Results

The AUC values of ethinylestradiol and levonorgestrel were not affected by oral semaglutide co-administration (estimated ratios [90% CI] 1.06 [1.01–1.10] and 1.06 [0.97–1.17], respectively); C_max was not affected. The no-effect criterion was not met for furosemide or rosuvastatin for the AUC (1.28 [1.16–1.42] and 1.41 [1.24–1.60], respectively) or C_max. SNAC alone did not affect the AUC or C_max of ethinylestradiol, levonorgestrel or rosuvastatin; the C_max of furosemide was slightly decreased. Adverse events were similar to those previously observed for GLP-1RAs (both trials).

Conclusion

Co-administration with oral semaglutide did not affect the pharmacokinetics of ethinylestradiol or levonorgestrel. There was a small increase in exposure of furosemide and rosuvastatin; however, these increases are not expected to be of clinical relevance.

Clinical Trial Registration Numbers

NCT02845219 and NCT03010475.

Supplementary Information

The online version contains supplementary material available at (10.1007/s40262-020-00976-x).

Endometrial vascular development in heavy menstrual bleeding: altered spatio-temporal expression of endothelial cell markers and extracellular matrix components

STUDY QUESTION

Are there any phenotypic and structural/architectural changes in the vessels of endometrium and superficial myometrium during the normal menstrual cycle in healthy women and those with heavy menstrual bleeding (HMB)?

SUMMARY ANSWER

Spatial and temporal differences in protein levels of endothelial cell (EC) markers and components of the extracellular matrix (ECM) were detected across the menstrual cycle in healthy women and these are altered in HMB.

WHAT IS KNOWN ALREADY

HMB affects 30% of women of reproductive age with ~50% of cases being idiopathic. We have previously shown that the differentiation status of endometrial vascular smooth muscle cells (VSMCs) is altered in women with HMB, suggesting altered vessel maturation compared to controls. Endometrial arteriogenesis requires the co-ordinated maturation not only of the VSMCs but also the underlying ECs and surrounding ECM. We hypothesized that there are spatial and temporal patterns of protein expression of EC markers and vascular ECM components in the endometrium across the menstrual cycle, which are altered in women with HMB.

STUDY DESIGN, SIZE, DURATION

Biopsies containing endometrium and superficial myometrium were taken from hysterectomy specimens from both healthy control women without endometrial pathology and women with subjective HMB in the proliferative (PP), early secretory (ESP), mid secretory (MSP) and late secretory (LSP) phases (N = 5 for each cycle phase and subject group). Samples were fixed in formalin and embedded in paraffin wax.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Serial sections (3μm thick) were immunostained for EC markers (factor VIII related antigen (F8RA), CD34, CD31 and ulex europaeus-agglutinin I (UEA-1) lectin), structural ECM markers (osteopontin, laminin, fibronectin and collagen IV) and for Ki67 to assess proliferation. Immunoreactivity of vessels in superficial myometrium, endometrial stratum basalis, stratum functionalis and luminal region was scored using either a modified Quickscore or by counting the number of positive vessels.

MAIN RESULTS AND THE ROLE OF CHANCE

In control samples, all four EC markers showed a dynamic expression pattern according to the menstrual cycle phase, in both endometrial and myometrial vessels. EC protein marker expression was altered in women with HMB compared with controls, especially in the secretory phase in the endometrial luminal region and stratum functionalis. For example, in the LSP expression of UEA-1 and CD31 in the luminal region decreased in HMB (mean quickscore: 1 and 5, respectively) compared with controls (3.2 and 7.4, respectively) (both P = 0.008), while expression of F8RA and CD34 increased in HMB (1.4 and 8, respectively) compared with controls (0 and 5.8, respectively) (both P = 0.008). There was also a distinct pattern of expression of the vascular structural ECM protein components osteopontin, laminin, fibronectin and collagen IV in the superficial myometrium, stratum functionalis and stratum basalis during the menstrual cycle, which was altered in HMB. In particular, compared with controls, osteopontin expression in HMB was higher in stratum functionalis in the LSP (7.2 and 11.2, respectively P = 0.008), while collagen IV expression was reduced in stratum basalis in the MSP (4.6 and 2.8, respectively P = 0.002) and in stratum functionalis in the ESP (7 and 3.2, respectively P = 0.008).

