An ultrastructural study of menstrual blood in normal menstruation and dysfunctional uterine bleeding

Endometrial glandular and stromal breakdown, Part 4: Cytomorphology of "condensed cluster of stromal cells including a light green body"

This study was undertaken to clarify the origin of the chromophilic substance that stained in light green [light green body (LGB)] was observed in the condensed cluster of stromal cells and in the background of endometrial glandular and stromal breakdown cases. The material consists of cytologic smears of endometrial glandular and stromal breakdown (EGBD) from 58 samples in which a histopathological diagnosis was subsequently obtained by endometrial curettage. The following parameters were examined. (1) The occurrence and number of a LGB. As for the "condensed cluster of stromal cells," "condensed cluster of stromal cells including LGB" and "LBG in background," it was observed with all fields on one slide per case. When it was observed more than one in a preparation, the occurrence was determined and the number was also calculated. (2) Immunostaining of paraffin-embedded tissue sections and cytologic preparations. 1 The occurrence of "condensed cluster of stromal cells," "condensed cluster of stromal cells including LGB" and "LGB in background" was 100%, 44.8% and 91.4%, respectively. The number of "condensed cluster of stromal cells," "condensed cluster of stromal cells including LGB" and "LGB in background" was 21.2, 2.0 and 4.0, respectively. 2 When histological sections from paraffin-embedded tissue were tested by immunocytochemistry, "LGB" stained weakly or negative for fibrinogen, whereas it stained positively for CD31 and factor VIII. In addition, it stained positively for CD42b. 3 When cytologic preparation was tested by immunocytochemistry, "LGB" stained positively for CD31, factor VIII and CD42b. However, as for the fibrinogen, quantitative and qualitative evaluation of the immunocytochemical stain was not feasible due to extensive nonspecific reaction in the whole preparation. The "LGB" in EGBD cases proved to be a thrombus mostly made up by platelets, and it seemed that the recognition of the LGB showed to be a useful cytomorphological criterion for an always more accurate diagnosis of EGBD cases.

Cyclic changes in endometrial tissue plasminogen activator and plasminogen activator inhibitor type 1 in women with normal menstruation and essential menorrhagia

OBJECTIVE

The purpose of this study was to investigate the role of fibrinolysis in the pathogenesis of essential menorrhagia.

STUDY DESIGN

We measured fibrinolytic activity and the concentration of the fibrinolytic activators, tissue plasminogen activator, and plasminogen activator inhibitor type 1 in endometrial extracts at various stages of the menstrual cycle in patients with normal menstrual loss (< or = 80 ml per cycle) and essential menorrhagia (> 80 ml per cycle). Tissue plasminogen activator activity was assayed by measuring the rate of conversion of Glu-plasminogen to plasmin with a chromogenic plasmin substrate. Enzyme-linked immunoassays were used to measure tissue plasminogen activator and plasminogen activator inhibitor type 1 antigen levels.

RESULTS

Women with essential menorrhagia had higher endometrial tissue plasminogen activator activity in the menstrual phase compared with controls (p < 0.01). Endometrial tissue plasminogen activator antigen levels were higher in both the late secretory (p < 0.01) and menstrual (p < 0.001) phases in essential menorrhagia than in the normal group. Endometrial plasminogen activator inhibitor type 1 was significantly higher in essential menorrhagia only in the menstrual phase (p < 0.01).

CONCLUSION

The premenstrual rise in tissue plasminogen activator antigen production with delayed increase in plasminogen activator inhibitor type 1 is the probable cause of the greater endometrial tissue plasminogen activator activity that occurs during menstruation in women with essential menorrhagia.

Endometrial fibrinolytic enzymes in women with normal menstruation and dysfunctional uterine bleeding

OBJECTIVE

To study fibrinolysis in the endometrium in women with normal menstruation and dysfunctional uterine bleeding (DUB).

DESIGN

Tissue plasminogen activator activity (t-PA) and antigen (t-PAAg) and plasminogen activator inhibitor Type 1 antigen (PAI-1) were measured in homogenates of endometrium sampled between 24 and 36 h after the onset of menstruation.