LIMITATIONS, REASONS FOR CAUTION

The protein expression of vascular EC markers and ECM components was assessed using a semi-quantitative approach in both straight and spiral arterioles. In our hospital, HMB is determined by subjective criteria and levels of blood loss were not assessed.

WIDER IMPLICATIONS OF THE FINDINGS

Variation in the protein expression pattern between the four EC markers highlights the importance of choice of EC marker for investigation of endometrial vessels. Differences in expression of the different EC markers may reflect developmental stage dependent expression of EC markers in endometrial vessels, and their altered expression in HMB may reflect dysregulated vascular development. This hypothesis is supported by altered expression of ECM proteins within endometrial vessel walls, as well as our previous data showing a dysregulation in VSMC contractile protein expression in the endometrium of women with HMB. Taken together, these data support the suggestion that HMB symptoms are associated with weaker vascular structures, particularly in the LSP of the menstrual cycle, which may lead to increased and extended blood flow during menstruation.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by Wellbeing of Women (RG1342) and Newcastle University. There are no competing interests to declare.

TRIAL REGISTRATION NUMBER

Not applicable.

Addition of power Doppler to grey scale transvaginal ultrasonography for improving the prediction of endometrial pathology in perimenopausal women with abnormal uterine bleeding

Background & objectives:

Transvaginal ultrasonography (TVS) is a non-invasive procedure and can be used as a screening tool among women with abnormal uterine bleeding (AUB). Power Doppler is useful in depicting the vascular architecture better than the conventional Doppler. Hence, this study was conducted to evaluate whether addition of power Doppler to grey scale TVS can replace invasive hysteroscopy for the prediction of endometrial pathology in perimenopausal women with AUB.

Methods:

One hundred women (>45 yr) with perimenopausal AUB underwent evaluation with TVS, power Doppler and hysteroscopy-guided biopsy after a detailed history and examination. Histopathology was considered as gold standard and other tools such as grey scale TVS with power Doppler and hysteroscopy were compared with it.

Results:

Fifty six per cent women had no vascularity on power Doppler. Among those who had vascularity, the vascular patterns noted were single-vessel in 18 per cent, scattered-vessel in 15 per cent and multiple-vessel in 11 per cent. The sensitivity, specificity, positive predictive value and negative predictive value of TVS-endometrial thickness with power Doppler in detecting hyperplasia were 50, 86.5, 13.3 and 97.6 per cent, respectively, whereas the same for hysteroscopy were 100, 97.6, 88.1 and 100 per cent, respectively.

Interpretation & conclusions:

Addition of power Doppler to grey scale TVS improved the specificity and negative predictive value almost comparable to hysteroscopy for evaluation of AUB, but sensitivity and positive predictive value remained poor.

Primary care endometrial sampling for abnormal uterine bleeding: a pilot study

AIM

To design and evaluate a pilot service for primary care endometrial sampling (PCES).

DESIGN

Retrospective analysis of data from two service evaluations.

SETTING

General practices and the gynaecology department in a large city in the UK.

METHODS

These were two-fold: (1) To design the new service we identified all the endometrial samples taken in the city's gynaecology department in 2012/2013 and estimated the proportion of these with abnormal uterine bleeding (AUB) that would be suitable for PCES. (2) To evaluate the new PCES service we analysed data from the first year of activity.

RESULTS

(1) A total of 1894 endometrial samples were taken in hospital in 2012/2013. An estimated 424 (22.4%) of these were from patients with AUB who fitted the criteria for PCES. (2) In the first year of the PCES service 108 samples were taken by general practitioners (GPs). Initial management of these patients was exclusively in primary care in 97.2% (104/108) of cases; most patients were treated with the Mirena intrauterine system (79/109; 73.1%) and there were no cases of hyperplasia or cancer.

CONCLUSIONS

Most premenopausal patients with AUB could potentially be managed in primary care without referral to hospital if endometrial sampling (ES) was made available to appropriately trained and supported GPs. However, this study was limited by its retrospective, non-interventional design, and more research is required to demonstrate safety and cost-effectiveness.

Menstrual cycle distribution of uterine natural killer cells is altered in heavy menstrual bleeding

Heavy menstrual bleeding (HMB) affects 30% of women of reproductive age and significantly interferes with quality of life. Altered endometrial vascular maturation has been reported in HMB and recurrent miscarriage, the latter associated with increased uterine natural killer (uNK) cell numbers. This study compared endometrial leukocyte populations in controls and women with HMB. Formalin-fixed paraffin-embedded endometrial biopsies from controls (without endometrial pathology) and HMB were immunostained for CD14 (macrophages), CD56 (uNK cells), CD83 (dendritic cells), FOXP3 (regulatory T cells/Tregs), CD3 and CD8 (T cells). Leukocyte numbers were analysed as a percentage of total stromal cells in five randomly selected fields of view in the stratum functionalis of each sample. In control women across the menstrual cycle, 2-8% of total stromal cells were CD3(+) cells, 2-4% were CD8(+) T cells and 6-8% were CD14(+) macrophages. Compared with controls, CD3(+) cells were reduced during the mid-secretory phase (4%, P<0.01) and increased in the late secretory phase (12%, P=0.01) in HMB. CD83(+) dendritic cells and FOXP3(+) Tregs were scarce throughout the menstrual cycle in both groups. In controls, 2% of stromal cells in proliferative endometrium were CD56(+) uNK cells, increasing to 17% during the late secretory phase. In HMB, CD56(+) uNK cells were increased in the proliferative (5%, P<0.01) and early secretory (4%, P<0.02) phases, but reduced (10%, P<0.01) in the late secretory phase. This study demonstrates dysregulation of uNK cells in HMB, the functional consequence of which may have an impact on endometrial vascular development and/or endometrial preparation for menstruation.

Scientific evaluation of medicinal plants used for the treatment of abnormal uterine bleeding by Avicenna

PURPOSE

Abnormal uterine bleeding (AUB) is one of the prevalent gynecological disorders that cause considerable morbidity and management of that plays an important role in protecting women's health. This review focuses on medicinal plants mentioned by Avicenna, a great Iranian philosopher and physician (A.D. 980-1037), in his book Canon for treatment of AUB.

METHODS

Medicinal plants mentioned in Canon for treatment of AUB were elicited and searched in electronic databases including PubMed, Scopus, Google Scholar and Cochrane library to find studies that confirmed their efficacy. Data were collected for the years 1980-2014.

RESULTS

The findings included 23 plants belonging to 18 families. Scientific findings have revealed that these plants control AUB through four mechanisms of action including inhibition of inflammatory process, inhibition of prostaglandins production, antiproliferative activity on human cervical cancer cells (HeLa), and estrogenic activity. All of the plants exhibited anti-inflammatory activity in vitro and/or in vivo. Cuscuta chinensis and Portulaca oleracea exhibited estrogenic activity. Boswellia carteri, Lens culinaris, Myrtus communis, Polygonum aviculare, Pistacia lentiscus, and Punica granatum have revealed inhibitory activity on biosynthesis of prostaglandins. Some of the mentioned plants including: Ceratonia siliqua, Cuscuta chinensis, Cuscuta epithymum, Cydonia oblonga, Paeonia sp., Portulaca oleracea, Solanum nigrum, Rumex acetosa and Onopordum acanthium have shown antiproliferative activity on HeLa cells.

CONCLUSION

Investigation of traditional Iranian medicine literatures can lead to the identification of effective natural medicines for the management of AUB; however, conclusive confirmation of the efficacy and safety of these treatments needs more evaluations.

Altered vascular smooth muscle cell differentiation in the endometrial vasculature in menorrhagia

STUDY QUESTION

How does the smooth muscle content and differentiation stage of vascular smooth muscle cells (VSMCs) in endometrial blood vessels change according to the different phases of the menstrual cycle and is this altered in women with menorrhagia?

SUMMARY ANSWER

The smooth muscle content (as a proportion of the vascular cross-sectional area) of endometrial blood vessels remained unchanged during the normal menstrual cycle and in menorrhagia; however, expression of the VSMC differentiation markers, smoothelin and calponin, was dysregulated in endometrial blood vessels in samples from women with menorrhagia compared with controls.