SUBJECTS

Women complaining of menorrhagia who had negative findings at clinical examination and curettage had their menstrual blood loss (MBL) measured from the third cycle after D&C. Those with MBL greater than 80 ml per cycle formed the DUB group.

MEASUREMENTS

Fibrinolytic enzyme antigen levels were measured with ELISAs. Tissue plasminogen activator activity was assayed by measuring the rate of conversion of Glu-plasminogen to plasmin, using a chromogenic plasmin substrate.

CONCLUSIONS

There is a strong positive correlation between endometrial t-PA activity on the second day of menstruation and measured menstrual loss (P < 0.05). Concentrations of endometrial t-PAAg and PAI-1 antigen are higher in women with DUB compared with normal women during menstruation.

Dysfunctional uterine bleeding

The diagnosis of DUB is made by the exclusion of organic disease as a cause of the abnormal menses; the condition accounts for about 80% of cases of menorrhagia. Of these, over 80% will have no abnormality of the hypothalamo-pituitary-ovarian axis, and it is likely that the disorder is the result of local endometrial factors. There appears to be not only a preponderance of vasodilatory prostaglandins in the endometrium of women with menorrhagia, but also an excessive increase in fibrinolytic activity within the uterine cavity. Once a diagnosis has been reached with the aid of history, examination, haematological and endocrine investigations, and dilatation and curettage when appropriate, medical treatment is the usual first line approach. Non-steroidal anti-inflammatory drugs such as mefenamic acid, or antifibrinolytic agents such as tranexamic or epsilon aminocaproic acids, will reduce blood loss by between 25 and 50%. Though the former drugs are relatively free from side-effects in healthy women, intracranial thrombosis has been reported with the latter (Agnelli et al, 1982). Medications which suppress ovarian function, such as danazol or gonadotrophin releasing hormone analogues, are highly effective in lessening, or inhibiting, menstrual loss, but at the expense of side-effects and convenience respectively. The combined contraceptive pill may reduce blood loss by 50% but is not appropriate for older women. Cyclical gestagens such as norethisterone have been widely employed, particularly for the treatment of anovulatory cycles, but their place in the management of ovulatory DUB is less clear. If medical treatment fails hysterectomy should be considered, though less invasive surgical methods of endometrial ablation are being developed. Finally, it should be remembered that in the absence of associated signs or symptoms of iron-deficiency anaemia, heavy menstrual bleeding is a subjective complaint and up to 50% of women describing menorrhagia will have a measured monthly blood loss within normal limits.

Coagulation factors and fibrinolytic proteins in menstrual fluid collected from normal and menorrhagic women

Menstrual fluid was collected in vaginal cups inserted for 2 h during the first 2 days of menstruation and selected coagulation and fibrinolytic proteins were measured. All the samples showed a virtual absence of thrombin generating activity and exhaustion of fibrinolytic proteins. In 14 women in whom menstrual fluid was collected on both days, no significant difference in the levels of any factor was found apart from alpha-2-macroglobulin which were lower on day 1 than on day 2. Except for plasminogen and alpha-2-macroglobulin concentrations on day 1, no correlation was found between any of the factors on either day and menstrual blood loss (range 15-666 ml).

A functional study of platelets in menstrual fluid

Platelets were isolated from menstrual and peripheral venous blood samples taken from nine women during the first 2 days of menstruation. The washed platelets were tested for their ability to aggregate in response to arachidonic acid, ADP, and collagen, and to metabolize arachidonic acid. Menstrual platelets differed from venous platelets in (1) failing to aggregate when challenged with aggregatory stimuli and (2) producing no appreciable cyclo-oxygenase products from arachidonic acid as reflected in thromboxane B2 release. However, incubation of peripheral venous platelets with menstrual serum obtained from the same patients induced aggregation. The responses of menstrual and peripheral venous platelets were the same irrespective of the patients' total menstrual blood loss. Uterine venous platelets collected during menstruation from two patients at hysterectomy aggregated normally and produced thromboxane B2.