WHAT IS KNOWN ALREADY

Menorrhagia affects 30% of women of reproductive age and is the leading indication for hysterectomy. Previous studies have suggested important structural and functional roles for endometrial blood vessels, including impaired vascular contractility. Differentiation of VSMC from a synthetic to contractile state is associated with altered cellular phenotype that contributes to normal blood flow and pressure. This vascular maturation process has been little studied in endometrium both across the normal menstrual cycle and in menorrhagia.

STUDY DESIGN, SIZE, DURATION

Endometrial biopsies were taken from hysterectomy specimens or by pipelle biopsy prior to hysterectomy in controls without endometrial pathology and in women with menorrhagia (n = 7 for each of proliferative, early-secretory, mid-secretory and late-secretory phases for both groups). Biopsies were formalin fixed and embedded in paraffin wax.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Paraffin-embedded sections were immunostained for α smooth muscle actin (αSMA), myosin heavy chain (MyHC), H-caldesmon, desmin, smoothelin and calponin (h1 or basic). VSMC content was measured in 25 αSMA(+) vascular cross sections per sample and expressed as a ratio of the muscular area:gross vascular cross-sectional area. VSMC differentiation was analysed by the presence/absence of differentiation markers compared with αSMA expression. Smoothelin and calponin expression was also analysed in relation to total number of blood vessels by double immunostaining for endothelial cell markers.

MAIN RESULTS AND THE ROLE OF CHANCE

Study of VSMC differentiation markers revealed decreased expression of calponin both in αSMA(+) vessels (P = 0.008) and in relation to total number of vessels (P = 0.001) in late secretory phase endometrium in menorrhagia compared with controls. Smoothelin expression in αSMA(+) vessels was increased (P = 0.03) in menorrhagia, although this was not significant in relation to the total number of vessels. In normal endometrium, the proportion of blood vessels expressing αSMA increased from 63% in proliferative endometrium to 81% in the late secretory phase (P = 0.002). The overall arterial muscle content did not differ between control and menorrhagia at any phase of the menstrual cycle, occupying 78-81% of gross vascular cross-sectional area during the different menstrual cycle phases.

LIMITATIONS, REASONS FOR CAUTION

This study included both straight and spiral arterioles and analysed only stratum functionalis. The VSMC differentiation with respect to αSMA expression is an observational study and the data are presented as presence or absence of the differentiation markers in each field of view, corresponding with the vascular cross sections included in the study of vascular muscle content.

WIDER IMPLICATIONS OF THE FINDINGS

Smoothelin and calponin have been widely implicated as important regulators of vascular tone, vascular contractility and rate of blood flow. Our results have uncovered a disparate pattern of calponin expression, potentially indicating a dysfunctional contraction mechanism in the endometrial blood vessels in menorrhagia, thus implicating calponin as a potential therapeutic target.

STUDY FUNDING/COMPETING INTERESTS

This study was funded by Wellbeing of Women (RG1342) and Newcastle University. There are no competing interests to declare.

TRIAL REGISTRATION NUMBER

Not applicable.

Abnormal bleeding during menopause hormone therapy: insights for clinical management

OBJECTIVE

Our objective was to review the involved mechanisms and propose actions for controlling/treating abnormal uterine bleeding during climacteric hormone therapy.

METHODS

A systemic search of the databases SciELO, MEDLINE, and Pubmed was performed for identifying relevant publications on normal endometrial bleeding, abnormal uterine bleeding, and hormone therapy bleeding.

RESULTS

Before starting hormone therapy, it is essential to exclude any abnormal organic condition, identify women at higher risk for bleeding, and adapt the regimen to suit eachwoman's characteristics. Abnormal bleeding with progesterone/progestogen only, combined sequential, or combined continuous regimens may be corrected by changing the progestogen, adjusting the progestogen or estrogen/progestogen doses, or even switching the initial regimen to other formulation.

CONCLUSION

To diminish the occurrence of abnormal bleeding during hormone therapy (HT), it is important to tailor the regimen to the needs of individual women and identify those with higher risk of bleeding. The use of new agents as adjuvant therapies for decreasing abnormal bleeding in women on HT awaits future studies.

Management of heavy menstrual bleeding in general practice

BACKGROUND

Heavy menstrual bleeding (HMB) is a common symptom that leads women to seek medical treatment. Sources of HMB are variable; patients may present with obvious uterine pathology, systemic disease, or even localized hemostatic dysregulation that defies clinical measurement. Whereas surgical intervention even in the absence of overt pathology had historically been the most common route of treatment for HMB, an expanding therapeutic armamentarium provides greater options and the possibility of maintaining fertility in affected women.

SCOPE

A descriptive literature review was performed to identify relevant articles discussing the management of HMB. The PubMed database was searched using the terms 'heavy menstrual bleeding', 'menorrhagia', 'abnormal uterine bleeding', or 'dysfunctional uterine bleeding' in combination with 'diagnosis', 'treatment', 'management', or 'guidelines'. Results were limited to articles published in English within the past 10 years. Additional statements, consensus documents, and clinical guidelines were located through review of professional society websites.

FINDINGS

For practical purposes, a subjective definition of HMB (i.e., excessive menstrual blood loss that is not tolerated by the patient and adversely affects quality of life) rather than objective measures can be used by the clinician as the basis for further investigation. Standard diagnostic examinations and initiation of therapy are well within the purview of the general practitioner. A wide variety of medical therapy options are available, although few treatments are specifically indicated for the management of HMB. The approval of tranexamic acid in the United States specifically for the treatment of HMB is a recent development that provides practitioners with an effective, noncontraceptive alternative medical therapy. For women without evidence of uterine pathology, invasive/surgical procedures are generally considered as a second-line treatment option.

CONCLUSIONS

Given the breadth of available medical and surgical treatment choices, identifying a suitable therapeutic strategy should be feasible for all patients, even in this highly heterogeneous population.

Management of menorrhagia associated with chemotherapy-induced thrombocytopenia in women with hematologic malignancy

Abnormal uterine bleeding in women with a blood dyscrasia, such as leukemia, or who experience thrombocytopenia secondary to myelosuppressive chemotherapy is a clinical condition associated with significant morbidity. Consequently, effective management is necessary to prevent adverse outcomes. Prevention of menorrhagia, defined as heavy regular menstrual cycles with more than 80 ml of blood loss/cycle or a cycle duration longer than 7 days, in this patient population is the goal of therapy. Gonadotropin-releasing hormone analogs (e.g., leuprolide) are promising therapies that have been shown to decrease vaginal bleeding during periods of thrombocytopenia and to have minimal adverse effects other than those associated with gonadal inhibition. In patients who experience menorrhagia despite preventive therapies, or in patients who have thrombocytopenia and menorrhagia at diagnosis, treatment is indicated. For these women, treatment options may include platelet transfusions, antifibrinolytic therapy (e.g., tranexamic acid), continuous high-dose oral contraceptives, cyclic progestins, or other therapies for more refractory patients such as danazol, desmopressin, and recombinant factor VIIa. Hormonal therapies are often the mainstay of therapy in women with menorrhagia secondary to thrombocytopenia, but data for these agents are sparse. The most robust data for the treatment of menorrhagia are for tranexamic acid. Most women receiving tranexamic acid in randomized trials experienced meaningful reductions in menstrual bleeding, and this translated into improved quality of life; however, these trials were not performed in patients with cancer. Further clinical trials are warranted to evaluate both preventive and therapeutic agents for menorrhagia in premenopausal women with cancer who are receiving myelosuppressive chemotherapy.

Ulipristal acetate versus placebo for fibroid treatment before surgery

BACKGROUND

The efficacy and safety of oral ulipristal acetate for the treatment of symptomatic uterine fibroids before surgery are uncertain.

METHODS

We randomly assigned women with symptomatic fibroids, excessive uterine bleeding (a score of >100 on the pictorial blood-loss assessment chart [PBAC, an objective assessment of blood loss, in which monthly scores range from 0 to >500, with higher numbers indicating more bleeding]) and anemia (hemoglobin level of ≤10.2 g per deciliter) to receive treatment for up to 13 weeks with oral ulipristal acetate at a dose of 5 mg per day (96 women) or 10 mg per day (98 women) or to receive placebo (48 women). All patients received iron supplementation. The coprimary efficacy end points were control of uterine bleeding (PBAC score of <75) and reduction of fibroid volume at week 13, after which patients could undergo surgery.

RESULTS

At 13 weeks, uterine bleeding was controlled in 91% of the women receiving 5 mg of ulipristal acetate, 92% of those receiving 10 mg of ulipristal acetate, and 19% of those receiving placebo (P<0.001 for the comparison of each dose of ulipristal acetate with placebo). The rates of amenorrhea were 73%, 82%, and 6%, respectively, with amenorrhea occurring within 10 days in the majority of patients receiving ulipristal acetate. The median changes in total fibroid volume were -21%, -12%, and +3% (P=0.002 for the comparison of 5 mg of ulipristal acetate with placebo, and P=0.006 for the comparison of 10 mg of ulipristal acetate with placebo). Ulipristal acetate induced benign histologic endometrial changes that had resolved by 6 months after the end of therapy. Serious adverse events occurred in one patient during treatment with 10 mg of ulipristal acetate (uterine hemorrhage) and in one patient during receipt of placebo (fibroid protruding through the cervix). Headache and breast tenderness were the most common adverse events associated with ulipristal acetate but did not occur significantly more frequently than with placebo.

CONCLUSIONS

Treatment with ulipristal acetate for 13 weeks effectively controlled excessive bleeding due to uterine fibroids and reduced the size of the fibroids. (Funded by PregLem; ClinicalTrials.gov number, NCT00755755.).

Chronic pelvic pain and endometriosis: translational evidence of the relationship and implications

BACKGROUND

Many clinicians and patients believe that endometriosis-associated pain is due to the lesions. Yet causality remains an enigma, because pain symptoms attributed to endometriosis occur in women without endometriosis and because pain symptoms and severity correlate poorly with lesion characteristics. Most research and reviews focus on the lesions, not the pain. This review starts with the recognition that the experience of pain is determined by the central nervous system (CNS) and focuses on the pain symptoms.

METHODS

Comprehensive searches of Pubmed, Medline and Embase were conducted for current basic and clinical research on chronic pelvic pain and endometriosis. The information was mutually interpreted by a basic scientist and a clinical researcher, both in the field of endometriosis. The goal was to develop new ways to conceptualize how endometriosis contributes to pain symptoms in the context of current treatments and the reproductive tract.

RESULTS

Endometriotic lesions can develop their own nerve supply, thereby creating a direct and two-way interaction between lesions and the CNS. This engagement provides a mechanism by which the dynamic and hormonally responsive nervous system is brought directly into play to produce a variety of individual differences in pain that can, in some women, become independent of the disease itself.

CONCLUSIONS

Major advances in improving understanding and alleviating pain in endometriosis will likely occur if the focus changes from lesions to pain. In turn, how endometriosis affects the CNS would be best examined in the context of mechanisms underlying other chronic pain conditions.

Cervical cytology in patients with postmenopausal bleeding

In this study, the role of cervical cytology in the diagnosis of post or perimenopausal (PM) bleeding was explored. A total of 135 patients with PM bleeding were selected. In all these cases both conventional cervical cytology and histopathology follow up were available. The commonest causes of postmenopausal (PM) bleeding with abnormal histopathology were squamous cell carcinoma of cervix (14), endocervical polyp (13), endometrial adenocarcinomas (13) and simple hyperplasia without atypia (13). There were a total 13 cases of endometrial adenocarcinoma and cervical smears of these cases were reported as high grade squamous intra epithelial lesion (1), presence of endometrial cells (4), unsatisfactory due to low cellularity (2), and within normal limit (6). In brief, endometrial carcinoma and hyperplasia are the predominant causes of PM bleeding due to endometrial pathology. The presence of benign looking endometrial cells with PM bleeding always indicates a careful work upto exclude endometrial pathology.

Safety, efficacy and patient satisfaction with continuous daily administration of levonorgestrel/ethinylestradiol oral contraceptives

The progestational steroid norgestrel was synthesized and tested between 1960 and 1965 through an international cooperation between Wyeth, USA and Schering, Berlin. It is a mixture of two "enantiomers," with only one form (designated as levonorgestrel) biologically active. When taken orally, it is rapidly absorbed, not subjected to a "first-pass" effect and is approximately 90% bioavailable, with a circulating half-life around 15 hours. Its contraceptive action is exerted at the central (hypothalamic) and peripheral (cervical mucus and endometrium) levels. Levonorgestrel (LNG), alone or in combination with ethinyl estradiol (EE), is the most widely employed contraceptive progestin: it is used in combined oral contraceptives, progestogen-only pills, long-acting contraceptive implants, intrauterine contraceptive systems and in emergency contraception. It is also the steroid of choice for new oral contraceptive regimens aimed at reducing the frequency of bleeding episodes. This novel approach, already tried more than 30 years ago, gained interest around the year 2000 when surveys of women's attitudes toward monthly menstrual bleeding started to show a major change: more and more women declared that they would welcome a hormonal contraceptive method that reduced bleeding episodes to 4, 2 or even 1 per year. At this point, while the debate on the significance and "usefulness" of menstruation went on, attention focused on new regimens. The first new modality consisted of changing the 7-day medication-free interval, either shortening it to fewer than 7 days, or by the administration of low-dose estrogens during the interval between packages. Then, continuous administration regimens started to be investigated. This, however, did not happen suddenly, since, in specific situations, doctors had for years empirically utilized various continuous administration regimens. The first extended-cycle oral contraceptive regimen introduced in clinical practice is an 84-day regimen that results in bleeding only 4 times a year. A commercial product specifically packed for continuous use is now available in Europe and contains 30 mug EE and 150 mug LNG. In a variation of this regimen, after administration of the same combination for 84 days, women are given 7 pills containing 10 mug EE. A 6-monthly regimen has also been tested in a small study using EE 20 mug plus LNG 100 mug taken with and without a hormone-free interval. Women in the continuous group reported significantly fewer bleeding days requiring protection and were more likely to have amenorrhea; in addition they also reported significantly fewer days of bloating and menstrual pain. A yearly regimen is now being developed. Each pill of this novel formulation contains EE 20 mug and LNG 90 mug to be taken continuously for 364 days (13 cycles) per year. A phase III trial has now evaluated safety, efficacy and menses inhibition. At the end of the 1-year trial amenorrhea was present in 58.7% of the women and a complete absence of bleeding in 79.0%. Overall, the number of bleeding and spotting days per pill pack declined with time and adverse events and discontinuations were comparable to those reported for cyclic oral contraceptive regimens.

Enhanced expressions of matrix metalloproteinase (MMP)-2 and -9 and vascular endothelial growth factors (VEGF) and increased microvascular density in the endometrial hyperplasia of women with anovulatory dysfunctional uterine bleeding

OBJECTIVE

To evaluate the roles of endometrial matrix metalloproteinase (MMP)-2 and -9, vascular endothelial growth factors (VEGF), and microvascular density (MVD) in the occurrence of anovulatory dysfunctional uterine bleeding (DUB).

DESIGN

A prospective analytical design.

SETTING

The obstetrics and gynecology department of an academic training hospital.

PATIENT(S)

Sixty women with anovulatory DUB and 20 control women.

INTERVENTION(S)

Endometrial biopsies were obtained for the assessment of immunohistochemical staining of MMP-2 and -9, VEGF, and endometrial MVD using an antibody to CD34.

MAIN OUTCOME MEASURE(S)

The results were determined through the expressions of MMP-2 and -9, VEGF, and CD34.

RESULT(S)

The frequencies of MMP-2 and -9 expression in endometrial stroma and of VEGF expression in endometrial glands were all significantly higher in the endometrial hyperplasia of women with anovulatory DUB than they were in the control group. Additionally, the mean score of endometrial MVD was significantly higher in the endometrial hyperplasia of women with anovulatory DUB than it was in the control group. In women with anovulatory DUB, VEGF expression in endometrial glands was statistically correlated with MMP-2 and -9 expressions in endometrial stroma and endometrial MVD.

CONCLUSION(S)

These results suggest that enhanced expressions of MMP-2 and -9, VEGF, and increased MVD in endometrial hyperplasia may play important roles in the pathogenesis of women with anovulatory DUB.